Home care assistance

America is experiencing a dramatic shift in demographics, people older than 65 years outnumber those younger than five. As Americans age and live longer, increasing numbers of will live with multiple chronic conditions, such as diabetes or dementia, and functional impairments, such as difficulty with the basics of life like mobility and managing one’s household ¹. Eighty percent of adults requiring long-term care currently live at home in the community, and unpaid family caregivers provide 90% of their care ². One of the greatest health care challenges facing the country is ensuring that older Americans with serious chronic illness and other maladies of aging can remain as independent as possible.

Characteristics of personal home care assistance recipients ³:

• Average age: 69 years
• Female (65%)
• Need assistance with instrumental activities of daily living (99%)
• Need assistance with activities of daily living [ADL] (59%)
• Hospitalized in past 12 months (53%)
• Memory problems (26%)
• Behavioral problems (7%)

Home health care assistance helps older adults live independently for as long as possible, even with an illness or injury. It covers a wide range of services and can often delay the need for long-term nursing home care. Home care services range from medical care, occupational and physical therapy, speech therapy, and skilled nursing to help with daily household chores such as cleaning, cooking and running errands. Home care assistance may involve helping older adults with activities of daily living, such as bathing, dressing, and eating. It can also include assistance with cooking, cleaning, other housekeeping, and monitoring one’s medication regimen.

If you are recovering from surgery or need long-term care for a chronic illness — or you have a loved one facing a similar situation — you might be interested in home care services.

It is important to understand the difference between home health care and home care services. Although home health care may include some home care services, it is medical in nature. Home care services include chores and housecleaning, whereas home health care usually involves helping someone to recover from an illness or injury. Home health care professionals are often licensed practical nurses, therapists, or home health aides. Most of them work for home health agencies, hospitals, or public health departments licensed by the state.

If you’re considering a home care services agency, it is wise to talk with your friends, family, neighbors, your doctor, your loved one’s doctor, social worker, hospital discharge planner, and the federal government’s Eldercare Locator to find your local agency (https://eldercare.acl.gov/Public/Index.aspx) or call 800-677-1116 to learn more about the home health care agencies in your community and for recommendations. Medicare’s Home Health Compare (https://www.medicare.gov/care-compare/?providerType=HomeHealth&redirect=true) is a useful online tool for finding and researching home health agencies in your area. It offers detailed information on what services they provide and how patients rate them. Although most states require home health care agencies to perform criminal background checks on their workers and carefully screen applicants, actual regulations will vary depending on where you live. Therefore, before contacting a home health care agency, you may want to call your local area agency on aging or department of public health to learn what laws apply in your state. To learn more about home care, visit LongTermCare.gov (https://acl.gov/ltc).

Choose an agency that will provide all the services you need for your parent or loved one. If you need help identifying these, speak with a doctor, care manager, or hospital discharge planner if the person just left the hospital. These people can refer you to agencies. Once you make your list of agencies, start by calling them.

Consider using the following questions to guide your search:

• Is the agency licensed by the state? Most states — but not all — require agencies to be licensed and reviewed regularly. Check with your state health department.
• What type of employee screening is done? Can the agency provide references? Ask for a list of doctors, hospital discharge planners or other professionals who have experience with the agency.
• How long has the agency served this community?
• Does the agency have a brochure describing services and costs? If so, take or download it.
• Will you receive a written care plan before service begins? The care plan should include details about medical equipment, specific care needs, and responsibilities of the aide or agency. It should also contain input from the doctor, and be updated frequently.
• Will the agency work directly with you or your loved one, family members, and health care providers?
• How are problems addressed and resolved? Whom can you or another family member contact with requests, questions or complaints?
• Is the agency an approved and certified by Medicare to meet federal requirements for health and safety? If not, ask why.
• Patient’s bill of rights. Will you receive a list of the rights and responsibilities of all parties involved?
• Does a national accrediting body, such as the Joint Commission for the Accreditation of Healthcare Organizations, certify the quality of care?
• Does the agency have a current license to practice (if required by the state)?
• Does the agency offer a “Bill of Rights” that describes the rights and responsibilities of both the agency and the person receiving care?
• Does the agency prepare a care plan for the patient (with input from the patient, his or her doctor, and family members)? Will the agency update the plan as necessary?
• How closely do supervisors oversee care to ensure quality?
• When will service be provided?
• When can services begin?
• Is care available round-the-clock, if necessary? Are agency staff members available around the clock, seven days a week, if necessary?
• Does the agency have a nursing supervisor available for on-call assistance at all times?
• What procedures are in place for emergencies? Ask how the agency or home health aide will deliver services in the event of a power failure or natural disaster.
• Whom does the agency call if the home health care worker cannot come when scheduled?
• How does the agency ensure patient confidentiality?
• How are agency caregivers hired and trained?
• How does the agency screen prospective employees?
• Will the agency provide a list of references for its caregivers?
• How does the agency train and monitor caregivers? Does the agency provide continuing education?
• Are the caregivers licensed, insured and accredited?
• What is the procedure for resolving problems, if they occur? Whom can I call with questions or complaints?
• Is there a sliding fee schedule based on ability to pay, and is financial assistance available to pay for services?

When purchasing home health care directly from an individual provider (instead of an agency), it is even more important to conduct thorough screening. This should include an interview with the home health caregiver. You should also request references. Prepare for the interview by making a list of the older adult’s special needs. For example, the patient may require help getting into or out of a wheelchair. If so, the caregiver must be able to provide appropriate assistance. If you’re concerned about the care or services provided, discuss the issue promptly with the agency or home health aide. If necessary, involve your loved one’s doctor.

If you’re considering a home health aide:

• What are the aide’s credentials? If he or she claims to be licensed, check with the licensing body.
• Can the aide provide references from at least two employers? Check them thoroughly.
• Does the home health aide have a positive attitude?
• Are you and your loved one comfortable with the home health aide?

Whether you arrange for home health care through an agency or hire an independent aide, it helps to spend time preparing the person who will provide your care. Ideally, you will spend a day with the caregiver, before the job formally begins, to discuss what is involved in your daily routine. At a minimum, inform the caregiver (verbally and in writing) of the following things that he or she should know.

• Health conditions, including illnesses and injuries
• Signs of an emergency medical situation
• General likes and dislikes
• Medication, including how and when each must be taken
• Need for dentures, eyeglasses, canes, walkers, hearing aids, etc.
• Possible behavior problems and how best to handle them
• Mobility issues (trouble walking, getting into or out of a wheelchair, etc.)
• Allergies, special diets, or other nutritional needs
• Therapeutic exercises with detailed instructions

Home care assistance costs

The cost of home health care varies across and within states. In addition, costs will fluctuate based on the type of health care professional required. Home care services can be paid directly by patients and their families or through a variety of public and private sources. Sources for home health care funding include Medicare, Medicaid, the Older Americans Act, the Veterans Administration, and private insurance. If your family member has long-term care insurance, Medicare or Medicaid, you will need a doctor’s report confirming the need for in-home care. Original Medicare does not cover personal care if it is the only care needed, but some Medicare Advantage plans do — check with your plan provider.

