What are the four key indicators?

The four key indicators are: Nature, Intensity, Complexity and Unpredictability.

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When looking at whether your relative is eligible for NHS Continuing Healthcare Funding (CHC) you first have to consider whether they have a ‘primary health need’. In short, they must have health needs over and above what Social Services would ordinarily be expected to provide. Your relative’s needs will be assessed at a Multi-Disciplinary Team Meeting (MDT) and their health needs will be scored using the Decision Support Tool (DST). However, the DST is just what it says – a ‘tool’ to help practitioners assess an individual’s healthcare needs across the various Care Domains (listed below) and reach a decision as to eligibility for CHC Funding: The 12 Care Domains are: Breathing, Nutrition – Food and Drink, Continence, Skin integrity (including tissue viability), Mobility, Communication, Psychological and emotional needs, Cognition, Behaviour, Drugs/Medication/Symptom control, Altered state of consciousness & Other. Whilst a high score in one or more of the Care Domains may indicate that your relative has a primary health need, you still have to look at the overall totality of their needs – and in particular, consider the four indicators (or ‘characteristics’) and how they impact on the level of care needed. This is the essential point that most people fail to grasp.

The four key indicators are: Nature, Intensity, Complexity and Unpredictability.

So, for example an individual diagnosed with Dementia is unlikely to be eligible for CHC Funding on that basis alone. It is not the diagnosis that is critical, but the nature of those healthcare needs, and whether they require intense nursing, are complex in their management or are unpredictable. The four key indicators are set out in paragraph 60 the National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (revised October 2018), and are summarised below: Nature: describes the particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them. Intensity: relates both to the extent (‘quantity’) and severity (‘degree’) of the needs and to the support required to meet them, including the need for sustained/ongoing care (‘continuity’). Complexity: looks at how the needs present and interact with one or more other conditions to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care. Unpredictability: describes the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the person’s health if adequate and timely care is not provided. An individual with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition. According to the NHS National Framework, “Each of these characteristics may, alone or in combination, demonstrate a primary health need, because of the quality and/or quantity of care that is required to meet the individual’s needs.” Here’s an example of how you need to look carefully at the four key indicators when considering the interaction between all the Care Domains and assessing your relative’s eligibility for CHC Funding:

Example: Fictional Case study

NATURE

Mrs Jones (not her real name) has Diabetes and was diagnosed with Alzheimer’s disease. She is confused, disoriented and has poor short term memory. Mini-Mental State Examination shows a deterioration over many years.

COMPLEXITY

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Mrs Jones is at risk of a seizure or hypoglycaemic attack. She was reported to have a vacant episode preceded by very pronounced jerky movements and tremors. Mrs Jones needs staff to manage and monitor her continence needs which at times are problematic. Because of her memory loss she needs prompting to go to the toilet every 2 hours. She has a history of haemorrhoids and chronic constipation. However laxatives are usually ineffective and she needs District Nurse intervention with manual evacuation at times and phosphate enemas. Due to Mrs Jones’s diabetes, she requires a managed diet to ensure that her blood glucose levels remain as constant as possible. She frequently suffers with diarrhoea, and on particularly bad days, must only take a small diet to avoid further aggravating her bowel. Her Blood Sugar levels are high and are monitored by the District Nurse. She needs regular courses of antibiotics for infections. She was prescribed Metformin, but her appetite had deteriorated. She is very shaky and unsteady on her feet. Mrs Jones is susceptible to weight loss because of her sporadic bowel, health and diabetic condition, and staff must ensure that her nutritional needs are met sufficiently. Staff are needed to observe her and record her dietary intake, and the District Nurse has intervened to educate staff about her diet. Mrs Jones needs trained staff to administer and monitor her medication for its effectiveness. She has a complex regime which is frequently reviewed. Mrs Jones has a history of depression, and takes sertraline to alleviate some of the symptoms. She suffers from tremors and shakes, and Diazepam has been tried to alleviate her anxiety and reduce her movements. However this proved to be ineffective and she was prescribed Lorazepam. Sometimes Mrs Jones has swollen legs and these need to be kept elevated to dissipate built up fluids. As Mrs Jones is diabetic, special attention is due to her extremities as she is at risk of neuropathy and specialist advice may be necessary.

