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Name: DOB: NHS DONCASTER CLINICAL COMMISSIONING GROUP CHILDREN’S CONTINUING CARE (DECISION SUPPORT TOOL)ASSESSMENT DOCUMENT DETAILS OF CHILD / YOUNG PERSON Child / Young Person Name: DOB: NHS Number: Permanent Address: Current Address (if applicable): Telephone Number: School Details: Parental responsibility status: Ethnicity: Mother: Father: First Language: Is an interpreter required? Name & address of nursery/school/college Parent / Carers Full Names: Relationship: mother Contact Number: Address if different from above Relationship: Father Contact Number: Address if different from above: ECHP Domain Funding Stream Health Continuing Care Aiming High DP/Sessional SEND Social Care Current Package of Care (Total hours allocated provision/name of provider) Start Date Last Review Date Education Any additional care provider Date assessment request received from Doncaster CCG: Date of Completion of assessment: Initial Assessment/ Review assessment Version 5 – November 2015 1 Name: DOB: Completed by: Designation: Telephone contact: Date assessment submitted to Doncaster CCG: Decision Panel date: PERMISSION TO SHARE INFORMATION The information recorded during this assessment may be shared with others involved in your child’s care assessment and will be used for consideration of your child’s eligibility for NHS Continuing Care. Do you and your child give consent for information of your child, recorded during this assessment, being shared with other involved in your care? Yes No Is there any specific information about your child you would NOT wish to be shared? (please give details below): INFORMATION NOT TO BE SHARED: Yes No Are there any agencies or individuals with whom you would NOT wish information about your child to be shared? (please give details Yes below): INFORMATION NOT TO BE SHARED: Service user / patient able to give consent? (please give details below in respect to Fraser Competent): Signature of service use / patient or their representative Parental responsibility: Name: Relationship: Version 5 – November 2015 Yes No No Date: 2 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT HEALTH HISTORY Relevant Medical History including primary and secondary diagnosis Dates of significant health events and current health status Previous diagnosis, Current diagnosis, Allergies, Previous admission (including when and where), etc. Any recent changes including any improvement or deterioration FAMILY CIRCUMSTANCES Include the family structure Has a social care assessment been made? Yes/No Support received from the family circle [relations &friends], do any siblings have health or care needs Parent/carers occupation, effect of child’s condition on the parents ability to work HOUSING Housing – issues, adequacy, include adaptation requirement assessments EDUCATION, PLAY & LEISURE Recreation & leisure what are their interest and are they able to choose and participate Education/Play & Learning ability to access recreation and education able to access curriculum, what provision is in place to support continuity of learning. If the child is too ill to access a setting , what other provision is in place to ensure continuity of learning? Version 5 – November 2015 3 Name: DOB: Transport - issues & adequacy Views and aspirations of child/young person – issues, concerns, anxieties, preferences about care deliver Is the child / young person attending school Y/ N Does the child have : a Statement of Special Educational Need or Education Health Care Plan? Version 5 – November 2015 4 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESMENT DOCUMENT EQUIPMENT IN PLACE: SUPPLIED BY: 1.Disposable equipment 2.Permanant equipment 1. 2. EQUIPMENT OUTSTANDING: TO BE SUPPLIED BY: 1. 1. TREATMENT NEEDS: Symptom management Are there times when specific interventions are required? Is an assessment required by another service? CARE NEEDS Interventions who provides and monitors care plans? What is the 24hr daily care routine TRANSITION ( Age 14 and over) Has transition commenced?: YES/NO Please include Future plans for: education, accommodation package including whether they can be assisted to achieve independent living will their parent/carer need extra emotional and/or practical support Has the Adults Continuing Healthcare referral and assessment been completed? Y/N If so when and what is the outcome? If no please make referral at aged 16+ Name & contact details of Lead Professional for transition: Version 5 – November 2015 5 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT PROFESSIONALS AND SERVICES INVOLVED IN THE CARE Contact Number: GP: Location: Consultant : Contact Number: Location: Community Paediatrician: Contact Number: Location: Psychologist: Contact Number: Location: Community Children’s Nurse : Contact Number: Location: CAMHS: Contact Number: Location: Health Visitor or School Nurse: Contact Number: Location: Social Worker: Contact Number: Location: Occupational Therapist: Contact Number: Location: Speech and Language