The cost of long-term care depends on the type and duration of care you need, the provider you use, and where you live. Costs can be affected by certain factors, such as:

• Time of day. Home health and home care services, provided in two-to-four-hour blocks of time referred to as “visits,” are generally more expensive in the evening, on weekends, and on holidays
• Extra charges for services provided beyond the basic room, food and housekeeping charges at facilities, although some may have “all inclusive” fees.
• Variable rates in some community programs, such as adult day service, are provided at a per-day rate, but can be more based on extra events and activities

Below are some national average costs for long-term care in the United States (in 2016). Average costs for specific states are also available here (https://www.genworth.com/aging-and-you/finances/cost-of-care.html):

• $225 a day or $6,844 per month for a semi-private room in a nursing home
• $253 a day or $7,698 per month for a private room in a nursing home
• $119 a day or $3,628 per month for care in an assisted living facility (for a one-bedroom unit)
• $20.50 an hour for a health aide
• $20 an hour for homemaker services
• $68 per day for services in an adult day health care center

Monthly Median Costs: National (2020)

• In-Home Care
  • Homemaker Services $4,481
    • Homemaker Services make it possible for people to live in their own homes or return to their homes by helping them complete household tasks that they can’t manage alone. Homemaker services aides may clean houses, cook meals or run errands.
  • Home Health Aide $4,576
    • Home Health Aides help those who live in their own homes instead of residential care facilities. Home health aides may offer care to people who need more extensive personal care than family or friends are able to or have the time or resources to provide.
• Community and Assisted Living
  • Adult Day Health Care $1,603
    • Adult Day Health Care can offer a break to caregivers. This type of care provides services at a community-based center for adults who need assistance or supervision during the day but who do not need round the clock care. The centers may provide health services, therapeutic services and social activities.
  • Assisted Living Facility $4,300
    • Assisted Living Facilities (referred to as Residential Care Facilities in California) are living arrangements that provide personal care and health services for people who may need assistance with Activities of Daily Living (ADLs). The level of care provided is not as extensive as that which may be provided in a nursing home. Assisted living is not an alternative to a nursing home, but an intermediate level of long term care.
• Nursing Home Facility. Nursing Home Facility Care is for people who may need a higher level of supervision and care than in an assisted living facility. They offer residents personal care, room and board, supervision, medication, therapies and rehabilitation, as well as skilled nursing care 24 hours a day.
  
  • Semi-Private Room $7,756
  • Private Room $8,821

If you’re considering a home care services agency:

• How does the agency handle expenses and billing? Ask for literature explaining all services and fees, as well as detailed explanations of all costs associated with home care.
• Will agency fees be covered by health insurance or Medicare? Check to see what kind of coverage your health insurance offers, and be sure to understand what criteria Medicare requires. For instance, do they require your loved one to be homebound?
• What resources does the agency provide for financial assistance, if needed? For instance, is a payment plan available?
• Get details about costs and payments in writing.

If you’re considering a home health aide:

• How much does the aide charge for home health services? What services are included in those fees?
• What about payment for sick days, vacation days or holidays? Clarify how many sick and vacation days are allowed, as well as which days are considered holidays.
• Will you be responsible for social security and other payroll taxes?

Who pays for Long-Term Care?

Long-Term Care Services are services that include medical and non-medical care for people with a chronic illness or disability. Long-term care helps meet health or personal needs. Most long-term care services assists people with Activities of Daily Living (ADL), such as dressing, bathing, and using the bathroom. Long-term care can be provided at home, in the community, or in a facility. For purposes of Medicaid eligibility and payment, long-term care services are those provided to an individual who requires a level of care equivalent to that received in a nursing facility.

Like public programs, private sources of payment have their own rules, eligibility requirements, copayments, and premiums for the services they cover.

Medicare (https://www.medicare.gov):

• Only pays for long-term care if you require skilled services or rehabilitative care:
  • In a nursing home for a maximum of 100 days, however, the average Medicare covered stay is much shorter (22 days).
  • At home if you are also receiving skilled home health or other skilled in-home services. Generally, long-term care services are provided only for a short period of time.
• Does NOT pay for non-skilled assistance with Activities of Daily Living (ADL), which make up the majority of long-term care services
• You will have to pay for long-term care services that are not covered by a public or private insurance program

Medicaid (https://www.medicaid.gov):

• Does pay for the largest share of long-term care services, but to qualify, your income must be below a certain level and you must meet minimum state eligibility requirements
• Such requirements are based on the amount of assistance you need with Activities of Daily Living (ADL)
• Other federal programs such as the Older Americans Act and the Department of Veterans Affairs pay for long-term care services, but only for specific populations and in certain circumstances

Health Insurance:

• Most employer-sponsored or private health insurance, including health insurance plans, cover only the same kinds of limited services as Medicare
• If they do cover long-term care, it is typically only for skilled, short-term, medically necessary care
• There are an increasing number of private payment options including:
  • Long-Term Care Insurance
    • Long-Term Care Insurance is an insurance policy designed to offer financial support to pay for your long-term care services. Unlike traditional health insurance, long-term care insurance is designed to cover long-term services and supports, including personal and custodial care in a variety of settings such as your home, a community organization, or other facility. Long-term care insurance policies reimburse policyholders a daily amount (up to a pre-selected limit) for services to assist them with activities of daily living such as bathing, dressing, or eating. You can select a range of care options and benefits that allow you to get the services you need, where you need them. Many long-term care insurance policies have limits on how long or how much they will pay. Some policies will pay the costs of your long-term care for two to five years, while other insurance companies offer policies that will pay your long-term care costs for as long as you live—no matter how much it costs. But there are very few that have no such limits. People with certain conditions may not qualify for long-term care insurance. Since standards vary between different insurance companies, if one company denies you, it is possible that another company will accept you. Common reasons why you might not be able to buy long-term care insurance include:
      • You currently use long-term care services
      • You already need help with Activities of Daily Living (ADL)
      • You have AIDS or AIDS-Related Complex
      • You have Alzheimer’s Disease or any form of dementia or cognitive dysfunction
      • You have a progressive neurological condition such as multiple sclerosis or Parkinson’s Disease
      • You had a stroke within the past year to two years or a history of strokes
      • You have metastatic cancer (cancer that has spread beyond its original site)
      • Insurance companies also consider other health conditions when determining your eligibility. If you buy your long-term care insurance before you develop one of the health conditions listed above, then your policy will cover the care you need for that condition.
    • You should consider a number of things before purchasing Long-Term Care Insurance:
      • Don’t buy more insurance than you think you may need. You may have enough income to pay a portion of your care costs and you may only need a small policy for the remainder. You also may have family members willing and able to supplement your care needs
      • Don’t buy too little insurance. That will only delay the use of your own assets or income to pay for care. Think about how you feel about having care costs that are not covered. While you can usually decrease your coverage, it is more difficult to increase coverage, especially if your health has declined
      • Look carefully at each policy. There is no “one-size-fits-all” policy
      • If you choose a policy that only pays for room and board in a facility, plan for other expenses, such as supplies, medications, linens, and other items and services that your policy may not cover
      • It costs less to buy coverage when you are younger. The average age of people buying long-term care insurance today is about 60. The average age of those purchasing policies offered at work is about 50
      • Make sure that you can afford the long-term care insurance policy over time, as your monthly income may change
      • Before you buy a policy, be aware that the insurance company may raise the premium on your policy. It is a good idea to request information on the company’s premium rate history.
      • Research and consider different options and talk with a professional before finalizing your decision
      • The best way to find out which insurance companies offer long-term care coverage in your state is to contact your state’s Department of Insurance (https://www.usa.gov/state-consumer)
      • Don’t feel pressured into making a decision
    • The cost of your long-term care policy is based on:
      • How old you are when you buy the policy
      • The maximum amount that a policy will pay per day
      • The maximum number of days (years) that a policy will pay
      • The maximum amount per day times the number of days determines the lifetime maximum amount that the policy will pay.
      • Any optional benefits you choose, such as benefits that increase with inflation
  • Life insurance options
    • You can use your life insurance policy to help pay for long-term care services through the following options:
      • Combination (Life/Long-Term Care) Products
        • Many consumers are reluctant to buy long-term care insurance because they fear that their investment will be wasted if they do not use it. Some insurance companies have attempted to solve this problem by combining life insurance with long-term care insurance. The idea is that policy benefits will always be paid, in one form or another. These products are relatively new and the features are changing as the product evolves. The amount of the long-term care benefit if often expressed in terms of a percentage of the life insurance benefit.
  • • • Accelerated Death Benefits (ADBs)
        • Accelerated Death Benefits (ADBs) is a feature included in some life insurance policies that allows you to receive a tax-free advance on your life insurance death benefit while you are still alive. Sometimes you must pay an extra premium to add this feature to your life insurance policy. Sometimes the insurance company includes it in the policy for little or no cost. There are different types of Accelerated Death Benefits (ADBs) each of which serves a different purpose. Depending on the type of policy you have, you may be able to receive a cash advance on your life insurance policy’s death benefit if:
          • You are terminally ill
          • You have a life-threatening diagnosis, such as AIDS
          • You need long-term care services for an extended amount of time
          • You are permanently confined to a nursing home and incapable of performing Activities of Daily Living (ADL), such as bathing or dressing.
            • The amount of money you receive from these types of policies varies, but typically the accelerated benefit payment amount is capped at 50 percent of the death benefit. Some policies, however, allow you to use the full amount of the death benefit. For ADB policies that cover long-term care services, the monthly benefit you can use for nursing home care is typically equal to two percent of the life insurance policy’s face value. The amount available for home care (if it is included in the policy) is typically half that amount.
            • When you receive payments from an Accelerated Death Benefit (ADB) policy while you are alive, the amount you receive is subtracted from the amount that will be paid to your beneficiaries when you die.
            • Key things to consider before taking advantage of an ADB policy include:
              • If your life insurance policy includes an ADB feature, you may be able to use your life insurance policy to help cover long-term care services. Depending on the policy amount, there may be little or no health screenings required. So if you have a health condition that might exclude you from long-term care insurance eligibility, you can still obtain a long-term care insurance policy through the ADB feature on a life insurance policy.
              • ADB policy payouts for long-term care services are often more limited than the benefits you could receive from a typical long-term care insurance policy.
              • The face value of your life insurance policy may not be enough to allow ADB payments that are enough to cover your long-term care services needs. The benefit payments may be too low and the duration may be too short to cover your long-term care services expenses.
              • ADB riders on life insurance policies may not offer inflation protection. If the policy does not include inflation protection, the ADB payment may not be sufficient to cover your future long-term care service costs.
              • If you want to leave an inheritance, you should consider whether using your life insurance death benefit to pay for long-term care services is the right option. If you use the ADB feature for long-term care services, there may be little or no death benefit remaining for your survivors.
              • Using the ADB option may affect your eligibility for Medicaid. Check with your state Medicaid agency (https://www.medicaid.gov) for more information.
    • Life settlements
      • Life Settlements plans allow you to sell your life insurance policy for its present value to raise cash for any reason. This option is usually only available to women age 74 and older and to men age 70 and older. You may choose to use the proceeds to pay for long-term care services.
      • Key things to consider before moving forward with a life settlement:
        • If you sell your life insurance policy, there may be little or no death benefit left for your heirs when you die
        • The process does not require any health screens; you may be in good or poor health
        • The proceeds of the sale may be taxed
    • Viatical settlements
      • Viatical Settlements plans allow you to sell your life insurance policy to a third party and use the money you receive to pay for long-term care. A viatical settlement is like a life settlement, but it is only possible if you are terminally ill. During the settlement process, a viatical company pays you a percentage of the death benefit on your life insurance policy, which is based on your life expectancy. The viatical company then owns the policy and is its beneficiary. The viatical company also takes over payment of premiums on the policy. As a result, you get money to pay for care, and the viatical company receives the full death benefit after you die. Unlike the life settlement, money you receive from a viatical settlement is tax-free, if you have a life expectancy of two years or less or are chronically ill and the viatical company is licensed in the states in which it does business.
      • Key things to consider before using a viatical settlement:
        • You can only use the viatical settlement if you are terminally ill and have a life expectancy of two years or less
        • If you use the viatical settlement option, you do not have to satisfy the health requirements for long-term care insurance
        • If you use the viatical settlement option, your life insurance policy will not pay a death benefit to your heirs
        • Viatical companies approve less than 50 percent of applicants
        • The amount that you receive in cash from a viatical settlement is a percent of the death benefit on your life insurance policy. Table 1 below lists guidelines from the National Association of Insurance Commissioners (NAIC), for how that percent varies based on your life expectancy.
  • Reverse mortgages. A reverse mortgage is a special type of home equity loan that allows you to receive cash against the value of your home without selling it. A reverse mortgage type of loan is based on home equity that enables older homeowners (age 62 or older) to convert part of their equity in their homes into tax-free income without having to sell the home, give up title, or take on a new monthly mortgage payment. Instead of making monthly payments to a lender, as you do with a regular mortgage, a lender makes payments to you. The loan, along with financing costs and interest on the loan, does not need to be repaid until the homeowner dies or no longer lives in the home.
    • For most reverse mortgages:
      • You can choose to receive a lump-sum payment, a monthly payment, or a line of credit
      • There are no restrictions on how you use the remainder of the money
      • You continue to live in the home and you retain title and ownership of it
      • You are also still responsible for taxes, hazard insurance, and home repairs
      • However, you do not have to repay the loan as long as you continue to live in the home. Instead, the amount you owe, based on loan payouts and interest on the loan, becomes due when you or the last borrower, usually the last remaining spouse, dies, sells, or permanently moves out of the home.
    • To qualify for a reverse mortgage:
      • You must be age 62 and older
      • Unlike a traditional mortgage, you do not have to provide an income or credit history to get the loan
      • The home must be your primary residence.
    • How to apply:
      • You must meet with an approved reverse mortgage counselor before you can start the loan process. These counselors can help you decide whether a reverse mortgage is right for you.
  • Annuities
    • Annuity is a contract in which an individual gives an insurance company money that is later distributed back to the person over time. Annuity contracts traditionally provide a guaranteed distribution of income over time, until the death of the person or persons named in the contract or until a final date, whichever comes first. You may choose to enter into an annuity contract with an insurance company to help pay for long-term care services. In exchange for a single payment or a series of payments, the insurance company will send you an annuity, which is a series of regular payments over a specified and defined period of time. There are two types of annuities:
      1. Immediate annuity
         • If you have an immediate long-term care annuity, the insurance company will send you a specified monthly income in return for a single premium payment. This option is available regardless of your current health status. If you do not qualify for long-term care insurance because of age or poor health or if you are already receiving long-term care, you can still purchase an annuity. The insurance company converts your single premium payment into a guaranteed monthly income stream for a specified period of time or for the rest of your life. How much you receive in income each month depends on the amount of your initial premium, your age, and gender. Since women tend to live longer than men, women generally receive a smaller monthly payment over a longer period of time than do men of the same age.
         • Key things to consider before purchasing an annuity:
           • The annuity amount you receive may not be enough to pay for your long-term care expenses.
           • Inflation may reduce the value of the monthly income you receive from the annuity.
           • The effect that annuities can have on your taxes is complicated. Consult your tax professional before purchasing one.
      2. Deferred long-term care annuity
         • Deferred Long-term Care Annuity plans are available to people up to age 85. Similar to other annuities, in exchange for a single premium payment, you receive a stream of monthly income for a specified period of time. The annuity creates two funds: one for long-term care expenses and another separate fund that you can use however you desire. You can access the long-term care fund immediately, but you must wait until a specified day in the future to access the separate cash portion. The rules of the annuity define how much you can access on a monthly basis from the long-term care fund and how much you can access on an annual basis from the cash fund. To qualify for a deferred long-term care annuity, you must satisfy some health criteria.
         • Key things to consider before purchasing a deferred long-term care annuity:
           • If you do not use the long-term care fund, you can pass it on to your heirs
           • The annuity may not be enough to pay for your long-term care expenses
           • The long-term care portion of the annuity may satisfy the requirements for a tax-qualified long-term care policy.
           • The effect that annuities can have on your taxes is complicated. Consult your tax professional before purchasing one
           • An annuity can affect your eligibility for Medicaid, and whether Medicaid will pay for your long-term care services.

