Care Transitions in North Carolina: A Guide for Families

Moving from one level of care to another — from home to assisted living, from assisted living to skilled nursing, or from hospital to rehabilitation — is one of the most stressful experiences families face. Decisions happen fast, information is scattered, and the emotional weight is enormous. This guide gives you a framework for understanding what's happening and what your rights are at each stage.

The Levels of Care in NC

Understanding what each level of care provides — and requires — is the first step.

Living at Home

The starting point for most families. Care at home ranges from informal family support to full-time professional caregiving. As care needs increase, home care becomes more complex and expensive:

Home health agencies provide skilled nursing, therapy, and aide services — often covered by Medicare for qualifying patients after a hospitalization
Private duty home care provides companion care, personal care, and homemaking — generally not covered by Medicare, paid privately or through long-term care insurance
Private caregivers hired directly by families — common but carries legal and insurance considerations (see below)

→ See: Hiring private caregivers in NC: what families need to know about liability

Assisted Living (Adult Care Homes in NC)

NC's licensed adult care homes provide housing, meals, personal care, and some health-related services for adults who need assistance with daily living but do not require continuous skilled nursing care.

What NC law requires of these facilities — including individualized care plans, assessment requirements, and conditions that require transfer to a higher level of care — is specifically regulated under 10A NCAC 13F.

→ See: Are NC assisted living facilities required to have care plans?

Skilled Nursing Facilities (Nursing Homes)

Provide 24-hour licensed nursing care for people with complex medical needs, including wound care, IV therapy, rehabilitation, and full-assist transfers. Skilled nursing is the highest level of non-hospital care and is significantly more expensive than assisted living.

Cost in NC: Approximately $7,000–$10,000 per month depending on location and room type.

When Medicare pays: Medicare covers short-term skilled nursing care (rehabilitation) following a qualifying hospital stay of 3+ days. It does not cover long-term custodial care. After Medicare coverage ends, costs are private-pay until Medicaid eligibility is established.

→ See: When your parent's assisted living recommends skilled nursing

Memory Care

Specialized units — within assisted living facilities or skilled nursing facilities — designed for people with Alzheimer's disease or other forms of dementia. Features typically include secure environments, structured programming, and staff trained specifically in dementia care.

Hospice

Provides comfort-focused care for people with a terminal illness and a life expectancy of 6 months or less. Hospice can be provided at home, in assisted living, or in a skilled nursing facility. Medicare covers hospice for eligible patients.

When Assisted Living Recommends a Move to Skilled Nursing

Facilities recommend higher levels of care when a resident's needs exceed what the facility is licensed or equipped to handle. Common triggers include:

Inability to transfer without full mechanical assistance
Need for 24-hour licensed nursing care
Repeated falls or significant fall-related injury
Medical conditions requiring skilled nursing procedures
Behavioral or cognitive deterioration beyond the facility's capacity

Families have rights in this process — including written notice, the right to a care conference, and the right to appeal a discharge decision through DHSR.

→ See: When your parent's assisted living recommends skilled nursing

Evaluating Skilled Nursing Facilities

Not all skilled nursing facilities are equal. Use these tools to compare:

Medicare's Care Compare: medicare.gov/care-compare — 5-star ratings for every Medicare-certified nursing facility, covering health inspections, staffing, and quality measures.

NC DHSR Facility Search: The NC Division of Health Service Regulation maintains inspection reports, deficiency records, and complaint histories for all licensed NC care facilities at ncdhhs.gov/dhsr.

What to ask on a tour:

What are your CNA-to-resident ratios at night?
How often are overnight rounds conducted?
What fall prevention systems do you use?
What experience do you have with [specific condition]?
Can I see a sample care plan?

The Role of Rehabilitation

Many families first encounter skilled nursing facilities in the context of short-term rehabilitation — after a hospitalization for a hip fracture, stroke, or other acute event. Medicare covers up to 100 days of skilled nursing facility care for rehabilitation following a qualifying hospital stay, with a daily co-pay after day 20.

Short-term rehab is different from long-term placement. Use the rehab period to assess the facility, understand your family member's trajectory, and plan for what comes next — because Medicare coverage has limits and the transition to long-term care or back home requires planning.

Planning the Finances

Long-term care insurance: If your parent has a policy, review its terms now — before care is needed. Understand the elimination period, daily benefit amount, inflation protection, and qualifying conditions. Many people don't know what their policy covers until they're trying to use it.

Medicaid: For families without long-term care insurance or substantial assets, Medicaid is the primary payer for nursing facility care. Eligibility requires meeting income and asset limits, and the application process can take weeks to months.

→ See: Medicaid Planning in North Carolina

Veterans benefits: Veterans and their surviving spouses may be eligible for the VA Aid and Attendance benefit, which can help pay for in-home care, assisted living, or nursing facility care. Contact your county Veterans Service Office or the NC Department of Military and Veterans Affairs for eligibility information.

Legal Planning for Transitions

Care transitions often coincide with — or precipitate — the need for legal planning. Before or during a transition is the right time to ensure:

A durable power of attorney is in place and the agent is current
A health care power of attorney and advance directive are on file at the new facility
The facility has copies of all relevant legal documents
The agent under any POA is clearly established as the authorized representative with the facility, county DSS, and Medicaid

→ See: How to get NCDHHS and DSS to recognize your POA

Care Transitions and Guardianship

If a family member is being moved to a higher level of care and there is no legal authority in place — no valid POA, a disputed POA, or an incapacitated person who cannot consent — guardianship may be needed to authorize placement decisions.

Facilities are generally required to accept direction from a legal guardian. They may decline to accept direction from a family member who has no legal authority, even in urgent situations.

→ See: How to file for emergency guardianship in NC

Resources for NC Families

Area Agencies on Aging: NC's regional Area Agencies on Aging provide information, referral, and care coordination services for older adults. Find your AAA at ncdhhs.gov/divisions/aging.

NC DHSR Facility Search: Compare licensed care facilities at ncdhhs.gov/dhsr.

Medicare Nursing Home Compare: medicare.gov/care-compare

Legal Aid of NC: Free civil legal help for qualifying residents at legalaidnc.org.

NC Bar Association Lawyer Referral: 1-800-662-7660

Care Transitions Articles on This Site

The information on this page is for educational purposes only and does not constitute legal advice. Please consult a licensed North Carolina attorney for guidance specific to your situation. Learn more about ElderAdvocate.law.