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As well as Complex Care who commission care to adults with largely physical needs, we have teams who commission care to Adults who have a primary health need within their Mental Health or have a Learning Disability.

As with persons' commissioned by Complex Care the teams below will assess the person using the CHC Framework following the same processes to indicate if there is eligibility for CHC.

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There is a team for commissioning of Mental Health patients that meet a Primary Health Need.

In order to be funded under Mental Health Commissioning, there needs to be a primary diagnosis of a functional mental health disease/disorder with a primary health need or reason to believe it is above what local authority can provide legally under the Social and Wellbeing Act 2014.

Contacts below:

Mental Health Case Managers:

Simon.carne@wales.nhs.uk

Pauline.gething@wales.nhs.uk

emily.gilbert@wales.nhs.uk

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Telephone Number - 01633436982

Learning Disability:

Sarah.Summerfield@wales.nhs.uk

Jon.Povall@wales.nhs.uk

Venessa.May-Thorpe@wales.nhs.uk

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Enhanced Levels of Care Padlet available here.

This Padlet will inform around all things enhanced levels of care.

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Fast Track assessments are completed by NHS professionals only who are assessing the person/patient. Other disciplines outside of the NHS can support with a fast track assessment and advice, however cannot complete in full.

When a fast track assessment is requested from a NHS professional, the framework indicates that this should be done within 2 days of that request.

A Fast track, be that 1 or 2 needs to be supported with a medical opinion by a medic. This could be the GP, Palliative doctor/consultant. This must be sent alongside the Fast Track Paperwork.

A Care Plan must be devised when submitting a fast track application. This will identify the care requirements for the patient and inform the carers within a community package of care, or the nursing home upon admission.

All submissions of fast track must be sent to complex.care@wales.nhs.uk.

There is a cut off for Fast Track 2's to be submitted to the Complex Care Team which is a Thursday at midday. The reason for this, is that a care package cannot be sourced at that point for community care, or a safe discharge to a nursing home. Please contact the complex care team if we wish to disuss any cases.

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Updated from the 1983 Act

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This is the Framework for Continuing Healthcare in Wales. This is an All Wales Framework set out by Welsh Government. England have their own Framework of implementation of CHC which is not to be utilised in Wales and vice versa.

This National Framework is used across all disciplines in Wales. Within ABUHB, Complex Care (Adult/General), Mental Health and Learning Disability use the same framework, the paperwork attached and processes involved.

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This is the document that is used to consider eligibility for Continuing Healthcare as part of an MDT. Application on how to use this document, who should be involved and the process of considering eligibility is held within the CHC Framework.

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This leaflet can be given to patients and NOK to inform them what CHC is and the processes taken to identify eligibility. This leaflet is a compulsory component of the DST process and should be given to patients/NOK prior to the DST giving them time to read and understand. This is normally done a few weeks prior to the DST.

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To be completed at a DST Meeting.

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Within ABUHB this document is used to identify the individuals needs and whether there is eligibility for Funded Nursing Care (FNC) or 'triggers' for CHC to move forward to an MDT with the use of the DST.

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Consent form attached requires completion prior to any DST. This is an important part of the process.

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Use this checklist to ensure all steps have been taken when completing a DST. Submit this alongside the DST, assessments, opinions and evidence.

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Blank Process Checklist for DST Completion V1

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Professional Opinion for completion when going to DST. Professionals can include but not exhaustive:

Dietician

Specialist Nurse (Diabetes, MND, Parkinson etc)

Physio

OT

SALT

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GP/Medical Opinion form for completion when commencing a DST

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Section 117 Aftercare is what is received by any person who is or has been detained under Section 3 of the Mental Health Act.

There will be a care coordinator attached to the person who is normally a Social Worker or Community Psychiatric Nurse.

Funding of Section 117 comes from a range of avenues, but within normal circumstances is funded by the Local Authority.

