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Assisted Living Levels of Care

How Levels of Care Affect Cost

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If you're shopping for assisted living, you'll need to familiarize yourself with the levels of care, as the monthly rate for assisted living will depend on the level of care that the resident requires.

Cost is a factor for most consumers. Be sure to ask whether the cost of care is included in the monthly rate. If it isn't, it's likely the costs of care are stratified into levels of care or the individual services are charged separately. Most assisted living facilities that stratify costs have three or four levels of care. A higher level of care will result in higher monthly payments. Sometimes services will be charged on an individual basis even when a pricing structure is in place for basic levels of care. These individually priced services are usually specialized; examples include incontinence care and medication management. Pricing structures that incorporate levels of care as well as á la carte services can be very complicated, so ask specific questions before signing an agreement.

Why are there levels of care? What's the point?

Levels of care help facilities to simplify their pricing structures; once a resident requires a certain amount or kind of care, then the costs rise. This avoids a constant reassessment of costs every time a resident's needs change. Levels of care are also convenient for the consumer: you know the pricing up front, and can avoid feeling "nickeled-and-dimed" every time a change occurs in care needs.

How are care levels assessed?

Although the components of each level of care vary from facility to facility, there are some basic guidelines. Many facilities use a point system to determine a resident's required level of care. No cost-of-care fee applies if the resident is considered independent and doesn't require any help. This can also apply to residents who only need verbal instructions to complete the activities of daily living (ADLs). Residents who do require care are assessed prior to moving into the facility. The components that typically determine the level of care a resident requires are listed below.

Bathing

There are two factors to consider regarding a resident's bathing needs: (1) whether the person requires help showering or bathing and (2) how often they require it. For example, a resident who needs help washing and setting her hair on a weekly basis would require a lower level of care than a resident who requires help with all bathing activities.

Clothing

An assisted living facility will want to know if a resident can dress without assistance. Dressing oneself requires a certain amount of dexterity (e.g., zipping things up, buttoning, and moving one's body). It also requires making good choices such as picking appropriate clothing for the weather or occasion.

Grooming

Grooming includes activities such as brushing one's hair and teeth, and shaving for men. This means not only being physically able to do it, but also remembering to do so daily or on an as-needed basis.

Mobility

Assisted living facilities need to determine how much help a new resident needs in getting around-this includes walking as well as moving from a seated to a standing position. At the highest level of care, a resident might need a Hoyer lift to be transferred. Lower levels of care could mean that a resident only requires minimal assistance with walking or help moving to his or her wheelchair. At move-in, most assisted living facilities require residents to be able to walk into the facility without assistance from another person (using a mobility aid such as a walker is okay).

Continence

Residents who are able to manage their incontinence without assistance (e.g., a resident who is able to change his or her own liner or diaper) shouldn't have incontinence factored into the costs of care. Residents who require help with their supplies will be charged. Higher levels of care include residents who exhibit behavioral issues around their incontinence; for example, a resident who refuses to let aides change his or her diapers.

It is relatively common for facilities to price incontinence care according to an individual resident's needs, rather than incorporating the cost into the levels of care.

Caregivers

A resident who requires care from multiple caregivers simultaneously is likely to be assessed at a higher level of care. Some situations that would require multiple caregivers include a resident who needs a high level of pain management, and a resident who is combative when receiving assistance in bathing or having his or her diaper changed. Other examples include residents who have a tendency to wander or leave the facility, residents who are at a very high risk for falls, and residents who require assistance with physical therapy exercises.

Eating

Residents who require eating assistance can fall into all levels of care. The lowest level includes residents who can feed themselves, but need help cutting up food into bite-sized pieces. Higher levels of care might require a caregiver to be present during all mealtimes, either because the resident is physically unable to eat independently or because he or she is at risk for choking. Some residents may be placed at a higher level of care if they have issues with consuming or hoarding food items that present a dietary, safety or medical hazard.

Medication

Lower levels of care provide assistance in keeping prescriptions filled and supervising or administering medications taken orally or in an inhaled form. Higher levels of care are for residents who require help with injectable medications and for those who require nursing supervision. Some facilities also place residents who require advanced medication management on a higher level of care. For example, even if all of a resident's medications are taken orally and do not require an injection, he or she may be placed at a higher level of care. Usually this will occur when a facility has a specified number of medications, such as six or seven, that determines the threshold.

Laundry

Laundry service is sometimes included in the monthly rate, but sometimes it's charged separately. Every facility has a different policy, so make sure to ask.

Dementia

Residents with Alzheimer's or dementia usually require a higher level of care. Since dementia tends to be progressive, these residents will need to be reassessed regularly. Most facilities determine a resident's needs by considering the following criteria:

  • Diagnosis: Has the resident been diagnosed with dementia? If so, how severe is it?
  • Behavior: Does the resident exhibit combative or inappropriate behaviors?
  • Monitoring: Does the resident need to be watched very often, or are a few daily checks sufficient-such as in the morning, evenings and a few times throughout the day? Some facilities have devices to track dementia residents, which can help reduce the workload on caregivers, and potentially the cost for consumers.