Care assessment – what to be aware of

Anyone who wants to claim long-term care insurance benefits must first be recognized as being “in need of care”. This is the purpose of the care assessment. In the applicant’s home environment, assessors from the Medical Review Board determine whether the person is in need of care and to what extent.

To do this, they judge how independently the applicant copes in different areas of everyday life.

Depending how limited the applicant’s independence is and how dependent they are on assistance, the assessors assign one of five care grades to them. The higher the care grade, the higher the level of care required and the greater the number of benefits that can be claimed.

It is important that applicants understand the purpose and process of the assessment so that the outcome of the assessment corresponds to their actual need for support. It is also helpful to seek personal advice from care advisory centers and to prepare well for the home visit.

This is also important for loved ones, family caregivers and other people involved in providing care. They often play an important role in the application and the assessment, particularly in the case of people with dementia. During the home visit, they are helpful as an emotional support, and they can bring their perspectives and other issues to the process.

If an applicant does not agree with the result of the care assessment, they can appeal against it.

An informal communication by phone or email to the statutory long-term care insurance fund or private long-term care insurance company is all that’s required to apply for an assessment of care needs or for long-term care insurance benefits. The date of the communication is important because, if you are assigned a care grade, your entitlement to benefits will be back-dated to this date.

Your long-term care insurance fund or private long-term care insurance company will then send you an application form. They must also inform you, in full and free of charge, about your entitlements. You can get help with completing the application from the care insurance fund, private care insurance company or a local advisory center, such as a care support center.

If you yourself are unable to submit an application, you can also have a family member or a legal guardian do so on your behalf. However, they must have been granted an appropriate power of attorney in this case.

The next step is that the long-term care insurance fund asks the Medical Review Board of the Health Funds to conduct an assessment. Meanwhile, the private care insurance companies contact Medicproof, the private care insurance companies’ medical review board. The assessors from these medical review boards check whether and to what extent you are in need of care as defined by the long-term care insurance scheme. Both bodies are guided by the same standards.

The Medical Review Board’s home visit

The assessors are specially trained care workers and doctors. They visit you at home to get an idea of the extent to which you are coping independently with everyday life. They use the Assessment Guidelines to check the extent to which your independence is affected in such a way that you are dependent on care support.

They also estimate how long your need for care is likely to last. The assessors also check whether you have enough care aids, and whether prevention and rehabilitation services should be recommended.

After an accident or a surgical intervention, the assessment may also take place in the hospital or a rehab center.

If you yourself do not speak German well enough, you need to ensure that a person is present at the visit from the Medical Review Board who can interpret – for example, a family member or acquaintance with sufficient language skills, or an interpreter service.

The decision

The Medical Review Board communicates the result of their assessment to the long-term care insurance fund or private long-term care insurance company and gives them the assessment and all the relevant documentation. This determines whether the person is in need of care and, if so, what the allocated care grade is. Your long-term care insurance fund or private long-term care insurance company must inform you in writing of their decision regarding your allocated care grade within 25 days of receiving your application.

People are deemed to be in need of care if they are likely to be dependent on care support for at least 6 months because their independence or certain capabilities have been affected for health reasons.

To determine the need for care, the assessors examine documents relating to the person’s medical and care history. But the personal home visit is a key part of the assessment. The assessors themselves use the standard national assessment procedure to get a picture of the extent to which the applicant is in need of care. The modules it contains equate to six basic areas of life in which care support is important:

• Mobility: How independently can the person move, adopt and change a posture – for example, sit down, walk and climb a staircase?
• Cognitive and communicative abilities: How is the person coping with time and space in their everyday life? For example, are they able to make decisions alone, hold conversations and communicate their needs?
• Behavior and psychiatric problems: How often does the person need support from a caregiver, for example due to psychiatric problems such as aggressive or anxious behavior?
• Self-care: How independently can the person look after themselves in everyday life, for example in terms of personal hygiene and nutrition?
• Managing and independently dealing with requirements and difficulties due to illness and therapy: How successfully is the person dealing independently with illnesses and therapies? What support does the applicant need from caregivers in terms of dealing with their illness and treatments?
• Organization of everyday life and social contacts: How independently can the person plan their day and maintain contacts?

Calculating the care grade

Each module has several different criteria (for example, eating, drinking, using a toilet or a wheeled commode). The assessors award points for each criterion – the higher the score, the worse the impairment of their independence and capabilities. The scores in each module are added together.

Depending on their importance for everyday life, the modules are weighted differently for the overall total: the “Self-care” module, for example, is 40 percent, while “Structuring everyday life” is 15 percent. The overall score from all modules determines whether you are in need of care in the sense of the long-term care insurance scheme and, if so, what your care grade is, i.e., what level of care you require.

The home visit also looks at activities outside the home and household management, although these are not included in the care grade calculation. They are, however, important for the personal care plan that is also drawn up during the visit.

Recommendations on prevention and rehabilitation

As part of their assessment, the assessors also make recommendations that can help you maintain or improve your independence or capabilities. These recommendations may include, for example, specific aids, training courses, and preventive and rehabilitation measures. Aids that are recommended in the assessment are automatically deemed to have been requested. You do not need any other medical prescription for them.

Assistance from other people

It is important that your main caregiver is present to support you during the assessment. It is often helpful if this caregiver also shares their perspective. However, you need to give your consent before this can happen.
In the case of people with dementia or people with a legal guardian, the caregiver or the appointed guardian should be present at the assessment in any case.

