Continuing healthcare: Care planning and review

On this page you can learn about:

  • how care is planned and managed
  • how care is reviewed
  • What happens after a review
  • How care is arranged locally
  • Paying for extra care
  • Paying for more expensive care
  • Joint plans (health and social care, or health and mental health care)
  • NHS funded nursing care

How is my care planned and managed?

The Continuing Healthcare Team is responsible for your continuing healthcare planning, arranging services or support to meet your needs, and coordinating your care. A named professional from the Continuing Healthcare Team will coordinate your care and work with you to make sure that the needs identified in your assessment are met.  

Your care coordinator will work with you to: 

  • Make sure that a suitable personalised care plan has been made
  • Make sure that your package of help continues to meet your health and associated care needs, and the outcomes you want to achieve
  • Where the care plan includes access to non-NHS services, make sure that the arrangements for these are in place and are working well
  • Monitor the quality of your care and make sure any difficulties/concerns are sorted out quickly
  • Act as a link person to coordinate services for you
  • Ensure that any changes in your needs are taken into account
  • Review your needs and care arrangements

The Continuing Healthcare Team is responsible for making sure your needs are met, and for working out what care you need to meet them. The care you get is what the Team decides is enough to meet your assessed health and associated care needs, taking into account your wishes and preferences. 

It is important that you feel comfortable with your care coordinator. Please let the Team know if you have any problems. In the unlikely event that you aren’t comfortable, a different care coordinator can usually be allocated to you.

How is my care reviewed?

A review should happen within three months of the eligibility decision being made. After this, reviews will happen at least one every year. Each review will look at whether your care plan and care arrangements are meeting your needs. The most recently completed decision support tool (DST) assessment will normally be used to help identify any change in your needs. The Continuing Healthcare Team will also look at your personal health budget as part of the review. The amount of your budget may change if your care package changes. 

If there is a lot of change in your needs, that might change whether you are eligible for continuing healthcare. If there is a lot of change, your care coordinator will arrange a reassessment of eligibility for continuing healthcare.

Reviews can be completed jointly with other agencies, such as the council, if they provide you with help too.

After the first three months reviews happen annually, but a review can happen sooner if you feel there have been significant changes in your needs that should not wait until a scheduled review. A review gives you the chance to tell your care coordinator how well you feel the care package is working, if there is anything you would like to change, and whether you have any concerns.  

What happens after a review?

After a review, the Continuing Healthcare Team will send you an updated care plan. If the review shows that changes to your care package and personal budget amount are needed, the Team will explain this to you in writing. If you need a new assessment, the Team will ask you and others involved in your care, to help with completing a decision support tool (DST) assessment.

How is my care commissioned (arranged) locally?

Once you are assessed as having needs that are eligible, your care coordinator will discuss with you how best to meet them.

The Continuing Healthcare Team and local council have a close working relationship and use the same local services to meet care and support needs. The Team and the council also use the same decision-making framework. The decision-making framework is a list of things that professionals take into account when deciding how to meet your needs. Your care coordinator will use the decision-making framework to decide what type of care you need, and how much of it you need. When deciding, they will consider your wishes and preferences, and what kind of care will offer best value. For more information about the decision-making framework, please see our Micro-Commissioning Policy.

What if I want to pay for extra care?

Care packages provided by the NHS should be enough to meet your needs, but you can choose to privately fund extra care if you want to. If you do choose to fund extra care, anyone providing you with care must coordinate with others who are caring for you, and make sure that they only provide the care they are funded to. If you feel your care package doesn’t meet your needs without extra help, please speak to your care coordinator.

What if I want more expensive care than my care coordinator recommends?

If you want to choose higher cost care, such as more expensive accommodation or services, please tell your care coordinator. If the Continuing Healthcare Team thinks the higher cost care is necessary to meet your assessed needs, it should meet the costs of it as part of your continuing healthcare package. The Team will not meet the costs of care that it does not think are necessary.  

What if I have a joint health and social care plan or care provided under section 117 of the Mental Health Act 1983?

In some circumstances, you might have a joint package of care, for example, where you have both health and social care needs. When this happens, the Continuing Healthcare Team will work with the council to prepare a joint plan covering both your health and social care needs. Similarly, you may have a joint plan if you get help with your mental health needs. 

You might have more than one agency involved in your care planning, but there will be a single point of contact – a care coordinator – you can speak to about all elements of your care plan. Joint care packages can be provided in any setting (such as your own home, or a residential care home) to make sure your needs are met in the best way for you.

Having a joint package of care does not necessarily mean that you are eligible for continuing healthcare, but that means some elements may be funded by the NHS.

What is NHS Funded Nursing Care?

NHS funded nursing care is the funding provided by the NHS to care homes that offer nursing help.  Nursing help means nursing care for those who are assessed as needing the oversight of a registered nurse, 24 hours a day. If you might need this level of oversight from a nurse, a nursing needs assessment, which specifies your day-to-day care and support needs, should be used to assess whether you are eligible for funded nursing care.  

Your eligibility for continuing healthcare will be considered first, before a decision is made on whether you are eligible for funded nursing care. If you are not eligible for continuing healthcare, that doesn’t mean you are not eligible for funded nursing care.

NHS funded nursing care is reviewed in a similar way to continuing healthcare. As part of the review of funded nursing care, your eligibility for continuing healthcare will also be considered.


Go back to Continuing healthcare.