VOL: 100, ISSUE: 02, PAGE NO: 38
William Anderson, RGN, is clinical nurse, specialist care of older people/lead nurse for free nursing care, Canterbury & Coastal Primary Care Trust
Hilary Bungay, PhD, MA, HDCR, is Senectus programme manager, Centre for Health Service Studies, University of Kent
The NHS Plan (Department of Health, 2000) included specific proposals for achieving a fairer approach to the funding of long-term care, and provided the government’s response to the recommendations made by the Royal Commission on Long Term Care (1999).
It was stated in The NHS Plan that NHS nursing care would be made free in all settings, so ending the unfair situation of some people in nursing homes paying for all or part of their nursing care. Free nursing care was to be made available from October 2001 to everyone in care homes who required it.
It was estimated that around 35,000 people at any one time would benefit from free nursing care and that it could save patients up to £5,000 for each year’s stay in a care home.
Defining nursing care
Nursing care has been defined by the DoH as: ‘Services provided by a registered nurse and involving either the provision of care or the planning, supervision or delegation of the provision of care, other than any services which, having regard to their nature and the circumstances in which they are provided, do not need to be provided by a registered nurse’ (DoH, 2001a). This definition does not include services from other personnel, such as care assistants, who may also be involved in the provision of care, but includes the input of registered nurses monitoring care delegated to others (DoH, 2001a). The introduction of free care in nursing homes means that the care given by a registered nurse has to be determined as part of a patient’s health and social care needs assessment. Following this assessment, people’s needs are placed in an appropriate category or band known as the registered nursing contribution to care (RNCC).
Designated registered nurses employed by the NHS must undertake this assessment and the DoH has stipulated that primary care trusts or health authorities should identify two people to implement NHS-funded nursing care - a nursing home coordinator and a lead nurse (DoH, 2001a). The role of the lead nurse is as follows:
- To provide professional nursing advice to nursing homes, councils and the nursing home coordinator about the carrying out of assessments and how the RNCC should be determined;
- To monitor the quality and consistency of RNCC determinations carried out by registered nurses within the health authority or primary care trust;
- To ensure sufficient numbers of nurses receive training in how to determine the RNCC.
The bands of care
The government intended that determination of the RNCC should be an integral part of the care planning process. Each nursing home resident, therefore, is given a comprehensive assessment covering all the domains of the single assessment process, from which an individualised care plan is drawn up.
The most appropriate level of registered nursing input required is based on the assessment information in conjunction with the designated nurse’s professional skills, knowledge and observations of the resident concerned. There are three bands of care: low, medium and high, and each is set within the framework of stability, predictability, risk, frequency and complexity.
The high band
People with high needs for care from a registered nurse will have complex needs that require frequent mechanical, technical and/or therapeutic interventions. They will need to be reassessed by a registered nurse throughout a 24-hour period, and their physical/mental state will be unstable and/or unpredictable (DoH, 2001b).
The medium band
People whose needs for nursing care are judged to be in the medium band may have multiple care needs. They will require the intervention of a registered nurse on at least a daily basis, and may need access to a nurse at any time. However, their condition (including physical, behavioural and psychosocial needs) is stable and predictable, and likely to remain so if treatment and care regimes continue (DoH, 2001b).
The low band
People who are in the low band of need for nursing care will be those who are self-funding and whose care needs it is possible to meet with only minimal input from a registered nurse.
Assessment will indicate that their needs could normally be met in another setting (such as at home, or in a care home that does not provide nursing care, with support from the district nurse), but that, nevertheless, these people have chosen to place themselves in a nursing home (DoH, 2001b).
The importance of appropriate banding
It is important that individuals are banded appropriately and consistently for the following reasons:
- Placing residents in the wrong bands may have a detrimental effect on their quality of care;
- High quality care will result from the development of an individualised care plan;
- There are financial implications for the resident according to which band he or she is placed in.
Consistency of assessments
The specialist support team in East Kent found that their judgements on individual residents sometimes differed regarding stability, predictability, risk and complexity. To address the difficulties of monitoring the quality and consistency of assessments, the East Kent team decided to pilot the minimum data set/resident assessment instrument on residents living in nursing homes as an assessment tool.
The assessment tool
The minimum data set/resident assessment instrument is a comprehensive, multidimensional, standardised assessment tool that links problems, risk factors or potential for improvement to assessment protocols that guide the assessor through best practice in developing care plans. It consists of:
- A minimum set of data;
- A structured assessment tool;
- Resident assessment protocols.
These three parts of the tool guide the assessor through areas of potential patient need to ascertain whether further action is required. The link to care planning is an important factor because it establishes a quality initiative associated with the NHS assessor’s determinations, and is not just concentrating on banding in terms of finance.
The assessment tool not only provides a means of obtaining objective individual assessments, but also has scales that measure the following:
- Activities of daily living;
- Cognitive function;
- Psychosocial function;
- Disturbed behaviour patterns.
The tool has been tested so as to ensure that if two different professionals assess the same person, the resulting assessment will be identical. As the time required for caring for an older person is directly related to that person’s physical, mental and clinical state, a system for identifying the time required to care for an individual has been developed - the Resource Utilisation Group Casemix System, Version III (RUG-III) (Carpenter et al, 2002) (Box 1).
Using the assessment tool
A pilot was set up to use the assessment tool and determine whether it would:
- Facilitate monitoring the quality of assessments;
- Assist the assessors to band residents more accurately and consistently, thereby confidently justifying to residents, their families and other multi-agency professionals the assessment band chosen;
- Confirm funding and eligibility criteria.
A person-centred approach was adopted and the client was involved on all occasions as well as the nurses within the nursing home and those people who knew the residents best.
