Who decides if my parent needs nursing home level of care?

Level of care is decided by assessment

Nobody decides this over the phone, and no single doctor decides it alone. Georgia establishes level of care through a structured assessment in the person’s home, supported by a medical form completed by a physician.

The question being answered is narrow and specific: does this person need the level of care a nursing home provides? If the answer is yes, the waiver exists so that care can be delivered at home instead. If the answer is no, the waiver is not the right program, and other supports may be.

The DON-R

The DON-R - Determination of Need - Revised - is the instrument used. An assessor comes to the home and works through how the person manages the ordinary business of a day, scoring both how much help is needed and how often.

What it looks at:

• Daily activities. Bathing, dressing, grooming, using the toilet, eating, getting in and out of bed and chairs, moving around the home.
• Household tasks that keep someone independent. Preparing meals, managing medication, using the telephone, handling money, getting to appointments.
• Medical needs. Treatments, wounds, equipment, conditions that need monitoring, anything requiring a nurse’s judgment.
• Safety and supervision. Whether the person can be left alone, for how long, and what has already gone wrong - falls, wandering, a stove left on, medication missed or doubled.

The scoring is about a typical day, not the best day. This matters more than families expect. Someone who has been quietly doing three hours of help every morning for two years stops seeing it as help, and describes their parent as managing fine. The assessment is not served by that.

The DMA-6

Alongside the DON-R, a physician completes the DMA-6, the medical form for the waiver. It sets out diagnoses, treatments, medications and medical needs.

The two documents do different jobs. The DMA-6 says what is medically true. The DON-R says what that means for the person’s day. Both are needed, and a strong medical picture with no documented functional need is not enough on its own.

Who signs off on the plan of care

This is the step that quietly holds up more applications than any other, because it depends on a physician’s office returning paperwork.

Georgia’s General Services policy at §602.11 allows the plan of care to be approved, and the level-of-care need to be attested, by either the member’s own physician or the case management agency’s medical director. Both routes are provided for in policy.

The practical effect is straightforward: where a case management agency has a medical director on staff, that step does not have to wait on the member’s own doctor’s schedule. This is program mechanics, not a promise about timing - nothing about it changes the assessment, the Medicaid financial determination, or whether a waiver slot is available.

What this does not decide

Level of care is one of two tests. Meeting it does not establish Medicaid financial eligibility, which is decided separately by the Division of Family and Children Services, and it does not by itself produce a waiver slot when slots are limited.

It is also not permanent. Needs change. A person assessed today can be reassessed if their condition worsens, and a determination that goes against you can be appealed. If you are told no and you believe the assessment did not capture what your household actually looks like, say so and ask what the appeal route is.

Preparing for the assessment

The single most useful thing you can do is write down, over a week, what help you actually give and what actually goes wrong. Times, not impressions. That record is what turns ‘she manages all right’ into an accurate picture of a typical day, and the assessment visit page covers the rest of the preparation.