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The Paper Trail: Assessments and Documents Needed for a Long-Term Care Move

Moving a loved one into a long-term care facility is a huge step, and the paperwork can feel overwhelming. This guide walks you through exactly what assessments and documents are needed to get the admission approved and ensure your family member receives the right care from day one. You don't have to figure this out alone — here are the concrete steps and the exact words to use with doctors and facility staff.

Key points

  • Start gathering documents at least two weeks before the move to avoid last-minute stress.
  • The two main categories of documents are medical assessments (cognition, ADLs, mobility, depression) and legal/financial documents (advance directives, power of attorney, Medicaid application).
  • A comprehensive medical assessment should include a mentation evaluation (cognitive capacity and depression screening) and a functional assessment of ADLs.
  • Legal documents like power of attorney and advance directives should be completed before a formal dementia diagnosis if possible, as it becomes harder afterward.
  • Create a 'care notebook' or 'life file' with all documents in one place, and keep a copy on the refrigerator for emergencies.
  • Communicate any dementia-related behaviors and their management strategies to the facility in writing to ensure continuity of care.
  • Medicaid applications can take months, so start early and consult with an elder law attorney if needed.

Why the Facility Needs So Much Paperwork

When your loved one moves into a long-term care facility, the staff is taking over a complex set of responsibilities — managing medications, preventing falls, addressing behavioral changes, and providing daily personal care. To do this safely and legally, they need a complete picture of the person's health, cognition, and functional abilities. This isn't bureaucracy for its own sake; it's how the facility creates a care plan that keeps your family member safe and comfortable.

The transition itself is a high-risk event. Research shows that moving between care settings — from home to hospital to nursing home — is a vulnerable time when medical errors, medication mix-ups, and falls are more likely. The assessments and documents you gather serve as a bridge, ensuring the new team has the same information the previous providers had. Without this transfer of information, your loved one might receive the wrong diet, miss a critical medication, or be treated for a condition they don't have.

For people with dementia or Alzheimer's, the move can be especially disorienting. The term 'transfer trauma' describes the distress that can occur when a person with cognitive impairment is removed from familiar surroundings. Having thorough documentation helps the facility anticipate and prevent problems — for example, knowing that your mother becomes agitated when approached from behind allows staff to approach her face-to-face, reducing her anxiety and the risk of a behavioral crisis.

The Two Main Categories: Medical Assessments and Legal/Financial Documents

The paperwork you need falls into two broad buckets. First, the medical assessments: these are clinical evaluations that document your loved one's current health status, cognitive function, mobility, and care needs. The facility uses these to determine what level of care is required, what staff training is needed, and what services must be provided. Key assessments include a cognitive evaluation (often using tools like the Mini-Mental State Exam or Montreal Cognitive Assessment), a depression screening (such as the Geriatric Depression Scale or PHQ-9), a functional assessment of activities of daily living (ADLs) like bathing, dressing, and eating, and a mobility assessment that documents any limitations with walking, transferring, or using adaptive equipment.

Second, the legal and financial documents: these establish who has the authority to make decisions for your loved one and how the care will be paid for. This includes advance directives (living will, healthcare power of attorney), financial power of attorney, and, if applicable, Medicaid application paperwork. These documents are critical because they ensure that your loved one's wishes are respected even when they can no longer speak for themselves, and they prevent delays in payment that could jeopardize the placement.

Many families don't realize that some of these documents need to be in place before the diagnosis of dementia is formally recorded. Once a dementia diagnosis is on the medical record, it can be more difficult to obtain long-term care insurance or to complete certain legal documents like a power of attorney. If you are still in the early stages, consider consulting with an elder law attorney before the formal diagnosis is made to get these documents in order.

General caregiving information, not medical advice. Check medications and major care changes with your clinician.

