1. Priority Training Module
The National Framework for the Implementation of Continuing NHS Healthcare in Wales (2014)
Priority Training Module
June to October 2014
Note for Trainer:
It’s important at the start of the session to emphasise the purpose of this module – it focuses on what is new/different in the revised 2014 CHC National Framework and is intended to provide practitioners with an understanding of the differences prior to it’s implementation from 1 October 2014.
It is not the only training being developed, work is underway to develop further modules, including a ‘foundation’ module that will go back to basics and provide a more comprehensive understanding of CHC.
This module has been developed to be delivered as a concise update. It should take no more than two hours to deliver, allowing for discussion and to answer questions as you go through the slides.
In preparing for the training session the trainer should:
Have read through the slides and the notes supplied to ensure they are aware of the flow of the session and the content;
Have an up to date understanding of CHC, and have read the revised CHC National Framework and the associated information guides;
Have accessed the CCISS website to familiarise themselves with its format and content to allow signposting access to documents;
Ensure they have as a minimum one copy of the revised National Framework and associated information;
Be prepared for questions and the need to respond to queries;
Be aware of timescales – the revised National Framework is to be issued on 1 October 2014 and those practitioners involved in assessment should, as a minimum, have received this training module by then to ensure they are aware of what’s new;
Ensure there is an accurate record of attendees as the health board will need to maintain a record of those trained.
It the initial training sessions a number of issues and questions have been asked. You may find the same happens when you deliver this session. Whilst you will find you are able to answer most questions that arise as part of the discussion, you may come across questions you feel unable to answer. If this happens don’t worry, just commit to finding out and ensure you provide feedback as soon as you can.

2. What is CHC? (A reminder….)
“A complete package of ongoing care arranged and funded solely by the NHS, where it has been assessed that the individual’s primary need is a health need. Continuing NHS Healthcare can be provided in any setting.”
Note for Trainer
This is purely a reminder – it restates the definition of CHC that people will be aware of as it’s the same as in the 2010 National Framework.

3. Why we need to take a different approach……
Why we need to take a different approach…….the user & carer perspective
‘I felt bullied and misled by a sick system within the National Health Service that is being deplorably used in order to save money.’
‘They just ticked the boxes and didn’t seem to care about my beautiful and amazing mother’
‘I barely understood a word, there was so much jargon’
‘It was like watching dogs fight over scraps of meat. It was all about the money, not my Dad’
‘Of course I took my lawyer; it’s a legal process isn’t it??’
Note for Trainer:
These are just an example of the comments Welsh Government regularly receive via phone calls, s, complaints and assembly member correspondence.
The slide is powerful, and is intended to be. The statements in the slide are challenging and difficult to read but they are real life examples. It might be helpful to ask people what they think about these comments, whether they recognise them or similar comments, and how they made staff feel.
It can be helpful to end on a more positive note – these are real concerns but they represent a very small minority of those undergoing the process. By the time people write to Welsh Government, or their Assembly Member, or Member of Parliament they can be pretty cross and feel strongly about their experience. Ask staff to recall when they have received positive feedback and what they think made the difference.

4. Key Message
For those people who are eligible to receive it, Continuing NHS Healthcare is an entitlement
Note for Trainer:
People often think that CHC has to be ‘awarded’ as if they have to earn it. This slide just emphasises very clearly that if a person is eligible then it is an entitlement.

5. Background
Wales Audit Office Report (June 2013)
Note for Trainer:
Start this slide by asking those present if they have seen or read the WAO report. The experience from the Training Workshops indicates that many will not have heard of it before. Explain briefly what the report set out to do – to review the Implementation of the 2010 Framework, and as part of this the report included a number of recommendations. It’s also helpful to inform those attending that the recommendations have formed part of the review that has been undertaken, so as you go through the session people will recognise some of these findings and recommendations have resulted in changes to the National Framework.
Key Recommendations were: that Welsh Government should:
Strengthen strategic oversight and ensure consistency
Require health boards to allocate responsibility for CHC at executive director level. They should ensure consistency, allocation of adequate resources and effective joint working with local authority partners
Consider introducing a screening tool
Review whether differences in Welsh and English DSTs can continue to be justified
Require health boards to establish mechanisms for peer review
Promote the learning from peer review
Require LHBs to complete the Self Assessment Tool
Develop national protocols/share documentation
Set a deadline for post 2010 retrospective claims
Agree a national common approach to the review of retrospective claims, using the Powys process
Establish a national Executive Task & Finish Group chaired by a CEO to oversee all retrospective claims.

