Collaborative Care Team (CCT)

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What is NHS continuing healthcare?

Can I get NHS continuing healthcare?

How do I apply for NHS continuing healthcare?

How does the assessment for NHS continuing healthcare work?

What happens if I’m eligible for NHS continuing healthcare?

What happens if I’m not eligible for NHS continuing healthcare?

There's a process staff must follow and tools they must use to decide your eligibility for NHS continuing healthcare.

1. If your ongoing needs are clear and you have significant health needs, there are times when NHS staff or a member of the social work team should consider whether you may be eligible for NHS continuing healthcare.

These situations include:

If staff believe, after a period of rehabilitation following a hospital stay, that your condition is unlikely to improve and you have significant health needs before deciding you need NHS-funded nursing care in a nursing home when your health or social care needs are being reviewed as part of a community care assessment if your physical or mental health deteriorates significantly and your current level of care seems inadequate when your nursing needs are being reviewed – this should happen annually if you live in a nursing home if you have a rapidly deteriorating condition and may be approaching the end of your life.

2. The assessment process usually starts with the completion of the Checklist tool by a nurse or a social worker trained to complete it.

This identifies whether you need to have a full NHS continuing healthcare assessment. In some situations listed above, it'll be clear to health and social care staff that your needs don't qualify for NHS continuing healthcare at this time.

If health and care staff agree, they should record this in your notes with their reasons. If there's any doubt between staff, they should complete the Checklist. If your condition is getting worse rapidly and you may be approaching the end of life, the staff might decide to submit a proposal for you to be fast-tracked for NHS continuing healthcare, which follows a quicker process.

3. If you’re referred for a full assessment, evidence will be collected from all relevant health and social care professionals about your physical, mental health and social care needs.

4. A team of health and social care professionals will meet to look at this evidence, complete a Decision Support Tool, and make their recommendation on whether or not you’re eligible. You and/or your representative can attend and take part in this meeting.

5. Their recommendation is given to the ICB responsible for agreeing and funding your care package. Then the ICB confirms their recommendation, except in exceptional circumstances. 6. The ICB should write to you with their decision and explain the reasons for it.

If you’re found to be eligible for NHS continuing healthcare: The ICB will discuss with you what care and support you need – this could relate to care at home or in a care home.

You have the right to ask for a Personal Health Budget, which can give you more choice over the services and care you receive. However, this can't be used to pay care home fees.

The package of care and support that's agreed on will be reviewed after 3 months and then at least every year. The primary purpose of the review should be to make sure your care plan is still suitable and meet your needs.

It's expected that in most cases there'll be no need to reassess eligibility. If your care needs change in the future, your funding arrangements may also change. You have the right to challenge this decision.

When will I be discharged from hospital?

What will hospital staff do to prepare me for discharge?

How will I be assessed for help at home?

How are my needs for long-term care assessed?

Will I have to pay for help at home?

How is the support I need arranged?

How can I arrange my own home care?

What if I need to go into a care home?

How can I prepare to leave hospital?

What are intermediate care and reablement services?

If your admission was planned, hospital staff should be able to tell you how long your stay is likely to be before you arrive.

If you're admitted to hospital in an emergency, staff should make a diagnosis and agree a treatment plan with you before advising you on how long your stay might be.

During your stay, staff will discuss your discharge with you and your family and carers, where appropriate. You shouldn't be sent home from hospital until staff have assessed your immediate needs.

You might not need formal care and support when you leave, simply advice or support to arrange help with shopping or domestic tasks for a few weeks.

The nurse in charge of your care should explain the following to you (and your carer if you have one):

the criteria the doctor will use when deciding you no longer need to be in hospital when they think you'll be ready to leave where they think you're likely to be able to move to the needs you'll likely have at that time.

Once it’s decided that you no longer need to be in hospital, staff will usually arrange for you to be discharged the same day.

Many patients don’t need formal care, and only need help at home with domestic tasks for a few weeks.

Here are some of the basic things staff responsible for your discharge should make sure are in place, particularly if you don't need any formal care when you leave hospital:

1. you have clothes to wear home and front door keys

2. you have enough money for short-term needs there’s someone collecting you, or a taxi or hospital transport is booked for you

3. you (and your carer, where necessary) have a supply of medication to take home and understand any new medication you’ve been given

4. you (and your carer, where necessary) can use any new equipment aids with confidence

5. you have a supply of incontinence products, if you need them you know about support available from local organisations if you initially need help with tasks such as shopping or collecting prescriptions your GP has been informed of your discharge.

Many hospitals now use a 'discharge to assess' or 'home first' approach to hospital discharge planning as there's no longer a requirement to carry out a care needs assessment before you leave the hospital.