Therapist: Contact Number: Location: Physiotherapist: Contact Number: Location: Other Therapist: Contact Number: Location: Version 5 – November 2015 6 Name: DOB: Teacher: Contact Number: Location: Short Break Services: Contact Number: Location: Other Contact Number: Location: Lead Professional / Key Worker: Contact Number: Location: MULTI AGENCY ASSESSMENTS Please list any assessments that have been undertaken: Type of Assessment Completed By Date of Completion MULTI AGENCY REFERRALS Please list any referrals made that are outstanding: Type of Referral Version 5 – November 2015 Made to Date of Referral 7 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Challenging Behaviour Culturally abnormal behaviours of such intensity, frequency, or duration that the physical safety of the person or others is likely to be placed in jeopardy or behaviour which is likely to seriously limit use of or result in the person being denied assess to ordinary community facilities. A specialist assessment of an individual with serious behavioural issues will usually be required which included an overall assessment of the risk(s) which are likely to impair a child’s growth, development and family life. Describe the actual needs of the individual, including any episodic needs, such as the times and situations which the behaviour is likely to be performed across a range of typical daily routines and the frequency, duration and impact of the behaviour. Identify the child’s concerns & anxieties What is the effect of the persons condition on each member of the family Consider levels of cognitive impairment & communication overlap here Provide the evidence that informs the decision overleaf on which level is appropriate. This will include behaviour charts and school reports, incident logs, etc to support this domain. Circle the assessed level overleaf. Version 5 – November 2015 8 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESMENT DOCUMENT Challenging Behaviour Description No incidents of behaviour which challenge parents/carers/staff Some incidents of behaviour which challenge parents/carers/staff but which do not exceed behaviours for age or stage of development and which can be managed in mainstream services ( e.g. early years support, health visiting, school) Occasional challenging behaviour which are more frequent, more intense or more unusual than those expected for age or stage of development, which are having a negative impact on a child and their family/everyday life: Level of Need No additional needs Low Moderate Regular challenging behaviours such as aggression (hitting, kicking, biting, hair pulling) destruction(ripping clothes, breaking windows ,throwing objects),self-injury (head banging, self-biting, skin picking) or other behaviours(running away, eating inedible objects) despite specialist health intervention and which have a negative impact on the child and their family/everyday life . High Frequent, intense behaviours such as aggression, destruction, self-injury, despite multiagency support, which have a profoundly negative impact on quality of life for the child and their family, and risk exclusion from the home or school Behaviours of high frequency and intensity despite intense multiagency support, which threaten the immediate safety of the child or those around them and restrict every day activities (e.g exclusion from school or home environment) Severe Version 5 – November 2015 Supporting Reports Priority 9 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Communication This section is related to difficulties with receptive and expressive language, both verbal and non-verbal, or technology assisted that is not commensurate with age and developmental milestones. It does not include those children that do not speak English as their first language but are able to communicate in other languages. Describe the actual needs of the individual, including any episodic needs. Provide the evidence that informs the decision overleaf on which level is appropriate, including the frequency and intensity of need, unpredictability, deterioration and any instability. Circle the assessment level overleaf. Version 5 – November 2015 10 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Communication Description Able to understand or communicate clearly, verbally or nonverbally within their primary language, appropriate to their developmental level. The child / young person’s ability to understand or communicate is appropriate for their age and developmental level within their first language. Level of Need Supporting Reports No additional needs Needs prompting to communicate their needs. Special effort may be needed to ensure accurate interpretation of needs, or may need additional support visually, either through touch or with hearing. Family / carers may be able to anticipate needs through nonverbal signs due to familiarity with the individual. Expressive or receptive language. Low Communication of emotions and fundamental needs is difficult to understand or interpret, even