6. Retrospective Reviews: Lessons Learnt
Quality costs less! Need to get it right first time
Time taken to communicate is a good investment
We must give a clear and evidenced rationale for eligibility decisions.
Note for Trainer:
Not everyone will be familiar with the CHC Retrospective Claims process so it is worth spending a short time explaining it. Retrospective claims refer to those people who feel they should have been eligible for CHC, but for a range of reasons were either never considered or the assessment and consideration of eligibility process was flawed. NHS Wales has processes in place to review these cases, and where it is found a person should have been eligible recompense is made, subject to certain conditions.
The first bullet point is therefore very real and relevant – it costs Health Boards significant amounts of money to reimburse people – NHS Wales has paid out over £50M so far. It is very important therefore to get it right first time – mostly for the individual to ensure they receive appropriate care but also for the organisations we work for.
Communicate, communicate, communicate! CHC can be a difficult issue to explain and to understand, for those undergoing the assessment process, for their family/friends/carers, but also for staff. One of the key issues that is identified from complaints or comments is that we are not good at communicating well all the time. We get it right sometimes, even most times, but we need to make that more consistent.
We need to be able to explain to the person/their family/carer/representative/advocate why the MDT has reached the decision it has. We also need to make sure we support that explanation with copies of the relevant documents – more to follow on that.

7. 2014 Framework Published 30th June 2014
Published 30th June 2014
To be implemented from 1st October 2014
So what’s new?
Note for Trainer:
This policy document was issued by Welsh Government at the end of June, and has to be implemented by 1 October.
That might sound like a long time but we have three months to ensure that staff are, as a minimum, aware of the changes in the policy, and how those changes will impact upon the way they work. That is why the initial focus has been on providing this ‘what’s new’ module as a priority.

8. 1.Underpinning Principles
All guidance, however well crafted, is subject to interpretation.
These underpinning principles are designed to support practitioners and managers to keep to the spirit of the Framework when applying the guidance to practical situations.
Note for Trainer:
It might be helpful at this point to check how many people have actually seen the revised Framework. You may find as you work through the cascade training that whilst the more senior tiers of organisations might have seen it, it may not yet have filtered down to all operational staff. You can then urge people to access the framework and consider it in more detail.
The Framework contains a series of Underpinning Principles. These have been developed and included in the revised Framework by a number of Task Groups established by Welsh Government . They therefore reflect the principles that your colleagues and peers have identified as essential.
You can also advise that a Frequently Asked Questions document will be developed by Welsh Government that will help to provide more advice, guidance and background.

9. Principle 1: People first.
Note for Trainer:
Principle 1: People first.
Para 3.3 Individuals who turn to health and social care providers when they have complex needs have to know that their best interests are the primary focus of the people assessing and supporting them. The focus will be manifested in the dignity and respect shown to them as individuals.
Individuals who are have a primary health need are entitled to Continuing NHS Healthcare funding; they should feel supported throughout the process of determination of eligibility and be confident that they will receive the quality of care required to meet their needs.

10. Principle 2: Integrity of decision-making
Note for Trainer:
Principle 2: Integrity of Decisions
Para 3.4 Members of the multidisciplinary team are responsible for the integrity of their assessments, expert professional advice and decisions which should be underpinned with a rationale. Assessments can only be challenged on the basis of their quality. They cannot be challenged on financial grounds.
You may find that some people will lack confidence that they have sufficient knowledge to be involved in what can be complex decision making. Expertise takes time to develop, and so when working as a MDT you will often find that the various members will be have different levels of knowledge about decision making and problem solving. Collectively though there will be considerable expertise in an MDT and the skill is in working together to make the best use of those skills.
The care co-ordinator is responsible for ensuring that all the information is available for the MDT is able to provide robust advice to the LHB. They should be able to access specialist guidance and support from Discharge Liaison Nurses to help them fulfil this function if required. (para 3.22).