Even if you are sure that you or your family member will definitely be assigned a care grade, it is important to prepare thoroughly for the visit by the Medical Review Board. Give some thought beforehand to the particular problems you face in everyday life. What do you need help with in your everyday life? What are you able to do independently in your everyday life? Tell the assessors yourself about areas that are particularly difficult or challenging.

The entire assessment hinges on the outcome of the home visit. The assessors use an assessment procedure to record all impairments correctly.

The “National Association of Statutory Health Insurance Funds guidelines for determining the need for care” brochure provides explanations and examples for every criterion used in the process in order to help you understand how independence is evaluated.

Keeping a care diary

Take a look at the brochure. For each assessment criterion that applies to you or your loved one in terms of a lack of independence, think about how often and to what extent help is needed by you or your loved one during the course of the day. Think of specific examples that demonstrate what you want to say. Also useful are suggestions as to how, in your opinion, care could be improved. You can also offer to demonstrate this to the assessor.

It is also helpful to put special support requirements in writing. You can give this care diary to the assessor. If you become anxious or flustered during the meeting and forget to mention some things, he or she can read your main points in the diary afterwards. The care diary also helps you to address, during the assessment, every area in which you are unable to cope alone.

The home visit may also happen to take place on a day when the person in need of care is able to cope to a degree that is not normally the case. If things are likely to be very different again the following day, it may be important to include additional notes in the diary in advance – what can the person in need of care do independently on a normal day, and where does the person normally need help? It is usually helpful to note this down in a care diary that you update daily over a lengthy period of time before the home visit. More minor activities that may be considered self-evident, such as preparing food and drink, should be noted down too. This also clarifies the number of days per week or month that the person in need of care requires help.

Keep important documents to hand

The person’s medical and care history is also important for the assessment. You should keep copies of the following documents, because they play an important part in the assessment:

• medications and medication plan
• the latest hospital or doctor’s reports
• decisions and assessments by other social insurance providers (for example, decisions on whether someone is severely disabled)
• list of regular treatments (for example, putting on and taking off compression stockings, blood pressure measurements)
• list of all care aids used
• your own notes, for example a care diary
• where relevant, the latest care documentation from the care service 

First – and honest – impressions matter!

It is important that the assessor gets to know you in your normal, everyday environment and in a natural situation. They will not only ask questions about every criterion, but will also formulate their opinion of you and your environment. Even if you tend to always show yourself in the best light, you should not begin to tidy up beforehand or make things seem brighter or downplay problems. Instead, you need to give a completely honest picture of your situation. The assessors also note, for example, whether you open the door yourself and how you are clothed and groomed.

Independence is also evaluated in the six basic areas of life for children and adolescents. As children are still learning basic skills such as eating independently, sitting and dressing themselves in their early years, their level of care need is determined in a rather different way. The assessors compare the child’s independence and skills with those of a healthy child of the same age. Moreover, children under the age of 18 months are, by default, assigned a care grade that is one grade higher.

From their 11th birthday, the assessment is based on the same prerequisites as for adults.

The “National Association of Statutory Health Insurance Funds guidelines for determining the need for care” brochure lists the assessment guidelines with explanations and examples for children.

You are entitled, by law, to free professional, personalized advice. Your local care advisory center will help you select and apply for the assistance and care benefits that meet your needs. It will also help and advise you on preparing for the care assessment and on any other questions relating to care.

If you want, this advice can be given in your home environment or in the care facility where you live.

You can decide where to get the advice you need. Options include, for example, your long-term care insurance fund, a care advisor, or a local advice center such as a care support point.

The Centre for Quality in Care foundation (Stiftung Zentrum Qualität in der Pflege) has drawn up a checklist to enable you to identify good sources of advice on care.

It also provides a database of advisory centers near you.

Has your application been rejected? Or do you think that the care grade assigned to you is too low? If so, you can lodge an appeal against the decision made by the long-term care insurance fund. You have one month in which to do this. This time limit is based on the date of the communication.

To begin with, you only need to inform the long-term care insurance fund in a few sentences that you do not agree with the assessment decision. It is then important to carefully set out the reasons for your appeal.

If you send the appeal to your long-term care insurance fund, you should ensure that you obtain confirmation of receipt – for example by using registered mail with acknowledgment of receipt. If you send a fax, you should keep the transmission report safe.
Do not use email to send your appeal because it is not legally binding. There is no limit on the amount of time the long-term care insurance fund may take to process the appeal.

The assessment is the basis for the decision made by the long-term care insurance fund. You should first read it and check whether its content is correct. If the long-term care insurance fund has not sent you the assessment together with their decision, you can request it from them. You are entitled to view it.

The assessment may not be an accurate reflection of the reality of the care situation for one of the following reasons:

• Not all of the important issues were taken into account and weighted properly.
• The day of the assessment was not a normal care day because you were having an unusually good day.
• Not all of the issues were recorded correctly.
• A particular support requirement may not have been noted.
• Your application was not accompanied by all important documents required (medication plan, doctor’s or hospital reports).

It is important that you give reasons for, or evidence of, each of your objections. A care diary that you keep updated is helpful in this respect.

The website of the Federal Medical Review Board (Medizinischer Dienst Bund KöR – MD Bund) has checklists and information about the care assessment in over 10 languages.