Should the persons needs by more complex, intense or unpredictable, the Local Authority may seek Health funding. A person in receipt of Section 117 Aftercare is still entitled to a CHC assessment under the Continuing NHS Healthcare framework 2022.

A Section 117 meeting is routinely held every 12 months which involves the CPN, Social Worker and any additional commissioners. At this meeting a funding split is discussed. For example, should a person be in a nursing home under Section 117, Health fund the FNC portion of the care with no further identification of complexity, intensity and unpredictability.

Any Section 117 meeting should have recorded minutes that are held on file. The commissioners should be part of the meeting to agree funding at the time of the meeting, they will then take this away to their respective panels for agreement of funding split.

A person can also be removed from a Section 117 Aftercare Order if the professionals involved feel this appropriate.

Please see the 'How To' guides for training on a Section 117 meeting.

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What the CHC Framework is saying about Section 117

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What the CHC Framework is saying about Section 117

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Interface between Adult CHC Division and Section 117

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Interface between Adult CHC Division and Section 117

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Interface 117 aftercare and CHC report by Paul Walding Assitant Divisional Nurse

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50 Day Integrated Care Winter Challenge booklet

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This opinion is completed by a Medic (GP, Consultant, Doctor) on submission of a fast track assessment.

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This is alluded to in the CHC Framework and identifies this as a joint approach to be taken by LA and Health in order to discharge from hospital for a period of assessment.

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Complex Care MDT Facilitator Contact List

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Complex Care MDT Facilitator Contact List

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There is a team of MDT Facilitators within the hospital sites who support ward staff in the discharge process when a patient meets eligibility for CHC or has triggers.

There is a wider team under secondary care of discharge Liason nurses and assistants that support discharges out of hospital. Annie Lewis is the head of discharges for ABUHB.

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Positive Approach to Care

Positive Approach to Care is a framework of care that encourages staff to understand the person's perspective. There are specific techniques that enable staff to reflect on how they physically engage with a person, how to start conversations and support the person in any aspect of care. There is an emphasis on promoting independence by empowering choice. A popular technique is 'hand under hand', used for physically assisting hand / motor coordination (meal times, personal care).

The sessions are co-facilitated by Matthew Galloway and Amanda Strange, band 4 assistant practitioner. We are both trained as trainers and I am trained as a PAC coach. This means I am able to work along side staff and offer support in using PAC techniques.

Amanda Strange is taking a lead in offering ward 'bite size, refresher sessions to ward staff.

The staff training is 1 day, open to all inpatient staff, community teams and now there are limited spaces to care home staff. I have witnessed hand under hand being used and I've received positive feedback from care staff regarding PAC, plus, all the sessions are formally evaluated.

Regarding 1:1, I also facilitate Therapeutic Observations and Engagement training. There is a significant emphasis on engagement, use of 'this is me', life story work and how to develop positive, helpful relationships.

Contact Matthew Galloway for more information and upcoming training dates.

matthew.galloway@wales.nhs.uk

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Responsible Body Guidance for the NHS in Wales

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Responsible Body Guidance for the NHS in Wales

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Responsible Body Guidance for the NHS in Wales

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This very briefly described is a resident of Worcestershire who was detained under Section 3 of the Mental Health Act, later discharged to Swindon under Section 117 to be closer to her daughter. Worcestershire were responsible in funding the after care services as she was an ordinary resident of their area prior to detention. This lady was then detained for the second time under section 3 of the Mental health Act whilst living in Swindon. Worcestershire believed it was the responsibility of Swindon to take over the aftercare services under Section 117 as an ordinary resident of Swindon prior to detention.

Worcestershire won their case in court and it transferred to Swindon as the responsible body.

In essence this judgement indicates that wherever the person is detained is responsible for their aftercare services.