11. Principle 3: No decisions about me without me.
Note for Trainer:
Principle 3: No decisions about me without me.
Para 3.5 Individuals are the experts in their own lives. Including them and/or their carers (be they paid or unpaid) as empowered co-producers in the assessment and care planning process is not an optional extra.
Where the available care options carry financial or emotional consequences, professionals must not avoid honest and mature conversations with the individual and/or their representative. The Sustainability Policy adopted by all health boards provides a framework that can support these considerations.
Professionals must be mindful that some individuals may need support or advocacy to express their wishes, feelings and aspirations.

12. Principle 4: No delays in meeting an individual’s needs due to funding discussions
Note for Trainer:
Principle 4: No delays in meeting an individuals needs due to funding discussions.
Para 3.6 The individual must not experience delay in having their needs met because agencies are not working effectively together. Joint funding and pooled budget options must be considered wherever these can promote more agile, and as a consequence, more efficient responses to individual needs and preferences. Commissioners have a responsibility to resolve concerns/disputes at the earliest opportunity.
As the training programme cascades through your organisations and teams, you may find that practitioners are less aware of how the funding process works, or how to access any pooled budget arrangements that the health board and its partners have established. As a trainer you can use your knowledge of the pooled budgets and joint funding arrangements that are in place locally to advise on this.  

13. Understand diagnosis; focus on need.
Principle 5:
Understand diagnosis; focus on need.
Note for Trainer:
Principle 5: Understand diagnosis, focus on need.
Para 3.7 Individuals do not define themselves by their medical diagnosis and nor should the professionals who are supporting them. Health and social care providers must work together to gain a holistic understanding of need and the impact on the individual’s daily life. The aim of assessment, treatment and longer-term care planning/commissioning should be to deliver quality and tailored support which maximises independence and focuses on what is most important from the perspective of the individual and their carers.
This slide may open up discussion. People often think that a diagnosis of a specific illness is sufficient to determine eligibility for CHC. You may hear people say, for example, that they are aware that a family friend/neighbour has been assessed as eligible for CHC and they have Alzheimer’s Disease, therefore their relative with the same illness should also be eligible.
It is important to draw out in the conversation that consideration of eligibility is based upon a holistic assessment of need, not on diagnosis.

14. Co-ordinated care & continuity.
Principle 6:
Co-ordinated care & continuity.
Note for Trainer:
Principle 6: Co-ordinated Care & Continuity
Para 3.8 Fragmented care is distressing, unsafe and costly. It can result in unnecessary changes to living arrangements, which in turn creates instability and insecurity. Every effort must be made to avoid disruption to care arrangements wherever possible, or to provide smooth and safe transition where change is required in the best interests of the individual.
Para 3.9 The individual and their carers must have a named contact for advice and support, and who can co- ordinate a prompt response to any change in need.
The revised Framework refers to this role as the ‘care co-ordinator’ and includes guidance on what this person is responsible for.
However the care co-ordinator role is delivered in your team/organisation, it is essential that there is someone who is overseeing the person’s care. If the care co-ordinator changes if the person moves to another setting, then there must be a managed handover to ensure essential information is not lost.
You could open up this discussion to the group and ask how the care co-ordinator role might work in their area, and how a managed transfer of that role could best be undertaken.

15. Principle 7: Communicate. Note for Trainer: Principle 7: Communicate.
Para 3.10 The vast majority of complaints, concerns and disputes have poor communication at their core. It is unacceptable for professionals to claim not to have time to communicate – it will take longer to put the situation right later and trust will have been broken. The individuals seeking our help and their carers will, by the nature of the interaction, require clear communication and support.
In addition to the revised Framework, the Welsh Government has also introduced a series of information leaflets on CHC. These have been developed with practitioners, and have been subject to scrutiny and advice from third sector representative organisations to ensure they are clear, concise, and give the person/their family key information on how the CHC assessment and eligibility process happens. As Trainer, you should advise where these leaflets can be obtained.

16. 2. Governance, Accountability & Performance
Named Executive Director responsible for strategic oversight and performance
Equivalent status link in Local Authority
Active engagement with third & independent sectors
Required to use agreed national performance framework
Note for Trainer:
The level of discussion re this slide is likely to depend upon how far through the organisation the training has cascaded. It is important though to ensure that those you are training understand that:
CHC is core NHS business
The health board will have a named executive director who has responsibility for CHC
Performance will be captured through a performance framework
There will be an Annual conference to share learning, celebrate successes and address our challenges together.

