Understanding The Need For A Nursing Facility Level of Care

When an aging parent or loved one with disabilities requires long-term care, family caregivers may feel overwhelmed. What options are available for their loved ones? And how do you determine the level of care needed? Understanding today's nursing facility level of care criteria will help you find the best medical setting for your care recipient. 

What does the level of care mean in nursing?

When we talk about the level of care, we're referring to the different types and amounts of care a person needs based on their physical, cognitive, and functional abilities and overall health requirements. This includes a range of services, such as nursing, medical, therapy, and personal care that a person may require. 

The level of care also determines the most suitable environment for the individual and the level of supervision they may need to ensure they receive the appropriate care and support.

How do you determine the level of care?

A state assessor evaluates your care recipient before admission to a nursing facility. They will assess their health conditions, physical abilities, mental status, and capacity for activities of daily living. A doctor certifies their need for nursing home care. The assessment results determine which level of care the person requires.

What are the three basic levels of long-term care?

Not all care is equal. The amount of care your care recipient receives depends on many factors. Caregivers need to familiarize themselves with the different types of long-term care. The three primary levels of nursing facility care are:

• Skilled nursing - This is for those requiring or possibly requiring nursing care 24/7, including full physical and occupational therapy, medication administration, and all other forms of bedside nursing care that one might receive while in a hospital.
• Intermediate care - This is for those requiring very basic nursing care and/or living assistance offered 24/7.
• Assisted living - An assisted living facility has 24 hour protective oversight of the residents and can assist in some day-to-day items, such as feeding or dressing.
• Residential care facility - This is the most independent form of living for elderly, the facility might store and assist with distribution of medications, but nursing care is not required and the facility can offer pretty limited protective or safety oversight. 

The assessment matches the individual with the appropriate level based on their unique needs and capabilities. The level may change over time if their condition improves or declines. 

What are skilled nursing facilities?

Nursing facilities, nursing homes, or skilled nursing facilities care for those who require ongoing medical and personal assistance due to physical or cognitive limitations. They offer nursing, therapy, and other support services necessary when the individual cannot receive care at home.

If your care recipient has a limited income, Medicaid can cover the cost of nursing facility services. The nursing home must meet federal quality standards to qualify for this coverage. Medicare can also provide short-term rehabilitative care in nursing homes.

Where nursing facility services are provided

Regarding nursing facility services, it's important to remember that they are available only in facilities that have been licensed, certified, and have passed inspections. Private homes or adult day centers are not authorized to provide such services. If someone's payment source changes, they don't need to worry about relocating, as they can stay in the same facility for their nursing care.

Eligibility and admission process

States are mandated to provide nursing facility services to all individuals 21 and over who require that level of care. There are no waiting lists like with home and community-based services. How does the state determine eligibility? What is the admission process? 

1. The state's designated assessment entity evaluates the individual to determine their level of care eligibility before admission. 
2. They assess their physical health, functional abilities, and cognitive status.
3. A physician must certify the applicant's need for nursing facility services. 
4. States define their level of care criteria within federal minimum guidelines.
5. A specialized pre-admission screening is also required to identify any mental illness or intellectual/developmental disability that would require additional services.

Applicants may also qualify under higher income and asset limits for facility care compared to home and community-based care.

Levels of care and services provided

The highest level of nursing care is for those needing frequent skilled nursing interventions, restorative therapies, and close medical supervision. Examples include ventilator care, tube feedings, infected wounds, and post-operative rehabilitation. Medicare or other insurance may cover some skilled care.

Intermediate nursing care

This level is for those who need occasional skilled nursing services but primarily require daily assistance with activities of daily living and routine nursing care. Examples are management of chronic conditions like diabetes, ostomy care, dementia, and continence care.

Custodial care

This level of care provides personal care and protective supervision for those with functional deficits who are otherwise medically stable. Services can include bathing, dressing, meals, medication assistance, and monitoring for safety.

