CHC Funding Guide
The 12 care domains that decide
whether the NHS pays.
Every CHC assessment comes down to one question: does this person have a primary health need? The answer is determined by scoring their care needs across 12 domains, using a tool called the Decision Support Tool (DST).
Each domain is scored on a scale from No needs to Priority. The pattern of scores across all 12 domains — not any single domain in isolation — determines whether the person qualifies.
How the scoring works
The MDT panel scores each domain using these levels:
When does the scoring indicate eligibility?
The NHS National Framework (2022) states that a recommendation of eligibility is likely where there is: one Priority rating in any domain, or two or more Severe ratings across different domains. However, a person can also qualify with a combination of High ratings if the overall picture — assessed through the four characteristics of nature, complexity, intensity, and unpredictability — demonstrates a primary health need. There is no fixed points threshold.
All 12 domains explained
For each domain, we show what it measures and what High vs Severe looks like in practice. Use this alongside your evidence templates to build your case.
Behaviour
What this measures: Challenging behaviour that poses a risk to the individual or others — including aggression, self-harm, resistance to care, and disinhibition.
Low
Occasionally agitated or distressed but usually responds to verbal reassurance. No risk to self or others.
Moderate
Behaviour that challenges carers on a regular basis. May require a behaviour management plan. Some risk of harm to self or others.
High
Regular, significant challenging behaviour (daily or near-daily) that requires skilled intervention, de-escalation techniques, or PRN medication. Risk of injury to self or staff. Multiple staff may be needed.
Severe
Behaviour is unpredictable, intense, and poses a serious and ongoing risk. Requires constant observation, specialist staff, or regular use of restraint. Behaviour significantly impacts ability to deliver all other aspects of care.
Key evidence to gather
Incident logs with dates, triggers, duration, and staff response. PRN medication records. Risk assessments. Any specialist behaviour management assessments.
Cognition
What this measures: Cognitive impairment affecting the person's ability to make decisions, understand their environment, or recognise people and places.
Low
Some forgetfulness or confusion but can still participate in daily decisions with prompting.
Moderate
Significant memory loss or confusion. Needs regular supervision. May not recognise familiar people consistently. Difficulty following multi-step instructions.
High
Severe cognitive impairment. Cannot make decisions about care. Does not recognise family or surroundings. At risk of harm due to cognitive deficits (wandering, ingesting harmful substances, inability to recognise danger).
Severe
Profound cognitive impairment creating constant risk. Requires 24/7 supervision. Cognitive deficits directly cause life-threatening situations if unsupervised. May interact with behaviour domain to create compounded risk.
Key evidence to gather
Formal cognitive assessments (MMSE, ACE-III). Care home daily records showing confusion episodes. Wandering incidents. GP or consultant letters documenting cognitive decline.
Psychological / Emotional
What this measures: Mental health needs including depression, anxiety, psychosis, hallucinations, and emotional distress that require clinical intervention.
Low
Low mood or mild anxiety that responds to social interaction and reassurance.
Moderate
Persistent depression, anxiety, or emotional distress requiring ongoing clinical management. May be on psychiatric medication.
High
Significant mental health needs requiring specialist intervention. Hallucinations, delusions, or severe depression affecting daily functioning. May require CPN involvement or psychiatric review.
Severe
Severe and enduring mental health disorder causing constant distress and risk. May require section under the Mental Health Act or 24/7 specialist mental health support. Psychotic symptoms create ongoing risk to self or others.
Key evidence to gather
Mental health assessments. CPN notes. Psychiatric medication records. Incident logs showing distress episodes. Any Mental Health Act assessments.
Communication
What this measures: The person's ability to communicate their needs, understand information, and interact meaningfully with carers and family.
Low
Occasional difficulty finding words or following complex conversations. Can communicate basic needs.
Moderate
Significant communication difficulties. May rely on gestures, limited vocabulary, or communication aids. Staff need to use adapted communication approaches.
High
Very limited or no verbal communication. Relies entirely on non-verbal cues, which only familiar carers can interpret. Communication breakdown leads to distress, unmet needs, or misinterpreted symptoms.
Severe
No meaningful communication. Staff cannot reliably determine the person's needs, wishes, or pain levels. Communication deficit directly contributes to clinical risk (e.g., undetected pain, inability to report abuse).
Key evidence to gather
Speech and language therapy (SALT) assessments. Examples of communication breakdown and consequences. Care plans showing adapted communication methods.
Mobility
What this measures: The person's ability to move independently, transfer, and maintain posture — including falls risk and requirement for equipment or assistance.
Low
Can mobilise independently or with a walking aid. Occasional unsteadiness. Low falls risk.
Moderate
Requires regular assistance from one carer to mobilise or transfer. Uses wheelchair for longer distances. Some falls history.
High
Fully dependent on others for all mobility. Requires hoist for all transfers with two carers. Significant falls risk (multiple falls per month). May have contractures or postural issues requiring specialist positioning.
Severe
Completely immobile. All repositioning requires specialist equipment and two or more carers. High risk of pressure injury. Transfers carry significant risk of harm (fractures, skin tears). Specialist assessment for seating and positioning required.