17. 3. Roles & Responsibilities
The individual who is being assessed:
Give honest information
Express views
Ask if you don’t understand
Family/representatives
Provide information
Attend MDT (if individual wishes) in timely manner
Co-ordinate family communication through one person.
Note for Trainer:
The following text is quoted directly from the revised National Framework.
The person whose needs are being assessed.
Para 3.17 It is essential that the individual whose needs are being assessed is central to the assessment and care planning process. They are the experts in their own lives and situation. The assessment will by its nature often be triggered by illness or other life event and every effort must be made by the professionals involved to support the individual to participate in discussions which will impact on their future. This relies on the individual providing honest information, expressing their views and aspirations, and being open if they require further explanation, or there are issues that the team need to understand to effectively meet their needs.
The person’s carer/family members/representative
Para 3.18 The individual’s family and unpaid carers and/or appointed representative will have an important contribution to make in assessing their needs and advocating on their behalf. It is vital they engage in the assessment and planning process and professionals must make every effort to facilitate their involvement. In order to achieve the best possible outcome for the individual, including support for recovery and maintenance of independence, carers/family/representatives will be expected to respond to reasonable requests for information and/or to attend the multidisciplinary meeting in a timely manner. Where there are a number of family members involved, a key contact should be nominated, who will then be responsible for communicating with other family members.

18. Roles & Responsibilities (continued)
The Care Co-ordinator
Co-ordinate assessment & ensure evidence available (when should info be available to members of MDT? Ideally beforehand but with the caveat it should reflect current needs at MDT)
‘Back up’ CC required
Person centred not service centred
Make sure the individual and/or representative are informed and involved
Keep the process moving
Principles of managed handover
Make sure the decision and rationale is recorded and QA’d
Note for Trainer:
Annex 2 of the revised Framework includes a summary of the role of the care co-ordinator

19. Roles & Responsibilities (continued)
The multidisciplinary team
Work with individual and/or representative
Mature, mutually respectful MDT
Honest, thorough, detailed and objective assessment/discussion
Provide expert advice on eligibility to LHB- expert in the individual and expert in applying the process
Provide clear rationale about decision
Clearly articulate how they’ve reached decision
Recommend setting & skill set for service delivery
Advise if can identify date where Primary Health Need became apparent.
Note for Trainer:
The following paragraphs are quoted from the revised National Framework
Multidisciplinary team members
 Para 3.25 Multidisciplinary team members are responsible for working with the individual and/or their representatives to undertake a thorough and objective assessment of the person’s needs, for providing expert advice to the LHB regarding eligibility for NHS Continuing Health Care, and for making recommendations as to the setting and skill set required to deliver the co-produced care plan.
3.26 Members of the multi-disciplinary team are responsible for the integrity of their assessments, professional advice and decisions which should be underpinned with a clear rationale. Members of the multi-disciplinary team may be challenged on the quality of their assessment, if for example there are gaps in the information required. They must not be subjected to pressure to change their professional views due to financial constraints.
If the MDT can identify a date from which the primary health need became evident, this should be recorded in the recommendation section (page 45) of the DST, along with the rationale.

20. Roles & Responsibilities (continued)
The Commissioning Team
Commission services required to deliver the care plan
Balance individual preferences and sustainability
Must be aligned with wider commissioning agenda
Consider formal partnerships/pooled budgets
Note for Trainer:
The following paragraphs are quoted directly from the revised National Framework
Commissioning team
Para 3.27 Each Local Health Board will have a robust mechanism in place for commissioning the services required to meet the individual’s needs, as detailed in the assessment and care plan. It must consider and balance the preferences of the individual, the views of their family/representative(s) and the NHS Wales Sustainable Care Planning Policy (available on the Complex Care Information & Support site It will have the responsibility for identifying and addressing gaps in local service provision.
Para 3.28 The commissioning of services to meet the needs of individuals with continuing care needs cannot be undertaken in isolation to the commissioning of other similar services. LHBs and local authorities, for example, should have an integrated approach to the commissioning of residential and nursing home care, to exercise maximum influence over the development of provision. They will also need to work closely with providers to ensure that an appropriate range of services are in place to respond to the needs of their population. Partners may use formal partnerships with pooled funding arrangements to underpin their integrated approach to commissioning.

