Simply CHC were recently engaged to assist a lovely 85 year old lady who experienced an unfortunate fall in July 2022 which resulted in a C1/C2 PEG fracture with spinal compression. In view of Mrs J frailty and comorbidities, the consultants felt she would not be suitable for intervention.
The family would love their experience to provide some help and guidance to those currently fighting for NHS Continuing Healthcare Funding for themselves or a loved one. We have provided the DST levels and the appeal levels for each domain with a brief explanation which we hope you will find helpful.
At the time of the DST, Mrs J presented as an incomplete tetraplegic with some sparring of the upper limbs on the right side more than the left but with only minimal active function. As a result of her spinal injury, Mrs J was at increased risk of automatic dysreflexia, deep vein thrombosis, urinary tract infections, muscle spasms, osteoporosis, pressure ulcers, spasticity, and chronic pain. Further, Mrs J experienced chronic pain which has resulted in opioid medication alongside two transdermal patches.
Following her fall, she was placed on end-of-life care after needing resuscitation several times. When stable, she required daily catheter management and manual evacuations. Mrs J required full assistance with all daily tasks including personal care, nutrition and hydration, and medication management.
Mrs J also suffered from several comorbidities including hypertension, angina and osteoarthritis. Further, she has experienced a transient ischemic attack (TIA), breast cancer and an ectopic pregnancy.
Original DST scores:
The original DST scores were:
Breathing: Low
Nutrition: Moderate
Continence: Moderate
Skin: Moderate
Mobility: High
Communication: No Needs
Psychological and Emotional: Low
Cognition: No Needs
Behaviour: No Needs
Drug Therapy and Medication: High
ASC: Low
Our Senior Advocate, Danielle Whitfield-Freer gathered evidence from the hospital, care home and GP and created a report highlighting the discrepancies within each domain supporting each discrepancy with evidence.
We will go through each domain and explain what Danielle argued and what the Appeal Clinician awarded.
Breathing
DST: Low
Simply CHC: Low
Appeal: Low
Danielle suggested that whilst the Low was appropriate, there were elements of her care that were complex within this domain. Due to her incomplete spinal cord injury at C1/C2 and a paralysed diaphragm, she was at a significantly enhanced risk of dysphasia and chest infections. She experiences occasional bouts of difficulty with her breathing and required chest physio (which was put in place following the DST). Further, should she have become more mobile when her adapted equipment arrived, she would indeed require an abdo brace.
The Appeal Clinician agreed that this domain provided complexity. She also agreed that on the DST, her needs were encompassed within the Low level descriptor.
Nutrition
DST: Moderate
Simply CHC: High
Appeal: High
The DST highlighted that because Mrs J did not require input from the Speech and Language Therapy team, she didn’t experience dysphasia. Danielle highlighted the care plan which provided for a high choking risk and very specific instruction as to how Mrs J must be fed suggesting that special interventions were in place to manage the risk of Mrs J choking including positioning and speed. Further, paragraph 31 of the DST highlights that “Needs should not be marginalised just because they are successfully managed. Well managed needs are still needs.”.
The Appeal Clinician agreed stating that there was a high risk and there was clearly interventions in place. Accordingly, this domain was increased to a High level of need.
Continence
DST: Moderate
Simply CHC: High
Appeal: Moderate
Mrs J required digital stimulation, manual evacuations and had a catheter in situ whilst in hospital. On her admission to the care home, they were able to successfully manage her continence care for the 2 months prior to the DST assessment. Danielle suggested that a High level of need was appropriate as within one month of the DST, re-catheterisation was required 3 time and Mrs J was found to be faecally impacted which resulted in manual evacuations. Further, continence issues are a well-known trigger of autonomic dysreflexia.
