When Keeping Your Loved One at Home... | Caregiver Action Network

When Keeping Your Loved One at Home Means Bringing in Help

As any family caregiver knows, your commitment to your loved one is beyond question. Whether you’ve been providing care for a month, a year, or a decade, you’ve clearly dedicated yourself to ensuring that your loved one has the best care and quality of life possible for as long as possible.

There may come a time in any caregiving relationship, however, when outside help is needed to maintain that quality of care. This help may be necessary on a temporary basis or it may be crucial to keeping your loved one in his/her home. When that time comes, knowing just a little about the different aspects of home care will go a long way toward making you feel more in control.

What Is Home Care?
Home care is a general term that represents a wide range of community-based services, from supporting someone who is recuperating from an acute situation, such as a hip fracture, to providing in-home healthcare services to an individual with an ongoing chronic condition such as Alzheimer’s disease or cerebral palsy.

While the skills and duties of home care personnel vary, all have one thing in common: they make it possible for care recipients to remain at home in a safe environment and, in some cases, to have more independence than they did before. In the process, they also provide family caregivers with a chance to replenish their depleted physical and emotional reserves.

Home care personnel include:

  • Registered nurses (RNs) who provide skilled medical care, including giving medications, monitoring vital signs, dressing wounds, and teaching family caregivers how to use complicated equipment at home.
  • Therapists who work with patients to restore or maintain their motor, speech and cognitive skills.
  • Home care aides who provide personal services such as bathing, dressing, toileting, making meals, light cleaning, and transporting patients to the doctor.
  • Companion/homemakers who help with chores around the house but usually do not perform personal duties for the care recipient.

Non-medical home care often revolves around the Activities of Daily Living (ADLs) and the Instrumental Activities of Daily Living (IADLs).

ADLs are basic activities and functions performed on a daily basis that are usually done without assistance. The six ADLs are:

  • eating
  • dressing
  • bathing
  • toileting
  • transferring
  • continence

IADLs, on the other hand, are those activities instrumental to our daily routines, such as:

  • driving
  • preparing meals
  • doing housework
  • shopping
  • managing finances
  • managing medication
  • using the telephone

Getting Started With Home Care
If you are considering getting home care help to assist you with your caregiving responsibilities and/or to get some time for yourself, there are a number of things you need to consider:

• The first step is to make sure you and your loved one are comfortable with the idea of someone else taking on some of the tasks that you’ve been doing by yourself. There are many care recipients who are totally opposed to the idea and some negotiations will need to occur before any plan can be put in place. It’s important for all concerned to understand what is prompting the need for home care and the personal issues that lie beneath any refusal to consider it. Getting beyond objections isn’t necessarily easy and you might need some guidance on how to go about it — perhaps from other family caregivers who have dealt with the issue or from professionals who counsel family caregivers.

• Defining the tasks that need to be done by the home care worker will help you determine exactly what type of home care is most appropriate for your situation. Do you need a nurse to clean and bandage wounds and monitor equipment, a home care aide to help your loved one get showered and dressed, or would a companion/homemaker be more appropriate in your situation?

• Once you know what type of assistance you need, and all parties agree that it is necessary or desirable, the inevitable questions about where to find home care services, how much they will cost, and whether any of these costs will be covered by insurance or provided by government programs must be asked and answered. Some federally funded programs, insurance companies and health maintenance organizations (HMOs) do provide for some home healthcare services, but the coverage provided may not fit your needs. To be sure whether or not you have any coverage at all, it is imperative that you review your insurance benefits.

• If you’re like the majority of family caregivers, you need the most help with personal care tasks — the very type of care that is not typically covered by private health insurance programs or Medicare. So unless your loved one had the foresight and the funds to purchase long-term-care insurance prior to becoming ill, your access to home care will be limited by what you can afford.

You may be able to get some help from state programs that take into account your ability to pay and the age or extent of disability of your care recipient; but the sad reality is that more often than not, the costs of home care services will have to come out of your own pocket.

Who to Call for Non-Medical Home Care
Professional caregivers can be grouped into three different categories: agency employee, independent contractor with a registry, and independent caregivers.

Agency Employees 
Most agencies hire caregivers who are screened, trained, bonded and insured. They are employees of the individual company for whom they work. The agency handles all taxes and other employment obligations such as workers’ compensation, liability coverage, and addressing performance issues. The agency also provides additional support between the client and the caregiver.

Independent Contractor with a Registry 
An independent contractor with a registry is recruited, screened, and referred to the consumer. The family caregiver/care recipient becomes the employer and is responsible for all employment responsibilities such as hiring, scheduling, handling performance issues, and paying federal and state payroll taxes. The family caregiver/care recipient assumes the risk as the employer since the independent contractor will not be covered by workers’ compensation, liability and bond insurance. While the contractor may have had a criminal background check and reference checks, it is likely that he/she is not receiving support, training, or continuing education, nor is a replacement caregiver available should the contractor become sick.

Independent Caregivers 
Independent caregivers are responsible for marketing themselves and finding their own clients. They may have a criminal background and reference checks at the expense and effort of the consumer. The family caregiver/care recipient becomes the employer and is responsible for all employment responsibilities such as hiring, scheduling, handling performance issues, and paying federal and state payroll taxes. The consumer assumes the risk as the employer since the independent contractor will not be covered by workers’ compensation, liability and bond insurance. The independent caregiver does not receive support, training, or continuing education, nor is a replacement caregiver available should the independent caregiver become sick.