Determining eligibility for continuing care is a contentious area (DoH, 2002), and the pilot was an opportunity to test whether the assessment tool agreed with the decisions that had been made for people applying for fully funded NHS continuing care.
In the initial stage of the pilot, residents aged between 80 and 95 years old receiving continuing care within nursing homes and coastal hospitals within the East Kent area were assessed and reviewed.
Case study one of Angela Smith (not her real name) illustrates the use of the tool (Box 2, p40).
Case study one: assessing Angela Smith, a client receiving continuing care
Ms Smith was known to have dementia and had had a stroke in the past. She was a very dependent lady who had lost contact with all her family and friends. Her solicitor acted on her behalf and had the power of attorney. She is an example of a client receiving continuing care, and the assessment tool was used to link her needs to the RUG-III system.
The assessor’s view
The designated assessor had previously worked in an acute setting and initially considered that Ms Smith did not fit the criteria for continuing care as her condition was stable and predictable. Because Ms Smith did not need any mechanical or technical intervention, the assessor considered that Ms Smith required only basic nursing care. But, in reality, Ms Smith had very complex needs, which needed to be managed through intense skilled nursing interventions. She was totally dependent on registered nurses to manage and supervise her care 24 hours a day because of multiple risk factors.
How RUG-III determines the need for care
From the assessment, Ms Smith’s RUG-III group was calculated, and this placed her in the special care category (Box 1).
Scores for the following were also calculated:
- Activities of daily living: 18/18 (completely dependent);
- Instrumental activities of daily living (self-performance): 6/6 (complete disablement);
- Cognitive performance: 6/6 (severe impairment);
- Social engagement index: 0/6 (no social involvement).
These scores, in conjunction with the nurse’s professional judgement, placed Ms Smith in the highest level of the special care category.
The RUG-III system can help to identify continuing care clients accurately; for instance, they may be put in the special care group and also the clinically complex group. Professional judgement should then be exercised.
Reassessing to check banding allocations
After completing the pilot for continuing care clients, we had an understanding of the RUG-III system. The next step was to apply the assessment tool to residents who had previously been assessed using the RNCC and to ascertain where they would be identified within the RUG-III system.
Twenty-one residents who had already been allocated to a particular band using the RNCC tool were reassessed. We wanted to discover whether they would fit the same bands using the RUG-III system and, if not, why.
The lead nurse carried out the assessments, after which it was noted that the low, medium and high bands were not as easily defined on the RUG-III system as had been anticipated. Initially it had been thought that the reduced physical function group of RUG-III equated to the low band of the RNCC; that impaired cognition and behaviour problems equated to medium banding and that clinically complex and special care categories equated to high banding. However, the reasons these assessments were not accurate were identified and are explored in the following three case studies.
Case study two: Joseph Black
Joseph Black (not his real name) had been assessed by a registered nurse designated as an NHS assessor as being appropriate for allocation to the medium band, but according to the assessment tool he should have been in the low band. This was actually more appropriate as he could easily be cared for in his own home but had put himself into the nursing home because he did not want to look after himself at home: he liked to be looked after and did not want to be alone.
Mr Black was an example of someone who needed people around him. In the assessment he demonstrated that he could perform all the activities of daily living and that he was cognitively unimpaired. He knew his own mind and his nursing care plans demonstrated his ability to do things.
Case study three: Sarah White
Following her initial assessment with the NHS assessor, Sarah White (not her real name) was placed in a high band. However, reassessment suggested that she fitted into the medium band. The assessment tool on this occasion, did not tell the full story as Ms White had problems with severe breathlessness that were not highlighted. However, there is space on the assessment tool for the assessor to write comments while carrying out the assessment, and this has the advantage of allowing a more complete picture to be built up.
Within the confines of her own room, Ms White was independent, but her chronic chest condition, for which she required nebulisers and oxygen therapy, meant she could become disabled. This explains why the original assessment determined a high banding. However, socially and physically within the confines of her bed area she is independent and can be cared for adequately within the medium band.
Case study four: Iris Brown
Iris Brown (not her real name) had been assessed as suitable for allocation to a low band by the NHS assessor, but from the assessment tool it was clear that this was not appropriate, as she had clinical as well as potential problems. She was assessed as being appropriate for allocation to the high band using the assessment tool, which was also not appropriate. Professional judgement placed her in the medium band with a need for regular reviews. Both of the assessments provided a platform from which to make a professional and clinical decision.
When comparing the findings of the RNCC assessments with the assessment tool we found that the RNCC assessment had correctly placed 11 out of 18 patients in the right level of care, with three undecided. The RUG-III level determined from the assessment tool placed 19 out of 21 patients in the right level of care. This gave an assessment that described each person clearly, and the reason the patient required the level of care that had been agreed was evident.
We found the minimum data set/resident assessment instrument to be a comprehensive assessment tool that can improve the quality of assessments within nursing homes. The fact that it is standardised gives it a universal feel, and training is not required for its use because specific instructions are given on how to complete the assessment correctly.
The information gathered using the assessment tool enabled an accurate picture of residents to be built up, which included their strengths and abilities and whether or not there had been any deterioration in their condition over a certain time. The tool also ensured that staff consider the person as a whole, as the clinical diagnosis is left until near the end of the assessment. This gives the assessor an opportunity to find out about a resident’s views before making a clinical diagnosis.
The Resource Utilisation Group Casemix System Version III (RUG-III) is evidence-based, and allows the professional to evaluate a patient’s needs on a sound basis while minimising political, moral and social pressures. The assessment tool allows an objective decision to be made, which can accurately place people in the correct band of care needs: continuing, high, medium or low care. This is important at the moment, as there have been complaints to the ombudsman from patients, relatives and carers about charges for long-term care. In response, the ombudsman has recommended that there should be a framework in place for eligibility criteria for this type of care.
- This article has been double-blind peer-reviewed.