The 5 Levels of Assisted Living for Seniors Explained

Author: Amanda Lambert, MS, CMC, ALCP

Years ago, assisted living care was relatively simple and more closely resembled the independent senior living of today. As the older population has grown, so has the need for an adjustment to a more robust level of care in assisted living. People age and chronic conditions or a general decline in functioning have more families looking to assisted living to take care of loved ones.

Most older adults state they would rather age in place at home, but sometimes that isn’t possible due to increasing caregiver duties and the cost of care. And in some situations, seniors decide to move to assisted before they need extensive care to avoid a move later.

When you are looking for assisted living, understanding the levels of care will help you decide the appropriate placement for your loved one. It is common for seniors to prefer the least care possible to maintain as much independence as they age. But things rarely stay the same so keep in mind that sometimes you need to look to the end to figure out where to begin.

Why Are There Different Levels of Care in Assisted Living for Seniors?

Assisted living communities are complex, and there are numerous moving parts to keep everything running smoothly. Care staff, dining services, transportation, activities, maintenance, nursing, and admissions are all needed every day to meet the needs of residents. 

Levels of care are how assisted living communities determine the amount, duration, and type of care someone needs. Allocating staff time to different residents is a complicated endeavor, and the more time someone needs, the more labor-intensive and the higher the cost to the resident. 

For staff to meet the varying needs of individual residents, levels of care help with ensuring that assistance is available when the resident needs it. It’s all about matching the right facility with the right residents.

How Do You Choose a Level of Care?

It is unlikely that you will get to choose a level of care in assisted living. You can voice your opinion, but assisted living communities must ensure that they can safely care for your loved one. Each assisted living community may have a slightly different approach to assigning a level of care. Some have broad categories, and others have many more specific tiers of care.

A nurse completes an assessment on any person interested in an assisted living community. The assessment reviews medical records, medication list, how often each medication is taken, mobility, and ability to dress, bathe and eat. The nurse then recommends a level of care but understands that the care plan needs to be flexible and adjusted when your loved one moves in. 

If the level of care isn’t high enough when your loved one moves in, the nurse can adjust accordingly. Or, if it appears that the level of care is more than what your loved one requires, they can reduce the number of visits.

On occasion, the assisted living nurse may indicate that they can’t safely attend to your loved one’s needs. This could be because complex medical conditions make it too challenging for staff to manage, or cognitive impairment suggests memory care or a nursing home might be a better fit. In thinking about assisted living and what level of care your loved one might require, consider these questions:

Cognitive: Does your loved one have a cognitive impairment that threatens their safety at home?

• Daily activities: What specific activities of daily living do they need assistance with? Sometimes family caregivers are doing so much for a loved one they don’t realize how much help they need with activities of daily living.
• Medical conditions: What are chronic medical conditions likely to worsen over time that could require more care?
• Cost: Do you have the financial resources to pay for assisted living?
• Options: If your loved one should need a higher level of care than what assisted living can provide, what are your options?
• Wishes: What are your loved one’s wishes, and if they don’t want assisted living, do you have the resources to support in-home care.

The Different Levels of Care in Assisted Living for Seniors

Some assisted living communities have three levels of care; others have four or five. You always have the option of augmenting care with time-limited home health or home care. Although each assisted living will be different, in general, you can expect some form of these levels based on these activities of daily living and additional assisted living costs for each level:

• Bathing: Bathing is an activity that some people need hands-on assistance with and others reminders or stand-by help. If a resident has difficulty standing, they might need assistance getting to the bathroom as well.
• Dressing: Dressing involves choosing appropriate clothes and having the ability to put them on and take them off. Some people might need a reminder or placement of clothes, and they can put them on independently. Or others may need maximum assistance with all aspects of dressing. 
• Grooming: Grooming is caring for teeth, dentures, hair, shaving, and attention to hygiene after using the bathroom.
• Mobility: Mobility includes walking, the ability to use mobility aids like walkers and wheelchairs, and the capability to transfer or stand. Some assisted living communities will not accept someone who requires two people to assist them to a standing or sitting position. They may also not permit lifting devices such as hoyers. 
• Incontinence: Continence is the ability to use the bathroom independently. When someone needs the help of an aide to assist with this process, it will be a higher level of care. Care for incontinence can also include changing of briefs and hygiene.
• Eating: Some individuals can feed themselves but need help cutting their food. Others may require stand-by assistance to monitor for choking. For individuals who are at risk of choking they may require the presence of a caregiver as a safety precaution. 
• Medication: Most assisted living communities require medication dispensing as part of their levels of care. The number of medicines and how often they are taken can affect the level of care. 
• Quantity of aids: If an assisted living resident only needs assistance with one activity a day, they may only require one aide. Or, several aides might be required for multiple tasks during the day and at night.

