What Is A CHC Nurse Assessor?

“In February of this year the Department of Health and Social Care introduced the White Paper which builds on the NHS Long Term Plan to reduce bureaucracy and support the NHS and social care to work together.”

Gill takes us through the role of Nurse Assessor and highlights the importance of the job within Healthcare.

Topics covered in this article

Introduction

What Does A Nurse Assessor Do?

How Does Nurse Assessing Work?

Why Is The Role Of A Nurse Assessor Important?

These Are The Kind Of Patients I Work With

What Are My Main Duties?

Which Other Healthcare Staff Are Involved In The Work I Do?

Where Does Nurse Assessing Fit In The Process Of Patient Care?

What Are The Different Settings Nurse Assessors Work In?

What Are The Typical Nurse Assessor Roles in the NHS?

Are There Nurse Assessor Jobs In The Private Sector?

What Are The Career Opportunities For Nurse Assessors?

Brief History Of The Role Of Nurse Assessor

Brief Outline Of A Day In The Life Of A Nurse Assessor

What Does The Future Hold For CHC?

Introduction

A CHC Nurse Assessor is a qualified Nurse either General or Mental Health trained Band 5 upwards who completes Health Needs Assessments of patients with complex needs in a variety of settings under the Department of Health National framework for Continuing Health Care and NHS Funded Nursing Care.

What Does A Nurse Assessor Do?

A Nurse Assessor completes initial reviews of patients using a Health Needs Assessment tool to identify if a Registered Nurse is required to provide or monitor care over 24 hours which is above the capabilities of non- registered Carers.

Following on If appropriate, the Nurse Assessor will complete a check list which indicates whether the patient needs a referral for full consideration of NHS CHC funding.

Following this process if the checklist “triggers” a referral for allocation of a Social Worker is made to the Local Authority and an MDT (Multidisciplinary Team meeting) arranged for completion of a Decision Support Tool.

How Does Nurse Assessing Work?

As documented previously, there are various ways of assessing patient’s health needs however, they all involve the 11 “domains a mixture of both physical and mental health needs."

Every statement must be evidenced and discussed as listed below:

• Breathing – any shortness of breath, inhalers or nebulisers prescribed, requires CPAP (Continuous Positive Airway Pressure) or Oxygen?

• Nutrition – any recent significant weight loss, do they require full assistance with oral intake, and does it take longer than 30 mins, are supplements prescribed, is the patient at risk of choking, requiring a modified diet? PEG (artificial feeding regime) in situ is it problematic, MUST Nutritional Risk score. Are SALT (Speech and Language Team) or Dietitians involved?

• Continence – double incontinence, any Urine infections, constipation laxatives, problematic catheter, or stoma?

• Skin- At risk of pressure damage requiring equipment , re-positioning regularly. Any pressure sores, to what extent, is Tissue Viability Nurse involved and any specialist dressings required? Is the wound responding to treatment? Waterlow Risk score.

• Mobility- Independently mobile or requires assistance of 1 – 2 , any history of falls, able to co-operate or assist with transfers and re-positioning, nursed in bed or bed and chair, is a hoist required? Falls Risk assessment score?

• Communication- Able to reliably communicate , requires support ,can carers interpret and anticipate needs due to familiarity, unable to reliably communicate in any way?

• Psychological and Emotional- Any mood disturbances which impact on health and well-being, responds to reassurance/ distraction/ prompts, withdrawn from care planning / activities, any hallucinations, distress, anxiety, any medications for condition prescribed?

• Cognition- No impairment, requires support at times due to memory problems, awareness of risks, makes simple choices, difficult to make decisions about key aspects even with supervision, marked memory loss, severe disorientation to time /place /person, totally dependent on others, has a Mental Capacity Assessment been completed, can the patient consent to the assessment or is a Best Interest decision required? Does the next of kin have POA?

• Behaviour- Any challenging behaviour physically or verbally towards other residents/ care staff, risk to self, compliant with care, predictable or unpredictable behaviours, severity/ frequency, requires 1-1 care, is access to an immediate skilled response required, are Mental Health Team involved, any medications prescribed?

• Medications – Able to self-medicate, requires medications administering, compliant or non-compliant taking medications, any medications which require a trained nurse or carer to administer, any pain, monitoring for fluctuations in mental/physical health non-problematic/ problematic, is condition rapidly changing / deteriorating?

