Nursing Home Requirements: Who’s Eligible?

While assisted living facilities can help family members maintain a certain level of independence, it sometimes may not be enough support. Declining health or a major crisis like a debilitating stroke or serious fall may require rehabilitation or around-the-clock care from trained staff at nursing homes.

“Preserving older adults’ ability to remain independent should be a fundamental goal, but when they need help there are many high-quality facilities that can provide comprehensive care,” says Deborah Franklin, senior director of quality affairs at the Florida Health Care Association in Tallahassee, Florida.

An estimated 1.5 million older adults live in nursing homes, which is about 4.5% of the total older adult population. Nearly 94% of older Americans, or 33.4 million, live at a home or with a family member outside of any facilities, according to the National Institutes of Health.

[READ: Must-Ask Questions When You’re Choosing a Nursing Home.]

What Do Nursing Homes Offer?

Nursing homes, also known as skilled nursing facilities or long-term care facilities, offer medical services for residents who need comprehensive care. Most nursing homes have nursing aides and skilled nurses on hand 24 hours a day. The key difference from assisted living facilities is that nursing homes provide around-the-clock medical care and assistance with everyday activities, while assisted living facilities encourage residents to remain as independent as possible and offer help when needed.

“Assisted living is also largely paid for through personal resources, while many nursing home residents are covered by Medicare or Medicaid, due to the way those government programs currently cover long-term care,” says Beth Martino, senior vice president of public affairs at the American Health Care Association based in Washington, D.C.

Nursing home facilities provide a wide range of services including:

— Dietary services.

— Health care, including physician and nurse care.

— Laundry services.

— Meals, offered three times a day.

— Medication management.

— Personal care needs, such as bathing, dressing and toileting.

— Rehabilitation services, including short- and long-term care.

Social activities, such as entertainment, music, crafts and trips.

— Therapy, including occupational, physical or speech.

Why Consider a Nursing Home?

Some people remain at nursing homes for a short time to recover from an accident, medical complication or surgical procedure. After they regain strength and recover, they move back to their home or another facility. “Two-thirds of people admitted to a nursing home for short-term post-acute nursing or rehabilitation care are able to return home,” Martino says.

However, the majority of nursing home residents live there full time because they have physical, emotional or cognitive challenges that demand supervised care. There are a variety of reasons why older adults reside in nursing homes, including:

— Chronic, disabling disease.

Cognitive decline or dementia issues.

— Feeding assistance.

— Help with all personal care needs.

— Lack of mobility or bedridden.

— Major health event like a stroke or severe fall.

Nursing homes are sometimes associated with stories of unpleasant conditions, unskilled staff and neglected care. “There is a stigma associated with nursing homes that can make families hesitate to move a family member into one. That’s why it’s important for families to do thorough research and visit the top facilities in the area,” says Ann Orffeo, nurse care manager at Elder Care Solutions of WNY in Snyder, New York.

[Read: How to Pay for Nursing Home Costs.]

Nursing Home Admission Requirements

What qualifies a person for a nursing home will vary. Before moving into a nursing home, a thorough assessment is conducted to determine the right level of care for the individual’s needs. These assessments vary from state to state. In New York, nursing homes use a Patient Review Instrument or PRI. In Florida, the 3008 form is the standard assessment. “Assessments provide a holistic view of the person’s current medical, physical and cognitive abilities,” Orffeo says.

Assessment tools are very similar and are used to determine the person’s existing medical conditions and how independent they are in eating, mobility, moving from bed to chair and toileting. These forms sometimes serve as an admissions form, Franklin adds. “They want to know everything about the person from their chronic conditions and medications to food allergies, hearing problems and current medical insurance.”

The assessments — which are required for admission to a nursing home — are typically conducted by a nurse and often require review and signature by a doctor. In some states, the individual’s primary care doctor needs to sign the assessment.

[SEE: 11 Red Flags to Look for When Choosing a Nursing Home.]

Medicaid and Medicare Qualifications

Another purpose of the assessment is to collect information to determine Medicare or Medicaid reimbursement for nursing homes. In the nursing home admission process, the nurse or admissions case manager will ask questions about the individual’s financial and income information to see if they qualify for nursing home care under Medicare or Medicaid. To qualify, the individual must meet the program’s financial eligibility requirements that vary from state to state.

Medicare Part A, or hospital insurance for those over age 65, will cover nursing home care for a limited time if it’s determined to be medically necessary like changing sterile dressings. The individual must also have a qualifying inpatient hospital stay.

For longer-term nursing home coverage, many people look to see if they qualify for Medicaid. A single individual, 65 years or older, must have income less than $2,523 each month to qualify for Medicaid, according to the American Council on Aging. Federal and state authorities want to see how recently a person has given money to family members.

“An individual can put a house in a life estate, but it’s a federal requirement that it must be done 60 months prior to be eligible for Medicaid nursing home,” Orffeo explains.

For those who are eligible, Medicaid will pay for the complete cost of nursing home care, including room and board, but some facilities only have a few Medicaid-certified beds so there sometimes can be a long wait. For individuals with savings and retirement money who only qualify for private facilities, the monthly cost of a nursing home can range from $12,000 to $17,000, depending on region.

Nursing Home Checklist

Whether you’re just beginning the journey to determine nursing home eligibility for a family member or at the final stages of a decision, follow this list of recommended steps:

Caregiver and family role. Designate at least one person as the primary caregiver for the nursing home resident to serve as the main contact involved in participating and discussing the individual’s care plan. Caregivers need support and other family members should be involved and available to help and share in the responsibilities.

COVID rules. While nursing homes have opened up their facilities to visitors, a new variant outbreak could lead to stricter safety precautions and visitation rights. Under a new federal law, all nursing home residents can choose up to two people as their essential caregivers who can visit them in person and offer help 12 hours each day, seven days a week regardless of a serious COVID variant outbreak. Essential caregivers will need to follow local and state safety measures. The law applies to nursing homes only and not hospitals.

Elder care services. Families can engage the professional services of elder care managers or aging life specialists to determine short-term and long-term care needs and explore Medicare and Medicaid eligibility requirements. These experts provide help to individuals and families with decisions ranging from how to maintain independent living to rehabilitation services as well as skilled nursing care options.

Legal matters. Make sure there your loved one has an up-to-date health care proxy and power of attorney. These legal documents will allow a family member to make health care decisions on behalf of their family member living in the nursing home. A living will is also recommended to show what types of treatments the person wants or doesn’t want to keep them alive.

Personal items. Before your loved one moves to a nursing home, make sure to pack about seven to 10 days worth of clothing and write their initials or names on each item to avoid confusion with other residents’ clothing. Ask the staff whether you can bring their favorite chair, pictures of family and friends and other personal mementos.

Regular meetings. Most nursing homes will arrange semi-regular meetings to discuss your family members care plan and changes in their needs and medical care. Make sure these meetings happen on at least a quarterly basis with the key members of the nursing and administrative team.

Resources. The Department of Health & Human Services has developed several useful booklets, including: “Your Guide to Choosing a Nursing Home or Other Long?Term Services & Supports” and “Medicare Coverage of Skilled Nursing Facility Care.”

More from U.S. News

11 Red Flags to Look for When Choosing a Nursing Home

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Nursing Home Requirements: Who’s Eligible? originally appeared on usnews.com

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