Assessing Care: Navigating In-Home Care

by Eileen Jordan

There is no place like home.  We run our homes the way we feel most comfortable and it is our safe place where we can relax and be ourselves.  Our aging loved ones feel the same, even as daily chores become increasingly difficult for them to handle due to health and age-related issues slowing them down.  Helping our loved ones stay as independent as possible in their own home is not easy so it is wise to become familiar with the options and resources available for in-home care.  James 1:5 tells us, “If any of you lacks wisdom, let him ask of God who gives to all liberally and without reproach, and it will be given to him.”   And in James 5:11, “Indeed we count them blessed who endure. You have heard of the perseverance of Job and seen the end intended by the Lord—that the Lord is very compassionate and merciful.”

Do not be surprised when your efforts to help are met with resistance, and possibly very strong resistance.  Understand that they are holding onto their independence and way of life.  We need to put ourselves in their shoes and be as diplomatic as possible.  It helps to have a grasp of the tools that are available to come up with a plan.  The rule of thumb is to have only as much care as needed and gradually increase care as the need increases.  It is best to start out slowly and let them get used to the idea that help is not a bad thing and their desire for independence is understood and respected.  Bad things happen and we cannot wrap them up in bubble wrap to be sure they are safe, and we do not want to overreact to problems that come up.  The exception to this is when someone has a sudden medical need that may be temporary or permanent.  In that circumstance it is safer to start with the maximum amount of care needed and decrease it as the need decreases.

The first reaction is often, “We need a caregiver to come in and help Mom.”  That may seem like the most practical solution, but it can be the most expensive and met with the most resistance.  It may be prudent to see if there are ways to help that are less invasive.

Home Safety Check and Technology:  The first thing to do is perform a home inspection to see if there are any safety problems that may have gone unnoticed.  It is best to fix a problem before there is a fall rather than after a fall.  This effort can be met with resistance as well, and a good approach to take is to make it clear your goals are the same:  to keep them happy at home.  You can stress the idea that they are important members of the family and their family needs to feel comfortable that they are safe.  Try to avoid giving the impression you are “bossing” them.  Obvious things to look for are fall risks like area rugs and mats, slippery floors, showers that are unsafe, and stairs that may be difficult for them to navigate.  Other things to look for are worn spots on floors and carpeting that may cause a fall, crowding from furniture limiting passage, items that can be tripped over, swivel chairs that pose a fall hazard, items on high shelves that are often used, and small bathrooms or closets with doors that open into the room that could make it difficult for family or emergency personnel to get in if someone fell, blocking the door. Those are examples of what to look for, but every home and situation is unique, and the idea is to become safety conscious.

Downsizing can be helpful in enabling one to stay at home longer.  The more room there is to ambulate, the less likely to trip and the less chance of a serious injury due to falling on something hard and/or sharp.  It is a good idea to have enough room to navigate a walker or a wheelchair even if one isn’t currently being used because it can be needed suddenly, even temporarily.  Also, the more room there is in cupboards and drawers, the less need for keeping often used items on high shelves that can be dangerous to reach for.  Many falls happen in the bathroom so pay close attention there.  Common solutions are installing grab bars (installed, not suction cup type) in the shower and by the toilet, a hand-held showerhead and shower chair, and a raised toilet seat or commode that fits over the toilet and can be used bedside by replacing the splash guard with the bucket if your loved one is unable to safely get to the bathroom at night. 

Medical alert systems with buttons that can be worn on the wrist or around the neck are very important.  There are many types available, even some that can sense a fall and call for help without pushing a button which is important for seniors with memory and/or cognitive issues.  A simple medic alert bracelet is very important for people with cognitive issues and certain medical conditions, and these may be covered by insurance or they can be purchased online in a variety of styles at little cost. A lift chair is important for someone who has difficulty getting up and down from the sitting position.  Sofas and beds can also be difficult to maneuver because they tend to be lower to the ground and a set of lifts for the legs is a simple and inexpensive fix.  Cameras can also be a valuable tool from a simple baby monitor style, to a system with several cameras set up around the home that can be monitored by an app on a cell phone.  The cameras can be turned off when not needed and they can be a help to monitor caregivers as well. The idea is to know what tools are available and introduce them when needed.  Some may be needed on a temporary basis and it is good to have them available, such as canes, walkers, and commodes (which can be used as a shower chair as well).  A foldable, lightweight transport wheelchair (four small wheels rather than the two big wheels) can be useful for taking your loved one to appointments and events outside the home if they have difficulty walking long distances.  The proper equipment can delay the need for a caregiver or reduce the amount of help needed, and it can often be purchased online for cheaper than a local medical equipment store so it is good to plan ahead and price shop if you are able.    Also, you may want to research services in your area such as a “meals on wheels” type program or service, home grocery delivery, medical or senior or other transport services, and maybe a cleaning service to name a few.

