Medical and Functional Assessments
Before anyone can be admitted to a nursing home, a thorough medical and functional assessment is required. This process is used to determine if the individual needs a "nursing home level of care" (NFLOC), a standard that varies by state. A physician or qualified medical team must evaluate and certify that the person's needs cannot be met in a less restrictive environment, such as at home or in an assisted living facility.
Core Assessment Areas
While specific assessment tools differ by state, most evaluations focus on several key areas:
- Physical Functional Ability: This measures a person's capacity to perform Activities of Daily Living (ADLs). A person requiring extensive assistance with multiple ADLs, like bathing, dressing, eating, mobility, and toileting, is more likely to qualify.
- Medical Needs: Individuals with complex or chronic medical conditions that require constant monitoring or skilled care, such as intravenous injections, wound care, or frequent medication management, typically meet the medical necessity criteria.
- Cognitive Status: Cognitive decline, particularly from conditions like Alzheimer’s disease or other forms of dementia, is a significant factor. The assessment will look at the person’s ability to make decisions, follow directions, and their potential for wandering or other behavioral concerns.
- Behavioral Issues: For residents with cognitive impairments, behaviors such as wandering, aggression, or impulsiveness that cannot be safely managed elsewhere may necessitate nursing home placement.
Required Medical Documents
In addition to the assessment, the nursing home will require specific medical paperwork:
- A physician's order for admission.
- A medical history and physical exam.
- Physician's orders for medications and treatment.
- Results from recent health screenings, such as a negative tuberculosis (TB) test.
Financial Eligibility for Nursing Home Care
How a person pays for nursing home care is a critical part of the admission process. The average cost can be substantial, and payment sources can include private funds, long-term care insurance, Medicare, and Medicaid.
Payment Options Comparison
| Payment Source | Coverage Type | Duration of Coverage | Eligibility Criteria |
|---|---|---|---|
| Private Pay | Covers full cost of care, including room and board. | Unlimited, as long as funds are available. | No special criteria, but facilities may require a financial assessment. |
| Medicare | Covers short-term skilled care and rehab services following a qualifying 3-day inpatient hospital stay. | Up to 100 days per benefit period. | Requires Medicare Part A, qualifying hospital stay, and need for daily skilled care. |
| Medicaid | Covers long-term care for individuals with limited income and assets. | Unlimited, for as long as the person remains eligible. | Varies by state; requires meeting strict income and asset limits, with rules regarding asset transfers. |
| Long-Term Care Insurance | Varies based on the policy. Some plans cover skilled nursing care. | Varies based on the policy terms. | Requires an active policy, with benefits kicking in once coverage criteria are met. |
The Medicaid Spend Down and Financial Review
For those relying on Medicaid for long-term coverage, the financial review process is extensive. It involves a "spend down" of assets to meet state-mandated limits. Medicaid will review income and assets over a five-year look-back period to prevent the transfer of assets to become eligible. Special protections exist for a spouse who remains in the community.
Legal and Administrative Paperwork
Beyond medical and financial eligibility, a significant amount of legal and administrative paperwork is required for admission.
Key Legal Documents
- Admission Agreement: This is a contract between the nursing home and the resident (or their representative). It outlines the services, costs, resident rights, and other conditions. It is crucial to read this document carefully before signing, and legal counsel is recommended.
- Power of Attorney (POA): If the resident is unable to make their own decisions, a medical or durable financial POA is essential. It grants a designated person the authority to handle legal and financial matters.
- Advance Directives: Documents like a Living Will or Medical Orders for Life-Sustaining Treatment (MOLST) state the individual’s wishes regarding end-of-life care.
The Pre-Admission and Waiting List Process
Once medical necessity and financial plans are addressed, the administrative process continues. Many facilities have waiting lists, and admission can depend on various factors.
The Waiting List System
Facilities often admit residents on a first-come, first-served basis, but exceptions exist for special circumstances, such as emergency placement or spousal reunification. A facility that receives a high percentage of Medicaid residents may have specific rules about admitting new Medicaid patients.
The PASARR Screening
For facilities participating in Medicare and Medicaid, a federal requirement known as the Pre-Admission Screening and Annual Resident Review (PASARR) is mandatory. This screening determines if a person has a mental illness or intellectual disability. It is used to ensure the nursing home can provide appropriate care or, if necessary, assist in finding a more suitable alternative placement. For comprehensive information on resident rights and admission, families should consult authoritative resources, such as the Centers for Medicare & Medicaid Services (CMS) website.
Conclusion
Placing someone in a nursing home is a multi-step process involving medical certification, financial planning, and legal preparation. While the specifics can vary significantly by state and facility, the core requirements revolve around demonstrating medical necessity and securing a viable payment method. Being proactive, gathering all necessary documents, and understanding the process can alleviate stress and ensure your loved one receives the highest quality of care possible.