21. 4. User and Carer involvement
Not an optional extra
Onus on professionals to make the process accessible
Use of national public information leaflets
Note for Trainer:
The Leaflets have been developed with Age Cymru and Older People’s Commissioner’s office, and have then been tested with user groups.
The Care co-ordinator is responsible for ensuring that the individual/their representative(s) have them.
Public Information Leaflet – at outset of assessment process
Preparing you for a CHC Eligibility Meeting – prior to MDT meeting where eligibility will be determined
What receiving CHC funded services means for you – once CHC eligibility has been agreed
Printed copies (bilingual tilt and turn ) have been distributed to each LHB. Downloadable pdf on website
You may want to have some copies at hand for people to look at during the training session.
Easy read version available from early August 2014

22. 4. Advocacy
2014 Framework requires LHBs to routinely offer advocacy to anyone undergoing assessment and determination of CHC eligibility
Needs to be independent of HB’s and LA’s
Supporting/helping individuals/families understand a process which can be overwhelming
Advocates need to have comprehensive knowledge of the process
Training for Advocates
Note for Trainer:
Although the 2010 Framework included a requirement for access to advocacy, this is much more explicit in the revised Framework. (Para 3.50)
Work is underway to ensure that appropriately trained and prepared advocates are available to support those undergoing assessment, should they choose to seek advocate support.

23. 5. The Assessment Process
Right Process:
Robust comprehensive assessment.
CHC is not a separate assessment process.
Must provide the evidence to assess against the four key characteristics of a primary health need.
Meetings add value but shouldn’t add delay – we can work in between!
Note for Trainer:
The paragraphs below are quotes from the revised National Framework
Right Process
Para 3.30 Establishing that an individual’s primary need is a health need requires a clear, reasoned decision which is based on evidence of needs from a comprehensive assessment. There is therefore no separate assessment process for CHC.
Para 3.31 Rather the health and social care practitioners involved are expected to comply with existing Welsh Government and practice guidance on assessment and care planning including:
‘Integrated Assessment, Planning and Review Arrangements for Older People – Guidance for Professionals in supporting the Health, Care and Wellbeing of Older People; aged 65+)’.
The Unified Assessment Process for other Adult User groups.
The Care Programme Approach for Mental Health Service Users
NAFWC 17/2005 Hospital Discharge Planning Guidance
Passing the Baton: A Practical Guide to Effective Discharge Planning (2008).
Individuals should refer to this guidance directly and it can be accessed via the Complex Care Information & Support site .There is no attempt to replicate in this framework.
The use of a screening tool or checklist is not mandated but there may be specific circumstances where such a tool may be useful. It is important though that the Checklist must not used as a replacement for professional judgement or dialogue with the individual and their family/representative.
When used in Wales it should be completed by at least two practitioners, including a representative of the Local Authority. When completing the Checklist, practitioners must be mindful not to make premature assumptions regarding reablement and comprehensive assessment outcomes.

24. The Assessment Process (continued)
Right Place:
Transfer/discharge to assess model: ‘adopt or justify’
Rehabilitation & reablement
Step up/down
Own home with appropriate support x
Note for Trainer:
Other than in exceptional clinical circumstances, acute hospital is not the right place for assessment for longer-term care. Case reviews revealed too many cases where on the first or second consultant round people are told to look for a care home. This is not person-centred care.
Para 3.38 Care must be taken to ensure that no premature presumptions are made regarding the requirements for long-term care whilst the individual is acutely unwell. ‘Home first’ should be the default position and rehabilitation/reablement to support the retention of as much independence as possible, must always be considered.
Para 3.39 The MDT, working in partnership with the person and their carer(s), must consider the optimum environment in which the assessment for longer-term care should take place in order to maximise the individual’s potential for independence. Options to be considered include step-down/intermediate assessment facilities in the community, or the person’s own home with intensive short-term support.
Para 3.40 As a matter of principle, no-one should be discharged from an acute hospital environment to a new care home placement, as reflected in Welsh Government Guidance.
Para 3.41 Using an ‘adopt or justify’ approach, in circumstances where it is deemed clinically inappropriate to provide such a period of recovery/reablement prior to, or as part of, the assessment for long-term care, the rationale must be clearly recorded. Scrutiny of such cases should be included in the LHB’s CHC audit and performance framework.
NAFWC 17/2005 Hospital Discharge Planning Guidance
Some areas are considering the use of a ‘virtual pooled pot’ to support the transfer/discharge to assess pot. This will fund the reablement and assessment placement/support, which will not be chargeable to the individual. Once the assessment has taken place and the funding source(s) have been determined, the responsible agencies will reimburse the pot.
It is acknowledged that there may not be adequate step down facilities in each area and that these will need to be commissioned. Some areas have put in bids to the Intermediate Care Fund to support this.