In this domain, the Appeal Clinician disagreed that a High level of need was satisfied as the Nurse Assessor was not to know what would happen the month following the DST. She stated that the evidence in this domain will prove very helpful in the review and at the review meeting, Mrs J is likely to satisfy a High level of need. She accepted that at the time of the DST, there was a high level of monitoring involved in Mrs J’s needs which create further complexity in her healthcare needs.
Skin
DST: Moderate
Simply CHC: Moderate
Appeal: Moderate
All parties agreed that the evidence supported a Moderate level of need. Within the report Danielle highlighted the increased risk that having a spinal cord injury presents and she requires careful monitoring. The Appeal Clinician agreed.
Mobility
DST: High
Simply CHC: Severe
Appeal: Severe
Mrs J had no mobility from the neck down but maintained minimal movement in her hands however, the movement maintained was not enough to grip or move objects. She was completely unable to weight bare and had no sitting balance. She was unable to assist care staff with any transfers or repositioning. She required the full assistance of a minimum of 2 care staff with any movements, transfers, and all basic daily tasks. Further, her consultant had suggested that a neck brace should be used for all transfers and an abdo binder whilst in a chair. She also required monitoring for postural drop.
The Appeal Clinician agreed that Mrs J’s needs were higher than a High level of need would suggest but not quite in the Severe. She suggested somewhere in between would be appropriate due to the risks and the specialist equipment so she decided a Severe level of need would be awarded in the assessment.
Communication
DST: No Needs
Simply CHC: No Needs
Appeal: No Needs
Mrs J had no issues with communication.
Psychological and Emotional
DST: Low
Simply CHC: Moderate
Appeal: Low
Danielle highlighted that Mrs J experienced a life changing injury. Before her injury, she was living independently with assistance from carers and her family. She was active and sociable. Since her accident, she has been confined to her bed and is unable to attend any social events. Unsurprisingly this has had a detrimental effect on her mental well-being. Mrs J had also experienced tearful episodes and suicidal thoughts.
The Appeal Clinician highlighted that Mrs J was very sociable and these feelings would soon subside following the support of carers and support staff. Accordingly, she was responsive the reassurance which satisfied a Low level of need.
Cognition
DST: No Needs
Simply CHC: No Needs
Appeal: No Needs
Mrs J had no issues with her cognition.
Behaviour
DST: No Needs
Simply CHC: No Needs
Appeal: No Needs
Mrs J had no issues with any challenging behaviours and was compliant with her care.
Drug Therapy and Medications
DST: High
Simply CHC: Severe
Appeal: High
Danielle highlighted that Mrs J was in constant pain. Her pain medication had been increased significantly since the DST meeting and she was now administered pain patches, PRN (although routinely taken) opioid medication and nerve blockers yet she continued to experience breakthrough pain. At the time of the DST her pain medication was significantly less. Autonomic dysreflexia was also highlighted in this domain alongside poikilothermia.
The Appeal Clinician suggested that the increase will result in a Severe at review however, at the time of the DST she agreed with the High.
Altered States of Consciousness
DST: Low
Simply CHC: Low
Appeal: Low
Mrs J became unresponsive several times in hospital and had experienced a CVA. It was agreed by all parties that a Low level was satisfied.
Danielle also provided the panel with a comparison of needs between Mrs J and Pamala Coughlan.
Further, an in-depth analysis of the key indicators was provided to the panel who agreed with Danielle’s contention that Mrs J satisfied the Nature and Complexity key indicators. Whilst there were certain elements of Mrs J’s case that demonstrated Intensity and Unpredictability, it was undisputed that the Nature of her health needs and the Complexity of the same indicated a primary healthcare need.
Outcome
We are delighted that with the help of Simply Continuing Healthcare, Mrs J was successful in her appeal application and now has full CHC funding in place. Mrs J’s family very kindly left us reviews on Trustpilot too!
If you need some advice and guidance surrounding the NHS Continuing Healthcare process, please do not hesitate to contact us directly on contact@simplycontinuinghealthcare.co.uk or call 01733 595456 to talk to one of our advocates.