Continuing Healthcare – a well managed need is still a need

Families often ask us about ‘well-managed needs’ or quote the ‘well-managed needs’ principle, with very little understanding as to how it might apply to their relative’s assessment for NHS Continuing Healthcare.

The concept of a ‘well-managed need’ is admittedly confusing due to a lack of clarity and guidance in the NHS National Framework. As such, its application is frequently misapplied by Continuing Healthcare assessors – leading to incorrect decision outcomes and families being wrongly refused essential free NHS healthcare for their relative’s needs and accommodation.

The relevant provisions about well-managed needs are set out in two documents: The National Framework for NHS Continuing Healthcare, and the Decision Support Tool and Practice Guidance.

How does this work in Practice?

Perhaps an easier way of putting the ‘well-managed need’ principle is simply to say: what are the necessary care actions on a day-to-day basis and what training does the care provider need to properly carry out this care? The CHC assessor should ask pertinent questions to find out the answers.

The circumstances in which a need is being well-managed and the impact on the care of the individual will vary from patient to patient. Therefore, it is difficult to give hard and fast examples of the application of a well-managed need, or the questions necessary to identify the need and how it is being met. However, here are some examples which will help you:

Example 1

Supposing a patient has recently moved from one setting to another, and as a result, their needs have changed. It could be that the previous setting was not meeting their care needs – causing other problems – which have now been resolved. In this event ask:

• What has changed?
• Who is now providing the care, and what’s being done differently?
• What’s being done now on a day-to-day basis to manage the needs, and what training is needed by carers?

Some or even all needs created as a result of being in the wrong setting may have disappeared altogether, so it could be that those needs no longer exist. For example, a person with challenging behaviour around a member of the opposite sex could be moved to a single sex setting. In this case the problem has been resolved and no one is having to do anything now to meet that need; the need has disappeared.

Example 2

Consider a patient who may not be coping alone in their own home because they forget to take their medication. This in turn could cause lots of problems that are resolved once the person is being properly supported with their medication being administered by a carer. In the case of the medication being forgotten, the person now needs support with taking their medication. The need is being managed. The fact that support is needed to take medication should be measured using the Decision Support Tool. The assessor should ask questions such as:

• Is the medication being given covertly?
• Does the person refuse to take the medication?
• What medication is being administered, and does it need a level of skill to administer it?
• What monitoring is needed to ensure that the medication is effective?
• Are there any side effects?

Example 3

Take a patient who is now in a new setting, and the setting is a specialist provision, where the input of the specialist care has made all the difference. In these instances, it is necessary to ask:

• What exactly is being done now to meet the care needs?
• Is the care that is now being undertaken properly recorded?

It is the analysis of this care, and the training needed to do it, that’s important. As specialist care providers will have the staff with skills that conduct the care, the type and amount of care that these staff are providing needs to be measured and recorded on the Decision Support Tool. Amongst other things, the assessor should consider the skill needed to provide the care and what techniques are being used.

Example 4

It could be that a patient was displaying lots of challenging behaviour, and this has been well-managed with medication, meaning that the challenging behaviour is no longer happening. In this event, the CHC assessor should ask:

• What medication is now being administered?
• Does it require a level of skill to administer it?
• Are there any side effects?’
• If required, is PRN medication prescribed? This is relevant as it involves additional monitoring to determine whether and when the medication should be administered, and monitoring for effectiveness and adverse side effects.

What if the patient was aggressive, and still is aggressive, but the need for care to prevent this aggression has become easier to manage because, for example, they are no longer independently mobile, which stops them from becoming a high risk to themselves or others? In this instance, the need has simply decreased due to other factors rather than being well-managed. This could result in the level of need in behaviour reducing.

In conclusion:

The ‘well-managed need’ concept is difficult to grasp for both NHS seasoned assessors and practitioners as well as families, and the questions to be answered will differ from case to case.

Just because there is a well-managed need, it does not follow that there is eligibility for CHC. However, the well-managed need should be identified, and the care required to meet that need should be recorded on the Decision Support Tool.

It is vital to ask the right questions to figure out what, if any, needs still exist, what training is needed to meet those needs, and whether there have been other changes that now need to be considered as a result of the former needs being met.