25. The Assessment Process (continued)
Right People:
Care co-ordinator role pivotal
Everyone who is involved with individual
- include specialists
- recognise long-term relationships NB progressive disease
The person themselves and/or family
Advocate (if required)
Note for Trainer:
The following paragraphs are quoted from the revised National Framework
Right People.
Para 3.42 The assessment process should draw on those who have direct knowledge of the individual and their needs.
Para 3.43 When it becomes apparent through discussion with the individual, their carers and the MDT, that longer- term support to meet complex needs is likely to be required on discharge (or in the community if the person is at home), a named care co-ordinator/lead professional must be identified.
Para 3.44 The Care Co-ordinator is the named individual responsible for co-ordinating the whole process of assessment for longer-term care, including gathering evidence to inform the decision on CHC eligibility.
Para 3.45 The Care Co-ordinator is most likely to be a health professional and it will be important to maintain continuity where for example, the individual has a progressive disease and specialist key professional. This person-centred approach would suggest that it may also be acceptable for a social worker with a long-standing relationship with the individual and the family, to act as Care Co-ordinator. This would be subject to inter-agency agreement, with the final decision on who acts as Care Co-ordinator resting with the Local Health Board.   
Para 3.51 Involving social services colleagues as well as health professionals in the assessment process is essential and will make decision-making more effective, informed and consistent.
Para The assessment must include the input of the consultant or GP who has responsibility for the patient, so that the clinical facts and medical needs are considered alongside all other care needs.
3.53 The assessment should, where appropriate, involve other agencies who work with the individual and form part of their existing support mechanisms. This could include for example, third sector agencies and housing associations. .

26. 6. New Decision Support Tool
English DST now adopted but no need to duplicate paperwork:
Changes to some of the domains
Audit trail of assessment
DST summary sheet (matrix)
Summary record of recommendation & rationale
Equality Monitoring Form
Note for Trainer:
Process mapping and case reviews highlighted that assessment for CHC eligibility is perceived to be overly bureaucratic and pulls practitioners away from patient/person contact. This is not what we want. If the comprehensive assessment is robust and in one folder to provide a clear audit trail, there is no need to duplicate paperwork by completing every section of the DST. If you wish to put something in the boxes, you can cross reference to the relevant assessment.
Talking through each domain can provide structure to the meeting and ensure that all needs are understood.
The summary sheet (matrix), summary record of recommendation and rationale must be completed and a copy provided to the individual and/or their representative.
There are a number of changes between the DST used at the moment and the one that will be used from 1st October A hand-out is available that sets out the changes. You should encourage staff to ensure they take time to consider the changes to ensure they are ready to implement the revised process from 1 October.

27. Using the Decision Support Tool
It’s not:
An assessment or
A substitute for professional judgement or
A requirement for duplication
Move away from the tick box and focus rationale on the 4 key characteristics of a primary health need
Note for Trainer:
The revised Framework does not require the completion of the full DST, where there is comprehensive evidence of assessment that is available and referenced appropriately. This will be a different approach to that currently in place, and delegates may wish to spend some time exploring and considering this.
Feedback since the 2010 Framework was issued indicates that there has been a lot of time spent in duplicating assessment, transcribing text from a range of assessments onto the DST template. The revised approach is intended to reflect these concerns, and limits a lot of the duplication that is currently taking place.
There may though be implications for those considering MDT outcomes – there will be a need to ensure that the assessment evidence referred to in reaching a decision is available and accessible.

