The Decision Support Tool and the 12 Care Domains

NHS Continuing Healthcare

How the twelve care domains are scored, and what the completed tool has to show to point to a primary health need.

01What is the Decision Support Tool?

The Decision Support Tool (DST) brings together evidence from a comprehensive assessment of health and social-care needs to support an NHS Continuing Healthcare recommendation in England. It is not an assessment of needs by itself. The multidisciplinary team records needs and reasoning across twelve domains and considers nature, intensity, complexity and unpredictability together. The Integrated Care Board (ICB) makes the eligibility decision; the DST is not a points calculator.

Plain English

For families and professionals

England and Wales

National coverage

Registered professionals

Written and reviewed

The DST is normally completed after a positive Checklist, although a full assessment can be arranged without a Checklist. It should reflect the person’s assessed needs, the care required and how needs interact. Ask for the evidence and reasoning for each domain level and the overall primary-health-need recommendation, rather than treating individual levels as a simple total.

02The four key characteristics

The team must consider the totality of needs using four characteristics. Each may be relevant alone or in combination:

• Nature: the type of need and the kind of care it demands
• Intensity: the quantity, severity and continuity of needs, including the support required
• Complexity: how the needs interact and how skilled the response has to be
• Unpredictability: how far needs fluctuate and the risk that arises when they do

03How to prepare for the DST meeting

The tool can only score what the team can see. Preparation is what puts the real picture in front of them:

• Ask for the evidence pack in advance and read it against your own knowledge
• Describe current needs, the support and skill required to manage them, risks and interactions; successful management does not mean a need has disappeared
• Bring night records, incident logs, medication and continence charts
• Use representative records showing ordinary periods and fluctuations, including difficult episodes and what successful support achieves
• Ask for reasoning and any disagreement to be recorded against each domain

04Where people often go wrong

• Letting well-managed needs be scored low because current care keeps them stable
• Accepting domain levels that are agreed quickly without evidence
• Treating the total as a points score rather than a description of need
• Not challenging a domain left blank or marked no needs without discussion
• Leaving the meeting without the reasoning recorded against each domain
• Letting well-managed needs be scored low because current care keeps them stable
• Accepting domain levels that are agreed quickly without evidence
• Treating the total as a points score rather than a description of need
• Not challenging a domain left blank or marked no needs without discussion
• Leaving the meeting without the reasoning recorded against each domain

05The twelve care domains

The twelve domains are behaviour, cognition, psychological and emotional needs, communication, mobility, nutrition, continence, skin and tissue viability, breathing, drug therapies and medication, altered states of consciousness, and a final domain for other significant care needs. Each is scored on a scale that runs from no needs through low, moderate, high and severe, with four domains, behaviour, breathing, drug therapies and altered states of consciousness, able to reach the highest level of priority. The maximum level differs by domain, which is deliberate: it reflects how serious a need in that area can be.

06A social work led multidisciplinary practice

Before the meeting, organise evidence by the relevant domains and the four key characteristics. Ask how the person’s own views and any disagreement will be recorded. Afterward, obtain the completed DST, recommendation, decision and reasons, subject to the proper basis for sharing records.

07Related pages

The CHC Assessment ProcessCHC Eligibility and Primary Health NeedCHC domain levels explainedThe four key characteristicsCHC assessment support

08Frequently Asked Questions

How many domains do you need to qualify?

There is no simple domain total. The guidance normally expects a recommendation and decision of eligibility for one priority-level need or two or more severe-level needs. Other combinations can also indicate a primary health need. In every case, consider the overall needs, their interactions and the four key characteristics, with reasons recorded.

What is a well-managed need?

A well-managed need remains a need where active support or skill is still required. Describe that support, the current risk and the evidence. The guidance does not require every well-controlled condition to be scored as though medication or routine care were absent. A genuine permanent reduction or removal of a need must also be reflected.

Who completes the Decision Support Tool?

The minimum is two professionals from different healthcare professions, or a healthcare professional and a person responsible for assessing care-and-support needs under the Care Act. The team should usually include health and social-care knowledge of the individual. The person and their representative should be supported to contribute.

Is the DST the final decision?

No. The team makes a recommendation. The Integrated Care Board makes the decision and must confirm it in writing. If the Board departs from the recommendation it should give clear reasons.

This page explains the NHS Continuing Healthcare Decision Support Tool in England. It is general information rather than legal advice, and it does not replace an assessment of an individual's needs.

09Keep a record of the DST and decision

Retain the evidence list, domain reasoning, recorded disagreements, recommendation and written ICB decision. If the decision is disputed, identify the specific issue and the relevant records, then check the ICB’s local resolution instructions and dates.