Short answer: If your loved one’s authorized hours no longer match real life, more help at night, new falls, harder transfers, you can ask the plan for a reassessment and, if needed, file an appeal. This guide shows you what to document, how to prepare for the nurse visit, and what to do if the decision still isn’t enough. If you want hands-on help with the packet and phone calls, Individual Home Care can do this with you step by step.
When to ask for more hours (use these triggers)
Request a reassessment as soon as any of the following show up:
- Nighttime needs: multiple bathroom trips, wandering, sundowning, confusion, bed exits
- Safety changes: new falls or near-falls, dizziness, unsteady transfers
- Clinical changes: hospital/rehab discharge, new wounds, oxygen, infections, mobility decline
- Caregiver limits: primary caregiver illness, work schedule change, rising burnout
- ADL gaps: bathing or toileting now needs hands-on help, meals aren’t getting done, meds are missed
If you’re routinely stretching beyond what’s approved just to keep things safe, it’s time to act. Individual Home Care helps families identify the right moment, so you’re not waiting months while things get harder.
Build a simple “change in condition” packet (before you call)
Create a clear bundle of proof. It doesn’t need to be fancy, just specific and recent.
- Incident & night log (2–4 weeks)
Dates, times, what happened, and what hands-on help was needed. Example:
“10/03, 1:40 a.m. Assist to bathroom (hands-on), soaked linens, changed bedding. 4:15 a.m. second assist. Very unsteady.” - Discharge or clinic papers
After-visit summaries, new orders, PT/OT notes, anything showing increased needs. - Doctor note or message printout
A sentence confirming decline or new risks helps the plan justify more hours. - Updated medication list
New diuretics, pain meds, or sedatives often change timing and safety. - Caregiver statement (one page)
Bullet points: which tasks now require two people, how often nights interrupt sleep, what feels unsafe. - Photos (optional)
Only if they clarify hazards (tight hallways, steep bathroom step, lack of grab bars).
Keep copies of everything. If you need to appeal, you’ll reuse this packet with updates. Individual Home Care can assemble and format the bundle so it’s easy for the reviewer to follow.
Call the plan and request a reassessment
Use calm, direct language:
“Hi, we need a home care reassessment due to a change in condition, nighttime toileting and fall risk increased. Where can I send supporting documents before the nurse visit?”
Ask for the earliest available assessment date and the correct fax/email for documents. Send your packet right away and confirm receipt. If you use CDPAP, tell your Fiscal Intermediary a reassessment is scheduled so they’re aware of possible hour changes. Individual Home Care can make these calls for you with a signed authorization.
Prepare the home for the nurse visit
- Post the essentials: current med list, daily schedule, and your incident log on the table.
- Have the right person present: someone who knows the routine (you) or a Designated Representative if the consumer can’t self-direct.
- Show the hard moments: don’t over-help to make things look easy. Demonstrate the real transfer, the real night setup, the actual commode location.
- Safety gear visible: gait belt, walker, grab bars, commode, set up as used.
During the visit, be specific and measurable. “We assist to the bathroom two to three times nightly with hands-on help; without help there’s fall risk from bed to toilet.” Individual Home Care coaches families on phrasing so needs are clear and respectful.
What to say (and not say) during the assessment
Say
- “Transfers require hands-on help; it’s not safe with cues alone.”
- “Night toileting happens 2–3 times; linens are soaked twice a week.”
- “Needs cueing to initiate and redirection to complete meals and meds.”
- “Fatigues quickly; standing tolerance is under two minutes.”
Avoid
- Minimizing (“We manage somehow”), it hides risk.
- Vague requests (“We just need more hours”), replace with concrete frequency and assistance level.
- Overstating, stay truthful and consistent with your logs.
If the consumer has good and bad days, describe the typical week and the worst days, not the once-in-a-while best.
The decision: approval, partial approval, or denial
You’ll receive a written notice explaining the outcome. Keep it. It contains important deadlines if you disagree.
If the increase isn’t enough, you can appeal. In many cases, you can ask to keep your current hours in place during part of the appeal process (often called keeping benefits while you challenge a change). Timing and eligibility for this protection depend on the notice, read dates carefully and act promptly. Individual Home Care can track these dates and file correctly.
If the result isn’t enough: how to appeal without burning out
- Plan appeal (internal)
- File quickly following the notice.
- Attach your packet again plus any new evidence from the past two weeks (fresh night log, new clinic note).
- Write a short cover sheet:
“We request an increase due to nighttime toileting (2–3 times nightly, hands-on), recent fall (date), and new weakness after hospitalization (date). Current hours do not cover nights or safe transfers.”
- Independent/state review (if available) or hearing
- If the plan appeal still misses the mark, follow the notice instructions to escalate.
- Keep logging incidents right up to the decision; recent evidence is powerful.
Individual Home Care organizes documents, writes clean cover notes, and keeps the timeline moving so you don’t miss windows.
Special notes for CDPAP families
- Authorization controls hours the same way it does for agency aides; CDPAP doesn’t guarantee a number.
- Keep EVV time data and your night log, they demonstrate unmet needs.
- Line up a secondary caregiver so you’re covered if hours rise before staffing fully settles.
- If your chosen caregiver is burning out, that’s relevant, document it. Individual Home Care helps adjust schedules so peak needs (mornings/evenings, nights) are covered first.
Quick checklist you can print
- 2–4 weeks of incident/night logs completed
- Discharge papers or recent provider notes gathered
- Updated med list printed
- One-page caregiver statement drafted
- Photos of hazards (optional)
- Packet sent to plan before the nurse visit (confirm receipt)
- Assessment day: the right person present, gear set up, real routine demonstrated
- Decision letter saved; deadlines noted on a calendar
- Appeal filed on time with fresh evidence, if needed
If any of this feels heavy, Individual Home Care can take the lead and keep you organized.
Scripts you can copy/paste
Reassessment request (phone):
“Hi, we need a home care reassessment due to a change in condition. We now provide hands-on help for two to three nighttime bathroom trips and had a fall on [date]. Where can I send our logs and notes before the nurse visit?”
Assessment day (to the nurse):
“In the last three weeks, nights require hands-on assistance two to three times between midnight and 5 a.m. Bed is wet twice a week. Transfers are unsteady without physical support.”
Appeal cover note (short):
“We’re appealing because the current hours don’t cover nighttime toileting and unsafe transfers. Attached: updated night logs (dates), provider note (date), and medication changes (date). We request hours that include overnight coverage for safety.”
How Individual Home Care can help (so you’re not doing this alone)
- Evidence builder: We turn your week into a clean packet, logs, med list, caregiver statement, easy for reviewers to understand.
- Assessment coaching: We rehearse key phrases and set the home so needs are visible.
- Appeal support: We track deadlines, draft notes, and add fresh proof without overwhelming you.
- Schedule design: Once hours increase, we map coverage to peak-risk times (mornings/evenings, nights) and blend CDPAP with agency support if that’s safer.
You don’t have to fight for hours by yourself. Partnering with Individual Home Care keeps the process calm, timely, and evidence-driven.
Ready to match hours to real life?
Talk to Individual Home Care. We’ll help you request a reassessment, assemble proof, and design a safer weekly schedule, without guesswork.
Talk to a Care Planner