Key evidence to gather
Falls log with dates and outcomes. Physiotherapy assessments. Moving and handling risk assessments. Equipment inventory (hoist, profiling bed, specialist wheelchair, pressure-relieving mattress).
Nutrition
What this measures: The person's ability to eat and drink safely, maintain weight, and manage any swallowing difficulties (dysphagia).
Low
Eats and drinks independently. May need a modified diet for medical reasons but manages this safely.
Moderate
Requires assistance with eating (prompting, cutting food, adapted utensils). Mild swallowing difficulties — on SALT-recommended modified diet. Some weight monitoring needed.
High
Significant dysphagia requiring puree diet and thickened fluids. At risk of aspiration. Requires one-to-one supervision during meals. Ongoing weight loss despite intervention. SALT involved regularly.
Severe
Requires PEG feeding or is at severe aspiration risk despite maximum oral modification. Multiple aspiration pneumonia episodes. Nutritional status critically compromised. May require parenteral nutrition.
Key evidence to gather
SALT assessments with diet and fluid recommendations. Weight charts. Food and fluid intake records. Hospital admissions for aspiration. PEG feeding care plans.
Continence
What this measures: The person's ability to manage bladder and bowel function, including catheter care and the impact of incontinence on skin integrity and dignity.
Low
Continent or manages with minimal support (continence pads, reminders to use the toilet).
Moderate
Regular incontinence requiring scheduled pad changes. May have a catheter that is managed routinely. Some skin monitoring needed.
High
Doubly incontinent with frequent episodes. Skin at risk of breakdown (redness, excoriation). Catheter management with complications (bypassing, blockages, infections). Continence issues interact with mobility and skin domains.
Severe
Severe incontinence causing recurrent skin breakdown (pressure sores grade 2+). Catheter complications requiring frequent clinical intervention. Bowel management regime requiring trained staff (manual evacuation, rectal medications). Continence needs dominate care routine.
Key evidence to gather
Continence assessment records. Pad change frequency logs. Catheter care records. Tissue viability assessments for incontinence-related skin damage. Infection records (UTIs).
Skin Integrity
What this measures: The person's skin condition, including pressure sores, wounds, and the care regime required to maintain or restore skin integrity.
Low
Intact skin. Uses pressure-relieving equipment as a precaution. Low risk on Waterlow or Braden scale.
Moderate
Grade 1-2 pressure sore or minor wounds. Requires regular repositioning schedule and standard wound care. Moderate risk on Waterlow/Braden.
High
Grade 3 pressure sore or multiple wounds requiring daily specialist dressing. High risk of skin breakdown. Full pressure-relieving equipment in use. Tissue viability nurse involved.
Severe
Grade 4 pressure sore or non-healing wound requiring complex treatment (e.g., VAC therapy, surgical debridement). Multiple sites of skin breakdown. Skin management is a primary clinical focus requiring constant repositioning and specialist intervention.
Key evidence to gather
Wound assessment charts with grading. Waterlow/Braden risk assessments. Tissue viability nurse reports. Repositioning schedule. Equipment inventory (air mattress, cushion, heel protectors).
Breathing
What this measures: The person's respiratory function and any need for clinical support — including oxygen therapy, nebulisers, suction, and ventilation.
Low
No significant breathing issues. May use an inhaler for mild asthma or COPD but manages independently.
Moderate
Diagnosed respiratory condition requiring regular monitoring (peak flow, oxygen saturations). Uses nebulisers or regular inhalers. Occasional exacerbations.
High
Requires supplemental oxygen (continuous or frequent). Regular nebulisers and clinical monitoring. Multiple hospital admissions for respiratory issues. Suctioning may be needed. COPD or respiratory condition significantly limits daily functioning.
Severe
Ventilator-dependent or requires continuous oxygen with close monitoring. Frequent or unpredictable respiratory crises. Suctioning required regularly. Risk of respiratory arrest. May need tracheostomy care.
Key evidence to gather
Oxygen prescription and usage logs. Nebuliser frequency records. Hospital admission records for respiratory episodes. Oxygen saturation monitoring. Respiratory consultant letters.
Drug Therapies and Medication
What this measures: The complexity of the person's medication regime and any associated monitoring, administration challenges, or adverse effects.
Low
Simple medication regime. Takes oral medications independently or with reminders.
Moderate
Multiple medications requiring timed administration. May need medication administered by trained staff (e.g., blister packs, insulin). Routine monitoring required (blood pressure, blood sugar).
High
Complex medication regime involving injections (insulin, enoxaparin), regular clinical monitoring (INR for warfarin, lithium levels), and risk of significant adverse effects. Covert medication may be required. Drug interactions are a concern.
Severe
Medication regime is the primary clinical challenge. Requires specialist knowledge to administer safely (syringe driver, IV medications, complex titration). Frequent adverse reactions. Medication management dominates the care routine and requires constant clinical oversight.