CAREGIVING OPTIONS

There are many options for finding caregiving help, all with their own pros and cons.  The biggest factors are cost and getting your loved one to accept the appropriate help.  It is important to understand your options whether you use one option or a combination of several.

Family:  Caregiving often starts with help from family and friends.  This is usually easier for our loved ones to accept and they might even welcome the assistance and company, but it can be hard on family members.  Our loved ones are used to doing things their own way and expect to continue to do so, and they often want to control the kind of help that is given.  This is not always practical or safe or fair to the family caregiver.  It is important to set boundaries for everyone and try to work as a team with the ones needing help and those providing help.  Diplomacy is critical and in a perfect situation the caregiver will respect their need for independence, as the loved one receiving help respects the caregiver’s needs and limitations of time.  Some pros to consider:  Family bonding, zero-to-low cost, the ability to assess needs as they change, the opportunity to encourage safe behavior in our loved ones, and a greater ability to maintain control of care. Some cons to be aware of: Mental and physical stress on the caregivers due to limitations of time and energy, potential for strained family relations with the loved ones receiving care and family members working out their roles in care, difficulty performing personal care such as showering and dressing because of the close relationship, and maintaining the child/parent or spouse relationship as the caregiving role becomes predominant.

Friend or Volunteer:  This may be helpful for loved ones on limited income who need occasional or very limited help.  In most cases, this should just be for companion care, transportation, and simple tasks.  Some pros to consider:  A chance for bonding between friend/volunteer and your loved one, and your loved one receiving help that could not be afforded otherwise.  Some cons to be aware of:  The limited nature of the help, and balancing accepting help with taking advantage of the kindness of others.

Private Hire Caregiver:  There are many ways to find a caregiver.  It may be a neighbor or acquaintance who needs work, a referral from a friend, a cleaning person who is willing to expand their services, posting at a church or senior center, or an on-line service that matches caregivers with seniors, to list a few.  When hiring a caregiver, it is a good idea to have a family member or trusted family friend assist in the process.  The caregiver will probably want to see the home and if hoarding and/or cleanliness is an issue the caregiver may choose to not take the job.  Basic pet care can be a part of the job, but some caregivers have a fear or allergy with certain animals so information about pets in the home needs to be disclosed up front.  It is important to have a plan of care with specific duties for a caregiver, and an idea of other tasks which may come up.  Also, if the caregiver will be driving while on shift you will need to confirm there is a valid driver’s license and the appropriate insurance.  If a background check is important you may want to research that.  California has a caregiver registry that currently is not mandatory unless a caregiver works for a licensed agency, but it is optional for private caregivers.  Other states may have something similar and you can check online for information.

Caregivers have different levels of experience ranging from companion care (help with meals, shopping, transportation, light housecleaning and household chores, etc.) to skilled care (showering or bed bath, incontinence care, transfer assistance from wheelchair to bed or car, etc.), and many have some level of dementia care experience.  Some have worked professionally and some only with family.  The caregiver should have the ability to do the job or have a willingness to be trained, and he or she can grow in skills as the care needs change.  Personality is important as well since compatibility is a big consideration.  It is important to listen to and address the caregiver’s questions and concerns and be observant to their reactions to try to determine if this is a good fit.  A caregiver may be willing to take a job that is less than ideal while looking for another position that is more suitable, and to have to start the hiring and training process over again and get used to working with someone new can be very stressful.