Table 1. National Association of Insurance Commissioners (NAIC) Guidelines for Viatical Payments

Life Expectancy	Benefit (%)
1–6 months	80
6–12 months	70
12–18 months	65
18–24 months	60
Over 24 months	50

What is covered by Health and Disability Insurance?

Many people believe that the medical insurance they currently have will pay for all or much of their long-term care. In general, health insurance covers only very limited and specific types of long-term care, and disability policies don’t cover any at all.

The below chart shows the most common types of insurance and the very limited long-term care coverage they provide.

Table 2. Coverage Limits of Long-term Care Offered by Health Insurance

Public		Private
Long-term care Service	Medicare	Medigap Insurance	Private Health Insurance
Overview	Limited coverage for nursing home care following a hospital stay and home health if you require a nurse or other skilled provider	Insurance purchased to cover Medicare cost sharing	Varies, but generally only covers services for a short time following a hospital stay, surgery or while recovering from an injury
Nursing home care	Pays in full for days 1–20 if you are in a Skilled Nursing Facility following a recent 3-day hospital stayIf your need for skilled care continues, may pay for the difference between the total daily cost and your copayment of $137.50 per day for days 21-100. After day 100 does not pay	May cover the $137.50 per day copayment if your nursing home stay meets all other Medicare requirements	Varies, but limited
Assisted living facility (and similar facility options)	Does not pay	Does not pay	Does not pay
Continuing Care retirement community	Does not pay	Does not pay	Does not pay
Adult day services	Not covered	Not covered	Not covered
Home health and personal care	Limited to reasonable, necessary part-time or intermittent skilled nursing care and home health aide services, some therapies if a doctor orders them, and a Medicare-certified home health agency provides them.Does not pay for on-going personal care or only help with Activities of Daily Living (also called “custodial care”)	Not covered under current policies.Some policies sold prior to 2009 offered an at-home recovery benefit that pays up to $1,600 per year for short-term at-home assistance with activities of daily living (bathing, dressing, personal hygiene, etc.) for those recovering from an illness, injury, or surgery	Varies, but limited

Health Insurance

Most forms of insurance, such as the private health insurance or HMO you may have on your own or through your employer, follow the same general rules as Medicare with regard to paying for long-term care services. If they do cover long-term care services, it is typically only for skilled, short-term, medically necessary care.

• Like Medicare, the skilled nursing stay must follow a recent hospitalization for the same or related condition and is limited to 100 days
• Coverage of home care is also limited to medically necessary skilled care
• Most forms of private insurance do not cover custodial or personal care services at all
• Your plan may help you pay for some of the copayments or deductibles that Medicare imposes. For example, your plan may help cover the $137.50 per day for Medicare covered nursing home care for days 21 through 100

Medigap

Medigap also known as Medicare Supplemental Insurance,  are private policies designed to fill in some of the gaps in Medicare coverage. Specifically, these policies help to:

• Cover Medicare copayments and deductibles
• Enhance your hospital and doctor coverage, but does not extend to long-term care coverage
• Cover the daily Medicare copayment of $148.00 per day for days 21 through 100 for the small portion of nursing home stays that qualify for Medicare coverage
• Medigap insurance is not intended to meet long-term care needs and provides no coverage for the vast majority of long-term care expenses like care in a nursing home, vision or dental care, hearing aids, eyeglasses, or private-duty nursing.

There are a number of standardized Medigap plans defined by federal law. Find out more about Medigap and see what is covered at the official government website for Medicare (https://www.medicare.gov/supplements-other-insurance/how-to-compare-medigap-policies)

Disability Insurance

Disability insurance is intended to replace some of a working person’s income when a disability prevents them from working. It does NOT:

• Cover medical care or long-term care services
• Provide benefits once you are over age 65—when you are most likely to need long-term care services

Senior home care

Aging in place means staying in the comfort of your own home for as long as possible as you get older, rather than moving into a retirement or long-term care facility. Aging in place may be a viable option if you only need minor assistance with your daily activities, enjoy a close network of family and friends nearby, and can utilize the right home care services to cover your needs. By exploring the range of services available, you can decide if aging in place is the best way for you to maintain your independence and make the most of your golden years.

You may be used to handling everything yourself, dividing up duties with your spouse, or relying on family members for minor help around the home. But as you get older and your circumstances change, getting around and taking care of yourself can become more and more difficult. If the idea of moving to a retirement community, assisted living facility, or nursing home doesn’t appeal, home care services may be able to help keep you living in your own home for longer.

Home help for seniors include:

• Household maintenance. Keeping a household running smoothly takes a lot of work. If you’re finding it hard to keep up, you can look into laundry, shopping, gardening, housekeeping, and handyman services. If you’re having trouble staying on top of bills and appointments, financial and healthcare management may also be helpful.
• Transportation. Transportation is a key issue for older adults. Maybe you’re finding it hard to drive or don’t like to drive at night. Having access to trains, buses, rideshare apps, reduced fare taxis, and senior transportation services can help prolong your independence and maintain your social network.
• Home modifications. If your mobility is becoming limited, home modifications can go a long way towards keeping your existing residence comfortable and accessible. Modifications can include things such as grab bars in the shower, ramps to avoid or minimize the use of stairs, or even installing a new bathroom on the ground floor.
• Personal care. Help with the activities of daily living, such as dressing, bathing, or meal preparation, is called personal or custodial care. Home health aides can provide personal care services that range from a few hours a day to around-the-clock live-in care. They may also provide limited assistance with things such as taking blood pressure or offering medication reminders.
• Health care. Some healthcare services can be provided at home by trained professionals, such as occupational therapists, social workers, or home health nurses. Check with your insurance or health service to see what kind of coverage is available, although you may have to cover some cost out of pocket. Hospice care can also be provided at home.
• Day programs or Adult Day Care. Adult daycare or day programs is a planned program of activities in a professional care setting designed for seniors who require supervised care during the day, or those who are isolated and lonely. Adult day care centers enable seniors to socialize and enjoy planned activities in a group setting, while still receiving needed health services. At the same time, they offer family caregivers a break from caregiving duties while knowing that their loved one is in a safe place. Some daycare programs are primarily social, while others provide limited health services or specialize in disorders such as early stage Alzheimer’s disease. Services vary between facilities, including the level of care offered. While one type of center focuses mainly on social and recreation services, with a few health-related and personal care services, another type will provide more comprehensive medical and therapeutic services. These could include physical, occupational, or speech therapy, for example, or medical services administered by a registered nurse or other health professional. Finally, a third type of facility will offer specialized services for adults with a specific health condition, such as dementia or a disability. Adult day care centers tend to operate during daytime hours, Monday through Friday, although some services may be available in the evenings or at weekends. To find an Adult daycare center near you go here National Adult Day Services Association (https://www.nadsa.org). Whatever the range of services, the intent is primarily two-fold:
  • To provide older adults an opportunity to get out of the house and receive both mental and social stimulation, as well as the continuing care they need.
  • To give caregivers a much-needed break in which to work, attend to personal needs, or simply to rest and relax.

