Do dementia patients qualify for continuing healthcare? The full guide

According to the Nuffield Trust, persistent questions surround how to fund care for people with long-term health needs. This complex issue often raises the critical question: Do dementia patients qualify for continuing healthcare? This article provides a comprehensive guide to the eligibility criteria and assessment process.

Quick Summary

Eligibility for continuing healthcare isn't based solely on a dementia diagnosis, but on whether the individual has a “primary health need,” which is determined by a formal assessment of the nature, intensity, complexity, and unpredictability of their care needs.

Key Points

• Diagnosis is not enough: A dementia diagnosis alone does not automatically guarantee eligibility for continuing healthcare funding.

• Primary health need is key: Eligibility hinges on whether the individual has a 'primary health need', determined by assessing the nature, intensity, complexity, and unpredictability of their care needs.

• Assessment is mandatory: The process involves an initial Checklist screening and, if necessary, a full multidisciplinary team (MDT) assessment using a Decision Support Tool (DST).

• Complex needs increase chances: As dementia progresses and care needs in areas like cognition, behavior, and mobility become more severe, the likelihood of qualifying for CHC increases significantly.

• CHC is non-means-tested: If eligible, the NHS covers the full cost of the care package, which can be in a care home or at home, irrespective of the individual's finances.

• Reviews are standard: CHC eligibility is reviewed regularly (within 3 months, then annually) to ensure the care package remains appropriate for the individual's changing needs.

• Fast-track for urgent cases: A special fast-track pathway is available for individuals with a rapidly deteriorating condition who are nearing the end of their life.

Understanding NHS Continuing Healthcare (CHC)

NHS Continuing Healthcare (CHC) is a comprehensive care package funded solely by the NHS. It is available to adults with significant ongoing healthcare needs who have been deemed to have a “primary health need”. This funding is not means-tested and can cover all care costs, including accommodation, in a care home setting or support in the individual's own home.

It's a common misconception that a diagnosis of dementia or another specific condition automatically guarantees CHC funding. The process is far more nuanced, focusing on the individual's specific needs rather than their medical label.

The Concept of a 'Primary Health Need'

At the heart of CHC eligibility is the concept of a 'primary health need'. This is a holistic assessment that considers the totality of an individual's care needs to determine whether their primary requirement is for healthcare, rather than social care. Eligibility is determined by four key indicators:

• Nature: This refers to the characteristics and type of needs the person has and the effects these needs have on them. For dementia patients, this might include the progressive and irreversible decline of cognitive function.
• Complexity: This assesses how different health needs interact and how difficult they are to manage. For advanced dementia, this could involve managing multiple symptoms like cognitive impairment, challenging behavior, and mobility issues simultaneously.
• Intensity: This considers the severity and extent of the needs and the level of support required to manage them effectively. High intensity needs might mean constant supervision and frequent, skilled interventions.
• Unpredictability: This refers to the risk associated with changes in the individual's condition. The unpredictable nature of dementia, with potential for sudden changes in behavior or altered states of consciousness, is a key consideration.

The Two-Stage CHC Assessment Process

Stage 1: The Continuing Healthcare Checklist

The first step in the CHC process is a screening tool called the Checklist, conducted by a health or social care professional. It involves assessing the individual's needs across 11 care domains, including cognition, behavior, communication, and mobility. The Checklist has a scoring system (A, B, or C) to identify if there is a sufficient level of need to warrant a full assessment. A positive Checklist result does not guarantee funding but moves the process to the next stage.

Stage 2: The Multi-Disciplinary Team (MDT) and Decision Support Tool (DST)

If the Checklist indicates a need for a full assessment, an MDT—comprising at least two healthcare professionals—is convened. The MDT uses a more detailed Decision Support Tool (DST) to gather a comprehensive picture of the individual's needs across 12 domains.

For a dementia patient, needs in domains like cognition, behavior, and communication are often scored highly. The MDT uses the DST scores to determine if the individual has a 'primary health need' based on the four key indicators (nature, intensity, complexity, unpredictability). The final decision on eligibility is made by the local Integrated Care Board (ICB) based on the MDT's recommendation.

