Initiating the Nursing Home Admission Process
Beginning the process for nursing home admission typically starts with a medical necessity assessment. For most facilities, a licensed medical professional, such as a physician, must certify that the individual requires a nursing home level of care (NFLOC). This assessment evaluates several key areas to determine if care is needed beyond what can be provided at home or in an assisted living setting.
Key Medical and Functional Criteria for Admission
State criteria for nursing home admission generally focus on an individual's inability to live safely alone. These evaluations commonly address the following:
- Physical functional ability: A physician assesses the person's ability to perform activities of daily living (ADLs), such as bathing, dressing, and eating. Tools like the Katz Index or Functional Independence Measure (FIM) are often used to document the level of assistance needed.
- Health issues and medical needs: The presence of chronic conditions, pain management, medication needs, or complex treatments requiring 24-hour skilled nursing care are considered.
- Cognitive impairment: For conditions like Alzheimer's or other dementias, cognitive status is evaluated to determine if a specialized memory care unit is appropriate.
- Behavioral issues: Behaviors associated with cognitive decline, such as aggression or wandering, are assessed to ensure the facility can provide a safe and supportive environment.
Finding and Choosing the Right Facility
Once a medical need is established, the next step is researching and selecting a suitable nursing home. This often involves the family, the individual, and a hospital social worker or discharge planner if the person is currently hospitalized.
Considerations for facility selection include:
- Location: Proximity to family and friends for regular visits is often a priority.
- Quality of care: Resources like Medicare's Care Compare tool provide quality ratings, inspection results, and staffing information for certified facilities. The Joint Commission also offers accreditation information.
- Specialized services: Ensure the facility offers the specific care needed, such as dementia care, rehabilitation, or ventilator support.
- Availability: Due to waitlists, it is important to contact several facilities about current openings. Being transferred directly from a hospital often expedites placement.
Gathering Essential Documents
Admissions paperwork can be extensive. Having key documents prepared in advance helps streamline the process. The following is a general list of items required by most nursing homes:
- Medical Records:
- Physician's order for admission
- Orders for medications and treatments
- Medical history and physical examination results
- Proof of recent tests (e.g., TB test) and vaccinations
- Legal Documents:
- Power of Attorney (POA) for healthcare and finances
- Advance directives or living will
- Social Security card
- Financial Documents:
- Insurance information (Medicare, Medicaid, or private)
- Financial assessment or disclosure, especially if applying for Medicaid
- Relevant banking, investment, or asset information
Navigating Financial Considerations
Paying for nursing home care is a significant concern for most families. Costs can be high, and coverage options vary based on the individual's situation. It is crucial to understand the differences between the primary payment sources.
| Feature | Medicare | Medicaid | Private Pay |
|---|---|---|---|
| Coverage Duration | Short-term stays (up to 100 days) for skilled nursing and rehabilitation after a qualifying hospital stay. | Long-term care for eligible individuals with limited income and resources. | Covered by personal savings or long-term care insurance; no duration limit based on care level. |
| Eligibility | Age 65+ or certain disabilities; must meet specific post-hospitalization criteria for skilled care. | Income and asset limits apply, which vary by state. Many states have a "spend-down" program. | No income or asset requirements, but resources will be used to pay for care. |
| Cost to Resident | No cost for days 1-20, then a daily copayment for days 21-100. All costs fall to the resident after 100 days if long-term care is needed. | Must contribute most income towards care, but covers 100% of the covered expenses once enrolled. Retain a small monthly stipend. | Varies widely by facility. Can quickly deplete personal savings. |
| Application Process | Requires a qualifying three-day hospital stay and physician certification of skilled nursing need. | Contact your state Medicaid office. Requires financial and medical eligibility assessments. | Negotiate directly with the facility and its admissions office. |
For those relying on Medicaid, the “spend-down” process may be necessary, where an individual uses their assets to pay for care until they reach the state’s eligibility threshold. Financial planning with an elder law attorney can help navigate these complex rules. For more information, the Centers for Medicare & Medicaid Services website provides details on certified nursing homes and payment options, including resources for comparing facilities.(https://www.medicare.gov/care-compare/?providerType=NursingHome)
The Final Steps and Transition
After a facility has been chosen, and financial arrangements are confirmed, the final phase involves completing the admissions paperwork and coordinating the move. A hospital's discharge planner will assist with transfers from a hospital setting. For non-emergency admissions, arrangements can be made directly with the nursing home's admissions office. The transition should be as smooth as possible, with staff helping the new resident and their family get acquainted with the new environment. Bringing familiar personal items can also aid in the adjustment process.
Conclusion
Getting admitted to a nursing home is a multi-step process involving a thorough medical assessment, careful facility selection, and complex financial planning. It is a decision typically prompted by a person's inability to safely manage their health needs at home. Whether for short-term rehabilitation or long-term care, the process requires gathering extensive documentation and understanding the intricacies of different payment methods. By proactively navigating these steps and utilizing available resources, families can ensure a smoother and more informed transition for their loved one.
