Continuing care retirement communities (CCRCs), also known as “life plan communities,” offer older adults the ability to live independently today while having access to a full range of future care options, including assisted living, memory care, and skilled nursing. This model provides continuity of care and peace of mind, but it also raises important questions: who decides when a resident should move to a higher level of care, and how is that decision made?
The progressive care decision process
Most CCRC residency contracts use similar language: when assessing whether a resident should be transferred to a higher level of care, the community will consult with the resident whenever possible, along with the resident’s family, personal representative, and attending physician; however, the community’s decision is binding. This wording indicates that transfers are usually determined case by case rather than by a single fixed checklist. The community consults relevant parties, but ultimately retains authority to make the final determination.
Reputable communities typically approach this responsibility with the resident’s best interests in mind, treating residents with respect and aiming to preserve independence as long as safely possible. Some states, however, have clearer legal procedures that require specific steps if a transfer is being considered. Disagreements can occur—residents or family members sometimes wish to remain in independent living even if staff recommend a move to assisted living, memory care, or skilled nursing.
In my experience visiting CCRCs and speaking with families and staff across the country, such disputes are not extremely common. Most communities try to support independent living where it is safe to do so. Still, when a transfer is recommended there are opportunities for pushback, and it’s important to know what protections and processes exist to review or appeal a decision.
Assessing level of care transfer options
State rules and community policies vary, and some states provide formal safeguards to protect residents’ rights. For example, California has a defined “Level of Care Transfer Process” that offers several protections. According to the California Advocates for Nursing Home Reform (CANHR), residents have the right to request an assessment and then to seek a review of the level-of-care decision that follows. This process gives residents the chance to present medical evidence showing their needs can be met in independent living.
In California, the transfer process typically includes a series of steps: an initial care conference, a written notice of transfer, a second care conference, review by the state’s continuing care contracts branch, and then the actual transfer if upheld. Other states may have different procedures or fewer formal steps, so it’s important to ask each community about the specific transfer protocol where you live or plan to move.
CANHR also notes that a provider may only transfer a resident under certain circumstances, taking into account the appropriateness and necessity of the transfer while promoting resident independence. In California, those conditions generally include: 1) the resident is non-ambulatory and cannot leave the unit in an emergency; 2) the resident’s physical or mental condition endangers the health or safety of others; 3) the resident’s condition exceeds what can lawfully be provided in independent living; or 4) the resident requires a higher level of care that the community cannot provide. Keep in mind these examples reflect California law and may differ in other states.
Making the best decision
Choosing a CCRC brings many benefits, chief among them the assurance that appropriate care will be available as needs change. That said, prospective residents and their families should carefully review residency contracts and community policies regarding transfers to higher levels of care. Some contracts may require residents to accept a transfer if the community determines it to be the safest and most appropriate option based on the resident’s health. Understanding the process, knowing your state’s protections, and asking communities about their assessment and appeal procedures will help ensure decisions are made fairly and with the resident’s well-being as the priority.
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