This article is by Michelle Allen, LCSW. Michelle is an experienced social worker and geriatric care manager based in Atlanta and is a featured expert providing guidance in our Helping Older Parents programs.
At some point, you may need to have someone help your older parent – or perhaps you – with care in the home.
So, what do you do when you need some more hands to help with housekeeping, meal preparation, dressing, transportation, medication management, etc.? How do you find qualified, reliable, kind, and trustworthy people?
About two-thirds of all help comes from unpaid caregivers — such as daughters, sons, and friends — and about one-third of all help comes from paid caregivers.
It is easy to understand how you get a family member or friend to help — you usually just ask. But hiring paid caregivers can be a bit more daunting.
In this article, I’ll explain what you need to know, to better understand your options and get the care that is needed.
Home Care vs. Home Health
Basically, two types of care in the home are available: home care and home health.
Although they sound alike, they are very different. Home health agencies provide a range of medical services to homebound individuals. These services include physical therapy, occupational therapy, speech therapy, skilled nursing services, medication management, medical social work services, and some health aid services.
Medicare, Medicaid, the Veterans Health Administration, and many private insurance companies pay for some home health care services, usually with restrictions.
Medicare, for example, will cover limited home health care for homebound beneficiaries who need intermittent skilled nursing or therapy services as prescribed by a physician. Home health care is usually provided only intermittently (not 24/7 or even for several hours at a time) and is usually short-term.
You can learn more about Medicare’s coverage of home health services here.
Unlike home health services, home care services are not medical services. (So they are not usually covered by Medicare.) Home care is more focused on personal care needs and some household needs.
Home care workers help with dressing, bathing, meal preparation, companionship, and other daily activities. They also help with some household chores and light housekeeping.
Home care providers can be found through agencies, or you can hire an individual (more on this below). The cost for these services typically range from $20-27/hour if you use an agency and from $14-20/hour if you hire an individual (of course, this may vary by region).
Medicare will not pay for home care when no skilled care is needed, but some Medicaid waiver programs will pay for home care services if you meet the income, asset, and care level requirements.
Some private insurance companies (including some Medicare Advantage plans) are also starting to pay for home care services. For most families, though, home care is paid for out of pocket and/or by long term care insurance benefits.
Hiring Individuals vs. Agencies for Home Care Services
Caregivers providing home care services can be hired directly or through a private home care agency.
Caregivers can be found through personal recommendations, online matching services like Carelinx.com or Care.com, or one of the thousands of agencies.
Searching for a good, affordable home care provider can be overwhelming. Let’s start with the basics: should you hire a home care agency or an individual?
Here are the pros and cons of the two options. You’ll need to understand these, in order to decide on which might be the best fit for your situation.
Pros and Cons of Hiring through a Home care agency
Pros:
- Agencies handle the hiring, firing, and taxes.
- Agencies provide oversight and an intermediary that can help mitigate disputes with caregivers.
- Agencies may be required to conduct background checks on direct care staff.
- If a caregiver is sick, agencies can send a substitute.
- Other staff members at the agency can offer additional support or training to meet unique needs.
- Agencies provide workers’ compensation that will protect you and your assets should the caregiver have an on-the-job injury in your home.
Cons:
- You may have several caregivers and little continuity of care.
- You may have little choice in your caregiver and have to work with whoever they are able to send to you.
- Agencies usually charge more than individual caregivers (sometimes even double the amount).
Pros and Cons of Hiring Individual Caregivers
Pros:
- You may be able to establish a strong relationship with one or two caregivers that are loyal, dependable, and provide quality care.
- Hiring an individual caregiver costs less than caregivers provided through an agency.
Cons:
- You may have no caregiver if your regular caregiver is sick or cannot come into work.
- Screening, hiring, firing, and disciplinary actions will be handled by you.
- You are responsible for paying employment taxes.
- Your caregiver may not have adequate training, licensing, or screening.
- You may be liable for any injury that happens on the job.
As you can see, each option comes with advantages and disadvantages. You’ll have to weigh those for yourself, to decide which route to take.
