The RNCC tool applies to all adult client groups.
Before the decision is made to seek permanent admission to a care home, all other possible options must have been explored. Thus the nurse assessor must reconsider continuing care, long term rehabilitation courtesy of the NHS, intermediate care courtesy of the NHS, etc before deciding on which band is appropriate for FNC.
The tool works by dividing people up into High, Medium and Low categories against the following criteria: Stability, Predictability, Risk, and Complexity.
It is notable that Range, Continuity, Frequency, Intensity and Skill (the post Coughlan case criteria for continuing care) are not referred to, which is a shame, because people rated ‘High’ across that range of factors when being assessed for free nursing care could have argued that they should be counted as eligible for fully paid continuing care, instead of merely Free Nursing.
Hwever, the bands are predicated upon the results of a study by the University of Kent, which identified that complex patients needed 48 minutes of care from a registered nurse per day, whereas standard people required 31, on average. It is our view that anyone clearly needing appreciably more care than 48 minutes a day is a higher than High case, and should indeed be regarded as a legitimate candidate for Continuing Care.
The tool recommends a holistic approach to the totality of information gained from the domains of the single assessment process and care planning process.
There is a suggestion that the NHS nurses making these determinations will have observed or known the patients concerned, but as only 60 have been trained in some regions, that seems unlikely.
Full account must be taken of the prognosis of people’s conditions, and the likely outcomes if help were not to be provided, or provided in different ways. The nurse must have regard to the full range of the problems, not just the immediately obvious nursing needs. The patient’s usual profile over a week or a number of weeks is what must be considered.
The High band is meant for complex needs requiring frequent mechanical, technical or therapeutic interventions. These people will need frequent intervention and re-assessment by a registered nurse throughout a 24 hour period, and their physical or mental health state will be unstable and/or unpredictable.
Medium category people will have multiple care needs, needing the intervention of a registered nurse on at least a daily basis, and access to a nurse at any time. Their physical, behavioural, and psychosocial needs are stable and predictable, and likely to remain so if treatment and care regimes continue.
Stable means steady, and likely to remain so if correct treatment or care regimes continue. This could relate to a disease process, a disorder, including emotional, physical, behavioural and/or psychosocial needs. The opposite, unstable, is the situation when these factors fluctuate and alternate, requiring frequent or regular intervention or treatment
The difference between stability and predictability is as follows: how the patient responds to their condition or internal or external triggers can be anticipated with some certainty through regular, (ie scheduled) review and intervention. Unpredictability is the situation when responses are not able to be anticipated, such that there is a need for ongoing assessment, care planning, intervention and review.
A minimal risk is regarded as a situation where a person’s abilities are present most of the time, but risk needs to be regularly reassessed. ‘At risk’ is where abilities are compromised or absent most or all of the time, or sensory loss is multiple or self image is low, such that frequent reassessment of the risk is needed.
Complexity is graduated through medium to high: medium is where physical and mental needs are moderately complex, or when mechanical, technical or therapeutic assistance is needed regularly or intermittently, with regular reassessment being needed. Highly complex cases are where there is more complexity than this, or where intervention is needed frequently, ie frequently within a 24 hour period.
The nurse has to write a description of all the registered nursing input required, based on the current and anticipated health states.
The case studies given in the workbook do not involve an example from which one could discern the intended difference between a continuing care and a high needs care case, so no-one is any the wiser about how tight or how wide continuing care criteria should now be.
The ‘medium’ band example given is of a patient who requires at least daily intervention by a registered nurse for daily wound care of a sacral sore, and daily review of skin integrity, along with monitoring of fluid and nutritional intake, help with safe transfer, encouragement of participation in self-care and social interaction (the registered nurse working through care staff) and liaison with the GP regarding prescriptions. This person’s health status is seen as stable and predictable.
The two high band examples are instructive. They involve firstly a person with dementia, needing constant supervision, assistance with hygiene, dressing, feeding, communication, emotional state, restlessness, sleep, incontinence and aggression. These needs are seen as unstable and unpredictable with a need for frequent registered nursing intervention and re-assessment. The patient would need administration of medication and close monitoring of effects, supervision of feeding, planning of continence programme, weight monitoring, development of a behavioural programme, social stimulation and hygiene assistance (working through the team). We are surprised that this would be seen as ‘high’, because once the ongoing programmes are planned, it seems to us that the need for RNCC intervention in practice is slight, until there something occurs to change the picture; monitoring as such, will be passive, in practice. But it is encouraging that such clients get £110 a week rather than the £10 a day for ‘standard’ RN care.
Secondly, the other ‘high’ example involves someone unable to swallow or communicate, with partial paralysis and double incontinence, a pressure sore, and emotional distress, being PEG fed. Registered nursing care would include monitoring of tissue viability, treatment of pressure sores, management of PEG feeding, enemas to maintain bowel function, safe transfer, supporting daily living activities, help with balance, review of mood and medication. Such a profile should be seen as unstable, complex, and requiring frequent intervention.
Decision-making arrangements and single assessment
Since the RNCC determination cannot, without more, formally constitute the decision by the Local Authority that the patient meets their own criteria for nursing home care (those criteria being lawfully able to be tightened, within reason, (though not re-interpreted) with regard to available resources), and since the LA funding outcome of the multi-disciplinary assessment process is not usually for the care managers alone to determine, the decision making process before contracting for someone entitled to Free Nursing Care can actually take place, is bound to become complicated.
The guidance on Single Assessment suggests that the RNCC must come after the multi-disciplinary assessment and be taken in light of all the information gleaned through that process. But unless local authorities and health authorities/PCGs/PCTs use the Health Act flexibilities to delegate decision making to the RNCC determinations nurse, or RNCC decisions to the LA’s team manager or panel, there can be no single decision taken which counts for both agencies’ discharge of their entirely legally separate decision-making functions. Further legal advice may well be needed to make these arrangements work.