What is a Primary Health Need in CHC Assessments?

What needs are considered when assessing a primary health need?

There is no set list of needs that automatically amounts to a primary health need. However, relevant needs may include breathing difficulties, problems eating or drinking safely, complex medication needs, reduced mobility, cognitive impairment or challenging behaviour.

What matters is the overall nature and extent of those needs, how they interact and the care required to manage them. Having any one of these needs does not automatically mean your relative will qualify for CHC.

How is a primary health need assessed?

If your relative progresses to a full CHC assessment, their care needs will be considered in detail by a multidisciplinary team (MDT). The aim is to build an accurate picture of the care and support they require on a day-to-day basis.

The team records these needs using a Decision Support Tool (DST), which considers different areas of care, including mobility, cognition, nutrition, medication and behaviour. Each area is assessed according to the level of need your relative has.

However, the final decision is not simply a matter of adding up the scores in the DST.

To determine whether your relative has a primary health need, the team considers four key characteristics:

• Nature
• Intensity
• Complexity
• Unpredictability

These characteristics are used to consider the overall type and extent of care your relative requires and whether, taken as a whole, their needs demonstrate a primary health need.

What are the four key characteristics (the “primary health need test”)?

Nature – the type of care required

Nature refers to the type of needs your relative has and the care required to meet them. It considers what those needs involve, how they affect your relative and what interventions are needed to manage them.

It may not be enough simply to record that your relative needs help with medication. The assessment should consider why the medication is required, how it is administered and monitored, whether it is effective, and what could happen if it is missed or their condition changes.

Intensity – the amount of care required

Intensity looks at the amount and severity of the care your relative requires. This can include how often care or intervention is needed, how long it takes and whether support is required repeatedly throughout the day or night.

Your relative may need frequent administrations of medication, continuous monitoring throughout the day and night, or prolonged assistance with other care needs. The assessment should consider how often these interventions are required, how long they take, and the level of skill needed to provide them safely.

Complexity – how different needs interact

Complexity considers how your relative’s different needs interact and whether this makes their care more difficult to manage.

Cognitive impairment may mean your relative cannot reliably communicate pain or recognise risks. If they also have high-risk health conditions, such as epilepsy or breathing difficulties, those needs may become more difficult to monitor and manage when considered together. The assessment should therefore look at the interaction between needs, rather than considering each one in isolation.

Unpredictability – how needs change

Unpredictability looks at whether your relative’s needs fluctuate or change in a way that makes their care more difficult to manage. It also considers the risks if those changes are not identified and responded to appropriately.

Their condition may deteriorate unexpectedly, their symptoms may fluctuate, or they may require intervention at short notice. The assessment should consider how readily these changes can be anticipated and what could happen if the necessary care is delayed.

Do all four characteristics need to be present?

No. Your relative only needs to meet one of the four characteristics to qualify for CHC funding.

What if the CHC assessment does not reflect your relative’s needs?

A CHC assessment should accurately reflect your relative’s day-to-day care needs. If important needs are missed or understated, this can affect the assessment of whether they have a primary health need.

Problems may arise where:

• Needs are considered separately without recognising how they interact;
• The assessment relies on a short snapshot rather than evidence over time;
• A need is described as “stable” without recognising the care required to keep it stable;
• Important risks or interventions are missing from the DST; or
• Relevant care, nursing or medical records have not been properly considered.

Importantly: a well-managed need is still a need. If regular monitoring, supervision or intervention is keeping your relative stable, the assessment should still recognise the underlying need and the care required to manage it.

What evidence can help demonstrate a primary health need?

The evidence considered during a CHC assessment should help show what your relative’s needs are like in practice, including how often care is required, what interventions are needed and what risks arise if that care is not provided.

Relevant evidence may include:

• Care plans and daily care notes
• Nursing and medical records
• Medication records
• Risk assessments
• Incident, falls or behaviour records
• Food, fluid and weight charts
• Records relating to skin care, continence or other significant needs.

It is not simply a question of gathering as many records as possible. Look for evidence that shows the frequency, severity and changing nature of your relative’s needs, as well as the care required to manage them.

For example, if the DST describes your relative as “stable”, but their daily care records show frequent monitoring or repeated interventions, that evidence may provide a very different picture of the care they actually require.

What should you do if you disagree with the CHC assessment?

If you believe the assessment does not accurately reflect your relative’s needs, you should raise your concerns as early as possible.

Rather than simply stating that you disagree, identify the specific parts of the assessment you believe are inaccurate or incomplete.

You should:

• Identify any needs that have been understated or incorrectly described.
• Compare what is recorded in the DST with the care, nursing and medical records.
• Highlight any evidence that contradicts or is missing from the assessment.
• Check whether important risks, monitoring or interventions have been properly recorded.
• Consider whether the interaction between different needs has been taken into account.
• Explain how any inaccuracies affect the assessment of nature, intensity, complexity or unpredictability.

For example, if the DST states that an intervention is only required occasionally, but the care records show that it is needed several times each day, you should highlight that discrepancy and the evidence supporting it. Any disagreement should be clearly recorded rather than simply noted as a general concern.

If your relative is found not eligible for CHC and you believe the decision does not reflect the evidence, you can challenge it through the CHC appeal process. The merits of any challenge will depend on the individual assessment, the supporting evidence and how the primary health need test has been applied.

Getting help with a CHC assessment

Whether your relative has a primary health need will depend on their individual circumstances and the overall nature, intensity, complexity and unpredictability of their needs. A diagnosis, particular condition or the setting of care will not determine eligibility on its own.

What matters is whether the assessment accurately reflects the care your relative requires in practice. If important needs have been understated, interactions between needs have been overlooked or the evidence does not support what has been recorded in the DST, these are issues that should be raised.

If you are wondering whether your relative might qualify for CHC funding, Farley Dwek’s CHC Nurse Advice Line gives you the opportunity to discuss your relative’s circumstances directly with an experienced CHC Nurse Assessor. Our nurse can help you understand how their needs may be considered within the assessment, identify areas that may require closer attention and help you understand what evidence may be relevant.

If you are at an earlier stage and want a general overview of the CHC process, you can also download our free guide.