How to Build Strong Evidence for Every DST Domain in Your CHC Assessment

The Decision Support Tool is the document that determines whether your loved one qualifies for NHS Continuing Healthcare funding. Getting the evidence right for each of its 12 domains is the single most important thing you can do to influence the outcome. This guide explains exactly how.

What is the Decision Support Tool?

The Decision Support Tool (DST) is the standardised assessment framework used by Multi-Disciplinary Teams (MDTs) across England to evaluate whether someone has a “primary health need” — the legal test for NHS Continuing Healthcare eligibility. It was established under the NHS National Framework for Continuing Healthcare and NHS-Funded Nursing Care (2022).

The DST breaks a person's care needs into 12 distinct domains. For each domain, the assessor assigns a scoring level that reflects the nature, intensity, complexity, and unpredictability of the need. The MDT then considers the overall picture to decide whether the person's needs are beyond what a local authority can reasonably provide.

With an 80% rejection rate at initial assessment, most families are not told that they can — and should — submit their own evidence to support the scoring in each domain. The MDT is legally required to consider evidence from families, but only if you present it. This guide will show you how to do that effectively.

What are the 12 DST domains?

Each domain covers a specific area of care need. Understanding what each one means — and what evidence applies — is the first step to building your case. Here is a brief overview of all 12. For a deeper exploration of each domain, see our complete 12 Care Domains guide.

How is evidence scored in each domain?

Each of the 12 domains is scored on a scale with up to six levels, from “No needs” to “Priority”. Not every domain uses all six levels — some have fewer — but the general framework is consistent. The four key characteristics the MDT considers when scoring are:

• Nature — what type of intervention or care is required
• Intensity — how much care is needed and how often
• Complexity — how many interacting needs exist and the skill required
• Unpredictability — how variable or changeable the need is

Here are the scoring levels from highest to lowest:

What counts as strong DST evidence?

The quality of your evidence matters far more than the quantity. Strong evidence is specific, dated, professional, and linked to a particular domain. Here is what assessors find compelling:

• Specific incidents with dates, times, and descriptions of what happened — e.g. "On 14 March 2026 at 2:15am, Mum attempted to leave the care home through a fire exit. Two staff members intervened."
• Medical professional observations recorded in clinical notes, care plans, or correspondence — e.g. GP letters, consultant reports, CPN assessments.
• Current care plans that detail the level of intervention required — particularly those showing 1:1 supervision, specialist input, or clinical nursing tasks.
• Medication records (MAR charts) showing the complexity of the drug regime — multiple daily medications, PRN use, injections, or controlled drugs.
• Risk assessments completed by the care provider — falls risk, Waterlow score (skin integrity), MUST score (nutrition), choking risk.
• Daily care records and handover notes that show the frequency and intensity of care interventions throughout a 24-hour period.

What evidence do assessors dismiss?

Assessors are trained to identify evidence that lacks specificity. The following types of evidence are commonly discounted or given limited weight:

• Vague descriptions without dates or specifics — e.g. "She falls quite often" or "He gets confused sometimes." These give the MDT no basis for scoring.
• Undated observations that cannot be placed in a timeline — if there is no date, the assessor may assume the observation is outdated.
• Hearsay or secondhand accounts — statements like "the carer told me she had a bad night" carry less weight than the actual care record from that night.
• Emotional appeals without supporting facts — while understandable, statements about how difficult the situation is do not address the clinical criteria the MDT must apply.
• Outdated medical records from years ago — the assessment should reflect current needs, so evidence older than 12 months may need to be supplemented with recent documentation.

A well-prepared family statement can bridge the gap between clinical records and the daily reality of care. It should be factual, specific, and structured by domain.

How should you organise evidence by domain?

Presenting evidence in a disorganised way makes it easy for an MDT to overlook critical information. Organising by domain mirrors the structure the assessors themselves use, which makes it far harder to dismiss.

1. Create a folder (physical or digital) with 12 sections, one for each DST domain.
2. For each domain, gather every piece of relevant evidence: care plans, medical letters, incident reports, daily records, and your own observations.
3. Write a brief summary for each domain that connects the evidence to the scoring descriptors. For example: "Under Cognition, the care plan dated 10 January 2026 records that Mum requires prompting for all personal care tasks and cannot be left unsupervised due to wandering risk. This is consistent with a High or Severe score."
4. Highlight the four characteristics — nature, intensity, complexity, unpredictability — for each domain. If the need is unpredictable (e.g. seizures, sudden aggression), say so explicitly.
5. Prepare a one-page cover summary listing each domain and the score you believe the evidence supports, with a page reference to the supporting documentation.

If you are preparing for an MDT assessment, our step-by-step assessment preparation guide walks you through the full process from start to finish.

What is the “well-managed need” trap?

This is one of the most common — and most damaging — reasons families lose CHC assessments. It works like this: your loved one is receiving excellent care. Their pressure ulcers are healing because the nursing staff turn them every two hours. Their behaviour is manageable because three carers are assigned to them at all times. Their seizures are controlled because they receive carefully monitored anti-epileptic medication.

The assessor looks at the current situation and sees someone whose needs appear “moderate” or “low.” But the National Framework (2022) is unambiguous on this point:

“An individual's needs should be assessed on the basis of what their needs are, and not on the basis of how those needs are being met. Well-managed needs are still needs.”

— NHS National Framework for NHS Continuing Healthcare, 2022, paragraph 72

To counter this, your evidence should always document the underlying need, not just the outcome of care. Ask yourself: what would happen if this care were reduced or withdrawn? If the answer is “they would deteriorate rapidly,” then the need is being managed, not resolved. The scoring should reflect the need itself, not the success of the current care package.

Practical tips for documenting well-managed needs:

• Request the care provider's risk assessments — these documents describe what the risks would be without current interventions.
• Ask nursing staff: "What would happen if this intervention were stopped?" Document their answer with the date, time, and name of the person you spoke to.
• Record the resources being deployed: how many staff, how often, what qualifications. If it takes two nurses and a hoist to transfer someone, that is a Severe or Priority mobility need — regardless of how smoothly the transfer currently goes.
• Note any incidents where care was temporarily reduced (staff shortages, shift changes) and the person's condition deteriorated. These are powerful evidence that the need is real and ongoing.

Frequently Asked Questions

What should you do next?

Building strong DST evidence takes time, but it is the most effective thing you can do to influence the outcome of a CHC assessment. Start by understanding the 12 domains, then gather and organise your evidence systematically.

Not sure whether your loved one might qualify? Take our free CHC eligibility screener for an initial indication in under five minutes.

Sources: NHS National Framework (2022) | NHS.uk: Continuing Healthcare