when prompted, unless with familiar people, and requires regular support. Family/carers may be able to anticipate and interpret the childs needs due to familiarity Moderate Support is always required to facilitate communication, for example, the use of choice boards, signing and communication aids. Ability to communicate basic needs is variable depending on fluctuating mood; or the child / young person demonstrates severe frustration about their communication, for example, through challenging behaviour or withdrawal. Even with frequent or significant support from family / carers and professionals, the child / young person is rarely able to communicate basic needs, requirements or ideas,. Version 5 – November 2015 High 11 Name: DOB: NHS CHILDREN’S CONTINUING CARE – DECISION SUPPORT TOOL DOCUMENT Mobility Describe the actual needs of the individual, providing the evidence that informs the decision overleaf on which level is appropriate. Assessments should be submitted along with any therapy assessments / reports. Describe the frequency and intensity of need, unpredictability, deterioration and any instability. Circle the assessed level overleaf. Version 5 – November 2015 12 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Mobility Description Mobility typical for age and development. Able to stand, bear their weight and move with some assistance, and mobility aids Difficulties in standing or moving even with aids: although some mobility with assistance Or Sleep deprivation ( as opposed to wakefulness) due to underlying medical related need (muscle spasms, dystonia) occurring three times a night, several nights per week. Or Unable to move in a way typical for age; cared for in a single position, or a limited number of positions ( e.g. bed supportive chair) due to the risk of physical harm, loss of muscle tone, tissue viability or pain on movement, but is able to assist Unable to move in a way typical for age; cared for in single , or a limited number of positions (bed or supportive chair) and due to risk of physical harm, loss of muscle tone, tissue viability, or pain on movement; needs careful positioning and is unable to assist or needs more than one carer to reposition or transfer; Or At a high risk of fracture due to poor bone density, requiring a structured management plan to minimise risk, appropriate to stage of development; Or Involuntary spasms placing themselves and carers at risk; Or Extensive sleep deprivation due to underlying medical / mobility related needs, occurring one to two hours (and at least four nights per week). Completely immobile and unstable clinical condition such that on movement or transfer there is a high risk of serious physical harm; Or Where positioning is critical to physiological functioning or life. Version 5 – November 2015 Level of Need No additional needs Supporting Reports Low Moderate High Severe 13 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Nutrition, Food and Drink Describe the actual needs of the individual, providing the evidence that informs the decision overleaf on which level is appropriate. Including the frequency and intensity of need, unpredictability, deterioration and any instability. Circle the assessed level overleaf. Version 5 – November 2015 14 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Nutrition, Food and Drink Description Level of Supporting need Reports Able to take adequate food and drink by mouth, to meet all No additional nutritional requirements. Typical for their age. needs Some assistance required above what is appropriate for their age; Low Or Needs supervision, prompting and encouragement with food and drinks above their typical requirement for their age; Or needs support and advice about diet because the underlying condition gives greater change of non-compliance, including limited understanding or the consequences of food or drink intake; Or Needs feeding, when this is not typical for age, but is not time consuming or not unsafe if general guidance is adhered to Needs feeding to ensure safe and adequate intake of food; Moderate feeding (including liquidised feed) is lengthy; specialised feeding plan developed by speech and language therapist; Or unable to take sufficient food and drink by mouth, with most nutritional requirements taken by artificial means, for example, via a non problematic tube feeding device, including nasogastric tubes. Faltering growth, despite following specialised feeding plan by a High speech and language therapist and/ or dietician to manage nutritional status; Or dysphagia, requiring a management plan developed by speech and language therapist and multidisciplinary team, with additional skilled intervention to ensure adequate nutrition or hydration and to minimise the risk of choking, aspiration and to maintain a clear airway (or example, suction); Or problems with intake of food and drink, (which could include vomiting) requiring skilled intervention to manage nutritional status; weaning from tube feed dependency and/ recognised eating