Continuing healthcare (CHC) domains are the 12 specific areas of care assessed by the Decision Support Tool (DST). The 12 CHC domains are:
- Behaviour
- Cognition
- Psychological and emotional
- Communication
- Mobility
- Nutrition
- Continence
- Skin
- Breathing
- Drug therapies and medication
- Altered states of consciousness
- Other significant care needs.
These areas are evaluated using the DST by a Multidisciplinary Team (MDT) based on their level of need, taking into account nature, intensity, complexity, and unpredictability. Level of need can be scored from no needs to high needs or even severe and priority needs, depending on the domain. It’s this score that then determines whether a person is eligible for NHS Continuing Healthcare funding.
In this guide, we’ll explore each of the 12 care domains.
1. Behaviour
This domain focuses on whether a person has challenging or unpredictable behaviours that can put themselves or others at risk.
Challenging behaviour includes aggression, but also covers behaviours including severe disinhibition, intractable noisiness, restlessness, resistance to care, and severe fluctuations in mental states. This is not an exhaustive list, and many other behaviours might trigger a higher need score in this area.
Behaviour needs are scored from no needs to low, moderate, high, severe and finally priority needs.
2. Cognition
Cognition determines whether a person has a cognitive impairment, looking at their memory, decision-making, understanding, and risk awareness.
Examples of higher-need cognitive behaviours include memory issues, severe disorientation or a dependency on others to anticipate their needs and protect them from harm.
Cognition needs are scored from no needs to low, moderate, high and finally severe.
3. Psychological and emotional
The psychological and emotional domain assesses a person’s mental and emotional well-being and how they might contribute to their overall care needs.
This domain is assessed in two key aspects. Firstly, whether a person has mood disturbances, hallucinations, anxiety symptoms or periods of distress. Secondly, whether a person is withdrawing from engaging in their care planning, support, or daily activities. These aspects acknowledge the different forms that psychological and emotional needs can take.
Psychological and emotional needs are scored from no needs to low, moderate and finally high needs.
4. Communication
Communication examines an individual’s ability to express their needs and to understand others.
An example of a high-level communication need is when an individual is unable to reliably communicate their needs at any time in any way, even when steps have been taken to assist them. This can occur when a person has a severe cognitive impairment as a result of a condition such as dementia or Alzheimer’s.
Communication needs are scored from no needs to low, moderate and finally high needs.
5. Mobility
Mobility assesses a person’s ability to move around, their need for assistance with movement, and equipment needs.
This domain reviews several factors, as mobility issues can manifest in various ways. From someone being at high risk of falls to someone who is completely bed-bound.
Mobility needs are scored from no needs to low, moderate, high and finally severe needs.
6. Nutrition
Nutrition reviews an individual’s ability to eat, drink and maintain a healthy diet.
This domain considers how much support a person might need to ensure they are not at risk of malnutrition or dehydration. This can include those who have swallow function impairment, which can often flow from Parkinson’s or occur after a stroke.
Nutrition needs are scored from no needs to low, moderate, high and finally severe needs.
7. Continence
The continence domain examines a person’s bladder management or bowel needs.
A high continence need could be someone who requires timely and skilled intervention to manage their bladder or bowels. For example, someone who is having frequent bladder wash-outs or re-catheterisation.
Being double incontinent would likely fall within the moderate level of need according to the criteria set out in the DST.
Continence needs are scored from no needs to low, moderate and finally high needs.
8. Skin
Skin and tissue visibility needs look to review a person’s skin integrity, risk of sores or wound care.
This domain covers all skin-related problems, from when a person has open wounds to whether they have pressure sores. The degree of grading for pressure sores will reflect the severity of the need. For example, a grade 4 sore would be considered a severe need.
Skin needs are scored from no needs to low, moderate, high and finally severe needs.
9. Breathing
The breathing domain looks at a person’s respiratory needs, including if they need oxygen therapy.
COPD, emphysema or recurrent chest infections are all issues that are assessed within this domain. A priority level of need would be applied if someone is unable to breathe independently and requires mechanical ventilation.
Breathing needs are scored from no needs to low, moderate, high, severe and finally priority needs.
10. Drug therapies & medication
Drug therapies and medication needs consider the management of a person’s medication and how it controls their symptoms.
An example of the severe level of need for pain would be somebody who has severe recurrent or constant pain which is not responding to treatment.
Drug therapies and medication needs are scored from no needs to low, moderate, high, severe and finally priority needs.
11. Altered states of consciousness
Altered states of consciousness needs look at whether a person is affected by a condition that affects their consciousness.
Conditions reviewed can include epilepsy, transient ischaemic attacks (TIAs) or vasovagal syncope. A priority need in this domain could be someone who is in a coma.
Altered states of consciousness needs are scored from no needs to low, moderate, high, and finally priority needs. Unlike other domains, there is no severe level of need.
12. Other significant care needs
The 12th care domain – other significant care needs – is intended to review any other care needs that do not fall within the 11 defined domains.
The 12th CHC domain is available to ensure that an individual’s needs are not incorrectly weighted by the absence of such an opportunity to consider their issues.
Other significant care needs are scored from no needs to low, moderate, high and finally severe needs.
How eligibility is decided
Eligibility for NHS Continuing Healthcare funding is decided in the DST, which we know assesses the 12 CHC care domains explored in this guide.
There is no single score that automatically guarantees funding, except where a priority level is recorded. Instead, the multidisciplinary team will consider:
- The totality of needs across all 12 domains of CHC
- How those needs interact with one another
- Evidence of risk and skilled intervention being required.
A recommendation will then be made to the Integrated Care Board (ICB) as to whether there is a primary health need. The ICB then makes the final eligibility decision.
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