A Nursing Home Level of Care (NHLOC) is a formal level of care designation commonly used to determine if a person is eligible for Medicaid-funded, nursing home care. It is also used to determine if someone is eligible to receive long-term care and support from Medicaid at home.
Unfortunately, there is no consistency across the 50 U.S. states on the definition of NHLOC. All states define NHLOC differently. Furthermore, in addition to the lack of consistency, most states do not provide a simple definition.
Having said that, below we provide a simplified and generalized description that should be sufficient for families to determine if their loved one meets the “nursing home level of care” requirement.
If a person is unable to care for themselves for a sustained period of time and a lack of assistance would result in them being a danger to themselves, they would likely meet the requirement for Nursing Home Level of Care. Typically, states require individuals to be unable to care for themselves in more than one way. For example, a state might require the person to have a combination of memory issues and mobility issues. The reasons for which a person may be unable to care for themselves can be:
Unfortunately, the process to determine NHLOC and who makes that determination differs for each state. Most states require that an individual have a doctor’s diagnosis. However, that may not be sufficient. For example, a doctor may provide a formal diagnosis of Alzheimer’s, but the individual will also need to be observed, perhaps by an Occupational, Behavioral or Physical Therapist or a RN to determine what types of assistance and how much assistance they require. For example, is this individual able to transfer (move from the bed to a chair), bathe, get dressed, use a toilet, or prepare and consume food? What type of support system does the individual have? Is the person at risk of falling or at risk of being emotionally or physically abused? Is the individual able to administer his or her own medications?
Some states will also evaluate how much care the individual’s family can provide, taking into consideration work schedules, proximity, and other responsibilities. This type of analysis is not conducted by a medical doctor, but more likely an administrator or assessor in the state’s Medicaid office. Additional consideration factors include the length of time (in the past) for which the need for care has existed and the projected length of time in the future they will require assistance.
Practically speaking, if one is seeking Medicaid assistance, they should not begin by taking their loved one to a doctor to obtain a Nursing Home Level of Care designation. Instead, they should start by contacting their state Medicaid office. The state will likely require that a specific group of doctors, therapists or administrators be used to make the determination, and it is unlikely that one’s primary care doctor is included in this group.
One thing that remains consistent across the states is that each state uses some sort of assessment tool(s), which may be web-based, downloaded and printed, or goes through a client-server network. However, the assessments themselves and the various parts of the assessments vary greatly. The way the level of care (LOC) determination is made also varies by state. Some states may rank Level of Care (LOC) by low, medium, and high, while others may use a scoring system where the individual is given a numerical score to indicate LOC need.
The way a state defines a “nursing home level of care” is very different from one state to another. The below examples show how several populous states determine NHLOC. Please note, the information that follows may not be 100% accurate as it is quite common for states to revise their requirements and procedures with great frequency. Furthermore, while a policy may be statewide, local administrators may differ in how they execute the policy.
In California, Medicaid is called Medi-Cal, and another name used for nursing homes is Skilled Nursing Facilities (SNF). The elderly individual must be observed, the course of treatment assessed, and a doctor must find there is a need for nursing home care. A senior who has a medical condition, such as a feeding tube or has wounds that require care following surgery, that necessitates around the clock skilled nursing monitoring, might be found to need nursing home placement. The inability to self-administer medications, the inability to feed oneself, the need for substantial help with bathing and dressing, or a mental illness might also be reasons that a senior would require nursing home care. While Alzheimer’s disease and other related dementias are not specifically mentioned by name as reason for nursing home admission, if one presents with unpredictable behavior and moods, such as depression and anxiety, and lack of mental and physical functioning as the disease progresses, it is reasonable to assume mid-late stage Alzheimer’s would meet the requirements for SNF care.
In New York, an elderly individual must have a medical need for nursing home care in order to meet the requirements of nursing home level of care. The ability to perform ADLs is evaluated as part of the deciding factor. For example, is the senior able to eat, bathe, dress, get out of bed, and use the bathroom without assistance? To assist in determining one’s level of care need, a RN must complete an assessment known as the Hospital and Community Patient Review Instrument (H/C PRI). Via this tool, assessments are made based on one’s medical conditions, one’s ability to perform ADLs (eating, mobility, transferring from one position to another, etc.) 60% or more of the time in the past 7 days, and one’s behavior during the past week. For instance, has the senior’s behavior been verbally unpredictable, has the individual been physically aggressive, has behavior been inappropriate, or has the senior been hallucinating? Medications and course of treatment are also factored into the assessment.
In Florida, Medicaid is also referred to as the Statewide Medicaid Managed Care (SMMC) Program. In this state, the terminology Nursing Facility Level of Care (NFLOC) is used, and in order to be designated with requiring this level of care, care must be medically necessary as determined by a physician or registered nurse. The screening tool used to determine if an applicant requires nursing home care is called Comprehensive Assessment and Review for Long-Term Care Services (CARES).
The Department of Elder Affairs conducts CARES assessments, which involve an interview to determine if one requires NFLOC. This is based on medical conditions, functional needs, and behavioral factors.
In North Carolina, a physician must determine that an elderly individual require a Nursing Facility Level of Care. In making this determination, one must have a medical condition that results in the need for care. However, it appears that North Carolina’s requirements for a nursing home level of care might be a bit more lenient than other states. For instance, a senior might get a determination of NFLOC if they need at least 8 hours of care by a registered nurse on a day-to-day basis, require 24-hour nurse monitoring and assessment of needs, or if they are on medications and need them to be administered.
As with all of the states mentioned above, in Texas, one must also have a medical need in order to be determined to need a level of care consistent to that provided in a nursing home. The Texas Medicaid & Health Partnership (TMHP), which is the Medicaid claims administrator for Texas, is the one who makes this determination. A registered nurse completes an assessment, known as a Minimum Data Set (MDS), and once this is completed, TMHP conducts a review to determine if care is medically necessary. In order to meet this designation, a Medicaid applicant must have a medical issue that is severe enough that the needs are greater than can be handled by an individual who is untrained to provide care, and instead the applicant must need care provided by a licensed nurse. To satisfy the criteria that care is medically necessary, a physician must deem it so and care must be needed on a consistent basis.