Step-by-step

  1. Step 1: Schedule a comprehensive medical assessment with your loved one's primary care physician. Ask the doctor to perform a 'mentation evaluation' that assesses the patient's capacity to manage their own medical and executive affairs, and to formulate advance directives or name a surrogate decision maker. Use this exact language: 'Doctor, we need a full cognitive assessment and a depression screening using a validated tool like the Geriatric Depression Scale or PHQ-9, because the facility requires this for admission.'

  2. Step 2: Request a functional assessment of Activities of Daily Living (ADLs). This should document your loved one's ability to perform basic self-care tasks: bathing, dressing, toileting, transferring (moving from bed to chair), continence, and feeding. The facility will use this to determine the level of assistance needed. Ask the doctor or an occupational therapist to complete a standardized ADL assessment form, which many facilities provide.

  3. Step 3: Get a mobility assessment. This should document any limitations with walking, transferring, or using adaptive equipment like a walker or cane. The assessment should also include a fall risk evaluation. If your loved one uses a front-wheeled walker instead of a single-point cane, make sure this is noted, as it reduces fall risk. Ask for a physical therapy consultation if needed.

  4. Step 4: Gather all medication records. Create a complete list of all prescription drugs, over-the-counter medications, and supplements your loved one is taking, including dosages and frequencies. Also include any known allergies or adverse reactions. The facility needs this to prevent medication errors and to reconcile the medication list with the new prescriber.

  5. Step 5: Collect all legal documents: advance directives (living will and healthcare power of attorney), durable financial power of attorney, and any existing will or trust. If these documents are not yet in place, work with an elder law attorney to complete them before the move. The facility will need copies of these to know who can make medical and financial decisions.

  6. Step 6: If your loved one will be applying for Medicaid to pay for care, start the application process early. Contact your state's social services office or long-term care ombudsman to get the correct forms. The nursing home's billing department can also help you understand what is needed. Be prepared to provide information about income, assets, and any transfers of property or money in the past five years (the 'look-back period'). Note that Medicaid approval can take months, so do not wait until the last minute.

  7. Step 7: Complete a 'Release of Information' form that allows the facility to communicate with you and other family members. This is a HIPAA-compliant document that must be signed by the patient (or their legal representative) before the facility can share any health information with you. Make sure this is updated and on file with both the current doctor and the facility.

  8. Step 8: Create a 'care notebook' or 'life file' that contains all the gathered documents in one place. Keep a copy on your loved one's refrigerator (for emergency responders) and a backup copy in your own files. This should include the medication list, doctor contact information, emergency contacts, and a summary of special conditions or behaviors.

  9. Step 9: Communicate any dementia-related behaviors and psychiatric symptoms to the facility in writing. Include management plans that have worked at home — for example, 'Mom becomes agitated when approached from behind; approach her face-to-face and speak calmly.' This helps the facility prevent behavioral crises and provides continuity of care.

  10. Step 10: If your loved one has a feeding tube or swallowing difficulties, request a speech therapy evaluation and a modified diet order before the move. Document any dysphagia (swallowing problems) and the recommended diet consistency (e.g., pureed, mechanical soft, thickened liquids). This prevents aspiration and pneumonia.

What not to do

  • Do not assume the facility will accept verbal information. Common mistake: telling the admissions coordinator about your loved one's condition over the phone without providing written documentation. Why it backfires: the facility needs official records for liability and regulatory compliance; without them, they may delay admission or provide incorrect care. Instead, gather all documents in advance and provide copies.

  • Do not wait until the day of move to gather paperwork. Common mistake: scrambling to find medical records, legal documents, or insurance information at the last minute. Why it backfires: this causes stress for you and your loved one, and can delay the admission or result in an incomplete care plan. Instead, start collecting documents at least two weeks before the planned move.

  • Do not skip the cognitive assessment or depression screening. Common mistake: assuming the facility will do its own evaluation upon arrival. Why it backfires: the facility needs baseline data to track changes and to identify conditions like depression, which is common in older adults and can mimic dementia. Without this, they may miss treatable conditions. Instead, ask the doctor to perform these assessments and include the results in the transfer documentation.

