Why the domains matter to you
A multidisciplinary team completes the Decision Support Tool across these domains, and the integrated care board uses the completed tool to make its decision. Source: Department of Health and Social Care, NHS continuing healthcare decision support tool guidance, last updated 27 October 2022.
So the domains are the shape of the conversation. If your account of an ordinary week is written in the same shape, none of it gets lost for the simple reason that nobody thought to ask.
All 12 domains
Domain names are as the framework lists them. Everything under each name is our own plain description of the subject matter, plus the questions we ask a family about it.
Domain 1
Breathing
Breathing, and any help or equipment needed for it.
What this domain covers
- Breathlessness and how it is managed day to day
- Oxygen, nebulisers, inhalers and any breathing equipment
- Suction, tracheostomy care or ventilation where these are used
- Chest infections and how often they happen
Questions worth answering in your own words
- Describe breathing on an ordinary day. When is it worse, and what happens then?
- What equipment is used for breathing, who sets it up, and how often?
- Who checks the equipment or the settings, and what do they have to watch for?
- How often has a chest infection or a breathing problem needed a GP, a nurse, an out of hours call or an ambulance in the past year?
- Does breathing wake them or you at night, and what has to be done?
What has happened when the help was not there
- What has happened when the breathing equipment was not set up, ran out or failed?
- What have you seen happen when help with breathing arrived late or not at all?
Domain 2
Nutrition: food and drink
Eating and drinking, and any help, equipment or feeding regime needed.
What this domain covers
- Help needed to eat and drink
- Swallowing difficulties and any special consistency of food or fluid
- Tube feeding where it is used, and who manages it
- Weight change, appetite and how intake is kept up
Questions worth answering in your own words
- Walk through meals and drinks on an ordinary day. Who does what, and how long does each take?
- Is food or drink changed in any way before it is given, and who decides that?
- Does coughing, choking or difficulty swallowing happen, and how often?
- Is anything recorded, such as what was eaten or drunk, or weight, and who records it?
- Has weight or appetite changed in the past year, and what has been done about it?
What has happened when the help was not there
- What has happened when a meal or drink was missed, or when nobody was there to help?
- What have you seen happen when food or drink was given in the wrong form?
Domain 3
Continence
Bladder and bowel needs, and the help these take.
What this domain covers
- Help needed with the toilet, pads or other continence products
- Catheter or stoma care where these are used
- Constipation, and any regime used to manage bowels
- Washing, changing and skin care that follows an accident
Questions worth answering in your own words
- Describe an ordinary day and night for the toilet. How many times, and who helps?
- What is used, such as pads, a catheter or a stoma, and who manages it?
- How long does a change or a clean up take, and does it need more than one person?
- How often does this happen at night, and who gets up?
- Is there a regime for bowels, and who keeps track of it?
What has happened when the help was not there
- What has happened when a change was late, or when nobody was there?
- What have you seen happen to skin, sleep or dignity after an accident was not dealt with quickly?
Domain 4
Skin and tissue viability
Skin condition, wounds and pressure areas, and the care these take.
What this domain covers
- Pressure areas, repositioning and pressure relieving equipment
- Wounds, ulcers, dressings and who changes them
- Fragile skin, moisture damage and creams or barrier products
- District nurse or tissue viability involvement
Questions worth answering in your own words
- Describe the skin as it is now, and what is done for it each day.
- Is there a wound, ulcer or sore area? Who dresses it, and how often?
- Is repositioning needed, how often, day and night, and who does it?
- What equipment is used, such as a mattress or cushion, and who checks it?
- Which professionals come in for skin or wounds, and how often?
What has happened when the help was not there
- What has happened when repositioning or a dressing was missed or late?
- Has skin broken down before, and what was happening at the time?
Domain 5
Mobility
Moving, position, transfers and falls, and the help these take.
What this domain covers
- Getting up, sitting, standing, walking and transfers
- Hoists, slide sheets, wheelchairs and other equipment
- Falls, near misses and what is done to reduce risk
- Number of people needed to move safely
Questions worth answering in your own words
- Describe every move on an ordinary day, from waking to bed. Who helps with each one?
- What equipment is used, and how many people does a move take?
- How long does a transfer take, and what makes it harder on a bad day?
- Have there been falls or near misses in the past year? How many, and what happened?
- Is any position or movement painful, and how is that handled?
What has happened when the help was not there
- What has happened when a move was attempted without the right help or equipment?
- What do you see if they are left to move on their own?
Domain 6
Communication
Expressing needs and understanding others, and the help this takes.
What this domain covers
- Speech, hearing and understanding
- Ways needs are expressed when words are not available
- Aids, signs, pictures or other communication support
- Who is able to interpret what is meant, and how
Questions worth answering in your own words
- How do they let someone know what they need? Describe how it actually happens.
- Who can understand them, and who cannot?
- How do you know when something is wrong, such as pain or distress?
- What is used to help, such as hearing aids, writing, pictures or gestures?
- How often is something missed or misread, and what follows?
What has happened when the help was not there
- What has happened when a need could not be made known in time?
- What have you seen when someone unfamiliar was providing care?
Domain 7
Psychological and emotional needs
Mood, distress, anxiety and motivation, and the support these take.
