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 a paid in home caregiver 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 older adults 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 a higher hourly rate 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 to 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.
What to Include in a Job Description for In-Home Caregiving
Whether you’re planning to hire an individual caregiver or an agency, it’s important to be clear on what your family’s needs are, and what your expectations of the caregiver will be.
For instance, are you looking for someone to provide dementia care? And what type of personal care do you expect the professional caregiver to provide assistance with?
To create a job description, start by making a list of all the tasks that you want the paid in-home caregiver to do.
Creating a task list can help clarify what kinds of skills, qualifications, or past experience you hope to find in a paid caregiver.
You can then use this information to create a job description. In your job description, consider including the following sections:
- Roles and responsibilities
- Qualifications and education requirements
- Preferred skills and desired traits
- Additional notes/information
Don’t forget to mention if there are pets in the home, or other specific details that potential candidates should be aware of.
Even if you don’t end up publicly posting your job description, drafting a list of caregiving tasks and a job description will help you become much clearer on what you need. This, in turn, will make it easier for you to identify in-home caregivers who are a good fit for you needs.
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 the caregiver with the detailed list of tasks that you require them to complete and other responsibilities. Review your list of tasks with your caregiver(s)/agency and create a daily 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!
Ronna Davis says
Thank you so much for this helpful article with pros & cons for different kinds of caregiving sources.
Leslie Kernisan, MD MPH says
Glad you found it helpful!
JERRY RUNNELS says
Thanks for a very informative article. My twin sister, a retired nurse, is a paraplegic who has progressed from a nursing home, to assisted living and finally has lived with her daughter for the past 2 years. She is a Medicaid Passport patient and is supposed to receive home health care services 20 hours per week. Due to the impact of the pandemic she has only been able to obtain these services, either through her local COA organiztion, or by personally finding someone not from an agency, on a sporadic basis. The combo of lack of availability of qualified workers, or their hourly salary demands which always exceed what Medicaid will pay, has been a major problem for her and her daughter who travels frequently in her job. Even more surprisingly, if my sister’s daughter hires a caregiver directly at excessive cost >$20 per hour, she is unable to recover a dime of those payments from Ohio Medicaid. Medicaid readly acknowledges that they cant find people to assign to my sister’s case, but also that not only will they not reimburse my niece for her payments to caregivers they find on their own, in spite of a key problem being that Medicaid does not pay competitive hourly rates to attract caregivers for their cases. This has been going on for 9 months with no help in sight which is really pitiful.Finally, retaining those caregivers they have been able to hire has been nearly impossible due to their lack of reliability and/or willingness to perform all of their duties satisfactorily , or not at all.
Leslie Kernisan, MD MPH says
Thanks for sharing your family’s story. Yes, Medicaid is supposed to help pay for long-term care services, but even once one qualifies for Medicaid and applies, it can still be very difficult to obtain quality services. Unfortunately, the US has never been very good at investing in safety net services, nor is there much inclination towards public investment in services that most people will need (e.g. eldercare). I am hoping this will change as the boomers age, but we’ll see.
It sounds like your sister is muddling through…I hope she finds more of the support she deserves soon.
Sohenc says
Thank you for this article, it is all so challenging. I have witness various arrangements, and IHMO it often comes down to the person hired and the “chemistry” between them and the one they care for. But your advice to follow the legal aspects of this, to have clear communication and expectation and to “trust but verify” to assure things are going done as communicated/expected is key.
Know of one wonderful, trustworthy and committed caregiver (hired directly, but no paperwork check or legal stuff done) was outstanding but at the end of the day not a legal resident in the US. It all came crashing down when she was deported.
Know of another similarly hired direct (not via an agency) who worked from my friend’s family, caring for the parents and then mother once the husband passed. He was like family, a live in, trusted for 10 years; but it turns out he was a bad apple. It was not until the mother passed, that the adult children (one of my friends) learned he was embezzling all along. So yes, not good to give them any “financial power” to pay, write checks, use the family credit card, etc. That guy was arrested and now is in jail.
Another friend hired privately a wonder man when her husband was failing with cancer. He was wonderful, never any issues and remains a friend of the family.
There are great aides from agencies and not so great ones. Another friend with a broken pelvis and early stage dementia has aides 8 to 5 pm Monday-Friday while her husband works. Some have been great, attentive and helpful. One — I witnessed while visiting — slept the entire time and would not get up to answer the phone (my friend with the broken pelvis could not walk). Needless to say the “sleeping aide” was asked to not come back; and the agency sent another.
It can be a crap shoot or great. But tracking, checking and getting the right legal paperwork done can give you some protection.
Nicole Didyk, MD says
It’s been my experience as well that there’s a wide range of skills and levels of professionalism when it comes to hiring help for an older adult. Even within agencies there is some variability, depending on the type of training and screening that the employee has to undergo.
Like anything, good communication can alleviate a lot of problems down the road.
Eric F says
I L O V E your info and advice. I am an in-home care-giver. Not a health aid. No health aid training. I did work as a Lab tech, so I know something about that aspect of health. I would slightly disagree with anything physical related as part of my job. I do not have training in bathing, dressing, anything that a CNA would do. I do not want the liability and the mental anguish if I caused something like that, physically, to happen. I would also add I think some basic training in the Mental aspect of dealing with Family members, as a care-giver would be helpful. I sought basic psych training after I started doing this job. The BIGGEST aspect in my experience is the mental aspect of dealing with aging seniors and how their family deal with me, and the family member each day. The mental aspect is the BIGGEST issue in my mind.
Nicole Didyk, MD says
Thanks for sharing that and thank you for your important work.
You’re right that supporting older adults and their family members isn’t easy and the more psychological skills you have, the better! You might relate to this video about the qualities that lead someone to work in Geriatrics: https://youtu.be/oU3_1Nc39-k
Frank says
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!
Nicole Didyk, MD says
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.
Lorie says
What is your experience with L-Theanine to help an elderly person with dementia, sleep?
Nicole Didyk, MD says
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.
Amy Lane says
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).
Leslie Kernisan, MD MPH says
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.
Maggie Schmid says
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.
Leslie Kernisan, MD MPH says
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.
Ester Mendoza says
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.
Leslie Kernisan, MD MPH says
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.
Janet Sansone says
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.
Leslie Kernisan, MD MPH says
Thank you, I’m glad you found it helpful!