Continuing NHS Health Care

1
Continuing NHS Health Care

• Discharge planning
• Noreen OConnor
• Continuing Care Manager
• 07976056792

2
Change Agents

• Ombudsman Report (2003)
• Funded Nursing Care
• Framework for Implementation of Continuing Care
  in Wales
• Special Review Panels
• Discharge Planning Guidance
• Unified Assessment

3
Impact

• Structured written discharge plan
• Written evidence of MDT assessments
• Funded Nursing Care Assessments
• One record
• Consideration for Continuing Health Care funding,
  rationale for decision

4
Key Principles

• Individual assessment
• Multi-disciplinary/multi-agency comprehensive
  assessment
• Active involvement of patient/carer/family
• Professional involvement and judgement clearly
  documented
• Appropriately qualified/trained staff undertake
  the assessment

5
Key Principles

• Process to ensure appropriate and equitable
  access to health care for all individuals
• Patient/carer aware or process and rights to
  appeal

6
Criteria 1

• The nature, or complexity, or intensity, or
  unpredictability of the individuals health care
  needs or the risk to themselves or others means
  regular input is required by one or more members
  of the NHS MDT
• These health needs require more intense or
  specialist care than can be provided through
  primary care services or by a RN in a care home

7
Criteria 2

• The needs of the individual require the routine
  use of specialist health care equipment involving
  the supervision of NHS staff

8
Criteria 3

• The individual has a rapidly deteriorating or
  unstable medical, physical or mental health
  condition and requires regular input by a member
  of the NHS MDT

9
Criteria 4

• The individual is in the final stages of a
  terminal illness and is likely to die in the very
  near future.

10
Finally

• The MDTs consideration and decision of the
  individual against the criteria must be fully
  documented