Understanding Assisted Living Levels of Care

Care levels are dictated by the amount of help a person needs to complete activities of daily living, or ADLs. These activities include bathing, toileting, dressing, moving and transferring, etc.

The levels of assisted living can look different depending on the specific assisted living community. While some communities may have four levels of care, others could have five or six — all with varying definitions or criteria. Generally, though, there are three levels, and they’re discussed below.

Perhaps unsurprisingly, the level of care a senior receives will affect their cost. Bradley suggests discussing care needs and costs in person at the community during a tour, simply because care needs are so personalized to each senior in assisted living.

“Each community structures their care levels and pricing differently, but they are quite clear about it,” she says.

Level one covers the most basic of needs

Care at level one could include a wake-up visit in the morning and simple reminders throughout the day, says Perla, executive director of Heritage Hill Senior Community. These individuals might also need a little supervision as they complete ADLs. As residents need more direct help with additional ADLs, they move to a higher level of care.

Level two involves hands-on care

A senior at level two typically needs assistance with at least one ADL, such as bathing or dressing. They may receive assistance with more than one ADL at this level, or a mix of hands-on assistance and supervision. Blending assistance and independence is common at this level.

Level three means additional, ongoing support

At level three, an individual struggles to complete most or all of their ADLs and needs the help of more than one caregiver. Either supervision as they complete ADLs is required, or caregivers must complete most or all ADLs for the individual.

Additional levels of care

While we’ve broken down levels one through three from a low-to-high-level of care, some communities may have additional levels. These levels will likely expand on the levels of care based on either the number of ADLs a senior needs help with or how many caregivers are needed to offer assistance.

For example, At Heritage Hill, Level 2 accounts for hands-on help with one ADL, such as bathing, while residents at level 5 there — the community’s highest level — receive assistance with four or more ADLs, such as dressing, grooming, mobility, etc.

Read more:Staff-to-Resident Ratios in Assisted Living: A Detailed Look

Is assisted living the right fit?

Bradley notes that many assisted living communities offer different types of senior living. These could include one or more of the following in addition to assisted living:

• Independent living
• Memory care
• Skilled nursing

In these communities, there may be some overlap in services, and it may be difficult to know what your loved one will need. Most often, this will occur with assisted living communities that offer memory care. Bradley notes that in these communities, safety is usually the concern that may drive a move from assisted living to memory care.

“That could be a risk of wandering, falling, or a tendency to eat things that one should not,” says Bradley. “Aside from that, many people can stay in assisted living while exhibiting confusion or mild cognitive decline.”

If your loved one is experiencing signs of memory loss, they can still receive assistance with ADLs if they’re in the memory care wing of a community. And, they’ll likely be able to join their friends in assisted living for large community functions.

What is enhanced senior living?

In your journey to understand the level of care your loved one needs, you may encounter the phrase “enhanced senior living.” This isn’t a level of care, per se. Rather, it’s a more supportive version of independent living.

Think of enhanced senior living as the gateway from independent living to assisted living, or as home care in an independent living community. A resident in an independent living community may hire a caregiver for companion care, light housekeeping assistance, and other basic support. Sometimes the independent living community will partner with or recommend a home care agency. Other times, seniors will look for a caregiver on their own. During this time, the senior, the community, and the senior’s family are all trying to learn whether a move to assisted living may be needed.

Enhanced senior living is not the same as luxury assisted living, which offers upscale living accommodations.

Before nurses and assisted living staff members can develop a senior care plan, they’ll first need to conduct a needs assessment test. The assessment is performed by a health care professional to determine your loved one’s physical and mental well-being: their mobility, fine motor skills, medical conditions, tendency to depression, and much more.

A health care assessment could take place in several locations, depending on what works best for the senior and the community. This includes:

• In your loved one’s home, so the health care professional can observe your loved one in a familiar environment
• At a hospital or another clinical setting where your loved one is receiving treatment or a type of physical or occupational therapy
• During a tour of the community, if your loved one has come with you for the tour

Regardless of the setting, family members or a caregiver are typically welcome to observe. Depending on your state and how the community is licensed, there’s usually a specific timeline for when an assessment is conducted. Typically, this happens before a new resident moves into a community to help ensure that their care needs can be met.

Level of care assessment tools

A visiting health care professional will use a level-of-care assessment tool — either a paper form or mobile app — designed to record their observations of specific behaviors and responses to specific questions.

Perla typically relies on a “get up and go” test, which requires seniors to get up from their chair and take a few steps. This reveals their steadiness and agility, key indicators that can determine assisted living levels of care. If your parent uses a walker, the test indicates whether they use it correctly.

“You can get a good idea of how many people they’re going to need to assist them and what help they’re going to need when they get up in the morning,” Perla says. “It can be so simple, like dropping a pen. ‘Oh, can you help me get that pen?’ The best way of testing fine motor skills is asking someone to do something.”

Scoring level-of-care assessment tool outcomes

Each observation is usually assigned a score on a scale — a score of one to five, for instance — with a one indicating independence and a five demonstrating dependence on a caregiver. Many assessments use a point system that adds up all scores. A combined score is meant to provide insight into a senior’s level of independence. A higher score translates to a higher level of care in assisted living facilities.