In addition to nursing services at the appropriate level, required care includes:

• Specialized therapy like physical, occupational, and speech
• Medical social services
• Physician services
• Pharmacy management
• Dietary consultation and meals
• Activities suited to individual interests and abilities
• Dental, vision, and hearing care
• Medical supplies and equipment
• Room and board

Optional services for additional fees include private rooms, custom equipment, and one-on-one care. The interdisciplinary care planning team tailors services to the resident's needs and goals. The plan is updated as the individual's condition changes.

Transitioning between levels of care

An individual's care needs may change, requiring transitions between settings. For example, a nursing home resident who recovers sufficiently could be discharged home with community-based services. Family caregivers should work with the facility, medical professionals, and case managers during times of transition. 

A person managing at home may eventually require nursing facility care if they develop complex medical needs. Case managers facilitate transitions between levels of care to ensure appropriate ongoing support.

Accessing nursing facility level of care at home

It is possible for someone who requires the level of care provided by a nursing facility to receive care at home through a Home and Community-Based Services (HCBS) Medicaid waiver. This is known as "diversion" or "transition" from institutional care to community-based care, and it is a crucial aspect of HCBS waivers.

Here's how it generally works:

• Assessment: An individual's eligibility for an HCBS waiver is typically determined through an assessment process conducted by the state's Medicaid agency or another designated entity. This assessment considers the person's medical, functional, and support needs to determine if they qualify for the waiver.
• Choice of setting: If the assessment shows that the individual qualifies for an HCBS waiver and expresses a preference for receiving care at home or in a community setting rather than in a nursing facility, they can choose to transition from the institutional setting to the community.
• Development of a care plan: Once the choice is made to transition, a person-centered care plan is developed in collaboration with the individual, their family or legal guardian, and a team of professionals. This plan outlines the specific services and supports needed to meet the individual's needs in a community setting.
• Access to HCBS: With the care plan in place, the individual can access HCBS through the Medicaid waiver. These services can include personal care, respite care, behavioral support, home modifications, transportation, and other supports that enable them to live in the community.
• Monitoring and adjustments: The individual's care plan is regularly monitored and adjusted to ensure it continues to meet their needs and preferences. This can include changes in the types or levels of services provided.

Transitioning from a nursing facility to HCBS allows individuals to receive care in a less restrictive, more community-integrated environment, often more aligned with their preferences, and promotes greater independence. It's important to note that the specific eligibility criteria and available services under HCBS waivers can vary by state, as Medicaid is administered at the state level. Therefore, the process and services available may differ from one state to another.

Participant-direction for individuals who require a Nursing Facility Level of Care

Participant direction, also known as self-direction or consumer direction, is an option available in HCBS Medicaid waivers. It gives individuals with disabilities and their families more control and flexibility over the services and supports they receive.

This approach includes budget authority, allowing individuals to allocate and manage funds for services and hire caregivers. It also fosters closer provider relationships and encourages responsibility and compliance with program rules. While participants enjoy autonomy, they receive support from program coordinators and ensure service quality and safety through accountability measures, ultimately promoting advocacy and empowerment for individuals with disabilities.

Not all Home and Community-Based Services (HCBS) waivers offer participant-directed options, and the availability of such options may vary by state and program. If you're interested in participant direction, we recommend you work closely with your state's Medicaid agency or waiver program to understand the eligibility criteria, application process, and guidelines for participating in a participant-directed program. The specific rules and procedures may differ from one program to another, so it's important to gather as much information as possible before deciding.

Reach out to your state's Medicaid agency or the agency responsible for HCBS waiver programs if you or someone you know is interested in participant-directed services and needs a Nursing Facility Level of Care. These agencies can provide information on the availability of participant-directed options and the specific requirements for participation in your state. This will help you understand how to access and navigate the participant-directed services within your program and location.

Choosing the right level of care

Understanding the different levels of nursing care can help family caregivers choose the best facility when long-term services become necessary. While states vary in criteria, the goal is to match individuals with appropriate care and supervision based on their capabilities and medical needs.

For family caregivers looking to support their loved ones, a range of services and programs are available to help make the journey smoother and more comfortable. These services cater to the unique needs of your loved one as they age.