disorder, with self-imposed dietary regime or self-neglect, for example, anxiety and/ or depression leading to intake problems placing the child / young person at risk and needing skilled intervention; Or problems relating to a feeding device(e.g. nasogastric tube) which require skilled risk assessment and management plan undertaken by a speech and language therapist and multidisciplinary team and requiring regular review and re assessment. Despite the plan, there remains a risk of choking and review. The majority of fluids and nutritional requirements are routinely Severe taken by intravenous means. Version 5 – November 2015 15 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Continence and Elimination Where continence problems are identified, a full continence assessment should be undertaken, any underlying conditions identified and the impact and likelihood of any risk factors evaluated. Describe the actual needs of the individual, providing the evidence that informs the decision overleaf on which level is appropriate. Including the frequency and intensity of need, unpredictability, deterioration and any instability. Take into account any aspect of continence are associated with behaviour in the behaviour domain. Circle the assessed level overleaf. Version 5 – November 2015 16 Name: DOB: NHS CHILDREN’S CONTINUING CARE – DECISION SUPPORT TOOL DOCUMENT Continence and Elimination Description Continence care is routine and typical of age Incontinent of urine but managed by others means, for example, medication, regular toileting, pads, use of penile sheaths; Or Is able to maintain full control over bowel movements or has a stable stoma, but may have occasional faecal incontinence; Has a stoma requiring routine attention. Or doubly incontinent but care is routine; Or Self-catheterisation; Or Difficulties in toileting due to constipation, or irritable bowel syndrome, requires encouragement and support Continence care is problematic and requires timely intervention by a skilled practitioner or trained carer; Or Intermittent catheterisation by a trained carer or care workers; Or Has a stoma that needs extensive attention every day. Or requires haemodialysis in hospital to sustain life Requires dialysis in the home to sustain life. Version 5 – November 2015 Level of Need No additional needs Low Supporting Reports Moderate High Priority 17 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Skin and Tissue Viability Stomas should be considered under Continence or elimination and tracheostomies under Breathing Describe the actual needs of the individual, providing the evidence that informs the decision overleaf on which level is appropriate. Including the frequency and intensity of need, unpredictability, deterioration and any instability. Circle the assessed level overleaf. Please include any tissue viability reports with this document. Version 5 – November 2015 18 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Skin and Tissue Viability Description No evidence of pressure damage or condition affecting the skin. Evidence of pressure damage and pressure, or a minor wound requiring treatment; Or Skin condition that requires clinical reassessment less then weekly Or Well established stoma which requires routine care. Or has a tissue viability plan which requires regular review Open wound(s), which is (are) responding to treatment; Or Active skin condition requiring a minimum of weekly reassessment and which is responding to treatment; Or High risk of skin breakdown that require preventative intervention from a skilled carer several times a day, without which skin integrity would break down. Or High risk of tissue breakdown because of stoma (gastrostomy, tracheostomy, colostomy stomas) which require skilled care to maintain skin integrity Open wound(s), which is (are) not responding to treatment and require a minimum of daily monitoring / reassessment; Or Active skin condition, which requires a minimum of daily monitoring or reassessment; Or Specialist dressing regime, several times weekly, which is responding to treatment and requires regular supervision. Life-threatening skin conditions or burns requiring complex, painful dressing routines over a prolonged period. Version 5 – November 2015 Level of Need No additional needs Low Supporting Reports Moderate High Severe 19 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Breathing Describe the actual needs of the individual, providing the evidence that informs the decision overleaf on which level is appropriate. Including the frequency and intensity of need, unpredictability, deterioration and any instability. Circle the assessed level overleaf. Version 5 – November 2015 20 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Breathing Description Breathing typical for age and development Routine use of inhalers, nebulisers, etc; Or Care plan or management plan in place to reduce aspiration Episodes of acute breathlessness, which do not respond to selfmanagement and need specialist recommended input; Or