Who Decides When a Senior Resident Needs a Higher Level of Care?

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by Brad Breeding

Continuing care retirement communities, often referred to as CCRCs or “life plan communities,” provide residents who are living independently today with access to a full spectrum of care services that may be necessary in the future, including assisted living, memory care, and/or skilled nursing care.

But this leads to a couple of questions from prospective residents: “Who actually decides if and when it is necessary for a resident to move to a higher level of care, and what is the process?”

The progressive care decision process

Almost every CCRC residency contract I have seen has virtually the same language: “When evaluating the resident’s need to be transferred to a higher level of care, the community will consult with the resident to the extent possible, along with the resident’s family, personal representative, and attending physician; however, the community’s decision is binding.”

This language implies that there isn’t a specific set of markers or triggers to determine if a resident needs to move to a higher level of care and that it is decided on a case by case basis following a consultation between the various parties described above. But, the contract language makes it clear that the community has the final say, and this is where it can sometimes get sticky.

The very best retirement communities treat their residents like family, and the hope is that the staff is making a decision that is felt to be in the very best interest of the resident’s well-being. And, as I’ll describe below, some states have a specific set of conditions whereby a CCRC would actually be required to move a resident into a certain level of care. Yet, you can imagine a situation where a resident (or resident’s family members) disagrees with the decision and wishes to remain in the independent living unit, despite the CCRC’s recommendation.

My impression from visiting CCRCs all over the country and talking with families and staff is that this type of situation does not occur too frequently. I think most CCRCs try to keep residents in independent living as long as they possibly can in most cases. But if the decision is made to move a resident from independent living to assisted living, memory care, or skilled nursing care, there is always the chance for push back or disagreement. So, what are the protections that a resident or resident’s family members have if they disagree with the decision?

Assessing level of care transfer options

One example of safeguards that are in place to ensure the rights of residents are honored comes from the state of California. According to the California Advocates for Nursing Home Reform (CANHR), “The ‘Level of Care Transfer Process’ offers some protections to residents [in the state of California]…The most important right to exercise is to request an assessment and then to exercise your right to a review of the level of care decision triggered by the assessment. The process gives the resident the best chance to present medical evidence that their care needs can be met in the independent unit.” In the state of California, this transfer process includes five distinct steps, including an initial care conference, notice of transfer, second care conference, review by continuing care contracts branch, and actual transfer. (Other states may have different or less defined processes. Be sure to ask what the official process is for your state.)

 The CANHR website also describes that a CCRC provider may only transfer a resident under one of four conditions, while also taking into account the appropriateness and necessity of the transfer and the goal of promoting resident independence. These four conditions include: 1) being non-ambulatory and, therefore, unable to leave their unit in the case of an emergency, 2) physical or mental condition that endangers the health or safety of other residents, 3) resident’s condition exceeds that which can lawfully be provided in independent living, and 4) resident’s condition requires a higher level of care that cannot be provided by the CCRC. Again, keep in mind that these are the conditions for the state of California, which may be different than other states.

Making the best decision

There are so many benefits to moving to a CCRC, not the least of which is peace of mind knowing that you will be cared for no matter what your needs may be in the future. But it is also important to understand the policies of the communities you are considering when it comes to transferring residents to a higher level of care. It could be that you are contractually required to accept a transfer out of your independent living residence if the community determines it to be the most appropriate and safe option based on your health needs.

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