Determining the need for care - the process
Martina Feichter studied biology with an elective subject pharmacy in Innsbruck and also immersed herself in the world of medicinal plants. From there it was not far to other medical topics that still captivate her to this day. She trained as a journalist at the Axel Springer Academy in Hamburg and has been working for since 2007 - first as an editor and since 2012 as a freelance writer.
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Anyone who is regularly, permanently and to a considerable extent dependent on help in everyday life due to an illness or disability can be entitled to benefits from long-term care insurance. To do this, however, the person concerned must first be classified as in need of care. We explain the procedure behind it here!
What does "in need of care" mean?
The concept of the need for care is redefined in the Care Strengthening Act II: Since January 1, 2017, all those people are considered to be in need of care who, because of a physical, mental or emotional illness or disability in the area of personal hygiene, nutrition, mobility and domestic care - probably for at least six months - need significant or greater help. When determining the need for care, an expert examines whether and how the patient in question can cope with his everyday life on his own.
Before 2017, the determination of the need for long-term care focused mainly on physical limitations and the time needed for help with physical activities (such as washing, dressing, eating, etc.). Mental and mental impairments (as in dementia) played a subordinate role, but now they are on an equal footing.
Another innovation of the Long-Term Care Strengthening Act II is that the need for long-term care is divided into five care levels (and not, as before, into three care levels).
Maintenance certificate
Those who were already classified as in need of care according to the old definition did not have to be reassessed. Rather, there was an automatic transition from the previous level of care to the appropriate level of care.
This assessment instrument was and is used for all patients who were not classified as in need of care before the amendment to the law or who would now like to be classified as in need of care:
- Statutory insurance: To determine the need for care, the patient or a relative must first submit an application to the long-term care insurance company (located at the health insurance company). The long-term care fund then commissions the medical service of the health insurance funds (MDK) or another independent expert to determine the patient's need for care.
- Privately insured persons: A privately insured patient or a relative must submit the application for classification as a person in need of care to the respective private insurance company. This then instructs the medical service MEDICPROOF to determine the need for care.
Appointment for the assessment
The expert (nurse or doctor) does not come to the house or the facility in which the patient lives unannounced. He or she makes an appointment for the assessment with the patient or his or her relatives or carers.
When announcing the appointment, the reviewer also asks the applicant to have relevant documents ready for the review. This includes, for example, reports from supervisory services, care diaries (*) and comparable own records of the insured person, medical documents, information about currently used medication as well as reports and notifications from other social service providers.
* Nursing diary: Records by a caregiver of every help the patient receives (e.g. with eating, getting dressed, etc.) and the time that the individual assistance measures take.
What is being assessed?
The expert assesses the following six areas of life ("modules"):
- Mobility (physical mobility, for example when getting up in the morning, going to the bathroom, climbing stairs, etc.)
- cognitive and communicative skills (e.g. orientation about time and place, understanding facts, recognizing risks, understanding what other people are saying)
- Behaviors and psychological problems (such as fears, aggression, defense against care measures, nocturnal restlessness)
- Self-sufficiency (e.g. washing yourself, using the toilet, dressing, eating, drinking)
- Coping with and independent handling of illness or therapy-related demands and stresses (independent taking of medication, independent going to the doctor, etc.)
- Organization of everyday life and social contacts (independent organization of the daily routine, making contact with other people, independent participation in social events, etc.)
The appraiser evaluates independence and skills in every area of life and awards a point value for this. Depending on the total number of points, the expert suggests a certain level of care or does not determine the need for care. On the basis of this report, the statutory or private health insurance will decide on the application for long-term care. A couple of weeks can pass between the application and the notification stating the need for care.
