
The term “nursing home level of care” (NHLOC) describes a common standard for measuring the minimum level of medical support an individual needs to become eligible for admittance to a nursing home and for Medicaid’s coverage of this care. The measure is also used to determine eligibility for other Medicaid-funded programs, such as the Program of All-Inclusive Care for the Elderly (PACE), and for acceptance into some other facilities. This article will explain what a nursing home level of care means in practice and where it is relevant. We’ll also highlight some challenges in understanding NHLOC, particularly as no federal definition exists.
General definition of a nursing home level of care
While no single nationally accepted definition of NHLOC exists, the various state-specific definitions have similar elements. Notably, individuals must require a significant level of care to the extent that they can no longer safely meet their own needs for an extended period.
Many definitions state that an individual must have limitations in at least two different areas, and these issues must be ongoing. In other words, a temporary injury or illness that reduces a person’s ability to support themselves would not necessarily qualify them for NHLOC.
The four areas commonly considered for NHLOC are highlighted below. However, there are still many differences in how these areas are defined and assessed, and states do not necessarily incorporate all four.
- Functional needs: This refers to whether someone can take care of their basic activities of daily living (ADLs), such as personal hygiene, bathing, eating, and dressing.
- Medical needs: This area considers any health conditions, plus whether the individual needs medical care, such as assistance with IV drips, injections, or catheter care.
- Cognitive impairment: Here, the focus is on whether there are notable memory issues or cognitive challenges, often due to dementia. This can lead to difficulty following a schedule or instructions.
- Behavioral issues: Finally, can the individual control their behavior, or are they prone to mood swings, aggressiveness, impulsiveness, and the like? Concerning behaviors may arise from conditions like dementia and some mental health problems but can also arise from poorly managed medications.
Challenges in understanding a nursing home level of care
Using NHLOC as a measure is complex because every state defines it differently. A person may meet the requirements for NHLOC in one state and not in another, which creates challenges if they need to move to a different state.
At the same time, NHLOC definitions often aren’t simple. States may highlight multiple areas that assessors should consider, including the functional, medical, cognitive, and behavioral areas discussed above. For that matter, the term “nursing home level of care” isn’t even used in all states. Some states use other terms, like Florida, which uses “nursing facility level of care.”
Differences don’t end with the definition of NHLOC either. States also vary in their assessment tools and how different needs are assessed. This contributes to how people can meet NHLOC requirements in one state and not in another.
Here are a few examples of how the definitions and assessments can vary:
- California: California’s approach includes an observation of the individual and an assessment of their treatment course. A doctor then assesses whether there is a need for a nursing home level of care, considering factors like whether the individual can complete their ADLs, administer their own medications, and have predictable behavior.
- Florida: A physician or registered nurse must determine whether an individual has the required care needs. An assessment tool called CARES (Comprehensive Assessment and Review for Long-Term Care Services) is used as part of the process.
- Texas: Texas uses an MDS (Minimum Data Set) assessment. This assessment is completed by a registered nurse and then reviewed by the Texas Medicaid and Health Partnership. To meet the criteria, individuals must have a significant medical issue that could not be treated by someone untrained.
Why NHLOC is important
It’s crucial to be aware of NHLOC requirements in your state, as the measure is relevant in multiple situations. It can influence your acceptance into some facilities and the financial assistance you receive.
Nursing home acceptance
Not surprisingly, NHLOC plays a key role in determining whether a person is accepted to a nursing home. Potential residents need to demonstrate that their needs are sufficient to require this level of care. If the individual’s needs don’t meet the standard for NHLOC, they may be better suited to assisted living instead of a nursing home.
Assisted living communities and CCRCs
The nursing home level of care is also relevant to other environments. In particular, assisted living facilities will likely refuse residents with NHLOC requirements, as the facility cannot meet such care needs.
Continuing care retirement communities (CCRCs) may also use NHLOC to determine where a new resident should be placed and when to transition someone from assisted living to skilled nursing care. Those with relatively low levels of care needs may start in assisted living or even independent living, where care needs are minimal.
Health-needs-related programs
Being assessed as requiring a nursing home level of care is also essential for some programs.
The first of these is the Programs of All-Inclusive Care for the Elderly (PACE). This Medicare and Medicaid program is designed to help people remain in their homes for as long as possible, even when they would typically need care in a nursing home. Being certified as requiring NHLOC is key to being eligible for PACE services. Home- and community-based services (HCBS) Medicaid waivers also frequently use NHLOC as a criterion for providing support.
Medicaid itself also relies on NHLOC assessment. Notably, individuals need to be assessed as requiring a nursing home level of care before Medicaid will pay for such care.
Understanding NHLOC is crucial for determining eligibility for nursing home care and financial assistance for this level of care. While the exact definition varies by state, the general principle is that the individual has care needs that exceed what can be provided by family members or in assisted living. Familiarizing yourself with your state’s definition of NHLOC can help you more effectively navigate senior care options for yourself or a loved one.If you need to look for a community and either don’t know where to start or would like the support of a professional, find the Oasis Senior Advisor in your area.