Adult Day care or Day programs

Adult daycare or day programs is a planned program of activities in a professional care setting designed for seniors who require supervised care during the day, or those who are isolated and lonely. Adult day care centers enable seniors to socialize and enjoy planned activities in a group setting, while still receiving needed health services. At the same time, they offer family caregivers a break from caregiving duties while knowing that their loved one is in a safe place. A well-run adult day care center’s goals will focus on enriching participants’ lives, building upon their skills and strengths, and providing lots of social interaction. Each facility differs in terms of features, but services may include:

• Social activities. Planned activities tend to be tailored to the participants’ abilities and health conditions, but may encompass such things as arts and crafts, musical entertainment and sing-a-longs, mental stimulation games such as bingo, stretching or other gentle exercise, discussion groups (for books, films, or current events, for example), holiday and birthday celebrations, and local outings.
• Nutrition. Day care centers provide seniors with nutritious meals, including those that accommodate special diets, along with snacks.
• Personal care. Center staff can help with the activities of daily living such as grooming, toilet hygiene, walking, and feeding.
• Health services. These can vary from medication dispensing, blood pressure monitoring, hearing checks, and vision screening, for example, to symptom management and more intensive medical or therapeutic services.
• Transportation. Some adult day care centers provide transportation to and from the center and for any local outings.
• Services for caregivers. Some centers may provide counseling, support groups for caregivers, help for care planning, and caregiving education.

Some centers even offer pet therapy or programs that include children. The Friendship Center in California, for example, developed The GOLD Project where older adults are encouraged to visit local classrooms and share their life experiences with the children, educating and enlivening both groups in the process.

To find an Adult daycare center near you go here National Adult Day Services Association (https://www.nadsa.org)

Good candidates for adult day care centers are seniors who:

• Can benefit from the friendship and functional assistance a day care center offers.
• May be physically or cognitively challenged but do not require 24-hour supervision.
• Are in the early stages of Alzheimer’s disease.
• Are mobile, with the possible assistance of a cane, walker, or wheelchair.
• Are continent (in most cases).

You may want to consider using adult day care when a senior:

• Can no longer structure their own daily activities.
• Is isolated and desires companionship.
• Can’t be safely left alone at home.
• Lives with someone who works outside the home or who is frequently away from home for other reasons.

Benefits of adult day care

For the participant, an adult day care center’s benefits can be extensive.

• Adult day care provides a safe, secure environment in which to spend the day or part of the day.
• Offers enjoyable and educational activities.
• Appropriate physical exercise can help to reduce falls.
• Meaningful social interaction can improve both mental and physical health and help to prevent or delay cognitive decline.
• Mental and social stimulation during the day can improve the quality of your sleep at night.
• Participation in adult day care activities may even enhance or maintain your level of independence, keeping you living at home longer by relieving caregiver fatigue and delaying your escalation of dependence.
• Having control over activities you partake in can bolster your self-esteem.
• Adult day care offers the chance to build new friendships and enjoy peer support.

Benefits for the caregiver

Seeking support and maintaining your own health are key to managing your role as a caregiver, so it’s not selfish to use the services of an adult day care center to give you some time to yourself. If you’re overwhelmed by the daily grind of caregiving, your patience and compassion will wear thin, you’ll find it harder to connect with the person you’re caring for, and you’ll probably both feel unfulfilled.

• Taking regular breaks from the demands of caregiving can reduce your stress levels and help you to avoid burnout.
• Being able to recharge your batteries can leave you feeling more energetic, focused, and reinvigorated about your caregiving role.
• Using an adult day care facility can enable you to continue working, attend school, or devote more time to other family members.
• Can give you peace of mind that your loved one isn’t home alone but is in a supervised and safe environment.

When you contact the adult day care centers you’ve chosen to consider, ask questions such as the following:

• Who owns or sponsors the adult day care center? How long has it been operating? Is it licensed or certified? (If required in your country or state)
• What are the days and hours of operation?
• Which conditions are accepted (e.g., memory loss, limited mobility, incontinence)?
• What is the ratio of staff to participants? How are care providers screened? What is the training and level of experience of the care providers? How, and by whom, are the care providers supervised?
• What procedures does the program have for emergencies?
• What activities are offered? Are there a variety of individual and group programs?
• Is transportation to and from the adult day care center provided?
• Are meals and snacks included? Are special diets accommodated?
• What is the cost of services? How is payment arranged?

Senior Housing Options

Aging is a time of adaptation and change, and planning your future housing needs is an important part of ensuring that you continue to thrive as you get older. Whether your search for senior housing is prompted by a serious medical condition or the desire for a lifestyle change, finding the right place to live can be challenging and stressful for both you and your family. However, the earlier you assess your current needs and how those needs may evolve over time, the more choices and control you’ll have. Of course, every older adult is different, so the senior housing choice that’s right for one person may not be suitable for you. The key to making the best choice is to match your housing with your lifestyle, health, and financial needs. This may mean modifying your own home to make it safer and more comfortable, or it could mean moving to a housing facility with more support and social options available on site. It could even involve enrolling in a network of like-minded people to share specialized services, or moving to a retirement community, an apartment building where the majority of tenants are over the age of 65, or even a nursing home.

By learning about the different types of senior housing available, you can make the choice that’s right for you and ensure you enjoy a happy, healthy, and fulfilling home environment as you age.

The names of the different types of senior living facilities and housing options can sometimes be confusing, as the terminology can vary from region to region. For example, the term “assisted living” can mean one thing in one state or country and something slightly different elsewhere. However, in general, the different types of senior housing vary according to the amount of support offered for the activities of daily living and medical care. When researching a senior housing option, make sure it covers your required level of care and that you understand exactly what facilities are offered and how much they’ll cost.

You family doctor can refer you to a geriatric care manager. Geriatric care managers can provide a housing assessment as well as assistance with managing your circumstances, whether that involves interviewing in-home help or assisting with placement in an assisted living facility or nursing home.

1. Staying in your own home

Staying in your own home also known as “aging in place”, has the advantage of keeping you in a familiar place where you know your neighbors and the community. You can take advantage of home care services and make home repairs or modifications to make your life easier and safer.