Level one: minimal assistance

Level one will vary depending upon the community. But in general, at level one, a resident receives all of the basic amenities such as three meals a day, an emergency response system, weekly housekeeping, all activities, transportation, medication management, and daily safety checks. 

The additional cost comes with minimal assistance with one activity of daily living. All other subsequent levels include the base amenities, in addition to adding on care.

Level two: limited assistance

Level two in assisted living usually means all of the care level one services—additional occasional reminders for activities and meals and limited assistance with activities of daily living. For example, a resident may only need daily checking or a reminder for meals.

Level three: regular assistance

Level three usually means regular assistance with activities of daily living, frequent reminders, and assistance with manageable incontinence. For example, someone may need occasional assistance with incontinence, such as help with changing briefs. Regular support could also include daily blood sugar, blood pressure, and oxygen checks.

Level four: frequent assistance

Level four indicates frequent assistance with activities of daily living. Also included are regular reminders and consistent assistance with incontinence. In real-world terms, think of level four as help from aides all during the day with various tasks such as bathing, grooming, transferring, and dressing.

Level five: significant assistance

Level five is significant assistance and, in some cases, can extend to end-of-life care. For someone who is bed-bound, care can include weekly bed baths, emptying of a urine bag, assistance with eating, grooming, and dressing. 

Others may need help transferring from bed to chair and back again. They may require someone to accompany them to meals or bring meals to them. Every two-hour checks 24 hours a day is typical of the highest level of care.

Other Senior Living Options for Care

As you can see, if you have a loved one that requires consistent assistance with activities of daily living, it can be a challenge and expense to replicate those services at home, but not impossible. There are a few other senior housing options.

Home care

Home care is an option many families choose at the beginning to help a family member with daily tasks. As the need for assistance grows, so do the hours of care and the cost. In most states, home care caregivers can’t administer medications or provide any medical services. When that level of care is needed, families begin to consider assisted living, especially if an aide is required overnight at home.

Independent senior living

More and more independent senior living communities are in the same building as assisted living. The advantage? Independent residents can benefit from the basic amenities like meals, housekeeping, laundry, activities, and transportation. Sometimes, that support alone is enough to keep a loved one stable for quite some time.

Residential care home

A residential care home or board and care is a smaller, more intimate assisted living type senior housing option. Aides are available for help with activities of daily living, meals are provided, and there is medication management. Nursing and other medical services could be limited. Activities will not be as extensive as in larger traditional assisted living communities. 

Memory care

Memory care is a specific type of care for people with dementia or Alzheimer’s disease. Seniors enter memory care one of two ways. They may come to memory care straight from home after safety and care are more challenging to ensure. Others may do well in assisted living for a while but need more one-on-one specialized care available only in memory care. 

Levels of Assisted Living

Levels of assisted living are designed to accommodate your loved one’s care needs. In choosing the best assisted living, consider the level of care you might need for your loved one in the future, not just the one you need now. 

In all things, be as flexible as you can and always support your loved one’s safety and well-being. Though it can be complicated, it’s important to guide your loved one through this life transition. 

About the Author: Amanda Lambert is a Certified Care Manager and Aging Life Care Professional with over 20 years of experience in mental health, home health, guardianship, and care management. She is the co-author of Choose Your Place: Rethinking Home as You Age and Aging with Care: Your Guide to Hiring and Managing Caregivers at Home. Amanda specializes in long-term care planning and care management, helping families navigate the senior care landscape. Learn more about her work at Mindful Aging.