Be aware that it can be difficult to find someone to help for less than a four-hour shift, but there may be someone who lives close by who is willing to stop in once or twice a day.  If so, it would be appropriate to pay at a higher rate and with a minimum of one hour or whatever is agreed upon for short shifts.  The longer and more regular the shifts, the easier it is to find and keep a caregiver.  However, if only part time help is needed, you can try to work it so the shifts are longer but less often if you cannot find someone willing to do more frequent short shifts.  Also, the more flexible you are with the shift times, the easier it is for someone to work around another client which may allow them to be more dependable.  Keep in mind that for a business arrangement to be successful it must work for both parties and that is a goal to strive for as compromise may be required on both sides.  It is common for people to request a short shift in the morning and a short shift in the evening, but caregivers cannot help everyone at the same time, and they need enough hours to cover the cost of their commute.  Being creative in the plan of care is important, and it may be helpful to take suggestions from experienced caregivers. Meals that your loved one can easily heat up at mealtime can be prepared ahead, and showers do not have to be in the morning or evening.

Finally, you should become familiar with labor laws in your state.  Currently, California has a Nanny Law that applies to caregivers as well as babysitters and other states may have similar laws.  Some caregivers want to work with a 1099 (tax status) as a self-employed contractor, but that may not be lawful.  Household employers may be required to follow labor laws unless your state provides an exemption for caregivers.  For example, in California, up until a few years ago you could pay a 12-hour or 24-hour rate for caregiving within certain guidelines that was exempt from minimum wage and overtime rate laws, but that is no longer the case.  Workers’ Compensation insurance is another issue that needs to be addressed. There are also guidelines for paying someone mileage for using their own car on the job.  You can research this online, or you can hire a payroll service and there are many options including online services. The more assets the household employer has, the more critical it is to have professional advice in these matters.  It is desirable that all parties are comfortable with the arrangements that are made since any fallout from an unwise decision or error can affect everyone.

Some pros to consider:  The lower cost, having control over the hiring process, setting the rules and boundaries, and the potential to create a long-term relationship with a caregiver.  Some cons to be aware of: Having to hire and supervise caregivers, managing employee issues including termination, potential liability and providing enough insurance to cover it, dealing with payroll and tax issues and hiring paperwork, difficulty covering shifts if the caregiver is not available, and the effort and length of time required to find or replace a caregiver.

Caregiving Agency:  An agency can be the easiest and quickest way to find a caregiver, but also the most expensive.  Sometimes people use an agency to fill in the gaps that cannot be filled with family and private caregivers.  Also, agencies often offer respite care, which simply means scheduling shifts on an as-needed basis.  Not all agencies are alike, and the differences can be huge.  It is wise to not assume that all agencies are licensed and are in full compliance with labor laws, and they should show you the appropriate documentation if requested. If the caregivers are not actual employees of the agency, that can create liability for the client.  When interviewing agencies, remember that you are not hiring a caregiver, you are entering into a contract with an agency for a caregiving service.  The caregivers are not your employees, they are the employees of the agency and the agency has the responsibility regarding compliance with laws and providing insurance.  Agencies have restrictions about clients hiring their caregivers privately and this will be covered in the contract. The larger agencies and franchises will most likely be licensed and follow all the laws, and if an agency quotes a price that seems too low, you may want to do a little research.  It costs money for the agency to comply with all laws, and a low quote may indicate they are not providing the protection they are selling.  Once you choose an agency to interview, you call and schedule an in-home assessment, preferably with a care manager and not a salesperson.  An assessment can be long, anywhere from an hour or even 3 or 4 hours, depending on how much there is to cover.  They may bring a caregiver to introduce to you but understand that there is no guarantee they will send a specific caregiver even if you request it, and they may change caregivers at various times or send substitutes.  You will want to discuss their policy regarding this, and make your needs known as you may not want a stranger showing up without warning to assist your parent with dementia.  It is important that you have a good working relationship with the case/care manager or whoever is handling your case to help you get the type of service you need. Feel free to interview multiple agencies.  Check out their shift cancellation policy and find out how easy it is to cancel service.  You should not have to continue with an agency that is giving you poor service. 