• Altered States of Consciousness- Any seizures/ loss of consciousness / stroke/ TIA, if so how often, how are they managed?

The HNA identifies if the patient has nursing needs requiring RN’s to provide most of the care over 24 hrs.

This would qualify for Funded Nursing Care which is partially funded by the NHS from April 2021 £ 187.60 per week.

The checklist is an ABC scoring document in the 11 domains. 2 x A’s or 1 x A and 4 x B’s or 5 x B’s triggers for further consideration for CHC fully funded care.

The next stage of process is completion of the DST ( Decision Support Tool ) which is a guide to assist in assessing whether the patient has a Primary Health Need which would lead to a recommendation of eligibility for CHC funding ratified by a Lead Nurses.

Why Is The Role Of A Nurse Assessor Important?

It is important to ensure patients are safe, living in the correct environment and receiving the appropriate care to meet their needs.

The Nurse Assessor completes the assessments as necessary to identify if the criteria for funding from the NHS is met i.e. Funded Nursing care ( partially funded for patients in Care Homes requiring RN interventions ) or Continuing Health Care ( fully funded care for patients with complex needs ).

When patients are at the end stage of their lives and have a poor prognosis Nurse Assessors receive referrals from Community services, Care Homes, Discharge planners at the hospitals.

This is a Fast Track referral and a request documented on a proforma with all of the patients details is completed immediately.

The purpose of the request is to enable the patient to spend the terminal stage of their life in their Preferred Place of Care.

Most patients prefer to be in their own home with family, it is the responsibility of the Nurse Assessor to liaise with the referrer (District Nurses if at home) making sure the appropriate equipment is in place specifically a special profiling bed, pressure relieving mattress and any other moving and handling equipment needed.

Establish if a DNAR and Anticipatory medications (End of Life) are in place.

The referrer will confirm the package of care required, the Nurse Assessor sources the Package of Care, and the NHS fully funds it.

An example of a Package of Care.

Am 2 x carers for 1 hour – assist with personal care

Midday 2 x carers 30 mins – assist with personal hygiene, change of position. Tea 2 x carers 30 mins - assist with personal hygiene, change of position. Evening 2 x carers 1 hour - assist with personal hygiene, change of position, prepare for the night.

Overnight care can also be funded which enables the family to have some respite.

District Nurses visit to provide support, manage symptoms , monitor condition.

If a person has lived in a Care Home for many years and prefers to remain there at end of life, the Home can make a Fast Track application and if appropriate the NHS will fully fund the cost of the placement.

A CHC Review is carried out in 3 months as the patient may have stabilised or plateaued.

These Are The Kind Of Patients I Work With

The patients are mainly elderly, frail, and vulnerable who need to be cared for in a safe environment.

As the population is living longer the risk of Dementia is increasing and many patients I work with have some form of Dementia with or without physical conditions.

Therefore although being qualified as a Registered General Nurse I work frequently with patients suffering from Dementia.

Patients who are discharged from Hospital to a Care Home for rehabilitation as they may not be fully fit to return home.

Complex patients who have suffered from Spinal injuries, Acquired brain injuries, Neurological conditions, Metabolic disorders, Terminal illness, Transitional cases when a child (approaching 18 years old) is CHC Funded by children’s NHS but requires assessment to continue funding when becoming an adult.

Patients with Learning Disabilities if the allocated Social Worker requests an assessment for fully funded NHS CHC.

What Are My Main Duties?

Receiving and reviewing checklists from members of the Multi-Disciplinary Teams to identify the need for a full assessment.

Assessments of patients, identifying their needs and whether they meet the criteria for partial funding from the NHS, Funded Nursing Care or fully funded Continuing Health Care by completing Health Needs Assessments, following up with a Decision Support Tool if appropriate.

If a DST is required, I arrange the meeting act as Lead Coordinator, starting the meeting by explaining the process to patient’s representatives emphasising that eligibility for Continuing Health Care funding is not led by diagnosis but if a patient is assessed as having a Primary Health Need above the capabilities of the Local Authority.

Moving forward discussion of the 11 domains and levels of need with members of the MDT is completed.

From these levels of need the key indicators can be discussed and a recommendation made. (Nature, Intensity, Complexity, Unpredictability) Any comments or disagreement with the patient’s representative is noted.