28. MDT ‘Expert Advice’ or Recommendation - what does this mean?
The MDT:
Are the experts on the individual’s needs
Provide advice based on their professional expertise
Must be competent in determining eligibility
The combination of the above means that the LHB receives expert advice on that individual’s eligibility for CHC, and should only reject it in exceptional circumstances.
Note for Trainer:
See paragraphs 3.70 & 3.71
If the MDT is to operate effectively, it is essential that the professionals involved have a full understanding of the individual’s needs.
The principles set out in the Passing the Baton Training Framework can be used as a guide to determining competency, as referred to in the third bullet point above.
The Foundation Training module will have a competency framework attached to it.

29. 9.Trigger Tool/Checklist
Not mandated in Wales as risks premature assumptions re level of need prior to recovery/reablement
May be useful e.g. to trigger earlier review for individual in care home or to illustrate why someone is clearly outside the criteria and requires social care support only
Use DoH tool for consistency:
See paragraphs 3.34 to 3.37 in the Framework

30. 10. Reimbursement and Good Public Administration
Legal responsibility commences at the point where MDT recommendation is accepted by LHB
Principles of good public administration mean individual should be reimbursed (if they have paid for care) from date MDT determined eligibility
MDT to advise LHB if they can identify date at which PHN became evident & LHB should reimburse accordingly.
Note for Trainer:
See paragraph 3.82 of Framework
Where the MDT can identify a date at which the primary health need became evident, they must record this in the Recommendation Section (page 45) of the DST, along with the rationale.

31. 11. Eligibility in progressive disease
Use professional judgement
Take deterioration and disease progression into account when considering eligibility
Review more frequently if needed
MDT to advise if individual’s disease pattern indicates stabilisation is likely to be short-term.
Note for Trainer:
The following paragraphs are direct quotes from the revised National Framework
Paragraphs 3.62 and 3.63:
3.62 It is also important that deterioration and disease progression are taken into account when considering eligibility. The assessment should anticipate circumstances where deterioration or a material change in condition might reasonably be regarded as likely in the near future. In these circumstances, although the individual may not have a primary health need at the time of assessment, an earlier review should be considered.
3.63 The MDT should also advise commissioners if, in their professional opinion, any stabilisation of a progressive condition, and potential withdrawal of CHC funding, is likely to be short-term. In such cases commissioners should balance the contribution of well-managed need to the current assessment and the benefits to the individual of continuity of care provision, alongside financial considerations.

32. 12. Fast Track process extended to ‘catastrophic events’
Permission granted to use common sense
If someone has a ‘catastrophic event’, evidently has a primary health need, and is paying for their own care, consider fast track.
Build in earlier review date if necessary.
Note for Trainer:
This has been added following cases highlighted by the Public Services Ombudsman for Wales. An example is someone who is receiving FNC in a nursing home and suffers a massive stroke. Everyone agrees that it is in the individual’s best interests not to have their care disrupted and that they should continue to be looked after in the nursing home but they evidently have a primary health need. Fast track would be an appropriate and compassionate response in these circumstances.
In response to this new addition to the Framework, LHBs may need to review their current Fast Track procedures which focus on end of life care with rapidly changing need.
NB this does not mean that everyone who has a CVA will be eligible for CHC or that people who have a stroke in a care home should be denied access to the usual stroke pathway. This is about using common sense in exceptional circumstances.

33. 13. Quality Assurance
Can challenge quality of assessment but must not subject MDT to pressure to change views due to financial constraint
Must not delay the provision of the services the individual requires
Must be proportionate; should consider streamlining for non-contentious cases (the Framework does not require a panel process)
Must identify teams or individuals who do not follow the process to expected standards and tackle root cause.
Note for Trainer:
Case study reviews and process mapping showed too many instances where cases are referred between panel and MDT, often more than once, requesting further information . This can lead to delays and should not be viewed as acceptable practice.