Some pros to consider: The caregiver is not your employee, the agency handles all personnel issues, starting care is usually faster and easier than with private hire, insurance and liability issues should be covered by the agency, and within reason a shift should be covered even if the regular caregiver is not available unless you request otherwise. Some cons to be aware of:  Potential for inconsistency in personnel sent on shifts, inability to choose a caregiver, and the price; this is the most expensive in-home care option.

Live-In Care:  Often this is the option that seems the most practical to people, but it can be the most difficult and risky.  The greatest difficulty can be finding a person who is currently without a permanent housing situation, single unless you are okay with a couple moving in, has plenty of available time to be home with your loved one, is experienced enough to do the job, and is trustworthy and compatible with your loved one.  If you can find such a person, you should not expect, for example, to receive $2,000 or more worth of caregiving in exchange for a room rental worth about $500 per month so a salary may be required as well.  We are all set in our ways, and it is difficult to set boundaries in these situations, and it is important to be aware that live-in care can lead to a very bad situation.  If a person is currently without a permanent living situation, they may agree to something they are not suited for and may not want to or be able to do.  This can place you in a position of having to ask someone to move out who may not have anywhere to go.  Worse, you may come across someone who preys on vulnerable individuals by design or opportunity.  Although we may have every intention to oversee the situation closely, the relationship with the caregiver, whether a stranger or a family member, can come between our loved one and anyone who is looking after them.  Also, the caregiver may seem to be suitable, until their close relative or friend or spouse comes to stay for a little while and never leaves.  As far as pros and cons: when it works out it can be a tremendous blessing to all parties, but always keep in mind that your loved one is vulnerable. 

Important:  When someone moves into a home as a tenant, either for rent or service in lieu of rent, if they are asked to move and they refuse, you may have to go through the eviction process.  You can research this online or contact your local sheriff’s department, but it must be done lawfully, and it can take three months before the sheriff’s department can remove them.  If you do decide to have live-in care, then you must be very careful who you invite to move in.  Hiring a caregiver or agency for 24/7 care is not the same thing as live-in care if they are not tenants but employees of you or the agency and have their own home to go to when not on the job.

In-Home Resources:  There are medical resources that are available in the home.  In-home hospice care is available to those who qualify which provides benefits such as medications, medical equipment and supplies, nurse visits, help with showering, and a limited number of hours of continuous care by a nurse or qualified caregiver in certain situations.  To qualify, usually a person should be within the last six months of life, but there are exceptions to this, specifically with Alzheimer’s and Parkinson’s patients.  If there is a steady decline a person may be on Hospice for many more months than the usual six months.  Also, if a patient improves, they can be taken off hospice and put back on as their condition changes.  If a person does not qualify for end-of-life care with hospice, then palliative care may be a good option.  There are not as many benefits available for palliative care but having the medical support in-home can be very helpful and comforting for the family and patient.  Another resource is to ask your doctor to prescribe in-home health care in the form of visiting nurses, bathing help, and physical therapy if the patient qualifies.  These resources are all covered under Medicare and most insurance to qualifying patients.  Researching these services even before they are needed can be helpful. 

Note:  Non-medical care such as with private hire and agency caregivers may be covered by long term care insurance, but it is not usually covered by Medicare or most medical plans.  Most people do not carry long term care insurance because it is very expensive.  For low income individuals who qualify, there may be caregiving benefits for veterans and their spouses and there are companies who can help qualify veterans for no charge.  There may also be financial assistance from government agencies, and you may want to contact a social worker to discuss any help that may be available to your loved one.

Learn all you can about the tools and resources available, and trust God to show you what to use and how to use it.  It is a worthy goal to keep a loved one as independent as possible for as long as possible, but dementia and health issues as well as financial concerns can preclude home care at some point.  God knows your heart and will bless your efforts.  Sacrificial love is our Savior’s business and there is no greater testimony than sacrificial love in action. 

Let nothing be done through selfish ambition or conceit, but in lowliness of mind let each esteem others better than himself.  Philippians 2:3

Review a related testimony - Our Journey Through Caregiving


About Eileen Jordan: Eileen has been in the caregiving field for fourteen years, both as caregiver and care manager


Share