Elder Care Criteria and Senior Living Admissions

Assisted Living Admission Requirements and Criteria

Assisted living communities provide care to many seniors. There are about 30,000 assisted living facilities across the US and over 80 percent of the residents are 75 or older. The median monthly price can range from $3,300 in Missouri to $7,800 in Washington, D.C. Besides Alzheimer’s and other forms of dementia, the most common conditions residents have include arthritis, high blood pressure, and heart disease.1

Individuals entering assisted living facilities often need assistance with ADLs (activities of daily living) such as personal care, hygiene assistance, mobility, meal preparation, and medication management.

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

Most assisted living communities are wheelchair accessible. Federal regulations such as the Americans with Disabilities Act (ADA) and the Fair Housing Act mandate accessibility features for those with mobility challenges. These facilities typically provide features like ramps, elevators, and accessible bathrooms to accommodate residents who use wheelchairs​.

However, the degree of accessibility can vary depending on the facility. Find out about specific features before choosing a community.

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. You must provide:

• Facility admissions paperwork
• Medical history and physical
• Negative tuberculosis (TB) test or chest X-ray

Nursing Home Admission Requirements and Criteria

Offering both short-term and long-term residential care, nursing homes focus on helping older adults with chronic illnesses, significant physical or cognitive decline, and complex medical needs. Many people turn to nursing homes when they need more consistent medical help than assisted living provides.

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 provide this. Otherwise, schedule an appointment with your family doctor.
• 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 (listed 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: This determines how care will be paid for.

Skilled Nursing Facility Admission Requirements and Criteria

A skilled nursing facility is primarily for those who need to recover or rehabilitate from an illness or injury. It differs from a nursing home which admits those with chronic conditions that are ongoing and focuses on long-term care.

A skilled nursing facility will require proof of a demonstrable medical need for short-term, focused rehabilitation. Maybe the patient needs a type of physical therapy, wound care, or medication management following surgery or an illness. This is all usually documented by a physician. Therefore, skilled nursing facilities therefore usually have additional clinical requirements for rehabilitation therapies and post-acute care when compared to nursing home requirements.

The paperwork and requirements for a skilled nursing facility may differ, so it’s best to speak with the facility to learn what specific forms are required.

Memory Care Admission Requirements and Criteria

In 2023, about 6.7 million Americans aged 65 and older were living with Alzheimer’s, with estimations that this number could grow to 13.8 million by 2060. 3

When memory issues cause significant problems, an individual may no longer qualify for assisted living. Memory care can assist with ADLs, but this type of care primarily addresses the unique needs of someone with Alzheimer’s disease or another form of dementia.

Memory care units address specific behavioral challenges in those with memory loss like wandering and aggression. Memory care may require a higher level of individualized care, 24-hour supervision, and more security for those with cognitive impairment.

As rates of Alzheimer’s disease and other forms of dementia increase with our aging population, specific admissions criteria for memory care units have become more common across the U.S. Many facilities now require a documented diagnosis from a neurologist or primary care doctor to admit a patient to memory care. This is often supplemented with cognitive screenings. This criterion differentiates memory care from standard assisted living.

Individuals may enter a memory care facility from a private residence, rehabilitation center, skilled nursing facility, or a hospital. Regardless of where they come from, the admissions process is the same and requires:

• Facility admissions paperwork
• Medical history and physical: Assisted living facilities 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

According to the National Institute on Aging, hospice provides comfort care as well as support for the family, but attempts to cure the person's illness are stopped for those in hospice. 4

Hospice provides holistic care and support for an individual and their loved ones. The goal of hospice is to help people pass away with dignity and improve the quality of their end-of-life journey.

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)

Once this takes place and they can receive care, the medical director or another employee of a hospice agency will make 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 must look at local coverage determinations (LCDs) to see if services are reasonable, necessary, and eligible for Medicare coverage. Since LCDs are not regulations and shouldn’t be used as the absolute determining factors, (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 is often a component of hospice care. Palliative care is a type of treatment for the physical, emotional, and psychological symptoms that result from having a serious illness. This type of care focuses on providing relief for the symptoms and stress from life-limiting illness.

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:

• Occupational and/or physical therapy
• Speech/language pathology services
• Intermittent/occasional skilled nursing care
• 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

There might be limitations. For example, you may be ineligible for home health care services if you require more than just intermittent or part-time skilled nursing care. And while occasional trips out for non-medical reasons may be allowed, extended periods away from your home might jeopardize your eligibility according to Medicare.

A Step-by-Step Guide to Senior Living Facility Admissions

Below is a quick guide to help you get started with choosing a facility type and getting admitted.

1. Assess your needs

• Care requirements: Identify type of assistance needed (e.g., help with ADLs, temporary rehab at a skilled nursing facility, etc.).
• Budget: Review your finances and explore funding options like Medicare, Medicaid, and long-term care insurance.

2. Research facilities

• Location: Consider facility proximity to your family and support systems.
• Services: Ensure the facility meets your care needs (e.g. specialized services).
• Accreditation: Verify credentials of the facility.
• Reputation and reviews: Research ratings and testimonials.

3. Tour facilities

• Visit: Observe the environment and meet staff.
• Amenities: Evaluate their dining facilities, activities, and social offerings.
• Questions: Inquire about care plans, costs, and admissions process.

4. Prepare documents

• Medical: Collect recent medical records, medication lists, and physician reports.
• Financial: Gather insurance details, bank statements, and related documents.
• Legal: Be ready with your power of attorney and advance directives.
• Review the rest of this guide for specific things needed, depending on the facility.

5. Complete admission

• Assessment: The facility will discuss and evaluate your care needs with you.
• Paperwork: Fill out all necessary forms and agreements.
• Move-in: Make a plan for transport and moving personal items into the facility.

Additional tips

• Start early: Begin your research well in advance of your move-in.
• Visit multiple locations: Compare options based on your care needs and preferences.
• Stay organized: Keep all your documents accessible.
• Seek help: Involve your family, friends, and professional caregivers for support.