intermittent or continuous low level oxygen therapy is needed to prevent secondary health issues; Or Supportive but not dependant non-invasive ventilation which may include oxygen therapy which does not cause life threatening difficulties if disconnected; Or Has profoundly reduced mobility or other conditions which lead to increased susceptibility to chest infection( Gastroesphagael Reflux Disease and Dysphagia); Or Requires oral suction (at least weekly) due to the risk of aspiration and breathing difficulties. Or requires daily physiotherapy to maintain optimal respiratory function: Or requires oral suction (at least weekly) due to the risk of aspiration and breathing difficulties; Or has a history within the last three to six months of recurring aspiration/chest infections Requires high flow air/oxygen to maintain respiratory function overnight or for the majority of the day and night; Or Is able to breathe unaided during the day but needs to go onto a ventilator for supportive ventilation. The ventilation can be discontinued for up to 24 hours without clinical harm; Or Requires continuous high level oxygen dependency, determined by clinical need; Or has a high need for daily oral pharyngeal and or / nasopharyngeal suction with a management plan undertaken by a specialist practitioner Or Version 5 – November 2015 Level of Need No additional need Low Supporting Reports Moderate High 21 Name: DOB: stable tracheostomy that can be managed by the child or young person or only requires minimal and predictable suction/care from carer Has frequent, hard-to-predict apnoea’s( not related to seizures);; Or Severe, life-threatening breathing difficulties, which may require essential oral pharyngeal and / or naso pharyngeal suction, day or night; Or A tracheostomy tube that requires frequent essential interventions (additional to routine carer) by a fully trained carer, to maintain an airway; Or Requires ventilation at night for very poor respiratory function; has respiratory drive and would survive accidental disconnection, but would be unwell and may require hospital support. Unable to breath independently and requires permanent mechanical ventilation; or Has no respiratory drive when asleep or unconscious and requires ventilation, disconnection could be fatal; or A highly unstable tracheostomy, frequent occlusions and difficult to change tubes. Version 5 – November 2015 Severe Priority 22 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Drug Therapies and Medicines Describe the actual needs of the individual, providing the evidence that informs the decision overleaf on which level is appropriate. Including the frequency and intensity of need, unpredictability, deterioration and any instability. Circle the assessed level overleaf. Version 5 – November 2015 23 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Drug Therapies and Medicines Description Medicine administered by Parent, carer or self as appropriate for age. Requires a suitably trained family member, formal carer, teaching assistant, nurse or appropriately trained other to administer medicine due to: Age Non-compliance Type of medicine Route of medicine; and / or Site of medication administration Level of Need No additional needs Low Supporting Reports Requires administration of medicine regime by a registered nurse, Moderate formal employed carer, teaching assistant or family member specifically trained for this task, or appropriately trained other; and monitoring because of potential fluctuation of the medical condition that can be non-problematic to manage; or sleep deprivation due to essential medication management – occurring more than once a night (and at least twice a week). Drug regime that requires management by a registered nurse (within High prescription) at least weekly, due to a fluctuating and / or unstable condition; or Sleep deprivation caused by severe distress due to pain requiring medication management – occurring four times a night (and four times a week). or Requires monitoring and intervention for autonomic storming episodes Has a medicine regime that requires daily management by a registered nurse and reference to a medical practitioner to ensure effective symptom management associated with a rapidly changing / deteriorating condition; or Extensive sleep deprivation caused by severe intractable pain requiring essential pain medication management – occurring every one to two hours. or Requires continuous intravenous medication, which if stopped would be life threatening (e.g. epoprostenol infusion) Has a medicine regime that requires at least daily management by a registered nurse and reference to a medical practitioner to ensure effective symptom and pain management associated with rapidly changing / deteriorating condition, where one-to-one monitoring of symptoms and their management is essential? Version 5 – November 2015 Severe Priority 24 Name: DOB: NHS CHILDREN’S CONTINUING CARE DOCUMENT Psychological and Emotional Needs Describe the Psychological and Emotional Needs that