Planning and commissioning care for people with complex health and social care needs.
This occupation is found in a wide variety of organisations that oversee health and social care services such as Clinical commissioning groups, social services and community healthcare services. Continuing healthcare services provide care for over 60,000 people over the age of 18 annually across England. It is estimated that 70% are in nursing homes, and 30% have care in their own homes.
The broad purpose of the occupation is to work as part of a continuing healthcare team which provide packages of on-going care that are arranged and funded solely by the NHS. The associate continuing healthcare practitioner plays a key role in the assessment of individual’s complex health and social care needs that have arisen as a result of disability, accident or illness, and the planning and commissioning of the services for these individuals. They also act as the first point of contact for individuals and their carers offering support, care and advice about the service and for young adults and their family who are transitioning from children’s continuing care into this adult continuing healthcare service. The associate continuing healthcare practitioner may be required to work shifts including evenings and weekends.
In their daily work, an employee in this occupation interacts with the individuals and their family, friends and carers, that have been referred into the continuing healthcare service, are being assessed or are receiving packages of care. They work with nurses, social workers, doctors and other health and social care colleagues involved in planning, reviewing and delivering services provided to the individual guiding them with expert knowledge of the specialist continuing healthcare regulations. They also regularly work with finance and procurement colleagues and the service providers to ensure contracts are being delivered as agreed. They may also have contact with legal and claims companies who are representing individuals who do not agree with the outcome of the assessment process. The associate continuing healthcare practitioner will need to have good communication skills to advocate for individuals and guide them through the emotionally stressful assessment process and any dispute process. They will also be required to have a detailed knowledge of the health and social care services available for these individuals who have complex and varying needs. The associate continuing healthcare practitioner will be primarily office-based but will also visit the individual in their home, and in health and social care settings.
An employee in this occupation will be responsible for screening and assessing individuals for eligibility to continuing healthcare packages in line with the national framework for continuing healthcare, related legislation and policy. To support this assessment work, they undertake analysis, interpretation and evaluation of evidence from multiple health and social care professionals caring for the individual. The associate continuing healthcare practitioner will also be responsible for managing a caseload of individuals who have been found eligible. This involves the planning and reviewing of the complex health and social care packages ensuring they continue to meet their needs. They will work autonomously, exercising judgement and work in partnership with other health and social care professionals to undertake non-routine assessments and reviews on individuals in line with the law. In most instances their work will be overseen by a registered health or social care professional such as a nurse, social worker or occupational therapist. The associate continuing healthcare practitioner will also have line management or supervisory responsibility for junior members of the team, acting as a role model, planning and managing their work.
Whilst any entry requirements will be a matter for individual employers, typically an apprentice might be expected to have already had 2 years experience in a carer capacity for a health or social care provider organisation, or have worked within a Continuing Healthcare team
| Duty | KSBs |
|---|---|
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Duty 1 Undertake management and review of individual’s care packages, ensuring it continues to meet their agreed health and social care needs. |
K1 K2 K3 K4 K5 K6 K7 K8 K9 K12 K13 K17 K19 K21 K22 K25 K27 K29 |
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Duty 2 Contribute to planning an individual’s care plan ensuring it meets their agreed health and social care needs. |
K1 K2 K3 K5 K6 K7 K8 K12 K14 K17 K21 K22 K23 K25 K27 K30 |
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Duty 3 Contribute to continuing healthcare assessment of individuals health and social care needs using the mandated tools as outlined in the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care. |
K1 K2 K3 K4 K7 K8 K12 K17 K19 K20 K22 K25 K27 K29 K31 |
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Duty 4 Supervise staff assigned according to organisational policies and procedures. |
K8 K12 K17 K18 K23 K24 K25 K26 K27 K31 |
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Duty 5 Manage the continuing healthcare referral process ensuring referrals into the service are in line with the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care. |
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Duty 6 Collate and analyse evidence and assessment documentation from health and social care teams involved in caring for the needs of the individuals to enable a lawful eligibility decision to be made. |
K2 K3 K8 K9 K12 K22 K23 K24 K25 K27 K29 K30 |
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Duty 7 Co-ordinate and guide the multidisciplinary, multiagency team undertaking assessments using specialist policy knowledge to advise on appropriate process to deliver a policy-compliant recommendation regarding continuing healthcare eligibility. |
K2 K8 K17 K18 K19 K20 K22 K23 K25 K26 K28 K29 K31 S6 S7 S8 S14 S16 S17 S18 S19 S20 S21 S23 S24 S25 S26 S27 S28 |
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Duty 8 Contribute to resolution of disputed eligibility funding decisions fairly, consistently and lawfully. |
K2 K8 K12 K17 K18 K19 K20 K22 K24 K25 K26 K27 K28 |
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Duty 9 Contribute to commissioning services required to meet individual's health and social care needs as prescribed by the multidisciplinary team in partnership with the individual. |
K9 K10 K11 K12 K14 K15 K21 K22 K25 K27 K30 |
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Duty 10 Monitor continuing healthcare provider service and personal health budget (PHB) contracts in accordance with procurement law, national policy and local agreements. |
K8 K9 K10 K12 K13 K14 K15 K16 K21 K25 K27 K28 K30 |
K1: Understands the structures and functions of the human body.