The assessment may result in surprises, but Bradley notes that this isn’t always a bad thing.

“Some people underestimate the care a parent might need, and on the other hand, some are surprised by what a person can still do. The overall aim of assisted living is to encourage residents to do things on their own as long as they can to preserve health and independence,” Bradley says.

Perla, on the other hand, has noticed that a family may be more surprised at how much help a parent needs, especially if they’ve been living with their parent and offering assistance.

“Families are very used to covering up,” says Perla, “and they don’t do it on purpose.”

Assisted living questions? Get expert help

The cost of assisted living varies depending on the level of care, among other factors. Simply put, greater assistance comes at a greater cost. At each new level of care in assisted living facilities, the cost can rise by several hundred dollars per month.

“Oftentimes, a community will charge a base fee, and then there will either be care packages or an a la carte add-on list for services such as help with dressing, medications, and so forth,” explains Bradley. “This way the person is only paying for the care he or she needs at that time.”

Across A Place for Mom’s partner communities, the nationwide median cost of a one-bedroom assisted living apartment is $4,885 per month.^[01] This refers to the base fee Bradley mentions.

Across our partner communities, these are the nationwide monthly median care fees you can expect:

• Low-care needs fee: $519
• Medium-care needs fee: $1,250
• High-care needs fee: $2,235
• Medication fee: $500

Bradley notes that one of the biggest things that affects the cost of care is the amount of caregivers required to help a resident with their daily tasks. A senior with significant care needs, for instance, may need two caregivers for assistance transferring in and out of bed.

Since communities may have different additional levels of care, or a la carte packages that are different from what we’ve outlined above, families should remember to ask questions about what’s covered in the cost.

“When comparing pricing from one community to the next, it’s important to have the community price out the cost for all of the add-on services so that the family is comparing apples to apples with the bottom-line cost,” Bradley says.

Furthermore, if memory care becomes necessary, this level of care can add significant additional costs.

It’s natural for a senior’s needs to change as they age. With this in mind, assisted living staff and caregivers regularly reassess each senior care plan and corresponding level of care. Perla does this through monthly discussions at staff meetings. Other communities may conduct the same physical tests with residents at different intervals.

Bradley notes that it’s difficult to predict how often a senior’s care needs may change.

“Care needs can change quickly or slowly depending on an individual’s lifetime health and wellness history, genetics, accidents, and so on. Most communities reassess residents’ needs on a regular basis, such as quarterly, every six months, or annually,” Bradley says. “Adjustments to care plans are made as needed at that time, and sometimes in between if there has been a major change of condition such as after a stroke or other unexpected medical event.”

Because needs can change unpredictably, families are also welcome to share their concerns. Assisted living communities may reexamine a resident’s care plan based on family observations, as well as those from community caregivers.

In Bradley’s experience, she knows that sometimes the seniors themselves may realize that someone needs more help, whether it’s themselves or a fellow resident.

“Oftentimes a resident in assisted living will express concern for a friend they eat lunch with, remarking to staff that they think it might be time for memory care,” Bradley says.

She also notes that in these cases, it can be helpful to join in shared activities between levels of care.

“Residents get to know each other a bit and see how the other care levels work, which takes some of the fear or mystique out of it.”

While assisted living communities are home to residents with different care needs and at diverse stages in the aging journey, more complex health conditions may signal that skilled nursing or memory care could be a better fit. Examples of conditions requiring more intensive care include dementia, stage 3 and 4 wounds, and brittle diabetes.

Some assisted living communities may offer memory care or skilled nursing in a separate wing of the community. Other times, needing a higher level of care will mean moving to a different community or nursing home.

Many assisted living communities don’t staff nurses 24/7, meaning they have specific criteria that residents must meet in order to stay. Some communities may require residents be able to feed or move without assistance, while others may require that residents only need care from one staff member at a time.

Be prepared to ask about a community’s criteria, and consider asking these questions as well:

• If a resident exceeds a community’s capacity to care for them, how much time do they have to find new living arrangements?
• Are there exceptions to the criteria, such as when a resident is recovering from a health incident?
• Can the resident stay if they’re in therapy to regain their independence?
• Can an outside caregiver come in to help in situations when the community can’t?

In the end, Perla says it often comes down to one question: “Can we safely care for this person? That’s my rule of thumb across the board. Safety is my number-one priority. You have to look at each situation for each person.”

Read more:Assisted Living vs. Nursing Homes: Costs, Amenities, and How to Choose

A Place for Mom’s Senior Living Advisors have been helping families understand the levels of assisted living for over 20 years. Through speaking with a Senior Living Advisor, Bradley says families can expect to get a good, basic understanding of what kind of care their parent needs.

An advisor can ask detailed questions to help you understand your loved one’s care needs to find communities that will be a good fit. They’ll help you narrow your search by providing tailored recommendations based on how much assistance your loved one needs, their budget, and any other preferences. Additionally, Senior Living Advisors can help determine what care type is most appropriate, all at no cost to you.

Assisted living reviews from residents and families