What this domain covers
- Low mood, anxiety, fear and distress
- Withdrawal, or needing prompting and encouragement to engage
- Reassurance and how much presence is needed
- Mental health involvement where there is any
Questions worth answering in your own words
- Describe mood across an ordinary week. What is a good day, and what is a bad one?
- What does distress or anxiety look like when it happens, and how often?
- What has to be done to settle it, and how long does that take?
- How much prompting or encouragement is needed for ordinary things?
- Is anyone else involved, such as a mental health team, and how often?
What has happened when the help was not there
- What have you seen happen when nobody was there to reassure or settle them?
- What happens on a day when the usual routine or person is missing?
Domain 8
Cognition
Memory, understanding, awareness of risk and decision making.
What this domain covers
- Memory, orientation and recognition
- Awareness of risk and safety in the home
- Ability to follow or take part in a decision
- How much supervision or prompting is needed
Questions worth answering in your own words
- Describe what memory is like now, with something that actually happened.
- What can they no longer keep track of, and what goes wrong when they try?
- What risks are there around the house, and how are they managed?
- How much of the day needs someone present or checking in?
- How are decisions made, and who makes them?
What has happened when the help was not there
- What has happened when they were left alone, even briefly?
- What have you found afterwards, such as appliances, medication, doors or wandering?
Domain 9
Behaviour
Behaviour that carries risk to them or to others, and how it is managed.
What this domain covers
- Behaviour that puts them or someone else at risk
- Triggers, patterns and warning signs
- What is done to prevent it and what is done during it
- Any specialist involvement or plan
Questions worth answering in your own words
- Describe what happens, in plain terms, using a recent example.
- How often does it happen, at what times, and how long does it last?
- Is there any warning, or does it come without one?
- What is done to prevent it, and what has to be done during it?
- How many people does it take, and has anyone been hurt?
What has happened when the help was not there
- What has happened when there was nobody there, or only one person?
- What has happened when a plan or routine was not followed?
Domain 10
Drug therapies and medication: symptom control
Medication and symptom control, including pain, and the management these take.
What this domain covers
- Medicines given, and who gives them
- Pain and other symptoms, and how well they are controlled
- Refusal, resistance or difficulty taking medication
- Injections, syringe drivers or other routes where used
- Monitoring, side effects and reviews
Questions worth answering in your own words
- List what is given on an ordinary day, at what times, and who gives it.
- How is it given, and what makes that difficult?
- Which symptoms are being managed, and how well is that going day to day?
- What is done when a symptom flares up between doses?
- Who reviews the medication, how often, and how often has it changed in the past year?
What has happened when the help was not there
- What has happened when a dose was missed, late, refused or brought back up?
- What have you seen when a symptom was not controlled?
Domain 11
Altered states of consciousness
Episodes of reduced or lost consciousness, and what they require.
What this domain covers
- Blackouts, collapses, seizures or unresponsive episodes
- How often they happen and how long they last
- What has to be done during and after one
- Any plan or medication held for them
Questions worth answering in your own words
- Describe an episode from start to finish, using the most recent one.
- How often do they happen, and has that changed in the past year?
- Is there any warning beforehand?
- What has to be done during one, and who is able to do it?
- What happens afterwards, and how long does recovery take?
What has happened when the help was not there
- What has happened when an episode began with nobody present?
- Has an episode led to an injury, an ambulance or an admission? Describe what happened.
Domain 12
Other significant care needs
Needs that matter but do not fit the other eleven domains. The framework provides this domain for exactly that purpose.
What this domain covers
- Any significant need not already recorded under another domain
- Needs the family thinks have been left out of the record entirely
Questions worth answering in your own words
- Is there anything you do, or watch for, that none of the questions so far have asked about?
- Describe it as it happens, including how often and who is involved.
- Has anyone recorded it before, and if so where?
What has happened when the help was not there
- What has happened when this was not done, or not noticed in time?
Why we do not publish the levels of need
The Decision Support Tool attaches levels of need to each domain, and not every domain carries every level. We hold those definitions internally for accuracy checks and we deliberately keep them off this page and out of anything we generate. Two reasons, both about you rather than us.
- A level recorded by a multidisciplinary team after an assessment is a professional judgement. A level guessed from a website is not, and a family who arrives certain of a level they were promised has been set up badly.
- The decision is made on the overall picture, not by adding up domains. A page that invited you to total your own domains would be teaching you something untrue about the process. Source: Department of Health and Social Care, National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care, last updated 27 October 2022.
Eligibility for NHS Continuing Healthcare is decided by the integrated care board, informed by a multidisciplinary team assessment. We are not part of that assessment and cannot attend it, and nothing here predicts or implies a decision.
How to prepare, practically
Take one week. Write down what actually happens, with times and numbers, not adjectives. Six specific sentences about last Tuesday night are worth more than a page saying the nights are difficult.
Our free typical day record sheet is built for exactly that, and if you then want it written up across all twelve domains with the letter that matches your stage, that is the CHC Family Evidence Pack. The domains on this page and the domains inside the product come from the same file, so the two can never drift apart.
Sources
- Department of Health and Social Care, NHS continuing healthcare decision support tool guidance, last updated 27 October 2022.
- Department of Health and Social Care, National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care, last updated 27 October 2022.
- NHS website, NHS continuing healthcare, nhs.uk/conditions/social-care-and-support-guide.