Back to Duty
K2: Understand how to support people going through the continuing healthcare process.
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K3: Understand commonly encountered mental, physical, behavioural and cognitive health conditions, medication usage and treatments and and how ill health impacts on the individual and their family.
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K4: The principles of infection control.
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K5: Understand the principles of funded-nursing care and Joint packages of care and how the associate continuing healthcare practitioner can support the planning and assessment of these.
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K6: Knows how and when to plan and facilitate referal, discharge or transition of care between professionals, settings or services and what makes up an appropriate care package.
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K7: Understands the principles of a primary health need and the difference between health and social care needs.
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K8: Understand the importance and how to use a range of communication methods and media available to assist with communication.
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K9: The range of health and social care contract types used, including personal health budgets and services commissioned to treat and support individuals with ill health, disabilities and social care needs.
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K10: Knows the principles of healthcare business and financial planning, commissioning and procurement and how this impacts on continuing healthcare services and the numeracy to undertake basic budgetary analysis.
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K11: Understand the impact of co-morbidities and the demands of meeting people’s complex health and social care needs when commissioning services.
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K12: How to undertake risk assessment, using a range of commonly used tools, and know when to seek advice to avoid compromising quality and safety of others.
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K13: Understands the factors which affect vulnerable people and how this can impact on the health and social care needs and the role of safeguarding policy in oversight of their care.
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K14: Understand the differences between risk aversion and risk management and how to avoid compromising quality of care commissioned but work towards the choices of the individual where safe to do so.
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K15: Understand the role and function of the care quality commission for care home, supportive living and home care providers.
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K16: Understand the importance of contractual management in maintaining the quality, sustainability and effectiveness of services and what contractual levers can be used if concerns are identified.
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K17: Knows how discriminatory behaviour is exhibited and the impact this can have on individuals and the commissioning function.
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K18: Techniques to manage differences of opinion, conflict and difficult conversations between professionals.
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K19: Understand the principles of accountability and how this applies to the role of associate continuing healthcare practitioner.
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K20: Understands the principles of courage, transparency and the professional duty of candour.
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K21: Knows how care navigation/social prescribing can be used to address the individual’s needs and support them to move from dependence to more independence.
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K22: Understand roles, responsibilities and models of care of all members of the health and social care multidisciplinary team in providing and commissioning care and how the multi-disciplinary teams contribute to a lawful assessment for eligibility of Continuing healthcare.
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K23: Understand the principles of effective leadership and supervisory opportunities and roles for a associate continuing healthcare practitioner.
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K24: Understand the demands of multi-disciplinary practice and strategies to develop resilience in self and know how to seek support to help deal with uncertain situations.
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K25: Understand relevant legal, regulatory and governance requirements, policies, and frameworks, including any mandatory reporting duties, to all areas of practice.
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K26: Knows the financial implications that eligibility has and how this can influence demand on the service, behaviours and decisions made.
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K27: Knows how to critically appraise and reflect upon knowledge, research and practice and understand how this can be used in practice improve the quality of care and service delivered and commissioned.
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K28: The importance of accurate and timely data collection processes and how this has an impact on local and national assurance mechanisms.
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K29: Know how to review individual’s health and social care needs related to breathing, nutrition, bladder and bowel health, skin integrity, mobility, communication, psychological and emotional, cognition, behaviour, symptom control and consciousness.
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K30: Understand the challenges of providing safe care for people with complex co-morbidities and complex care needs.
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K31: Understands methods for dealing with potential conflict situations.
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K32: Recognises the impact of claims companies and solicitors on the appeals process.