Staying in your own home may be a good option if:

• You have a close network of nearby family, friends, and neighbors.
• Transportation is easily accessible, including alternate transportation to driving.
• Your neighborhood is safe.
• Your home can be modified to reflect your changing needs.
• Home and yard maintenance is not overwhelming.
• Your physical and medical needs do not require a high level of care.
• You fall within the geographical confines of an integrated community, such as a “village” or Naturally Occurring Retirement Community (NORC). A “village” or “Naturally Occurring Retirement Community” can range from a single age-integrated apartment building to a housing complex or an even wider community of one- or two-family homes. Members of the “village” can access specialized programs and services. These may include transportation to the grocery store, home health care, or help with household chores, as well as a network of planned social activities with other village members.

Of course, everyone’s needs vary, depending on factors such as how much support you have, your general health and mobility, and your financial situation.

If you feel overwhelmed by the upkeep of your home, cut off from social amenities, or simply want more companionship with others your age, an independent living or retirement community may be a better option. The housing is friendlier to aging adults and while residents live independently, most communities offer amenities and services. As the name suggests, independent living is more about making life easier rather than a loss of independence.

If you or your spouse have a lot of medical needs, though, you may be better off considering an assisted living facility or nursing home.

Here are some of the issues to consider when evaluating your aging in place and home care options:

• Location and accessibility. Where is your home located? Are you in a rural or suburban area that requires a lot of driving? If you’re in an area with more public transit, is it safe and easily accessible? How much time does it take you to get to services such as shopping or medical appointments? It’s also important to consider proximity to community services and activities.
• Home accessibility and maintenance. Is your home easily modified? Does it have a lot of steps or a steep hill to access? Do you have a large yard that needs to be maintained?
• Support available. Do you have family and friends nearby? How involved are they? Are they able to provide you the support you need? Many older adults prefer to rely on family to provide help, but as your needs increase, they might not be able to fill in all of the gaps. Caregiving can be physically and emotionally exhausting, especially if it is primarily on one person such as a spouse or child. Your relationships may be healthier if you are open to the idea of getting help from more than one source.
• Isolation. If it becomes difficult or impossible for you to leave home without help, isolation can rapidly set in. You may not be able to participate in hobbies you once loved, stay involved in community service that kept you motivated, or visit with friends and family. Losing these connections and support is a recipe for depression.
• Medical conditions. No one can predict the future. However, if you or your spouse has a chronic medical condition that is expected to worsen over time, it’s especially important to think about how you will handle health and mobility problems. What are common complications of your condition, and how will you handle them?
• Finances. Making a budget with anticipated expenses can help you weigh the pros and cons of your situation. Alternate arrangements like assisted living can be expensive, but extensive in-home help can rapidly become expensive as well, especially at higher levels of care and live-in or 24-hour coverage.
• Your family’s opinions. Naturally, you have the final decision as to where you want to live, but input from family members can be helpful. Are they worried about your safety or a health problem that will eventually require heavy care? Listening to concerns and keeping an open mind are key.

2. Independent living

Independent living is simply any housing arrangement designed exclusively for older adults, usually those aged 55 and over. Housing varies widely, from apartment-style living to freestanding single-family detached homes. In general, the housing is friendlier to seniors, often being more compact, with easier navigation and no maintenance or yard work to worry about. The key difference between independent living and other housing options is the level of assistance offered for daily living activities. If you require round-the-clock help with eating, dressing, and using the bathroom, or require regular medical assistance, other housing options such as assisted living facilities or nursing homes may be a better fit.

Other common names for independent living include:

• Retirement communities: Retirement communities are groups of housing units restricted for those over a certain age, often 55 or 62. These housing units can be single-family homes, duplexes, mobile homes, townhouses, or condominiums. If you decide to buy a unit, additional monthly fees may cover services such as outside maintenance, recreation centers, or clubhouses.
• Retirement homes
• Congregate care
• 62 and over or 55 and over apartments or communities
• Active adult or senior living communities
• Senior living apartments or senior housing: These are apartment complexes restricted by age, usually 55 or 62 and older. Rent may include community services such as recreational programs, transportation services, and meals served in a communal dining room.
• Continuing Care Retirement Community (CCRC): If you or your spouse are relatively healthy now, but anticipate significant health problems down the line, you may want to consider a CCRC. These facilities offer a spectrum of care from independent living to nursing home care in the same community. If residents begin to need help with activities of daily living, for example, they can transfer from independent living to an assisted living or skilled nursing facility on the same site. The main benefit of a CCRC is that you only need to relocate once to a new environment and can maintain your independence for as long as possible.
• Senior co-housing
• Low-income or subsidized senior housing. In the U.S., for example, there are senior housing complexes subsidized by the U.S. Department of Housing and Urban Development (HUD) for low-income seniors.

While residents live independently, most communities offer amenities, activities, and services. Often, recreational centers or clubhouses are available on site to give you the opportunity to connect with peers and participate in community activities, such as arts and crafts, holiday gatherings, continuing education classes, or movie nights. Independent living facilities may also offer facilities such as a swimming pool, fitness center, tennis courts, even a golf course or other clubs and interest groups. Other services offered may include onsite spas, beauty and barber salons, daily meals, and basic housekeeping and laundry services.

Since independent living facilities are aimed at older adults who need little or no assistance with the activities of daily living, most do not offer medical care or nursing staff. As with regular housing, though, you can hire in-home help separately as required.

As with any change in living situation, it’s important to plan ahead and give yourself time and space to cope with change. By using these tips, you can find an independent living arrangement that makes your life easier, prolongs your independence, and enables you to thrive in your retirement.

Independent living may be your best choice if:

• You see needing only minor assistance with activities of daily living.
• You’d like a place that does not require a lot of maintenance and upkeep.
• You like the idea of socializing with peers and having activity options nearby.

3. Assisted living facilities

Assisted living is a residential option for seniors who want or need help with some of the activities of daily living—things like cooking meals, getting to the bathroom in the middle of the night, house keeping, and traveling to appointments. An assisted living facility may be a good choice if you need more personal care services than you can get at home or in an independent living or retirement community, but you don’t need the round-the-clock medical care and supervision of a nursing home.

Other common names for assisted living:

• Residential care
• Board and care
• Congregate care
• Adult care home
• Adult group home
• Alternative care facility
• Sheltered housing
• Extra-care housing

Assisted living facilities offer the safety and security of 24-hour support and access to care. Day or night, help is only a phone call away. However, privacy and independence are encouraged. A good facility will develop a personalized plan that meets your needs and accommodates your disabilities, while giving you the freedom to do what you can for yourself.

In general, assisted living is in a residential type facility, ranging from converted homes or apartment complexes to renovated schools. Some provide apartment-style living with scaled down kitchens, while others provide just bedrooms. In some, you may even need to share a room unless you’re willing to pay a higher cost. Most facilities have a group dining area and common areas for social and recreational activities.

Services at a typical assisted living facility include:

• Three meals a day served in a common dining area.
• Assistance with eating, bathing, dressing, going to the bathroom, and walking.
• Housekeeping services.
• Emergency call systems in each resident’s living space.
• Transportation.
• Access to health and medical services.
• Round-the-clock security.
• Exercise and wellness programs.
• Medication management.
• Laundry services.
• Social and recreational activities.
• Staff available to help with scheduled needs, as well as unexpected issues.

An assisted living facility may be a good choice if:

• You need more personal care services than are feasible at home or in an independent living retirement community.
• You don’t need the round-the-clock medical care and supervision of a nursing home.