34. TIMEFRAME PROCESS Up to 8 weeks 1 week max. 2 weeks
OVERVIEW OF STANDARD ASSESSMENT & CHC ELIGIBILITY DECISION-MAKING PROCESS
TIMEFRAME
PROCESS
Up to 8 weeks
(can be longer if further rehabilitation is required but not due to eligibility process)
1 week max.
2 weeks
Comprehensive assessment for longer-term care needs triggered.
Identify the Care Co-ordinator/Lead Professional
Obtain valid consent to comprehensive assessment.
Transfer individual (if required) to the most appropriate environment for assessment.
Deliver rehabilitation/reablement programme (unless clinically contra-indicated)
Complete
The quality assurance process
Collate co-produced comprehensive assessment.
Arrange the MDT meeting at which CHC eligibility will be considered.
Ensure the individual and/or their representatives have the information and support they need to fully participate.
At the meeting, review the comprehensive assessment and determine whether the individual has a primary health need.
Ensure that a clear and agreed rationale is documented and shared with the individual and/or their representatives.
Arrange the care package
Contact individual and/or their representatives within 48 hours to answer queries etc.
Note for Trainer:
A number of timescales are set out in the revised Framework. This slide provides a summary of these.   
In some cases much speedier decisions should be taken in the individual’s best interests (Fast Track) 
Any exceptions to the timescales set out in the Framework and summarised above should be monitored locally as part of the performance framework and actioned as appropriate.
Para 3.81 It is the responsibility of the MDT to undertake robust assessment and to provide the LHB with expert advice as to whether the individual has a primary health need. It is the responsibility of the LHB to ensure consistency and fairness of the decision-making process; it should only be in exceptional circumstances that the LHB does not accept the MDT’s advice. The legal responsibility for the LHB to fund commences at the point at which it confirms that the MDT’s advice is consistent and fair. However, the principles of good public administration dictate that, if an individual has paid for their care in the interim, they should be reimbursed.
Para 3.82 Such reimbursement would normally commence from the date on which the MDT met and made its determination of eligibility. However the MDT should advise the Health Board if they can, in their reasoned professional judgement, identify a date at which the primary health need became evident and the individual should be reimbursed accordingly.
Para 3.83 The timescale for the provision of care following assessment can vary between the remainder of an individual’s life and episodes of care; people may move in and out of eligibility for CHC. Individuals, their families and carers, and other care purchasers and providers, must be made fully aware of the financial and practical implications of this as part of the information provided to support the assessment process.

35. 14. Review timescales Aligned to English Framework
Requirement for initial 6 week review removed
As a minimum the first review should be undertaken within 3 months unless triggered earlier by the individual their representative or the service provider.
Annual as a minimum thereafter but use professional judgement
If earlier review requested due to deterioration, this should be held within 2 weeks
Note for Trainer:
Review should follow assessment format.
Individual/family and service provider should have details of named contact to flag any change in condition.
Individuals reviewed for FNC on an annual basis should automatically consider potential eligibility for CHC and move to full assessment where indicated.

36. 15. Other issues addressed/expanded on in 2014 Framework
Service provision and joint working
The relationship between Direct Payments and CHC
The use of personal contributions (‘top ups’) in CHC
Guidance on the management of retrospective claims
Application of the Framework to specialist groups
Note for Trainer:
‘Specialist Groups’ = Mental Health and the interface with section 117, people with a learning disability and young people in transition between the Children’s and Adults Frameworks.

37. Proposed Training Programme
A modular training programme is under development and will be accessible from Autumn Will include:
CHC Foundation Course
Chairing an MDT meeting
The Care Co-ordinator Role
Specialist modules for mental health and learning disability practitioners and children’s services (transition)
Note for Trainer:
This slide provides those attending with an understanding of the work underway to deliver additional CHC training.
It is helpful at this point to reinforce that this module is being cascaded though organisations as a priority as it provides a summary of what’s new/different in the revised National Framework.
Some people may feel that the session does not provide them with all the information they require – as above, it is important to emphasise that further training is under development.

38. Complex Care Information & Support Site
An online resource will be available from July. Checkout the Complex Care Information and Support Site (CCISS) at
To be built on over time with contributions from partner agencies
Fine line between preparing for MDT and pre judging the decision
Skills/competence for chairing an MDT (specialist module)
Clear split re eligibility decision and commissioning/finance
Principles of Co-production
Note for Trainer:
The site is now available and will provide access to both policy guidance (the revised National Framework and the information leaflets can be accessed here) and with helpful systems, processes and approaches that other health boards have found to be helpful.
You can contribute to the development of the site by sharing processes that you have developed locally to meet the requirements in the Framework.