Some meetings can be challenging if the family strongly disagree with the levels of need and recommendation if found ineligible.

The recommendation whether the patient has a Primary Health Need, therefore meeting the criteria for fully funded CHC, is discussed, and agreed by the Nurse Assessor and the Social Worker.

If not in agreement the case must go to dispute resolution.

I complete the documentation and send for ratification to panel.

The patient and their families are informed of the outcome and how to appeal if they disagree with the recommendation.

A review is completed in 3 months if patients are deemed eligible as the most recent guidelines from October 2018 indicate to ensure the patient's needs are being managed in a suitable environment not if they still meet CHC eligibility.

Receive and process Fast Track applications for patients with a rapidly deteriorating condition approaching the end-of-life stage.

Securing funding for their care, ensuring they are in their preferred place of care.

Completing Assessments for patients in Discharge to assess beds therefore supporting the hospitals to expedite safe discharges.

Personal Health Budgets are to be offered to every client in their own homes who qualify for CHC funding by 2022.

This empowers the clients to arrange their own care having the choice of timely visits, choice of carers, social needs.

I am currently undergoing PHB Training as we are to case manage these clients.

Which Other Healthcare Staff Are Involved In The Work I Do?

Due to many years of experience in CHC I have a large network of contacts from all Multi-disciplinary professions.

However, I work closely with a representative from the LA who may already be involved with the patient or is allocated specifically to attend a DST.

If the recommendation agreed upon from the DST is that the patient meets the eligibility criteria for CHC funding the Social Worker is no longer involved in the case.

If the recommendation is that the patient does not meet the eligibility criteria for CHC, the Social Worker remains involved, and the Nurse Assessor can recommend FNC to be put in place with a review in 3 months.

Discharge Planning Teams from several Hospitals in my area who send referrals for funding to be assessed and patients discharged swiftly.

Mainly due to lack of beds and patients waiting in A and E.

The process is expected to be resolved within 2 hours which is not always possible.

District Nurses are usually involved to Fast Track patients who are at the end of life.

Community Matrons can refer complex patients living at home for assessment of eligibility for CHC funding.

I also work closely with Multi-disciplinary Teams who can provide evidence to confirm any conditions identified by the referrer. It is very useful to have individual reports to present to panel when eligibility for CHC funding is recommended.

The Teams can include Physiotherapists, Occupational Therapists, SALT (Speech and Language Therapists), Dietitians, Palliative Care Specialist Nurses, Tissue Viability Nurses, Mental Health Team, LD Nurses, and Specialist Diabetic Nurses.

Where Does Nurse Assessing Fit In The Process Of Patient Care?

As I explained earlier my role is important to ensure patients are safe, appropriately funded and in the correct environment which can manage their needs.

This is achieved by completing assessments, securing the funding, and ensuring a swift, safe discharge from hospital either to their own home or a placement.

What Are The Different Settings Nurse Assessors Work In?

The Pandemic has had a massive effect on the Nurse Assessors work.

Prior to March 2020, I was able to meet and assess patients face to face in hospitals, Care Homes, and their own homes.

Meeting with other professionals and patient’s family to discuss and complete initial Decision Support Tools, Reviews, Discharge to Assess placements.

I used to travel all over Lancashire until Covid 19 hit!

From March 23rd, 2020, my Organisation (Midlands and Lancashire Support Unit) began to gradually work from home, I have been working remotely for 15 months now.

My usual hours were 9-5 weekdays but during the first few months of Covid 19 the Team worked extra hours and provided a 7-day service supporting the hospitals and front line staff by expediting rapid discharges.

My way of working consists of organising virtual meetings to complete assessments on patients.

As an experienced Nurse meeting and communicating with a patient can alert me to any symptoms they may have, rather than relying on a third party to provide accurate information.

If the patient has full capacity, i.e. able to consent, understand the purpose of the assessment, weigh the information up and is able to retain it, they can represent themselves at the meetings.

If they do not have capacity a family member can attend to represent their relative or the assessments are completed in best interests.

I miss not being able to visit patients and having that face-to-face interaction.

What Are The Typical Nurse Assessor Roles in the NHS?