Questions to ask a non-medical home care provider:

  • Is the individual an agency employee, an independent contractor with a registry, or working on his/her own (independent)?
  • Has the caregiver been trained?By whom?
  • Extent of training?
  • Does the agency train all its caregivers?
  • Does this training include special dementia or Alzheimer’s training (if applicable)?
  • Have the agency’s caregivers passed criminal background checks and drug screenings, and have personal references been secured on all caregivers?
  • Are the caregivers bonded and insured? This means the company covers claims and insurance, so the homeowner is not liable should something happen.
  • Does the caregiver have workers’ compensation coverage?
  • Can you check references on the agency?
  • Does the agency offer back-up / replacement caregivers?
  • How much input will you have in selecting the caregivers?
  • What restrictions (if any) apply to the services provided?
  • Hours of service?
  • Weight restrictions?
  • How much flexibility will you have in setting a schedule for services?
  • How much notice does the agency need to begin or cancel service?
  • What is the cost of service, including:
  • Minimum hours of service per visit / week / month?
  • Special overnight rates?
  • Does the agency maintain a quality assurance or supervisory program?
  • What is the agency’s communication plan to keep families informed?
  • Does the agency require a service deposit?
  • Does the agency offer the personal care services the patient needs, like assistance with bathing, dressing, and using the bathroom?
  • Are patients’ special needs, such as language preferences, accommodated?

Who to Call for Home Healthcare
When hiring home healthcare, it’s important to seek out licensed medical caregivers. Many medical caregivers work though “home health agencies” that are Medicare-certified, meaning they have met minimum federal requirements for patient care and management.

Eligibility for home healthcare under Medicare is determined by the following:

  • The patient must require intermittent skilled nursing care, physical therapy or speech therapy.
  • The patient must be homebound.
  • The patient must currently be under a physician’s care.
  • All home health services must be ordered by the patient’s physician.

Services are delivered at home to recovering, disabled, chronically or terminally ill persons in need of medical, nursing, social, or therapeutic treatment and/or assistance with the essential activities of daily living.

When interviewing an agency, make sure you understand exactly what services it will provide and those it will not provide, including those services it is forbidden to provide by state law. Families are allowed to provide any care for a family member, but professionals must abide by state law. For instance, in many states, invasive procedures such as injections and maintenance of feeding tubes may not be administered by non-skilled professionals. You may need a doctor or a nurse to perform these procedures.*

Questions to ask a home healthcare provider:
In addition to all the questions you would ask a non-medical home care provider, it’s important to ask a home healthcare provider the following:

  • Is the home healthcare agency Medicare-certified? That means it is approved to provide services to patients with Medicare.
  • Does the home healthcare agency offer a full range of home healthcare services, including skilled nursing; physical, occupational and speech therapies; IV therapy; and home health aides?
  • How do you receive home healthcare agency services? A referral can be made by anyone involved in a patient’s care – physician, family or others. If someone other than a physician makes referrals, many home healthcare agencies contact the patient’s physician to approve orders for service.
  • Does the hospital discharge planner, doctor or social worker recommend the home healthcare agency? Those recommendations can serve as a second reference.
  • Does the home healthcare agency have the staff available at night and on weekends for emergencies?
  • Where else could you find information about Medicare-certified home healthcare agencies?
  • Does the home healthcare agency have staff available to provide the type and hours of care as prescribed by the physician?

Information about Medicare-certified agencies in your geographic area is available online at www.medicare.gov, including Home Health Compare, which allows you to compare the home healthcare agencies in your area. You can also call 800/MEDICARE for more information.

Whether the assistance you need is for the short term or the long term, whether you need a home care aide or a registered nurse, knowing where to look and what questions to ask will help ensure that you find the right kind of help for your particular situation. By being open to the possibility of seeking outside help, you can help ensure that you will continue to be the best family caregiver you can be.

The information in this article was provided by Home Instead Senior Care, a partner of Caregiver Action Network. Home Instead Senior Care is the world’s largest provider of non-medical home care services for seniors. To learn more, visit www.homeinstead.com.

The Cost of Non-Medical In-Home Care
The national average hourly rate for homemaker/companions was $19 in 2009, according to the 2009 MetLife Market Survey of Nursing Home, Assisted Living, Adult Day Services, and Home Care Costs. Other resources list the hourly cost between $15 and $25, depending on where you live.

How does the cost of non-medical home care compare to the cost of home health, assisted living, and nursing home care? According to John Hancock’s 2011 Cost of Care Survey:

  • The 2011 average cost of a private nursing home room was $235 a day/ $85,775 annually.
  • The 2011 average cost of a semi-private nursing home room was $207 a day/ $75,555 annually.
  • The 2011 average cost for a month in an assisted living facility was $3,270 a month/ $39,240 annually.
  • The 2011 average cost for a home health aide was $20 hourly/$37,440 annually.

Source: Home Instead Senior Care

Who Pays?
Home healthcare, which is provided by licensed medical professionals such as RNs and/or therapists, requires a prescription. Home healthcare services are often paid for by Medicare, Medicaid, and/or the patient’s private insurer.

Non-medical home care, such as personal care, homemaker or companionship services, is provided by professional caregivers and no prescription is required. Home care services are typically paid for using either long-term care insurance or out of pocket.


Medicare Home Health Compare
This tool has detailed information about every Medicare-certified home health agency in the country.

National Clearinghouse for Long-Term Care Information
This Web site was developed by the U.S. Department of Health and Human Services to provide information and resources to help you and your family plan for future long-term care (LTC) needs.

National Private Duty Homecare Association
This membership organization consists of providers of both medical and non-medical private duty care. The web site has good consumer info and lists not only its members but other providers as well.

* Source: Visiting Nurse Association, online at www.thevnacares.org.