  • Do not forget to update the Release of Information form. Common mistake: using an old form that does not include the facility or specific family members. Why it backfires: the facility cannot legally discuss your loved one's care with you, leaving you in the dark about important decisions. Instead, ensure the form is current and lists all relevant parties.

  • Do not assume Medicaid will be handled automatically. Common mistake: thinking the facility will take care of all Medicaid paperwork. Why it backfires: the facility can help, but the application is ultimately your responsibility. Delays in submission can lead to gaps in payment and potential discharge. Instead, contact your state's Medicaid office early and keep copies of all submitted documents.

  • Do not ignore the need for a swallowing evaluation if your loved one has had recent weight loss or choking episodes. Common mistake: assuming that because they eat at home without problems, they will be fine in the facility. Why it backfires: changes in environment can worsen swallowing difficulties, leading to aspiration pneumonia. Instead, request a speech therapy evaluation before the move and document any dietary modifications.

Practical tools

  • The 'Care Notebook' or 'Life File'

    A physical or digital binder that contains all the documents in one place. Include: medication list, doctor contact info, emergency contacts, advance directives, power of attorney, insurance cards, Medicaid application status, and a one-page summary of your loved one's condition, behaviors, and preferences. Keep a copy on the refrigerator (for emergency responders) and a backup with you. This tool ensures that no critical information is lost during the transition.

  • The 'What Matters' Conversation Guide

    Before the move, have a conversation with your loved one (if they are able) about what matters most to them. Use the 'What Matters' framework from the Age-Friendly Health Systems initiative. Ask: 'What is most important to you in your daily life?' and 'What worries you about moving to a facility?' Document their answers and share them with the facility. This helps the staff provide person-centered care that aligns with your loved one's values.

  • The 'ADL Assessment Checklist'

    A simple checklist you can use to document your loved one's abilities in six key areas: bathing, dressing, toileting, transferring, continence, and feeding. For each, note whether they are independent, need supervision, need some assistance, or are fully dependent. This information is critical for the facility to determine the level of care needed and to create a safe care plan. You can find free ADL assessment forms online or ask the facility for their preferred form.

  • The 'Medication Reconciliation Form'

    A form that lists all medications, dosages, frequencies, and the reason for each. Include over-the-counter drugs and supplements. Also list any allergies or adverse reactions. This form should be reviewed by the doctor and updated at every transition. The facility will use this to reconcile the medication list with their own prescriber, preventing errors.

  • The 'Behavioral Management Plan' Template

    A one-page document that describes any dementia-related behaviors (e.g., agitation, wandering, resistance to care) and the strategies that work at home. For example: 'When Mom becomes agitated, redirect her to look at a photo album' or 'Dad tends to wander in the evening; provide a calm, dimly lit environment.' Share this with the facility to ensure continuity of care and to reduce the risk of behavioral crises.

  • The 'State Medicaid Application Checklist'

    A checklist specific to your state that outlines all required documents for a Medicaid long-term care application. Common items include: proof of income (Social Security, pensions), proof of assets (bank statements, property deeds), proof of citizenship, and documentation of any asset transfers in the past five years. Contact your state's social services office or long-term care ombudsman to get the correct checklist. Start this process early, as approval can take months.

Discuss with your clinician

Ask the doctor: 'What specific cognitive assessment tool do you recommend for our situation, and how will the results be shared with the facility?'

Ask the doctor: 'Are there any medication adjustments needed before the move, especially for medications that affect cognition or balance?'

Ask the doctor: 'Should we have a swallowing evaluation before the move, given my loved one's recent weight loss or choking episodes?'

Ask the doctor: 'What is the best way to manage any dementia-related behaviors during the transition, and should we consider any short-term medications to reduce anxiety?'

Ask the doctor: 'Do you recommend any specific fall prevention measures or adaptive equipment that should be documented in the transfer paperwork?'

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