Nurse Assessor roles are currently Community based with Assessments for Funded Nursing Care usually allocated to Band 5 Trained Nurses.

Trained Band 6 and above Nurses can complete Decision Support Tools as they are more complex and may be contentious at times especially if the family do not agree with an ineligible recommendation.

Are There Nurse Assessor Jobs In The Private Sector?

Due to the huge volume of work to staff ratio the Clinical Commissiong Groups are employing Agency Nurses to help and support.

There are many Agencies who recruit Nurse Assessors. As CHC awareness by the public has greatly increased so have appeals against ineligible recommendations.

Professional firms employ CHC Nurse Assessors to assist and support the appeals.

What Are The Career Opportunities For Nurse Assessors?

There are various opportunities for Band 6 Nurse Assessors to progress to a Band 7 and upwards. Safe-guarding, DOLs (Deprivation of Liberties) Retrospective Review Teams.

The Team Leads are also Band 7 with the Clinical Leads being Band 8.

Brief History Of The Role Of Nurse Assessor

From my own experience I initially became involved with CHC in 2004 when it was not widely recognised.

I was a Band 5 District Nurse and asked to cover for 4 weeks absence in the D/N Liaison Team (it actually became 2 years!)

As my Manager was also the Lead Nurse for CHC funding in West Lancashire I became aware of the process and began completing Nursing Assessments.

I was based at our local hospital but in 2006 most wards and services were transferred to a larger acute hospital.

I also transferred to the Discharge Planning Team as a Band 6.

Although I assisted with the timely discharge of patients, I also continued to complete and process CHC applications.

We were allocated our own wards and educating ward staff about the process of CHC was challenging as it involved the RN’s completing Health Needs Assessments which was just more paperwork for them not realising at that time it was in everyone’s interest and an important part of discharging patients!

I also used to complete DST’s regularly but currently they are not processed in hospitals as it was found to be an inappropriate environment to assess patients.

I have continued being a Nurse Assessor to date experiencing all the major changes and policies over the years.

Brief Outline Of A Day In The Life Of A Nurse Assessor

Pre Covid 19, a typical day for me would be completing a DST in the morning travelling from home to the place of the meeting.

I usually arrived an hour prior to the allocated start time to meet the patient, staff, or family if in own home and look through all the case notes therefore gaining an insight into the patients’ medical history, current condition and needs.

Sometimes the meetings can continue for several hours, depending on the complexity of the patients’ needs, whether members of the MDT or family agree with the domains and recommendation.

I then have to complete all the paperwork and send for ratification.

During the afternoon I would complete a D2A.

During and post Covid 19 our ways of working completely changed and there have not been any typical days!

There is 1 week of planned assessments- which includes Telephone Care Reviews and DST ‘s.

1 week on SPOA – Single Point of Access duty which includes.

Triage- 2 Nurse Assessors are allocated, receiving emails and forwarding them to the correct inbox to be followed up by the Assessor working in that inbox. Checklists- ensure they are completed correctly and refer on for a DST to be arranged if required.

Fast tracks- I could be one of 3 Nurse Assessors ware usually allocated to the Fast-Track inbox due to the high volume of cases received on a daily basis and the urgency to complete the process.

D2A- which are now processed remotely by virtual assessments.

Approvals- As a Band 6 Nurse Assessor I have been trained to approve cases which cost less than £1000.

Urgent hospital discharges- 1 Nurse Assessor is allocated to complete rapid discharge cases from hospitals. We cover 8 major hospitals in North, Central, East and West Lancashire.

MH Nurses 1-1 inbox Mental Health Nurses cover this inbox.

General enquiries- There are generally a multitude of problems to try and solve by 1 Nurse Assessor.

What Does The Future Hold For CHC?

In February of this year the Department of Health and Social Care introduced the White Paper which builds on the NHS Long Term Plan to reduce bureaucracy and support the NHS and social care to work together.

I think this a good idea which will ultimately be beneficial to patients, if there is only one “pot of money" for funding there should be more agreements between Health and Social care especially during DST’s.

In each part of England new statutory Integrated Care Systems (ICS, s ) will be introduced and the current CCG’s will be absorbed into them.

My current employer Midlands and Lancashire Commissioning Support has provided a service for 3 CCG’s and going forwards the CSU hopes to continue providing the services to the ICSs to improve the health and well-being of the population.