Elder Care Criteria and Senior Living Admissions

Assisted Living Admission Requirements and Criteria

Assisted living communities provide care to individuals who are 18 years of age or older. Eligibility for admission is based on an individual’s care level requirements. Individuals entering assisted living facilities often need assistance with ADLs (activities of daily living) such as personal care, hygiene assistance, mobility, meal preparation, medication management, and more.

Assisted living is not appropriate for individuals who:

• Have severe cognitive impairment
• Show behavioral symptoms such as wandering
• Have extensive medical needs
• Require daily nursing services

Individuals who use a wheelchair may be discouraged from entering an assisted living facility.

Individuals may enter assisted living facilities from a private residence, rehabilitation center, skilled nursing facility, or a hospital. Regardless, the admissions process is the same.

• Facility Admissions Paperwork
• Medical History and Physical – assisted living facility may require a medical history and a physical.
• Negative Tuberculosis (TB) Test or Chest X-ray

Nursing Home Admission Requirements and Criteria

Moving into a nursing home requires a bit more paperwork, especially if a third party is to pay for the 24-hour care and supervision that a nursing home provides. Although a nursing home staff member will help you through the admissions process, the following will guide and alert you to the items you may need and enable you to prepare them in advance.

• Physician’s Order for Admission to a Skilled Nursing Facility – if being admitted from a hospital, the hospital staff will take care of this; otherwise, you can make an appointment with your family doctor to accomplish this.
• Physician’s Order for Medications and Treatment – these orders will help the nursing home provide the appropriate care. If you are admitted from a hospital, the hospital staff will take care of this; otherwise, you can make an appointment with your family doctor to complete this.
• Medical History and Physical – care providers in a nursing home need up-to-date information. After performing a physical, the primary care doctor can compile a current medical history. If admitted from a hospital, the hospital staff will complete this.
• State-Required Form – each state has its own form (going under various titles) certifying that a patient meets that state’s nursing home criteria. This form is filled out by a primary care doctor or hospital staff.
• Negative Tuberculosis (TB) Test or Chest X-ray
• Nursing Home Admissions Paperwork
• Financial Assessment Paperwork – to determine how care will be paid for.

Skilled Nursing Facility Admission Requirements and Criteria

Skilled nursing facility paperwork and requirements are identical to nursing home requirements, and require the following:

• Physician’s Order for Admission to a Skilled Nursing Facility – if being admitted from a hospital, the hospital staff will take care of this; otherwise, you can make an appointment with your family doctor to accomplish this.
• Physician’s Order for Medications and Treatment – these orders will help the skilled nursing facility to provide the appropriate care needed. If you are admitted from a hospital, the hospital staff will take care of this; otherwise, you can make an appointment with your family doctor to complete this.
• Medical History and Physical – care providers in a skilled nursing facility need up-to-date information. After performing a physical, the primary care doctor can compile a current medical history. If admitted from a hospital, the hospital staff will complete this.
• State-Required Form – each state has its own form (going under various titles) certifying that a patient meets that state’s skilled nursing facility criteria. This form is filled out by a primary care doctor or hospital staff.
• Negative Tuberculosis (TB) Test or Chest X-ray
• Skilled Nursing Facility Admissions Paperwork
• Financial Assessment Paperwork – to determine how care will be paid for.

Memory Care Admission Requirements and Criteria

When memory issues cause significant problems, an individual may no longer qualify for assisted living. Memory care goes beyond assisted living in that in addition to assisting with ADLs, it also addresses the unique needs of someone with memory loss – meaning additional care, supervision, and security.

Individuals may enter a memory care facility from a private residence, rehabilitation center, skilled nursing facility, or a hospital. Regardless, the admissions process is the same.

• Facility Admissions Paperwork
• Medical History and Physical – assisted living facility may require a medical history and a physical, including a report from the doctor who diagnosed the memory issue, such as Alzheimer’s or dementia.
• Negative Tuberculosis (TB) Test or Chest X-ray

Hospice Admission Requirements and Criteria

To receive hospice care under Medicare, an individual must:

• Be entitled to Medicare Part A
• Be certified by a physician to be terminally ill with a prognosis of not more than six months (if the disease were to run its normal course)

To receive care the medical director or another employee of a hospice agency will perform a one-time visit with the patient and/or their family to:

• Provide counseling concerning hospice and available care options
• Discuss advanced care planning
• Evaluate need for symptom and pain management

Since this is a one-time approved visit, in order to be eligible an individual should not have:

• Previously made a hospice election
• Previously received pre-election hospice services

To determine hospice eligibility, a doctor will use local coverage determinations (LCDs) to determine if services are reasonable, necessary and eligible for coverage by Medicare. Despite this, since LCDs are not regulations and should not be used as the absolute determining factor, (re)certification is based on a doctor or medical director’s clinical judgment.

An individual is admitted into hospice care:

• On the medical director's recommendation in consultation with an attending doctor.
• Upon consideration of the diagnosis of a terminal condition, other health conditions (related or unrelated to the terminal condition), and clinically relevant information supporting all diagnoses.

Palliative Care Admission Requirements and Criteria

Palliative care differs from hospice care, although it is often a component of hospice care. Palliative care focuses on providing relief for the symptoms and stress of a serious and life-limiting illness to improve the quality of life for the patient and their family.

Palliative care may be prescribed in the presence of a serious and chronic illness when one or more of the following is also present:

• The patient is considering hospice but has not been referred
• The patient is a previously enrolled hospice patient who has been admitted into the ER
• The patient is a long-term-care recipient who has been admitted into ER and also has Comfort Care (CC) and/or Do Not Resuscitate (DNR) orders
• Diminishing ability to complete ADLs
• Multiple hospitalizations
• More than one ICU admission during a single hospitalization
• Multi-organ failure
• Weight loss
• Patient or family experiencing spiritual or psychological distress
• Patient or family experiencing difficulty controlling emotional or physical symptoms related to serious illness
• Patient, family or doctor has uncertainty regarding goals of care or prognosis
• Limited social support (examples: chronic mental illness, homeless)
• Use of tube feeding or TPN in a seriously ill or cognitively impaired patient
• Patient has impending mechanical ventilation with an illness plus declining function or dementia
• Considering ventilator withdrawal which will likely cause death
• Difficult or prolonged ventilator withdrawal
• Considering transfer to a long-term ventilator facility
• Anoxic encephalopathy
• Patient has impending ICU admission

Home Care Eligibility Criteria

To receive home care, you must be under the care of a doctor who has created a plan of care that is regularly reviewed.

Additionally, a doctor must certify that you require one or more of the following:

• Physical and/or occupational therapy
• Speech/language pathology services
• Intermittent/occasional skilled nursing care
• A doctor certifies that you are homebound

When receiving home health benefits, you may:

• Leave home for short or infrequent periods for non-medical reasons, such as going to a religious service
• Leave home for medical treatments
• Attend adult day care

You are ineligible for home health care services if you require more than intermittent or part-time skilled nursing care.