are beyond what is normally expected from a child / young person of this age. Please include cognition impairment in this section. Cognition applies to disturbances of higher mental processes that can be measured by suitable psychological tests. This may apply to individuals when a learning disability acquired and degenerative disorders. Where cognition impairment is identified consideration should be made for referral to an appropriate specialist if one is not already involved Note that there is a domain that separately considers challenging behaviour Describe the actual needs of the individual, providing the evidence that informs the decision overleaf on which level is appropriate. Including the frequency and intensity of need, unpredictability, deterioration and any instability. Circle the assessed level overleaf. Version 5 – November 2015 25 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Psychological and Emotional Needs Interpretation point : assessors should avoid double counting the same need with behaviour domain Description Psychological or emotional needs apparent but age appropriate and similar to those of peer group. Periods of emotional distress (anxiety, mildly lowered mood) not dissimilar to those of age-appropriate peer group, which subside and are self-regulated by the child / young person, with prompts / reassurance from peers, family members, carers and / or key frontline staff with the children and young people’s workforce. Require prompts or support to remain within existing infrastructure; periods of variable attendance in school / college; noticeably fluctuating levels of concentration; noticeable deterioration in selfcare (outside prolonged intervention from additional key staff; intentional self-harm but not generally high risk; Or Evidence of low moods, depression, anxiety or periods of distress; reduced social functioning and increasingly solitary, with a marked withdrawal from social situations; limited response to prompts to remain within existing infrastructure (marked deterioration in selfcare outside or cultural / peer group norms and trends). Rapidly fluctuating moods of depression, necessitating specialist support and intervention, which have a severe impact on the child / young person’s health and well-being to such an extent that the individual cannot engage with daily activities such as eating, drinking, sleeping or which place the individual at risk; Or acute and / or prolonged presentation of emotional / psychological deregulation, poor impulse control placing the young person or others at serious risk, and / or symptoms of serious mental illness that places the young person at risk to his / her self and others; this will include high-risk, intentional self-harming behaviour. Version 5 – November 2015 Level of Need No additional needs Low Supporting Reports Moderate High 26 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT Seizures This encompasses the whole range of types of seizures and any associated risks Describe the actual needs of the individual, providing the evidence that informs the decision overleaf on which level is appropriate. Including the frequency and intensity of need, unpredictability, deterioration and any instability. Circle the assessed level overleaf. Version 5 – November 2015 27 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENTDOCUMENT Seizures This encompasses the whole range of types of seizures and any associated risks Description No evidence of seizures. History of seizures but none in the past three months; medication (if any) is stable. or Occasional absent seizures and there is low risk of harm Occasional seizures including absences that have occurred within the last three months which require the supervision of a carer to minimise the risk of self-harm. or Upto three tonic – clonic seizures every night requiring regular supervision . Tonic-clonic seizures requiring rescue medication on a weekly basis; Or 4 or more tonic-clonic seizures at night Severe uncontrolled seizures, occurring at least daily, Seizures often do not respond to rescue medication and the child needs hospital treatment on a regular basis. This results in a high probability of risk to his / her self or others. Version 5 – November 2015 Level of Supporting Need Reports No additional needs Low Moderate High Severe 28 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT PERSONAL DETAILS Summary of child / young person’s situation, relevant history and current needs clinical summary identified significant risks drawn from multi-disciplinary assessment: Other identified needs to be identified with analysis of severity& impact Child / young person’s or parent / carers view of care needs Do they consider that the multi-disciplinary assessment accurately reflects their need? Child /young person’s view What the aspiration for this child/young person? What are their issues, anxieties and concerns about care delivery? What are their preferences about care delivery? Version 5 – November 2015 29 