Whatever your circumstances, making the decision to leave your home can be difficult. But by taking time to explore your options and being honest about your needs and concerns, you can make a choice that ensures your senior years are happy and fulfilling.

It’s not always easy to tell when your parent or another loved one needs more help. The following warning signs may indicate that it’s time for a talk about assisted living:

• The refrigerator is empty or filled with spoiled food or your loved one is losing weight. These may be signs that they aren’t eating well because shopping or cooking is difficult.
• You notice frequent bruises, although your loved one may try to cover them up. This may be a sign of falling, or mobility and balance problems.
• Your loved one wears the same clothes over and over again or neglects their personal hygiene. This can indicate that doing laundry and bathing is physically challenging.
• The house and yard isn’t as clean and tidy as it used to be.
• Your loved one forgets things, such as doctor’s appointments or when to take their medication. This may be due to memory loss.
• Your loved one seems depressed. Depression is common in seniors who are isolated and alone.
• You notice strange or inappropriate behavior. For example, your loved one may dress inappropriately for the weather. This can be a sign that they are experiencing confusion.

4. Nursing homes

A nursing home provides some of the highest levels of care for seniors outside of a hospital. Nursing homes provide what is called custodial care, including getting in and out of bed and providing assistance with feeding, bathing, and dressing. However, nursing homes differ from other senior housing facilities in that they also provide a high level of medical care. A licensed physician supervises each patient’s care and a nurse or other medical professional is almost always on the premises. Skilled nursing care is available on site, usually 24 hours a day. Other medical professionals, such as occupational or physical therapists, are also available. This allows the delivery of medical procedures and therapies on site that would not be possible in other housing.

As the population ages, more of us are faced with the prospect of moving either ourselves or an older family member into a nursing or convalescent home. It may be a decision that arrives suddenly following hospitalization, or gradually as needs become more difficult to meet in other types of housing. Deciding to move can be stressful, but by learning all you can about nursing homes, you can ease your fears and make a decision that’s right for you or your family member.

A nursing home may be a good choice if:

• Both your medical and personal care needs have become too great to handle at home or in another facility. This may be due to a recent hospitalization, or a chronic illness which has gradually been worsening.
• You need a higher level of care temporarily after a hospitalization, but it’s anticipated you will be able to return to home or another facility after a period of time.

Finding the right senior home services

Once you’ve figured out your needs, it’s time to evaluate which home care services are right for you and where to find the best providers. Of course, it can be difficult to entrust your home or personal care to others, especially people you don’t know. The goal is to find a trustworthy, compassionate and responsible caregiver. Do you feel most confident using a home health agency with aides on staff? Or would you rather hire an independent contractor directly, through a staffing service or a friend’s referral?

Start by seeking referrals from family, friends, or neighbors. There may be a neighbor who could regularly check-in with you or provide yard maintenance, for example. Local religious groups sometimes offer meals or social activities for older adults. Ask the people you know if they have care providers they can recommend. Your doctor or other healthcare professional may also be able to provide referrals.

Full-service agencies usually come at a higher cost but provide prescreened applicants who have already had background checks. Since the caregiver works for the agency, they take care of billing and tax issues. They may also be bonded for issues such as theft. If a caregiver quits or is not working out, an agency can usually find a replacement quickly, and may also provide coverage if a caregiver calls in sick.

Independent providers usually come at a lower cost, but require more legwork on your part. You’ll need to handle any tax requirements and perform background checks and identity verification. In the case of illness or sudden termination, you’ll also be responsible for finding a replacement provider.

How you go about hiring home care providers will partially depend on what kind of help you are looking for. Hiring someone to handle shopping or yard maintenance, for example, is different from hiring someone to provide hands-on or live-in personal care. However, there are some basic tips to keep in mind. Remember that the more time and homework you spend in the initial hiring process, the better the chances of success.

• Conduct an in-depth interview with each candidate. Screening applicants on the phone should always be followed with an in-person interview.
• Be specific about all of the tasks, skills, and schedules involved and be sure that the person you are considering is comfortable with them all.
• Discuss compensation and payment schedules. Do not pay for services in advance.
• Request several work and personal references, and check them carefully. Verify the information provided, and ask all references about reliability, trustworthiness, punctuality, and the care provider’s ability to handle stress.
• Perform background checks. If you’re working through an agency, these are often provided, but you’ll want to check exactly what is covered. Background checks can be done inexpensively through online agencies and alert you to potentially serious problems.
• If you are working with an agency, make sure you understand what is covered. Are there additional fees that apply to specific services or add-ons? If needed, what are the procedures for termination or requesting another provider?
• Don’t be afraid to move on if it’s not the right fit. It’s important that you feel comfortable with a home care provider who’s delivering services in the privacy of your own home. If you don’t, try talking to the provider to see if any miscommunication can be resolved. If not, don’t be afraid to look for another.

How to hire a home caregiver?

Finding the right home care worker for your loved one is an important step. More than 2.3 million U.S. workers provide in-home personal and health care for older adults and people with disabilities, a labor force that has more than doubled since 2007, according to PHI, a New York–based nonprofit advocacy group that works to improve the quality of direct-care services and jobs.

Several types of paid in-home caregivers provide a range of services, everything from help around the house to skilled health care.

• Personal care aides are not licensed and have varying levels of experience and training. They serve as helpers and companions, providing bathing and dressing, conversation, light housekeeping, meals and neighborhood walks. They can offer transportation to shopping and appointments, as well as pick up prescriptions. Training requirements vary by state, and some states do not have formal standards. Expect personal care aide services to be an out-of-pocket expense; Medicare or private health insurance typically does not cover them. The median hourly wage is $11.55, according to May 2018 figures from the U.S. Bureau of Labor Statistics (the most recent data available). But the charge for this and other in-home health services can be considerably higher in tight markets and urban areas, especially if you hire an aide through an agency that acts as a middleman.
• Home health aides monitor the patient’s condition, check vital signs and assist with activities of daily living, including bathing, dressing and using the bathroom. Home health aides also provide companionship, do light housekeeping and prepare meals. Home health aides must meet a federal standard of 75 hours of training, but otherwise training and certification requirements vary by state. The median hourly wage is $11.63.
• Licensed nursing assistants and certified nursing assistants observe and report changes in the patient, take vital signs, set up medical equipment, change dressings, clean catheters, monitor infections, conduct range-of-motion exercises, offer walking assistance and administer some treatments. All medical-related tasks are performed as directed by a registered nurse (RN) or nurse practitioner. Certified nursing assistants also provide help with personal care, such as bathing, bathroom assistance, dental tasks and feeding, as well as domestic chores like changing bed linens and serving meals. As with home health aides, federal law requires nursing assistants to get at least 75 hours of training, but some states set higher bars. The median hourly wage is $13.72.
• Skilled nursing providers, also known as licensed practical nurses (LPNs), meet federal standards for health and safety and are licensed by states. Licensed practical nurses evaluate, manage and observe your family member’s care and provide direct care that nonmedical and home health aides cannot. Tasks could include administering IV drugs, tube feedings and shots; changing wound dressings; providing diabetes care; and educating caregivers and patients. Some licensed practical nurses are trained in occupational therapy, physical therapy and speech therapy. Medicare covers home health skilled nursing care that is part-time or intermittent, doctor-prescribed and arranged by a Medicare-certified home health agency. The median hourly wage for home-health skilled nursing is $23.02, according to the Bureau of Labor Statistics.
• Registered nurses (RNs) hold a nursing diploma or an associate’s degree in nursing; have passed the National Council Licensure Examination, administered by the National Council of State Boards of Nursing; and have met all other licensing requirements mandated by their state’s nursing board. Registered nurses provide direct care, administer medications, advise family members, operate medical monitoring equipment and assist doctors in medical procedures. The median hourly wage for registered nurses providing home care services is $34.54.

