Levels of Care
The phrase “level of care” is shorthand used by regulators and third-party payers to describe the type and amount of care a nursing home resident requires. The determination of a patient's level of care is made by the admitting facility or a third party review agency after reviewing information from the physician and nurses addressing:
- Medical needs – How often does the patient need to be seen by a physician - daily, weekly, monthly or less often?
- Nursing care needs – What, if any, services must be provided on a daily basis by a registered nurse, a licensed nurse and/or a nursing assistant?
- The patient's physical rehabilitation needs and potential
- Will short-term intensive physical, occupational and/or speech therapy result in a marked improvement in the patient's functional ability?
- Is the patient demonstrating steady progress toward the rehabilitation goal?
- Is therapy needed to maintain the patient's current level of functioning? Will the patient benefit at all from therapy?
- Personal care needs – What assistance does the patient need to complete activities of daily living?
After assessing the patient's needs in these areas, a patient in Maryland may be assigned one of three levels of care - skilled, intermediate or chronic.
If the patient's care needs require that licensed nursing staff be available in the facility 24 hours a day to provide direct care or make decisions regarding the patient's care, then a skilled level of care is assigned. A skilled level is also given if the patient will demonstrate improvement from the services of at least two disciplines of rehabilitation service (physical therapy, occupational therapy, speech therapy). Usually, skilled care is needed only on a short-term basis because the patient's condition stabilizes or improves and the level of care changes to intermediate care. Examples of skilled care include:
- Regular intravenous injections
- Regular care and treatment of a wound or bedsore
- Physical, speech and/or occupational therapy with a goal of improved functioning, towards which progress is being made
Medicare may pay for skilled care in a nursing home. The payment is limited, according to Medicare regulations, as is the number of days for which Medicare will pay. If a person continues to need care beyond the number of days Medicare authorizes, the individual will need to pay privately. If the resident does not have sufficient funds to pay privately, he or she may apply for the Medical Assistance Program.
Most nursing home residents do not need skilled care; rather they need an intermediate level of care. Intermediate care facilities provide intermediate-light, intermediate-moderate and/or intermediate-heavy levels of care. Intermediate, or non-skilled care, is also called custodial care and may include helping the resident with activities of daily living (which includes bathing, eating, dressing, toileting, transferring from bed to wheelchair or wheelchair to bed and moving around). The following is a brief description of intermediate light, moderate and heavy levels of care.
- Intermediate-Light Care
The resident is dependent on staff for up to two activities of daily living (described above), intermittent supervision and/or occasional behavior management.
- Intermediate-Moderate Care
The resident is dependent on staff for three or four activities of daily living, frequent supervision and/or behavior management.
- Intermediate-Heavy Care
The resident is dependent on staff for all five areas of daily living, constant supervision and/or behavior management.
Residents with certain, more intensive care needs, or who require special rehabilitation, may require a chronic level of care. Examples of this need for chronic care include:
- Frequent physician intervention of more than two visits per week
- Frequent drug and treatment adjustments on a 24-hour basis
- Continual skilled nursing services that can only be given by a registered or licensed practical nurse
Some examples that may warrant a chronic level of care include:
- Conditions requiring respiratory therapy
- Tracheostomy care
- Treatment of extensive decubitus ulcers (bed sores)
- Medication adjustments for intractable pain
- Isolation due to infectious diseases (AIDS, infected wounds, decubitus ulcers, etc.)
- Multiple medical problems (unstable diabetes, ulcers that will not heal, cardiac failure, specialized rehabilitation therapy, etc.)