Long-Term Care Facility Levels of Care Explained

Nobody sits families down and explains that a "nursing home," an "assisted living facility," a “subacute,” or other type of facility are actually licensed, staffed and equipped to provide different levels of care and are subject to different legal rules and regulations about the kinds of residents they can take care of.  They also have distinct staffing rules and levels of oversight.

If you are confused about what level of care might be right for your loved one, you are not alone. Often times even doctors, social workers, and even placement agencies who assist families with finding a facility are not clear on the distinction. Let’s break the levels of care down for you.

Levels of Care

• Acute care hospital: full medical staff, physicians on site who round on the patient typically daily, the highest level of oversight and nursing care

• LTACH / sub-acute care: hospital-level care but for residents who need medical care over a longer stretch of time.  This environment often serves people who have spinal cord injuries, are ventilated, are bed-bound, or have other complex conditions.

• Rehab / skilled nursing facility (SNF): nursing care and therapy, with limited medical oversight; they provide nursing services, but not at the level you would receive in a hospital.

• RCFE (assisted living): a residential setting, not a medical one. Folks in assisted living may need assistance with medication management, meal preparation, basic hygiene, and safety monitoring, but they are not dependent on staff for acute or chronic medical needs or robust therapy

• Home health / hospice: medical services brought into the home on a schedule; these visits can support someone staying in the home, but they are sporadic

• Home care agencies and in-home caregivers: non-medical help with daily living, and can include things like shopping, housekeeping, light meal preparation. Often, the caregivers are not clinically trained, they provide more social support.

  
  

Each of these levels of care are subject to different statutes and rules governing care. A skilled nursing facility has to have licensed nurses on staff. An RCFE does not. That's not a technicality. It's can be the whole reason someone’s needs are met or not.

How levels of care differ

The lower you go on that list, the less built-in oversight there is. In a hospital, physicians review charts daily. In a skilled nursing facility, there's a physician of record, but they're not there around the clock.  In California, physicians are only required to round once every 30 days, or as the person’s condition or needs change. They can also send a nurse practitioner or physician assistant in their place. 

In an RCFE, day-to-day care and monitoring falls to non-medical staff, and there's less regulatory scrutiny and less public data on how the facility actually provides care and how it performs in relation to other facilities and in relation to the rules that govern them.

That doesn't make RCFEs bad; plenty are wonderful and we need RCFEs to care for the population of people who need more help than they can get at home, but don’t need nursing care or specialty therapy. It does mean that RCFEs need to screen prospective residents to make sure the care needs are not too high for how it runs its business.  And it also means the family needs to keep a close eye on their loved one to make sure any changing needs are identified and met.  Nobody tells you that going in.

SNF staffing issues

Most SNF neglect cases come down to one thing: not enough staff. Not just numbers on paper, but having enough staff who are actually trained to do the work that is asked of them. When I evaluate neglect in a facility, I follow the money. Staffing is a facility's biggest expense, and usually the first place corners get cut to protect a margin.  When the staffing levels are low, assessments get missed, care gets skimped on or skipped altogether, communication suffers and documentation becomes sparse or is even falsified.

RCFEs aren't medical facilities, no matter what the brochure says

An RCFE,  Residential Care Facility for the Elderly, is first and foremost, a housing arrangement, not a health facility. It doesn't matter if their marketing materials tout “24 hour nurse on premises.”) Legally, it's not required to provide medical or nursing care. Those service have to be arranged separately.  Don't let a polished building or a friendly sales tour convince you it's something it isn't. 

If you're trying to figure out what level of care your loved one actually needs, or whether they're getting it, we're happy to talk it through, no obligation, just answers.