How is eligibility for continuing healthcare decided?

On this page you can learn about:

  • the continuing healthcare screening process or ‘checklist’ (this is sometimes called an ‘initial assessment’).
  • when the checklist is completed and who by.
  • what happens after the checklist has been completed.
  • the full assessment for eligibility of continuing healthcare, or ‘decision support tool’.
  • the role of the multi-disciplinary team.
  • who makes the final decision on eligibility.
  • what happens after a decision has been made.
  • appealing against a decision.

Continuing healthcare screening: the checklist

The purpose of the screening process is to check if you need a full assessment of eligibility for continuing healthcare. Screening is done using the continuing healthcare checklist (‘The Checklist’). The Checklist can be used in a variety of settings (for example, a care home, or your own home) to help professionals decide who might need a full assessment of eligibility. The Checklist is a document provided by the Department of Health and Social Care. It must be used for the screening process and must be completed by a trained professional. The Continuing Healthcare Team can’t accept a Checklist completed in any other format, or a checklist completed by you or a family member as part of a self-referral.

The Checklist has 11 care areas in it.  Each area is called a ‘domain’. Each area or domain is divided into three levels of need: A, B and C. A is the highest level of care need, and C is lowest level of care need. The outcome of the Checklist depends how many As, Bs, and Cs are identified in each domain (in other words, how high your needs are in each of the areas of care). Professionals must record in the Checklist a short description of each need, and the evidence they have taken into account when deciding about the level of each need.

Read a copy of the GOV.UK – NHS continuing healthcare checklist and guidance.

When is a Checklist completed and who completes it?

The Checklist can be completed by lots of different health and social care professionals, who have been trained to use it. This could include, for example: registered nurses employed by the NHS, GPs, or local authority staff such as social workers, care managers or social care assistants.

Ideally, the Checklist is completed when you are in a stable environment like your own home. This is so professionals can see what your needs are on a ‘normal day’, not when you’re at your worst. Professionals need to know how your needs could be met in the longer term, rather than just as a shorter term response to a crisis. This isn’t always possible, depending on your situation. If you are in a crisis, professionals can consider the best way forward for you, including shorter term help and funding to help see you through a difficult time.  

The professional completing your Checklist will consider where and when is best for it to be completed with you. Your part in completing the Checklist is very important. Professionals will help you to join in with completing it as much as possible.

What happens after a Checklist is completed?

A completed Checklist will show a negative or a positive result. If:

  1. The Checklist is negative, it means you don’t need a full assessment of continuing healthcare eligibility at the moment, and brings the process to an end.  This means you are not entitled to continuing healthcare. 
  2. The Checklist is positive, it means you do need a full assessment of eligibility for continuing healthcare.

A positive Checklist doesn’t automatically mean you are eligible for continuing healthcare. It means that more information about your needs is required, before a decision can be made about whether you are eligible.

Whatever the Checklist result, we will write to you with the result and the reasons for it. We will also send you a copy of the completed Checklist. If you want to challenge the result or the reasons given, the letter will tell you who to contact.

What is a full assessment of eligibility for continuing healthcare?

The NHS continuing healthcare decision support tool supports the application of the national framework for continuing healthcare and NHS-funded nursing care.

After the Checklist has been completed and you have been referred for a full assessment of eligibility, the next part of the process is led by a multi-disciplinary team (MDT). The MDT assesses whether you have a ‘primary health need’ using the Decision Support Tool (DST). The care areas (or ‘domains’) considered in the DST are:

  1. Breathing
  2. Nutrition
  3. Continence
  4. Skin integrity
  5. Mobility
  6. Communication
  7. Psychological and emotional needs
  8. Cognition
  9. Behaviour
  10. Drug therapies and medication
  11. Altered states of consciousness
  12. Other significant care needs

What’s a multi-disciplinary team (MDT) and what does it do?

The multi-disciplinary team (MDT) should include both health and social care professionals, who know about your health and social care needs. Where possible, they will recently have been part of your assessment, treatment, or care. Depending on your situation, this might include nursing staff, social workers, workers from residential care homes, or other types of support workers.

MDT assessments can happen in different ways like face-to-face or virtually (for example using Teams, Zoom or Skype). The aim is for everyone to be able to join in as much as possible, including you. Please tell the professionals working with you about any preferences you may have. Your views, thoughts and feelings are a very important part of the process. You can take part as much or as little as you want. You can have someone to support you during the assessment (such as a family member or friend), or pick someone to give views on your behalf if you find it difficult to give views yourself.

The professionals who are part of the MDT work together to find and look at information about your health and social care needs. With you, they look at your needs and the care areas (domains) listed above. They might also consider any recent assessments completed by other support services such as social work or occupational therapy, when thinking about your eligibility. The MDT will make a professional judgement about your eligibility for continuing healthcare. It will make a recommendation based on that judgement.

The MDT does not make the final decision about your eligibility but instead makes a recommendation to the Continuing Healthcare Decision Forum. The recommendation should include a summary of your needs in each of the care areas (domains), the level of your needs in each area, and what evidence they have used when deciding. The summary should include your view of your own needs. The recommendation should also:

  • give information about the nature, intensity, complexity, and unpredictability of your needs (see Primary health needs); and
  • based on this information, say whether you have a primary health need

Who makes the final decision on my eligibility?

The decision maker is the Continuing Healthcare Decision Forum, which is part of the NHS Integrated Care Board (ICB). The Decision Forum looks at the evidence from the Decision Support Tool (DST). The Decision Forum is made up of professionals in the ICB who have not been involved in the Multi-disciplinary Team’s (MDT) assessment and eligibility recommendation.  

If you are worried about any part of the eligibility process, you can contact a member of the Continuing Healthcare Team who will talk it though with you and try to resolve your concerns. Where it is not possible to resolve your concerns, they will be recorded in the DST so that the Decision Forum will know about your concerns when it makes its final eligibility decision.

What happens after a decision has been made?

Once the eligibility decision is made by the Continuing Healthcare Decision Forum, the Continuing Healthcare Team will write and tell you about it as soon as possible. Sometimes the Team might be able to tell you about the decision verbally first, but it will always write to you as well. The Team’s letter to you will include:

  • what decision has been made about whether you have a ‘primary health need’, and so whether you are eligible for continuing healthcare.
  • the reasons for the decision.
  • a copy of the completed decision support tool (DST).
  • details of who to contact if you want more information.
  • how to ask for a review of the eligibility decision.

Your eligibility for continuing healthcare is kept under review, along with your care package. Eligibility for continuing healthcare is not indefinite, because needs can and do change over time. We can reassess your eligibility based on any changes.

What happens if I am not happy with the decision made?

If you are not eligible for continuing healthcare, you can appeal against the decision in writing within six months of being told you are not eligible. The Continuing Healthcare Team will let you know that it has got your appeal, and is looking at it.

An appeal can only be made by you or someone on your behalf. Staff working for another organisation cannot appeal on your behalf.

If your appeal can’t be resolved quickly, you will be given chance to come to a formal meeting, to talk about the eligibility decision and the reasons for it. You will be asked to give your reasons for disagreeing with the decision.

You will be encouraged to attend the meeting with someone to help you, if you would like some support.  Continuing healthcare staff at the meeting will be independent of the professionals involved in the original assessment and eligibility recommendation.

After the meeting, the continuing healthcare staff will make a decision about whether to allow or deny your appeal. If you are unhappy with this new decision, you can request an independent review by writing to NHS England.     

To ask any questions about continuing healthcare, please contact the Continuing Healthcare Team on:

Telephone: 0300 330 2990

Email: hnyicb-nel.chc@nhs.net


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