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENTDOCUMENT CARE DOMAINS Transfer all the assessed Levels of need onto the matrix below to identify level of need Either 3 “high” ratings, 1 “severe” or 1 “priority” rating is likely to indicate continuing care needs Priority Severe High Moderate Low No Need Challenging behaviour Communication Mobility Nutrition, food and drink Continence and elimination Skin and tissue viability Breathing Drug therapies and medicines Psychological and emotional Seizures Other Total Version 5 – November 2015 30 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENTDOCUMENT Was the child / young person involved in the completion of the assessment? YES / NO. If no please state why the child / young person did not contribute to this assessment Was the parent / carer involved in the completion of the assessment? YES / NO Is the child / young person and their parent / carer happy with the recommendations made? YES / NO Please note below any views of the individual that have not been recorded elsewhere in this document. Please include whether the child/young person and or parent/carer agree with the domain levels selected. Where they disagree, this should be recorded below, including the reasons for the disagreement. Where the individual is represented or supported by a parent / carer or advocate their understanding of the individual’s views should be recorded. Version 5 – November 2015 31 Name: DOB: NHS CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT RECOMMENDATION Please now give a recommendation as to whether or not the individual is eligible for NHS continuing healthcare. Take into account the range and levels of need previously recorded and the individual’s primary need is for healthcare. Please indicate whether needs are expected to change (in terms of deterioration or improvement) before the case is next reviewed. If so, please state why and what needs you think will be different and therefore whether you are recommending that eligibility should be agreed now or that an early review date should be set Any disagreement on levels used or areas where needs have been counted against more then one domain should be highlighted here. Reach a recommendation on whether the individual’s primary needs are health need should include consideration of: Nature: This describes the particular characteristics of an individual’s needs (which can include physical, mental health, or psychological needs), and the type of those needs. This also describes the overall effect of those needs on the individual, including the type (quality) of interventions required to manage them. Intensity: this related to both the extent (quality) and severity (degree) of the needs and the support required to meet them, including the need for sustained / ongoing care (continuity) Complexity: This is concerned with how the needs present and interact in increase the skill needed to monitor the symptoms, treat the condition(s) and / or manage the care. This can arise with a single condition or can also include the presence of multiple conditions or the interactions between two or more conditions. Unpredictability: this describes the degree to which needs fluctuate, creating challenges in managing them. It also related to the level of risk to the person’s health if adequate and timely care is not provided. Someone with an unpredictable healthcare need is likely to have either a fluctuating, or unstable or rapidly deteriorating condition. . Version 5 – November 2015 32 Name: DOB: NHS DONCASTER CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT RECOMMENDATION Recommendation on eligibility for NHS continuing healthcare detailing the conclusions on the issues outlined on the previous pages: Please note that this application will not be processed unless this section is completed and a recommendation is provided. Version 5 – November 2015 33 Name: DOB: NHS DONCASTER CHILDREN’S CONTINUING CARE ASSESSMENT DOCUMENT REQUESTED CARE PACKAGE Request future care package and likely location(s) The decision on eligibility for NHS Continuing Healthcare is separate to any decision to commission a particular package. REQUESTED CARE PACKAGE/PLAN: START DATE : Please indicate the actual or expected start date of the package (where this is unknown, the lead professional must confirm it with the continuing care team as soon as possible). Outcomes to be achieved from delivery of care package/plan. Health: Name, designation & signature of the person completing this assessment Date completed: Name and designation of professionals that have participated in the completion of this assessment : Contact details Please forward this typed assessment via: Secure email: [email protected] Version 5 – November 2015 34 Name: DOB: For office use only: ECHP Domain Panel Date: Panel decision: Funding Stream Agreed Package of Care/Provision Review period Cost per (Total hours allocated Hour/week of Provision & Name of Provider) provision Health Social care Education Version 5 – November 2015 35 Cost per year to NHS