INTENSITY

Mrs Jones’ mobility is greatly affected by her tremors and dizziness which put her at risk of falling. She needs to be checked every 2 hours, and she needs staff to stay with her whilst she is getting washed and dressed. Mrs Jones suffers with bronchitis and other chest infections and needs antibiotics. At one point. Staff have to monitor and observe Mrs Jones for any symptoms that may indicate a latent chest infection and alert her GP as appropriate. Mrs Jones is diabetic and must adhere to a diabetic diet to maintain constant blood sugar levels and prevent hyperglycaemic seizures. Staff are responsible for providing Mrs Jones with suitable meals and monitoring her blood sugars for fluctuations. Due to her dementia, she needs assistance as she can no longer sequence clothes, and forgets one task to the next when washing and dressing. She needs prompting to use the toilet, and now needs full assistance to locate the toilet. She needs staff supervision to ensure she doesn’t use inappropriate creams on her face, and these have had to be removed. In particular, with her recent basal cell carcinoma.

UNPREDICTABILITY

Mrs Jones is suffering from Alzheimer’s disease and is therefore prone to becoming confused and disorientated, putting her at risk of falls and emotional trauma. Staff have to ensure that her environment remains safe and hazard free to minimise risks. She is unable to assess risks and hazards in her environment and has no insight into her condition and the impact it has on her activities of daily living and her health needs. Staff report that her memory has significantly deteriorated with decreased activities of daily living, and she is now doubly incontinent.

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She was initially able to express her needs and communicate; however her communication has deteriorated and is no longer reliable. She is able to speak but is repetitive and anecdotal in her communication. She needs staff to anticipate her needs and to make decisions for her. She has bleeding and painful piles and is very embarrassed about her continence status. On one occasion she locked herself in the toilet and would not let staff in, because she had faeces on the floor. She needs staff to bath her everyday to maintain good hygiene. Mrs Jones has suffered a marked deterioration in her mental health. She becomes anxious and confused and needs staff to offer reassurance and support her with daily tasks and situations. She can sometimes express a desire to die. Staff must monitor Mrs Jones to ensure that she does not try to harm herself, and that reassurance is given in a timely manner to prevent low mood progressing. Mrs Jones is frequently noted to be dizzy and shaking, which can prove to be problematic as she is currently quite mobile and could fall easily. Staff support Mrs Jones with all her mobility needs and assist her as much as possible. On particularly bad days, Mrs Jones is required to relocate to a downstairs room to prevent her falling down the stairs, as she could forget that she needs assistance to descend. Mrs Jones has fallen on several occasions. Her involuntary jerking movements which appear to be a fit or a hypoglycaemic attack are more pronounced when she is anxious. Mrs Jones is not able to dry herself properly after bathing, and this leads to red and sore areas developing in vulnerable areas. She is at high risk of developing pressure sores. She requires Canesten cream to be applied to fungal infections and daily creaming of dry areas.

Summary:

The example shows how you need to take a holistic approach and look at the overall totality of Mrs Jones’ needs in conjunction with the four key indicators, when assessing her eligibility for NHS Continuing Healthcare Funding. It is arguable that her needs could only be managed effectively by skilled intervention over a sustained 24 hour period to prevent further deterioration. ‘Apply for NHS Continuing Healthcare Funding if your relative has a ‘primary health need’…

‘Primary health need’ made simple – what does it really mean?

‘Take a holistic approach to improve your chances of getting CHC Funding’

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caretobedifferent.co.uk - Understanding the four key indicators - Care to be Different

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