Reputable agencies are bonded and insured, protecting you from liability and theft. They also provide supervision, background checks, and back-up coverage for when the regular caregiver is not available. But they are more expensive.
Monitoring Hired Caregivers
Evaluating your paid caregivers must be done on a regular basis to make sure your needs are being addressed.
Begin the relationship by providing a detailed list of tasks you require the caregiver to complete and other responsibilities. Review your list of tasks with your caregiver(s)/agency and create a care plan from that list of tasks. Have the caregiver(s)/agency agree upon this care plan prior to the first visit.
You’ll want to review the care plan on a regular basis (maybe once every 20-40 days) to monitor the work that is being done, make adjustments to the care plan, and clear up any misunderstandings.
There is often a conflict between what the caregiver is doing and what the care receiver wants done, and resolving this conflict can be hard. Having an agency representative to help manage these issues can save you time and stress.
Common Mistakes to Avoid
Here are some common mistakes that can cause families problems. You’ll want to try to avoid these situations if at all possible.
1.Paying individual caregivers “under the table.”
It may be tempting to hire an independent caregiver or one that does not work for an agency, because of the cost savings. But doing so can leave you in violation of IRS laws if the appropriate taxes are not filed and paid.
Federal laws consider paid caregivers to be “household employees,” and generally you must pay taxes and follow other rules if you pay them more than $2000 in a calendar year. (For more, see here.)
2. Allowing the paid caregiver to have too much control or access.
It is important that family members to stay involved in their loved one’s care, even when trusted caregivers are in place.
When there isn’t much family oversight, an older person can be vulnerable to abuse, neglect, and exploitation. So it’s essential that family members stay informed and aware of what is happening in their loved one’s life.
3. Naming a paid caregiver as a healthcare or financial agent.
It may seem unlikely, but this happens all too often! A trusted caregiver that has been with a family for years will be named as the healthcare or financial agent on powers of attorney out of a desire for efficiency and with a false sense of security.
Older adults may feel like their trust will not be betrayed by their loyal companion, but this situation puts the older adult in a vulnerable situation.
In general, if a trusted family member or friend can’t serve as healthcare or financial power of attorney, it’s better to choose a person who is not the usual paid caregiver. In some states, professionals can be hired for this role.
4. Not having a backup plan.
Aging in place with caregivers is a great idea, but it may not be the best idea for the entirety of a person’s final years.
Eventually, skilled care may be required or finding 24/7 caregivers to come to the home may be too challenging or too expensive. Every family should have a plan for when/if staying in the home no longer works.
Also, if you decide to rely on just one to two individual caregivers, you’ll want a plan in case they fall sick, or otherwise can’t continue working.
For more information
Hiring a paid caregiver can be a big transition for any family. Having a new person in your home, so intimately involved in your family’s life, is truly an adjustment. But a skilled, loving and dedicated helper can make a difference in everyone’s well-being.
Here are some resources to help you learn more and take your next steps:
Hiring In-Home Help (Family Caregiving Alliance)
VA Aid and Attendance Nuts and Bolts Guide
From Dr. K: I also interviewed Michelle on this topic for the podcast, see here: 093 – Interview: Hiring In-Home Care for Aging in Place: What to Know
Do you have any questions about hiring in-home help for yourself or for an older loved one? Please post them below!
I’ve been reading several sections of your column, and am finding the information you provide very clear and useful! I’m 76, and fortunately very healthy so far. I’m caregiver for my 79 year old husband, who has Parkinson’s. Your info is very helpful. Thank you, I’ll be reading more and more.
Thank you, I’m glad you found it helpful!
Thanks for the useful information about the pros/cons of choosing a caregiver. I want to validate that choosing an individual caregiver is better as I have witnessed in a family member who chose that option for some one who has dementia.
Sounds like hiring an individual person worked out well for your family member, I’m so glad.
It’s true that especially when it comes to dementia care, it can be really helpful to have the same person providing care, which makes it easier to provide stability and routine for the person with dementia.
I love your content and find it useful and relevant – both as someone who cared for my mother with Alzheimer’s for 12 years and as a home care agency owner. As a side note – I am proud of the fact that most of my clients have the same caregiver throughout our relationship. I have a client who has had the same aide for 27 years and one of my favorites who recently passed after 9 years had the same caregiver from day one.