How Dementia Symptoms Impact the Assessment

Many symptoms associated with dementia can directly influence eligibility for CHC by demonstrating complex, intense, and unpredictable health needs. Assessors will consider:

• Cognition: Severe memory loss, disorientation, and inability to understand or follow instructions.
• Behaviour: Challenging behaviors such as aggression, agitation, wandering, or disinhibition.
• Communication: Difficulty expressing needs, understanding language, or following conversations.
• Mobility: Impaired balance, reduced mobility, and increased risk of falls.
• Continence: Incontinence issues due to cognitive impairment.
• Psychological and Emotional Needs: Anxiety, depression, or distress requiring psychological support.

Comparison: CHC vs. Social Care Funding

Understanding the fundamental difference between CHC and social care funding is crucial for families. Here is a comparison of the key aspects:

Feature	NHS Continuing Healthcare (CHC)	Local Authority Funded Social Care
Basis of Eligibility	'Primary health need' based on complexity, intensity, unpredictability, and nature of needs.	Social care needs, such as help with daily living, after a needs assessment.
Funding Source	Fully funded by the NHS via the Integrated Care Board (ICB).	Means-tested, meaning the individual must contribute if their assets exceed a certain threshold.
Means-Testing	No means-testing. The individual's finances are irrelevant to the eligibility decision.	Yes, a financial assessment is conducted to determine the individual's contribution.
Scope of Care	Covers the full cost of care, including accommodation fees in a care home.	Covers assessed social care needs, but not typically accommodation, for those with limited assets.
Regular Reviews	Eligibility is reviewed regularly, usually after 3 months and then annually.	The local authority conducts regular reviews of social care needs and financial contributions.
Nursing Care	Includes all registered nursing care.	The NHS will still fund registered nursing care via a FNC (Funded Nursing Care) payment.

The Fast-Track Pathway for End-of-Life Care

For dementia patients whose health is deteriorating rapidly and who may be nearing the end of their life, there is a fast-track pathway to enable funding to be put in place quickly—often within 48 hours. This pathway bypasses the full assessment process and is initiated by a doctor or registered nurse. It is designed to ensure a quick and appropriate care package is arranged without unnecessary delays.

For more detailed information on eligibility and the assessment process, you can consult the official guidance provided by the NHS. A blank copy of the official checklist is available on the UK government's website at: https://www.gov.uk/government/publications/nhs-continuing-healthcare-checklist.

Challenging a CHC Decision

If you disagree with an eligibility decision, you have the right to appeal. The process starts with a request for local resolution, and if that is unsuccessful, you can appeal to NHS England. The appeals process can be lengthy, but it ensures that decisions are made fairly and according to the National Framework. It is advisable to gather all relevant medical and care notes to build a strong case for reconsideration.

Conclusion: Navigating CHC for Dementia Patients

Eligibility for Continuing Healthcare is not a foregone conclusion for individuals with dementia but is entirely possible, especially as the disease progresses and care needs become more complex and severe. The crucial element is a comprehensive assessment that accurately captures the nature, intensity, complexity, and unpredictability of the individual's health needs. Families should engage with health and social care professionals early in the process and be prepared to advocate for their loved one. By understanding the criteria and the assessment process, you can navigate this often confusing system and secure the appropriate level of funding for the care they need.

Frequently Asked Questions

Does a diagnosis of Alzheimer's automatically qualify someone for continuing healthcare?

No, eligibility is not based on having a specific diagnosis like Alzheimer's. The assessment process focuses on the individual's overall care needs, not the disease itself.

Is continuing healthcare means-tested for dementia patients?

No, NHS Continuing Healthcare is not means-tested. It is based solely on the individual's assessed health and care needs, not their financial situation.

What if a dementia patient is already in a care home? Can I still apply for CHC?

Yes, you can and should apply for CHC funding. If the person is found eligible, the NHS will cover the full cost of the care home fees, and a refund may be possible for previously paid care costs.

How do I start the continuing healthcare application for someone with dementia?

You can start the process by requesting a Checklist assessment from a health or social care professional involved in the person's care, such as their GP, nurse, or social worker.

What happens if a dementia patient is found ineligible for CHC?

If found ineligible for CHC, the individual may still be entitled to other forms of funding, such as NHS-funded nursing care or means-tested social care support from their local authority.

How long does the continuing healthcare assessment process take?

The initial assessment and decision process should ideally be completed within 28 days of the Checklist referral, though delays can occur. The fast-track pathway for end-of-life care is much quicker.

Can eligibility for continuing healthcare change for a dementia patient?

Yes, eligibility can and does change. All CHC packages are reviewed regularly (after 3 months, then annually) to ensure they still meet the individual's changing needs.