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K33: Understands the roles, responsibilities and functions of the health and social care professionals that form a multi-disciplinary team.
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S1: To make appropriate referrals of an individual into the continuing healthcare service via a standard or fast-track referral pathway, using the mandated screening tools as per national policy, rejecting and redirecting any inappropriate referrals.
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S2: To formulate, monitor and reassess person-centred, evidence based health and social care plan, delegated by registered practitioner, ensuring commissioned services maintain optimal independence and health and social care outcomes where possible and continues to meet the needs of the individual.
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S3: Take appropriate action where change in health or social care need requires screening, referral or further multi-disciplinary teams assessment to establish ongoing continuing healthcare eligibility.
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S4: Co-ordinate routine planning and management of referral, discharge or transition of care between professionals, settings or services.
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S5: Protect health through applying the principles of infection prevention and control.
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S6: Communicate and provide information in an accessible way that is sensitive and appropriate, using a range of skills and strategies with colleagues and people at all stages of life and with a range of mental, physical, cognitive and behavioural challenges recognising common barriers to communication.
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S7: Utilise report writing skills to formulate clear and evidence based multidisciplinary team recommendations.
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S8: Develop, manage and maintain appropriate relationships and rapport with people, their families, carers, colleagues and providers.
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S9: Facilitate discussions with individuals and their families to set an indicative Personal health budget.
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S10: Identify responsible commissioner for individuals referred into the continuing healthcare service.
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S11: Commission a package of care for an individual eligible for continuing healthcare, under the supervision of a clinical professional.
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S12: Manage and prioritise competing demands, prioritising workload based on level of risk.
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S13: Process referrals in a timely manner.
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S14: In a range of settings, recognise where people could be at risk, including from neglect, and take appropriate action to report potential risk for assessment.
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S15: Commission safe, effective and person-centred health and social care packages for people who have co-morbidities and complex care needs, under the supervision of a clinical professional.
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S16: Participate in data collection to support service delivery evaluation, audit or assurance activity to identify appropriate quality improvement activities or any gaps within the provider market.
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S17: Works within limits of own competence, experience and training, delegating tasks and escalating issues and duties appropriately.
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S18: Act as an advocate for the individual.
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S19: Use facilitation and co-ordination skills to make best use of the contributions of others across the multidisciplinary team for the purposes of a lawful assessment or review.
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S20: Apply the principles of effective leadership.
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S21: Act as a role model to colleagues, supervising and providing feedback about behaviour and actions of others, motivating them to reflect on and develop their practice.
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S22: Ensure the wellbeing and resilience needs of the team are met and recognise signs of vulnerability in themselves or their colleagues.
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S23: Act in accordance with legislation, national guidance and local policy at all times.
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S24: Can proactively engage with the individual or representative to support an amicable and lawful resolution of conflict or disagreement.
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S25: Identify and collate documents and evidence demonstrating current health and social care need from all professionals involved in the care of the individual, for lawful assessment or review of health and social care need to be undertaken.
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S26: Use a range of digital technologies to access, input, share and apply information and data within teams and between agencies.
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S27: Complete, store and retain accurate and contemporaneous records and data.
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S28: The ability to read, interpret and understand clinical records and notes.
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B1: Act in a non-discriminatory fashion, treating people with dignity and respecting individual's diversity, beliefs, culture, needs, values, privacy and preferences.
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B2: Be caring, sensitive and compassionate, nurturing the potential in others.
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B3: Have the courage to speak up and challenge areas of concern or any discriminatory behaviour, providing honest, accurate and constructive feedback.
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B4: Be competent, reliable and committed, using reflection to constantly improve and work to evidence based best practice always working within limits of own competence, experience and training.
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B5: Be adaptable, reliable and consistent, show discretion, resilience and self-awareness and demonstrate leadership.
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B6: Communicate in ways that are sensitive and appropriate, considering emotional, psychological, cognitive, language, social and other circumstances.
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B7: Constantly works to build the development of a positive associate CHC practitioner-patient relationship as a core element of the role.
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B8: Act as an ambassador and promote trust, upholding the reputation and promoting public confidence in the continuing healthcare service.
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B9: Demonstrates accountability in practice, engaging proactively in continuing development and training.
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5
24
| Version | Change detail | Earliest start date | Latest start date |
|---|---|---|---|
| 1.1 | Standard and end-point assessment plan revised | 05/09/2023 | Not set |
| 1.0 | Approved for delivery | 11/07/2019 | 04/09/2023 |
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