Thank you, I’m always very touched when professionals like yourself find my content valuable. And thank you for the work you are doing, it’s very needed. Great that you’ve been able to arrange for many of your clients to have the same caregiver.
Thank you for a good article that gives a very balanced view of what is available. I do believe that the range for a home care agency is very low. We are in Denver and I would say the range is closer to $27-$40/hour (1-2 hour shifts are available but the agencies that do them bill in the $40/hour range).
Thank you for your comment. Michelle Allen is based in the state of Georgia; it’s possible that rates are lower in that part of the country than where you are. This is a good reminder that readers will need to research and find out what’s the going rate in their area…or in any area to which older adults are considering moving to.
Good EARLY morning, I’ve been up counting 5 times tonight. It’s now 3:30 am. My mom who is 80 has had dementia since 2016 per multiple Dr’s. Initially is was considered “alcoholism” issues after multiple falls. In early 2017 she received a VP shunt for hydrocephalus. Set at 1.5. This has improved her “gate” somewhat. She lives with my wife and I. Allow me to preface this with the following: I am an only child. Father passed in 1997. Every night my mom is up multiple times searching for Frankie, (ME tho I haven’t gone by that name since I was a youth) I have installed Ring camera system as she is an escape risk. So whenever movement occurs I’m shaken from sleep. Dr currently has her on the following meds with hope of a better night’s sleep. @ bedtime hydroxyzine hcl 25mg. Donepezil 10mg 1x Daily & Fluoxetine 10mg 1x daily. I’m at my wits end as nothing is helping her sleep. Like so many others on this site, my loved one does much better when she receives 4-6 hrs sleep consistently. But that hasn’t been the case in several months. You had spoke of anti-psychotics which should I suggest to her PCP. Because both my wife and I work full-time 10hrs, and can’t be up all day and all night and continue to function. Please help!
Hi Frank and thanks for sharing your story. I’m sorry to hear about how difficult it has been for your family, but as a Geriatrician (in Canada) with a busy practice, I can tell you that you are not alone.
Medication for sleep is pretty tricky, most meds help people fall asleep but not stay asleep, and the donepezil and fluoxetine can actually be a bit activating, I usually prescribe them to be given in the morning. Anti-psychotics (such as risperidone, quetiapine, olanzepine) can be sedating for sure, but can also increase the risk of stroke or death in older adults with dementia, so we try to avoid them most times.
When there is a change in a behaviour pattern for someone with dementia, a good start is to review medical issues with a physician and make sure there isn’t something else brewing (like an infection or issue with the VP shunt). If that’s all clear, then it may be worth finding a behavioural consultant who can help you come up with strategies to redirect your Mom or prevent her nighttime restlessness (for example, maybe more daytime activity or exercise). Here is an article from Dr. K about behaviours with more information.
What is your experience with L-Theanine to help an elderly person with dementia, sleep?
Hi Lorie. I have not prescribed L-theanine, but I did read up on it! L-theanine is an amino acid that is found in green tea, along with caffeine and epigallocatechin gallate (EGCG). I found a meta-analysis examining the efect of green tea on cognition (a meta-analysis is a study that combines the results of other studies – Nutr Rev. 2014 Aug;72(8):507-22. Acute effects of tea constituents L-theanine, caffeine, and epigallocatechin gallate on cognitive function and mood: a systematic review and meta-analysis. Camfield DA). The authors concluded that in the short term (a few hours) the combination of phytochemicals in green tea can improve attention, alertness and some aspects of cognitive performance.
A few cautions though: these studies looked at the combination of L-theanine, caffeine, and EGCG, and in fact the authors indicated that much of the result may have been attributable to the caffeine, not the L-theanine.
Secondly, it’s not known whether these effects last any longer than a few hours.
And finally, better performance on a cognitive test doesn’t necessarily translate into an improved ability to manage day to day life, which is what really matters to most people.
So green tea can have a definite place in a healthy lifestyle, but I would not expect it to be a game changer in dementia.