The jigsaw principle: guidelines for developing a full and accurate needs portrayal

by Art Calder, Head of Clinical Services, CHS Healthcare

When assessors are being trained for roles with the Ombudsman, they are encouraged to perceive cases like a jigsaw: are there any pieces missing? If pieces A and B fit together, but B and C do not, what do they need to reconsider? This is a helpful concept when we consider the process of building the needs portrayal document (NPD); the foundation for retrospective claims for continuing healthcare funding.

Creating the NPD is undoubtedly the greatest challenge within retrospective claims management. Gathering evidence is a procedural challenge – obtaining records from care homes and services takes persistence and organisation. But the NPD requires the case manager to turn hundreds of pages of contemporaneous evidence into a single document. This requires a high level of skill, judgement and experience.

The NPD incorporates all the available evidence and considers individual needs in each of the domains we use in continuing healthcare: behaviour, cognition, psychological and emotional needs, communication, mobility, nutrition, continence, skin, breathing, drug therapies and medication, consciousness. The case manager developing the NPD is not judging whether that person should be eligible for continuing healthcare; their role is to establish an accurate picture of the person, their needs and capabilities.

When we meet families and go through the NPD, discussions are often about emphasis – we are seeking to portray needs on a typical day, not a particularly bad or good day. The care records may show what medication was needed during a spell of especially poor health, or might record communication on a day when it was notably good.

Discussions with the claimant should be a collaborative way of establishing what the true, typical needs would have been. In my own discussions with families, reading over a needs portrayal, often a relative will comment: “Yes, that would be Mum all over.” When I hear that sort of phrase, it gives me confidence in the portrayal.

We always seek to triangulate data. The majority of evidence for a needs portrayal comes from care home records, but we always seek to cross-reference care home records with other evidence, principally records from visiting professionals, such as GPs, occupational therapists, physiotherapists and hospital records.

Of course, we are evaluating care home records which go back more than a decade to 2004. It is often challenging to find the person within notes that can be very stark and factual. “Bill sat in a chair. Bill had dinner,” notes might tell us. Sometimes, residential care homes provide richer care records, giving us a more rounded picture of the whole person while nursing home records focus on medical details. Today’s care home records are more comprehensive, reflecting not only changes in the way we record care but also the fact that people are living longer with increasingly complex health needs. Records reflect this complexity, although a detailed record might provide more medical information but little about the person as a whole.

It is essential that the person producing the NPD is a clinician experienced in continuing healthcare. They must have the experience of delivering that care to understand what sometimes scant notes mean and how to accurately portray typical needs.

They must also have been comprehensively trained in the process of developing a NPD; to understand how the pieces fit together and the principles of triangulation. This is a specialist role and many CCG continuing healthcare departments are struggling to find the human resource and experience required.

A clinical background is only a very basic foundation for the role. Essential too is a keen eye for detail, honed analytical skills, deep insight to the principles and practice of Continuing Healthcare and in a culture of ongoing sea changes, a wider comprehension of the health and social care legislative world. In other words, we need to be both a Jack and a Master of all trades and there are few people with the necessarily broad skill set and experience.

The Ombudsman training comparison is highly pertinent: the needs portrayal must first stand up to scrutiny of solicitors, panel and ultimately, the Ombudsman, if a complaints process is enacted. Producing the needs portrayal is a testing but critical challenge.