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Mental Capacity Act (Refresher Day) and MHA & MCA Interface with Case Law Updates (sharepoint.com)

Mental Health Act and case law update training sessions are offered to all members of staff working within the Mental Health and Learning Disability Directorate of ABUHB. The sessions include an Introduction to Mental Health Law; Key Concepts in Mental Health Law; and Policy Requirements of the Code of Practice. Training also includes the interface between the Mental Health Act and the Mental Capacity Act. It has been designed to provide professionals engaged in the delivery of mental health services both with an understanding of mental health law, and the ability to apply that knowledge to every day scenarios.

Upon successful completion of the training, staff should demonstrate knowledge and understanding of key provisions of mental health law and have an appreciation of the consequences of an unlawful application of mental health law.

Contact Helen Moon for more details around upcoming dates.

helen.moon@wales.nhs.uk

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A full contact list of all the CHC managers and Senior Nurses in ABUHB to direct queries regarding anything CHC and Nursing Homes.

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Contact List - CHC managers and Senior Nurse

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Here is the link to our website, where full details of our programme can be found Digital Communities Wales (gov.wales)

Attached are the presentations that Digital Communities Wales did for the MAS team, here are the links to the videos that were shown:

Ballerina https://youtu.be/wlAXKJfesBM

Alexa- A Digital Lifeline https://youtu.be/U5vwhVDRT_8

Free Tech Support & Information | AbilityNet Abilitynet provides free tech support to older and disabled people, their family and friends, and the people who care for them.  Calls can be made to their helpline, or their network of volunteers can provide support to older and disabled people in their own homes.

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Slide show training for Fast Track assessments. If you require any further information or would like to speak to one of the Complex Care team about a Fast Track assessment, access the contact lists on the Padlet to get in touch.

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Staff Outcome Survey

Please complete the Staff Outcome Survey around Complex Discharges to better inform us of training needs across the sites.

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Easily create surveys and polls to collect customer feedback, measure employee satisfaction, and organize team events.

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Deprivation of Liberty Safeguards and Court of Protection

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Deprivation of Liberty Safeguards and Court of Protection

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The DoLS team have extensive information on the intranet that can be accessed via Deprivation of Liberty Safeguards (sharepoint.com)

Tel No: 01495 745801

Email: dols.team@wales.nhs.uk

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Within the Complex Care Team we have a Occupational Therapies team who support persons who have been deemed eligible for CHC. Any persons who have not been assessed and deemed eligible for CHC should not be referred to this service.

For more information please contact 01495363123 or email complexcareot.abb@wales.nhs.uk

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What do I do if a family member requests a CHC assessment but there are no CHC triggers?

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What do I do if a family member requests a CHC assessment but there are no CHC triggers?

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Ultimately a patient or their next of kin can request a CHC assessment as is their right under the framework. This is irrespective of professional views on eligibility.

If a patient is on the ward and a CHC assessment has been requested, this does not have to delay discharge. The patient can be discharged into their long term environment where they will then be assessed. The framework indicates a 'home first' approach to ensure that the patient is in the correct environment when assessed.

Follow the process of the CHC assessment which you can find on the 'How to Guides'

Link in with your local CHC team for any support or advise, contacts of which are held under the Continuing Healthcare Section. If in a hospital environment, your MDT facilitator can support and advise, contacts of which are under Discharges from hospital.

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A dispute means that the NHS professional and Social Worker did not come to an agreement at the DST on recommendation of a Primary Health Need.

This means that the decision is in Dispute and the policy attached is to be applied.

This is not the same as an appeal and there is an alternate process for this. Should family disagree with the recommendation at the DST meeting, they should be advised to submit their intent to appeal in writing within 28 days.

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CHC Disputes Resolution Process - FINAL - V2 HJ

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Section 117 Meeting and funding splits 'How to Guide'

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Section 117 Meeting and funding splits 'How to Guide'

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Please contact Complex Care for all appeals received.

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CONTINUING NHS HEALTHCARE Appeals Process 

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A health led process when making decisions on CHC.

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St Helen's Judgement - A Health Led Porcess

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Cheshire East Council - Ombudsman Decision 

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Cheshire East Council - Ombudsman Decision 

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Ombudsman Decision Section 117 - September 2024