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

This guide provides a framework to evaluate an individual’s need for formal or informal support. Informal care is provided by family and friends while formal care is available from community agencies that offer services such as home health care, personal care, care management, housekeeping, meals, transportation, and adult day health care.  Long term care is another option that is available in retirement communities, assisted living facilities and nursing homes.

There is no formula that determines exactly when formal support services are needed or when out-of-home placement might be necessary. Every individual and her/his circumstances differ. However, limited informal supports coupled with high care needs can be strong indicators for an increased need for formal community-based services or for investigation of out-of-home care. Use this guide to help determine what those care needs are as you evaluate yourself or your loved one.

A. Daily Care Abilities and Need

1. 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








*If an individual “Needs a Lot of Assistance” in 2 or more of the activities listed above in # 1, he or she may need formal support services or out-of-home care unless strong family support is available. Professionals use these “activities of daily living” (ADLs) to determine the appropriateness for a variety of certain services and for triggering insurance payments for care provided 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?

Yes No

Is the individual incontinent in bowel?

Yes No

Does the individual wander off?

Yes No

Does the individual stay awake during the night?

Yes No

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

Yes No

Does the individual require tube feeding?

Yes No

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

Yes No

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

Yes No

*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 options.

B. Informal (Family) Support Services

An individual’s ability to remain at home often depends on the availability, quantity and quality of his/her informal supports. 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?
    Yes No
  2. If there is an informal caregiver available, do they live within 45 minutes of the individual?
    Yes No
  3. Could the primary support person provide at least 20-30 hours of care each week?
    Yes No
  4. Taking the primary support person’s own health and physical ability into consideration, would you consider them able to meet the individual’s care needs on a daily basis?
    Yes No
  5. Taking the caregiver’s personal life (e.g., family, job, etc.) into consideration, would you consider them to be willing to provide the care that the individual needs on a daily basis?
    Yes No

*If you cannot comfortably answer “yes” to these questions, begin looking into formal support services to obtain the assistance and services that the informal caregiver cannot provide.

C. Formal (Agency Provided) Community-Based Services

Services provided by community agencies can help seniors maintain independence and provide necessary backup and relief to family caregivers. See CANHR’s fact sheet, “Community-Based Services for Seniors” for a list of the key services that 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 his or her 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 address how the help provided by the informal caregiver can better complement the formal support services the individual is receiving.

List any services that the individual needs but is not receiving:

_______________________________     _______________________________

_______________________________     _______________________________

Some of the services needed may be provided by one or more of the programs See CANHR’s fact sheet on “Community Based Services for Seniors”. There also may be additional services available in your communities that are not listed in this fact sheet. Call Senior Information & Referral for information: (800) 510-2020.

D. Out-of-Home Placement

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

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: Usually residents must be able to live independently. These residences provide a 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 (larger facilities) or board and care homes (6 beds or less), 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. Except through the Assisted Living Waiver Program (See CANHR’s ALW fact sheet), Medi-Cal does not pay for care in RCFEs. The average monthly cost for RCFEs in California is about $3,000+ per month, although prices vary widely.

Note: Residential Care/Assisted Living facilities might accept individuals who “need a lot of assistance” with activities of daily living (#1) but may not be willing to or able to accept persons who answer “yes” to questions in #3, Special Care Needs. If a facility accepts a person with special needs, monthly rates will be higher.

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. Medi-Cal eligible residents can use Medi-Cal to pay for nursing facilities that are Medi-Cal certified. See CANHR’s fact sheet “Overview of Long Term Care Medi-Cal.

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.

  • Talk to the doctor.  In order to identify an individual’s healthcare needs, it is good to consult 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.
  • Determine future financial capability.  Some care options may not be affordable.  For example, many people who might desire care in an assisted living/residential care facility cannot afford it.  Medi-Cal pays for nursing home care for qualified persons but except in limited circumstances, does not pay for care in an assisted living facility.  Keeping this in mind, consider your future ability to pay for care when exploring long term care facilities.  Those need nursing home care should select a Medi-Cal certified facility unless significant funds are available.  If you are considering an assisted living or residential care facility, factor likely rate increases into your decision. By carefully evaluating your financial means and available public assistance, you can help prevent traumatic relocations from long term care facilities due to lack of funds.
  • Designate legal representatives.  It is important to designate representatives and agents while an individual has the mental capacity to make decisions. This includes granting power of attorney for health care (AHCD-Advance Health Care Directive) and for finances. If neither of these is in place and the individual has already lost capacity, a conservatorship would be necessary to determine a legal representative. It may be difficult to designate someone else to make decisions for you, but should you lose capacity, it is important that somebody else has the legal authority to speak on your behalf For more information, see CANHR’s fact sheets onDurable Power of Attorney for Health Care/Advance Directive, Durable Power of Attorney for Property, Probate Conservatorships in California, and Planning for Incapacity.

Page Last Modified: April 26, 2016