Key evidence to gather
MAR charts (Medication Administration Records). Prescriptions showing complexity. Monitoring records (INR, HbA1c, lithium levels). Best interests decisions for covert medication. Adverse reaction records. Specialist nurse involvement.
Altered States of Consciousness
What this measures: Seizures, loss of consciousness, delirium, and fluctuating levels of awareness that create clinical risk.
Low
No history of seizures or altered consciousness. Occasional drowsiness from medication.
Moderate
History of seizures that are controlled by medication. Occasional episodes of delirium (e.g., during UTIs). Awareness fluctuates but is generally stable.
High
Recurrent seizures despite medication. Episodes of delirium requiring clinical intervention. Significant fluctuation in consciousness that creates safety risks and affects delivery of care.
Severe
Frequent, unpredictable seizures or prolonged episodes of altered consciousness. Status epilepticus risk. Requires emergency medication to be available at all times (buccal midazolam, rectal diazepam). Altered consciousness is a primary clinical risk requiring constant monitoring.
Key evidence to gather
Seizure log with dates, duration, and type. Post-ictal recovery records. Emergency medication administration records. Neurology consultant letters. Delirium assessments.
Other Significant Needs
What this measures: Any clinical needs not captured by the other 11 domains — including tracheostomy care, stoma care, renal dialysis, and complex pain management.
Low
No additional clinical needs beyond those covered in other domains.
Moderate
Additional clinical needs that are managed routinely (e.g., simple stoma care, compression stockings, routine blood tests).
High
Significant additional clinical needs requiring skilled nursing care (e.g., complex stoma management, peritoneal dialysis, complex wound care not captured in Skin domain).
Severe
Major additional clinical needs that dominate the care regime (e.g., tracheostomy care, haemodialysis, syringe driver management for palliative care). These needs require specialist training and constant clinical oversight.
Key evidence to gather
Specialist assessments and care plans. Equipment and consumable records. Consultant letters. Community nursing records. Palliative care team involvement.
The four characteristics: nature, complexity, intensity, unpredictability
After scoring the 12 domains, the MDT panel must consider the totality of needs through four characteristics. This is where many assessments go wrong — panels sometimes focus only on individual domain scores without properly considering how needs interact.
Nature
What type of care is needed? Is it care that the NHS would normally provide (clinical, nursing, therapeutic), or is it social care that a local authority would arrange?
A person who needs regular suctioning, PEG feeding, and clinical wound care has needs that are 'healthcare' in nature, even if delivered in a care home.
Complexity
How do different needs interact? Does the combination of needs require skilled clinical coordination, or are they straightforward even if numerous?
A person with dementia (cognition), dysphagia (nutrition), and recurrent UTIs (continence) has needs that interact — the dementia makes the dysphagia harder to manage, and the UTIs trigger delirium that worsens the dementia. This complexity requires coordinated clinical management.
Intensity
How much care is needed, and how often? This is about quantity — how many hours per day, how many staff, how frequently interventions occur.
A person requiring two-hourly repositioning, 6 pad changes per day, 4 nebulisers daily, and full assistance with all meals has a high intensity of care needs.
Unpredictability
How much do needs fluctuate? Can care be planned in advance, or must staff be ready to respond to sudden changes at any time?
A person with epilepsy whose seizures are uncontrolled despite medication has unpredictable needs — staff must be trained to administer emergency medication at any time, day or night.
Common questions
How many domains need to be scored 'Severe' to qualify for CHC?
There is no fixed formula. The NHS National Framework (2022) states that a recommendation of eligibility is likely where there is at least one domain rated Priority, or two or more domains rated Severe. However, eligibility can also arise from a combination of High scores across several domains — the test is whether the totality of needs demonstrates a 'primary health need'.
What is the difference between High and Severe in CHC scoring?
A High score indicates needs that require regular, skilled clinical intervention or management. A Severe score indicates needs that are intense, unpredictable, or require constant skilled supervision — often with significant risks if care is not delivered. The distinction matters because Severe carries more weight in the overall eligibility decision.
Can CHC eligibility be based on one domain alone?
Yes, if a single domain is scored Priority (the highest level). Priority means the person's needs in that domain are so severe and unpredictable that they require immediate and continuous clinical intervention. In practice, Priority ratings are rare and typically involve life-threatening situations.
Do all 12 domains carry equal weight?
No. The NHS National Framework does not assign explicit weights, but the four characteristics — nature, complexity, intensity, and unpredictability — are used to assess whether the totality of needs constitutes a primary health need. Domains that involve direct clinical management (breathing, drug therapies, altered states) tend to carry more weight in practice than domains like communication or psychological needs, though this is not formally stated.
What are the four characteristics used in CHC eligibility?
Nature (the type and quality of care needed), Complexity (how needs interact and require skilled coordination), Intensity (the quantity and frequency of care), and Unpredictability (the degree to which needs fluctuate and create risk). These characteristics are applied to the totality of needs across all 12 domains, not to individual domains.
Take the next step
See how your evidence maps to the 12 domains
Our Case Strength Report uses AI plus expert review to score your medical records against all 12 DST domains — identifying where your case is strongest and where the evidence gaps are.