An initial assessment will take place to ensure that you're discharged safely with an assessment of your long-term needs being carried out after a period of recovery.

Staff will discuss your needs and then agree with you a recovery and support plan, which might include any equipment you need or reablement support. This will help you learn or re-learn daily living skills, improve your mobility and rebuild confidence you may have lost while you were unwell.

If you're eligible for intermediate care or reablement, it should be provided free of charge for up to 6 weeks. Hospital staff should make sure support services and any home adaptations are ready for you before you're sent home.

If you need home adaptations, you may have to consider interim care in the meantime. It's a good idea to clarify any cost of services being offered when you're discharged, as there may be different rules in different areas.

After a period of recovery at home, there'll be an assessment of your long-term needs, which is discussed in the next section. How are my needs for long-term care assessed? If your condition is unlikely to improve further, staff will consider whether you have a longer-term need for care and support.

This might be after you receive recovery and support services. You may need an assessment for NHS continuing healthcare, if staff believe you may be eligible, or a local authority care needs assessment – or in some cases a joint assessment that leads to a decision about your eligibility for NHS continuing healthcare or for local authority support.

If you have a local authority care needs assessment, the staff will look at your health and care needs as well as the emotional and social side of your life. For example, you may need help with things like personal care or preparing and eating meals. The aim is to help you to live as independently as possible.

If you're found to have eligible care and support needs after your care needs assessment, you'll then be involved in the creation of your care plan. This should specify what care and support you need to meet your needs.

The council must provide you with a copy of your care plan, as well as a copy to anyone else you want, such as your carer. If you have a carer, they're entitled to a separate care assessment and there may be support available for them too.

If your condition is unlikely to improve further, staff will consider whether you have a longer-term need for care and support. This might be after you receive recovery and support services. You may need an assessment for NHS continuing healthcare, if staff believe you may be eligible, or a local authority care needs assessment – or in some cases a joint assessment that leads to a decision about your eligibility for NHS continuing healthcare or for local authority support.

If you have a local authority care needs assessment, the staff will look at your health and care needs as well as the emotional and social side of your life. For example, you may need help with things like personal care or preparing and eating meals. The aim is to help you to live as independently as possible.

If you're found to have eligible care and support needs after your care needs assessment, you'll then be involved in the creation of your care plan. This should specify what care and support you need to meet your needs.

The council must provide you with a copy of your care plan, as well as a copy to anyone else you want, such as your carer. If you have a carer, they're entitled to a separate care assessment and there may be support available for them too.

If you're eligible for support, staff work with you to decide how best to meet your needs. They give you a written care plan showing what help you’ll get and details of who to contact with any questions or problems.

Your local authority will help you arrange services either in your own home or a care home. If you received post-hospital support in a residential setting, you're eligible for local authority help and you're able to go back home, staff will make sure support services are ready to start before you leave.

If you have eligible care needs but aren’t eligible for financial support, you must arrange your own services to meet your needs and staff must be sure you’re able to do this.

If you're not assessed as being eligible for local authority support, you can still arrange your own home care and you should be given information and advice to help you arrange this.

If you’re arranging your own care, it’s always a good idea to get an outline of costs and services from several local agencies. When you find one you’re happy with, you can agree on a care plan.

If you only need help with domestic tasks for a few weeks while you recover, such as grocery shopping and housework, hospital staff may be able to organise this or suggest local organisations that can help.

For example, your local Age UK may be able to help with this by providing 'home from hospital support' on a free or paid-for basis.

Intermediate care is a type of short-term support that aims to help you be as independent as possible. It can be provided in a community hospital, care home or your own home.

Before you leave the hospital, staff consider if you'd benefit from intermediate care services. If this is the case, staff set achievable goals with you, which you'll receive support to reach.

This might involve health staff such as physiotherapists or social care staff, to help you to relearn skills you may have lost while unwell.

Reablement is a form of intermediate care focusing on helping you to learn or re-learn skills necessary for daily living.

Social care staff support you at home by observing and guiding you to complete tasks such as washing, dressing and preparing a snack for yourself, rather than doing these tasks for you.

The aim is to help rebuild your skills, improve your mobility and help rebuild your skills and confidence. If you’re eligible, you’ll receive up to 6 weeks of reablement care after hospital discharge for free.

Intermediate care including reablement services normally last no longer than 6 weeks, but can be as little as one or two weeks if you achieve your goals within this time.

Towards the end of your period of intermediate care or reablement, staff consider if you’re likely to make further progress. If you need care for longer than six weeks, you might have to pay for it. If you're unlikely to benefit from further reablement support, they'll carry out a care needs assessment to see if you need social care or NHS support in the long term.

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