Introduction to Care Communities


Assessment of Need for Community
Services & Out-of-Home Placement

The questions in this guide provide a framework to evaluate the effectiveness of a person’s formal supports (In-Home Supportive Services, case management, etc.), informal supports (family members, friends) and care needs. There is no magic formula that determines when more formal support services are needed or when out-of-home placement is necessary. Every individual and her/his circumstances differ. However, limited informal supports coupled with high care needs can be strong indicators for increased use of formal community-based services or for investigation of out-of-home placement. This guide can be used for yourself or your loved one.

A. Daily Care Abilities and Need

1. How would you evaluate the individuals abilities in the following areas?
Check all that pertain:


Needs No

Needs Some

Needs a Lot
of Assistance








* If an individual "Needs a Lot of Assistance" in 2 or more of the activities listed above in # 1, it is important to consider increasing formal support services or even to consider looking into out-of-home placement options. Professionals use these "activities of daily living" (ADLs) to determine appropriateness for a variety of services and for triggering insurance payments for care at home or in institutions.

2. How would you evaluate the individual’s abilities in the following areas?
Check all that pertain:


Needs No

Needs Some

Needs a Lot
of Assistance

Preparing Meals




Preparing Medication

Taking Medication

Bill Paying

Using Telephone

*If an individual "Needs a Lot of Assistance" in 2 or more of the activities listed above in #2, it is important to consider increasing informal or formal support services. Professionals use these "instrumental activities of daily living" (IADLs) to determine appropriateness for a variety of services.

3. How would you answer the following questions about special care needs?

Is the individual incontinent in bladder?

Is the individual incontinent in bowel?

Does the individual wander off?

Does the individual stay awake during the night?

Does the individual show combative behaviors, (e.g., shouting, hitting)?

Does the individual require tube feeding?

Does the individual require skin care treatment for an advanced stage bed sore?

Does the individual require frequent assistance in transferring to prevent falls, e.g., going from the bed to the wheelchair?

*If you checked "yes" for any of the questions above in #3, you may need to increase formal support services. Start investigating out-of-home placement options.

B. Informal (Family) Support Services

The ability of someone to remain at home often depends on the availability, quantity and quality of one’s informal supports, (e.g., services like personal care, shopping, housekeeping, cooking, etc. provided by spouse, family and friends). It also depends on the health and willingness of the primary informal caregiver to continue to provide care.

  1. Is there someone who either acts or can act as an informal caregiver for the individual?

  1. If there is an informal caregiver available, does he/she live within 45 minutes of the individual?

  1. Could the primary support person provide at least 20-30 hours of care each week?

  1. Taking the primary support person’s own health and physical ability into consideration, would you consider him/her able to meet the individual’s care needs on a daily basis?

  1. Taking the caregiver’s personal life (e.g., family, job, etc.) into consideration, would you consider him/her to be willing to provide the care that the individual needs on a daily basis?

*If you are unable to comfortably answer "yes" to these questions, you may want to consider looking into formal community-based options to provide the assistance and services that the informal caregiver cannot provide.

C. Formal (Agency Provided) Community-Based Services

The use of appropriate formal services (e.g., respite care, In-Home Supportive Services, case management, etc.) can be crucial for maintaining community independence and providing needed backup and relief to the informal, family support system. Refer to the fact sheet entitled "Community-Based Services for Seniors" for a list of some of the formal support services you can access.

If the individual already receives community-based services, it is important to evaluate the effectiveness of the combined formal and informal services in meeting the individual’s needs. If the combination has limited effectiveness in meeting the individual’s needs, you may want to consider accessing different or additional community-based services. You may also want to speak with your informal caregiver to discuss how the help he/she provides can better complement the formal support services you receive.

List any services that you believe the individual needs but is not receiving from the formal or informal support systems:






Some of the services needed may be provided by one or more of the community-based service organizations listed on the fact sheet entitled "Community-Based Services for Seniors". If there are services that you cannot find there, you may want to call Senior Information & Referral for other service providers: (800) 510-2020.

D. Out-of-Home Placement

The individual’s answers to questions #1 and #3 will help gauge what type of facility is most appropriate to meet his/her needs. It will also influence the facility’s decision to accept the individual, and it will definitely impact the amount of monthly payments to the facility. If you are unsure about the care needs of the individual, it is a good idea to speak with his/her physician, and perhaps a geriatric care coordinator, to find out what level of care would be most appropriate.

The following are types of residences/facilities that may be able to provide the level of care and supervision that the individual needs:

Senior Housing or Retirement Communities: Residents must usually be independent. These residences provide only room, light housekeeping, a meal plan, some social activities and scheduled trips for shopping and doctors appointments. Individuals needing even "some assistance" in activities of daily living as indicated in #1 might not be appropriate for this type of setting.

Residential Care Facilities for the Elderly (RCFEs): Often called assisted living or board and care homes, RCFEs are non-medical facilities that offer room, board and daily assistance with dressing, eating, personal hygiene, health maintenance, transportation and assistance with prescribed medication. RCFEs provide a level of care that is appropriate for people who are unable to live by themselves but do not need the extent of medical care provided by a nursing facility. Medi-Cal does not pay for care in RCFEs, and the average monthly cost for RCFEs in California is about $3,000 per month.

Note: Residential care facilities might accept individuals who "need a lot of assistance" with activities of daily living (#1) but become more hesitant to accept persons who answer "yes" to questions in #3, Special Care Needs.

Nursing Facilities: These facilities provide care for residents who need 24-hour nursing care and are dependent on others for assistance with most activities of daily living. Skilled nursing facilities often provide rehabilitative care for residents after medical procedures. Residents who are Medi-Cal eligible can use Medi-Cal to pay for nursing facilities that are Medi-Cal certified.

E. Next Steps

There are a number of factors involved in planning for care and support at home or long term care in a facility. These include the individual’s healthcare needs, financial considerations, mental capacity and legal considerations.

In order to identify an individual’s healthcare needs, it is usually a good idea to speak with his/her physician. A physician can tell you what level of care might be best for the individual on both a short- and long-term basis.

Financial hardship often keeps people from being placed in a facility with an appropriate level of care. There are many people who receive Medi-Cal at home that might benefit from a residential care facility, and there are also residents who go into nursing homes prematurely rather than remaining in residential care due to financial constraints. Remember, Medi-Cal still does not pay for Residential Care Facilities for the Elderly in California. Keeping this in mind, it is important to obtain a full financial picture when thinking about placement. If a person is going into a skilled nursing facility, he/she will want to go into a nursing facility that is Medi-Cal certified unless limitless funds are available. Additionally, if a person goes into a residential care facility, he/she will want to factor possible rate increases into the projected monthly fees. The sooner you determine the financial ability, the easier it will be to make informed decisions that will not force you to relocate due to financial constraint.

It is also important to designate representatives and agents while an individual still has the mental capacity to make decisions. This includes granting power of attorney for health care and durable power of attorney for finances, and it may include conservatorship if neither of these are in place and the individual has already lost capacity. It may be difficult to designate someone else to make decisions for you, but should you lose capacity, a person’s ability to make decisions for you will be compromised if there is nothing legal granting them that authority.



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