Activities of Daily Living (ADLs) are a standard measure used across the healthcare and long-term care industries to assess an individual’s functional status and degree of personal independence. These basic self-care tasks represent the fundamental actions required for a person to manage their physical needs daily. The ability to perform these activities determines the level of support an individual requires, especially with advancing age or chronic illness. This assessment framework is used by medical professionals and financial institutions to evaluate eligibility for long-term care benefits and services.
The Six Core Activities of Daily Living
The long-term care community focuses on six universally recognized activities that form the core ADL assessment. These tasks are Bathing, Dressing, Toileting, Transferring, Continence, and Feeding. These six activities allow for a standardized way to gauge an individual’s functional capacity.
Bathing involves the complete process of washing oneself, which includes getting into and out of the shower or tub, as well as maintaining personal hygiene like shaving and oral care. Dressing encompasses selecting clothes appropriate for the weather, putting them on, and managing fasteners such as zippers, buttons, and braces or artificial limbs. Toileting refers to the ability to get to and from the toilet, use it correctly, and perform the necessary cleaning afterward.
Transferring is the ability to move the body from one position or location to another, which includes getting in and out of a bed or chair without assistance. This activity is a strong indicator of mobility and balance, factors that directly relate to personal safety. Continence is the ability to maintain control over bladder and bowel function, or, if control is compromised, the capacity to manage a catheter or colostomy bag independently.
Finally, Feeding, sometimes called Eating, is the process of getting nourishment from a plate or receptacle into the body. This involves the physical acts of cutting food, using utensils, chewing, and swallowing. This ADL does not typically include meal preparation, but rather the physical consumption of the food once it is ready.
The Standard Threshold for Long-Term Care Qualification
The specific number of limitations a person must exhibit determines qualification for financial support. For most private long-term care insurance policies and for many public programs, the standard requirement is the inability to perform two out of the six core ADLs. Meeting this criterion is generally the trigger that makes a policyholder eligible to receive benefits.
This “2 out of 6” rule signifies a loss of functional capacity that requires “substantial assistance” from another person. Substantial assistance is defined in two primary ways: hands-on assistance or stand-by assistance. Hands-on assistance means the caregiver must physically help the individual complete the task, such as helping someone move from a wheelchair to a bed.
Stand-by assistance, also known as supervision, means a person must be present within arm’s reach to prevent injury, offer verbal cueing, or intervene if the individual is at risk of falling or making an error. This type of assistance is common when a person’s physical frailty or balance issues create a significant safety hazard. A second, equally important trigger for qualification is the presence of a severe cognitive impairment, such as advanced dementia.
In cases of severe cognitive impairment, a person may still be physically able to perform the six ADLs, but their lack of judgment or memory makes them a danger to themselves. For instance, a person might forget to turn off the stove or wander away from home. The requirement is often the need for substantial supervision to protect the individual from threats to their health and safety.
While the “2 out of 6” rule is the common benchmark for private insurance benefits, the exact number and definitions can vary slightly depending on the payer. Medicaid eligibility, for example, is governed by state-specific rules and programs that use ADL assessments to determine the necessary level of care, ranging from home-based services to a nursing facility level of care. Regardless of the program, the inability to manage multiple core ADLs is the primary metric indicating a non-medical need for extended personal care.
How Instrumental Activities of Daily Living Factor In
Separate from the core ADLs are the Instrumental Activities of Daily Living (IADLs), which involve more complex cognitive and social skills necessary for maintaining an independent household. IADLs include tasks such as:
- Managing finances
- Handling medication
- Preparing meals
- Performing light housekeeping
- Using transportation
- Communicating effectively via telephone or computer
These activities require organizational skills and abstract thinking, skills that are often compromised early in cognitive decline.
IADLs serve a distinct purpose in the long-term care assessment process because they are generally not used as the initial financial trigger for long-term care insurance benefits. The focus remains on the six core ADLs for the purpose of financial eligibility.
However, IADL limitations are extremely important for determining the appropriate setting and level of care a person needs. For example, a person who can manage all six core ADLs but can no longer manage their medication or finances may be deemed unsafe to live alone. This assessment helps healthcare providers and care planners determine if an assisted living facility, which supports IADLs like meal preparation and housekeeping, is a more appropriate option than remaining fully independent at home.
The inability to perform IADLs is a strong early indicator of reduced independence and often signals the need for supportive services. For care providers, assessing IADLs is a practical measure used to create a comprehensive care plan that addresses safety and autonomy.