Whatever method you select, you and your loved one should interview applicants together if possible. Prepare written questions, and be clear and honest about job requirements.

Another major consideration when hiring a caregiver is the cost, which can vary depending on your hiring route. In some cases you may be able to get help paying for in-home care.

Using an agency

Regardless of whether your family member is eligible for Medicare, Medicare’s Home Health Compare (https://www.medicare.gov/care-compare/?providerType=HomeHealth&redirect=true) is a useful online tool for finding and researching home health agencies in your area. It offers detailed information on what services they provide and how patients rate them. Although most states require home health care agencies to perform criminal background checks on their workers and carefully screen applicants, actual regulations will vary depending on where you live. Therefore, before contacting a home health care agency, you may want to call your local area agency on aging or department of public health to learn what laws apply in your state. To learn more about home care, visit LongTermCare.gov (https://acl.gov/ltc).

Once you have a list of promising agencies, arrange a consultation.

Working with an agency has pros and cons.

The pluses of working with an agency include:

• Prescreened workers. Caregivers have undergone and passed a background check.
• Relevant experience. Agencies are likely to have some caregivers who have looked after clients struggling with the illness or condition affecting your loved one.
• Backup care. If the original caregiver is sick or doesn’t work out, an agency usually can find a replacement quickly.
• Fast upgrades. If the client’s care needs or diagnosis changes, most agencies can promptly provide a worker with more training.
• Fewer problems. Concerns and complaints can be reported to, and handled by, the agency.
• Liability protection. If a caregiver is injured on the job, the agency covers the cost.
• No paperwork. You pay the agency. It takes a percentage, pays the worker, and handles payroll, scheduling and taxes.

Among the downsides of working with an agency:

• Expense. You pay more — sometimes substantially more — for an agency-provided caregiver.
• Little choice. The agency chooses the worker, who may or may not mesh well with you or your family member.
• Limited negotiation. Individuals are generally more flexible about duties, hours and overtime than agencies.
• Minimum hours. Many agencies do not allow a part-time schedule.

Here is a checklist of important questions to ask an Agency for In-Home Care before signing a home health contract:

• Is this agency licensed by the state?
• What services does it provide?
• Are services available 24 hours, 7 days a week?
• Would services begin immediately? If not, how long a wait?
• How does the agency decide what services are needed or not over time?
• What kind of different staff does the agency have available: registered nurse, physical therapist, speech therapist, occupational therapist, nutritionist, social worker, homemaker/home health aide?
• How many years of experience does the person have, and how long have they been with the agency?
• Does the agency conduct background checks on all staff?
• Who supervises the staff?
• Are the staff bonded (insured against theft or loss to a home) through the agency?
• Do the same staff members attend to a client, or do they rotate among different clients?
• What is the procedure if a staff person doesn’t show up?
• Can you request a different staff person to provide care if you are unhappy with the worker the agency sent?
• Is the agency certified to be paid by Medicare and Medicaid?
• Are there deposits, fees, or any extra costs besides those charged for each service?
• Does the agency reduce fees for people who can’t pay for all of their care themselves?
• When did the agency last increase its costs and by how much?
• How often does the agency bill for costs? Does it bill Medicare or the insurance company directly?
• Are all cost and payment expectations in writing?
• Is there a contract you can review before making a decision? Make sure you understand everything on the contract. Question any parts that are unclear or contradict information you’ve been told.
• Does the agency have references or satisfaction reports for itself and staff?
• Is the agency inspected by an outside organization? When was the last inspection? Are inspection reports available?
• Does staff receive ongoing training?
• Does the agency provide written job descriptions so clients know what duties to expect from the staff?
• Does the agency have quality of care standards and a plan or program to maintain and improve quality?
• How often does staff communicate with family members and by what means (written report, phone call, etc.)?
• What kind of system is there for receiving client problems or complaints and resolving them?
• Is there a written plan of care for each client? Are clients and family members involved in creating and reviewing it?
• How long has the agency been in business? Who owns and operates it?

Using a registry

Home health care registries, sometimes called private-duty registries or staffing services, connect families with independent home health workers. You tell the company what you are looking for, and it will refer you to matching candidates. These direct-hire firms often charge a onetime fee for a successful match, but otherwise the financial and professional relationship is between you and the caregiver.

Some local governments have publicly available registries of certified home care workers in the area, along with contact information.

Some pros of using a registry:

• Better fit. You may be more likely to find a caregiver who speaks a second language, shares interests with your relative or has personality traits your loved one will appreciate.
• Flex time. You are more likely to find a part-time caregiver or one who can work an unusual schedule.
• Spend less; pay more. Since a registry has no agency fees, you may be able to spend less out of pocket while still paying a higher wage than an agency caregiver gets. That could enable you to hire a provider with more skills or experience.
• Your rules. Agency caregivers must follow agency rules. If the worker is independent, the two of you and the care recipient can figure out what works for everyone.

Some cons of a registry:

• Time. A do-it-yourself search can take days or weeks, whereas agencies often can arrange next-day care.
• Emergency coverage. Sick days, vacation or a fast departure for a new job can upend everyone’s schedule. You’ll have no fallback plan unless you create it.
• Screening. You will have to do a background check and verify credentials. One resource is state health departments, many of which maintain databases of certified home health workers that you can search by name.
• Paperwork. You are responsible for getting an employer identification number and for withholding and paying Medicare, Social Security and unemployment taxes. You also must confirm that the applicant can work legally in the United States.
• Protection. Agencies insure their workers. You may be liable for an on-the-job accident unless you buy liability insurance that covers the caregiver. Workers’ compensation insurance, which covers lost wages and medical care, is required in some states, and some legal experts recommend it for all.
• Training. Agency health aides are trained. You may want to pay for a class or refresher.
• Ultimate responsibility. The person who handles complaints about your caregiver is you.

Personal referrals

Hiring a caregiver on the recommendation of someone you know or an organization you trust carries similar pros and cons as a direct hire through a registry. You have both more flexibility and more responsibilities than if you use an agency. But you also have the confidence that comes with a referral from a friend or a community group.

References

1. Landers, S., Madigan, E., Leff, B., Rosati, R. J., McCann, B. A., Hornbake, R., MacMillan, R., Jones, K., Bowles, K., Dowding, D., Lee, T., Moorhead, T., Rodriguez, S., & Breese, E. (2016). The Future of Home Health Care: A Strategic Framework for Optimizing Value. Home health care management & practice, 28(4), 262–278. https://doi.org/10.1177/1084822316666368
2. Caregiver Care. Am Fam Physician. 2019 Jun 1;99(11):699-706. https://www.aafp.org/afp/2019/0601/p699.html
3. AARP Public Policy Institute; National Alliance for Caregiving. Executive summary: caregiving in the U.S. June 2105. https://www.aarp.org/content/dam/aarp/ppi/2015/caregiving-in-the-united-states-2015-executive-summary-revised.pdf