Medical requirements for nursing home admission
Before a nursing home can admit a resident, they must ensure the individual's medical needs align with the care they provide. A comprehensive medical assessment determines if the person requires a "nursing facility level of care" (NFLOC). While specific criteria vary by state, several common factors are evaluated by a physician or qualified medical team.
Common evaluation criteria
- Physical functional ability: Assess the individual's ability to perform Activities of Daily Living (ADLs), such as bathing, dressing, eating, toileting, and mobility. Formal tools like the Katz Index may be used to document the level of assistance needed.
- Health issues and needs: Determine if the person has a chronic, disabling illness or requires complex daily medical care, such as injections, wound dressings, or catheter care.
- Cognitive impairment: Evaluate for conditions like Alzheimer's or dementia that affect mental function, memory, and decision-making capacity.
- Behavioral issues: Assess for challenging behaviors such as wandering, aggression, or impulsiveness that may pose a safety risk to the individual or others.
- Physician's order: A doctor's official order is required for admission, especially for Medicare or Medicaid payment. This order confirms the need for skilled nursing care and includes a plan for treatment.
- Preadmission Screening and Resident Review (PASRR): For Medicaid-funded facilities, a federally mandated screening determines if an individual has a serious mental illness or intellectual/developmental disability, ensuring they receive appropriate care.
Required medical documentation
- Physician's Admission Order: A written order from the doctor recommending admission.
- Medical History & Physical Exam: A record of past and current health conditions, medications, test results, and allergies.
- State-required assessment form: A form completed by a physician or hospital discharge planner certifying the person meets the state's nursing home criteria.
- TB test results: A negative tuberculosis test or chest X-ray is typically required for admission.
- Advance directives: Copies of the individual's living will or other end-of-life care wishes.
Legal authority and documentation
Clear legal authority is essential for making healthcare and financial decisions, especially if the individual lacks the mental capacity to do so. In most cases, a person cannot be forced into a nursing home against their will if they are mentally competent.
Legal documents and authority
- Medical Power of Attorney (POA): This document designates a trusted individual to make medical decisions, including nursing home placement, on the person's behalf if they become incapacitated.
- Guardianship/Conservatorship: If a person is deemed legally incompetent by a court, a guardian (for health decisions) or conservator (for financial affairs) is appointed. This process is used only when the individual cannot make their own decisions and is often a last resort.
- HIPAA Authorization: A form that allows the designated agent to access the individual's protected health information.
- Admission Agreement: A legally binding contract between the nursing home and the resident (or their representative). It details services, costs, and residents' rights. It is critical to have this reviewed by an elder law attorney.
Financial considerations and payment options
Nursing home care is expensive, and understanding payment options is a crucial part of the admission process. Facilities will require a financial assessment to ensure care can be paid for.
Comparison of payment options
| Payment Method | Covers Long-Term Nursing Home Care? | Eligibility & Coverage Details |
|---|---|---|
| Private Pay | Yes | Uses personal savings, pensions, annuities, or proceeds from asset sales. Offers the most flexibility but can deplete assets quickly. |
| Medicare | No (with exceptions) | Does not cover custodial long-term care. May cover a short-term stay (up to 100 days) for skilled nursing care following a qualifying 3-day hospital stay. |
| Medicaid | Yes | For those with limited income and assets who meet state-specific financial and medical criteria. Requires financial disclosure and potential asset "spend-down". |
| Long-Term Care Insurance | Yes (policy dependent) | Policy benefits and coverage can vary widely. Policies bought earlier in life are typically less expensive. Not available if care is already needed. |
| Veterans Affairs (VA) Benefits | Yes (for qualified veterans) | Benefits, such as VA Aid and Attendance, can help cover the cost of care for eligible veterans and their spouses. |
The admissions process: Step-by-step
- Assess the individual's needs: Consult with a physician or geriatric care manager to determine if nursing home care is the most appropriate option based on medical, cognitive, and functional needs.
- Evaluate alternatives: Consider alternatives like assisted living, home health aides, or PACE programs if the level of care required is lower.
- Research facilities: Use online tools like Medicare's Care Compare to research and compare nursing homes. Check for Medicare/Medicaid certification and review inspection histories.
- Tour and interview: Visit potential facilities. Ask questions about staffing, care plans, activities, and costs. Observe staff-resident interactions and facility cleanliness.
- Gather documentation: Collect all necessary medical, legal, and financial paperwork.
- Complete state-specific forms: Fill out any state-mandated assessment forms, such as the Preadmission Screening and Resident Review (PASRR).
- Submit applications: If needed, apply for Medicare, Medicaid, or VA benefits. Submit the admissions application to the chosen nursing home.
- Sign the contract: Carefully read and understand the admission agreement before signing. Seek legal review if needed.
- Coordinate the move: Work with the facility's admissions and social work staff to plan the transition. Arrange for necessary medical assessments and immunizations before move-in.
Conclusion
Placing a loved one in a nursing home involves a detailed process encompassing medical evaluations, securing legal authority, navigating complex financial options, and completing extensive paperwork. The journey requires careful research and planning, but understanding the steps—from assessing eligibility and gathering documents to touring facilities and coordinating the move—can make the process more manageable. While the decision is deeply personal and often emotional, having a clear understanding of the requirements ensures the individual receives the appropriate level of care and support in a safe and suitable environment.
Can you force someone into a nursing home?
If a person is mentally competent, they cannot be forced into a nursing home against their will. If they are deemed legally incompetent by a court, a guardian or conservator may be appointed to make placement decisions in their best interest.
What happens if an elderly person refuses nursing home care?
When a competent elderly person refuses nursing home care despite being unsafe at home, families may need to pursue alternatives like increased in-home care or seek guidance from Adult Protective Services (APS) or an elder law attorney.
When is a nursing home stay covered by Medicare?
Medicare only covers short-term skilled nursing care for up to 100 days, and only after a qualifying inpatient hospital stay. It does not cover long-term custodial care.
What are Activities of Daily Living (ADLs)?
ADLs are basic self-care tasks, such as bathing, dressing, eating, and walking. The inability to perform these tasks independently is a key factor in determining the need for nursing home-level care.
Do nursing homes require a deposit?
For residents whose stay is covered by Medicare or Medicaid, facilities cannot require a deposit. However, a deposit may be required for services not covered by these programs.
What is the difference between a nursing home and assisted living?
Nursing homes provide 24/7 skilled nursing care for individuals with complex medical needs, while assisted living offers supportive housing and assistance with daily tasks for those who are more independent.
Where can I find information on the quality of nursing homes?
Medicare's Care Compare website provides ratings and inspection histories for all Medicare and Medicaid-certified nursing homes.
