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Caregivers, Caregiving and Home Care Workers
As a caregiver, you are one of 12 million Americans who spend
all or part of their day assisting 5 million family members or
friends who need help to remain at home.
Many caregivers have multiple responsibilities. The great majority
of caregivers are women (75 percent)--a quarter of whom care for
both older parents and children. Half of all caregivers also work
outside the home. It is no wonder then that caregivers-whether
they are full or part-time-need respite and support. Otherwise
the demands and constraints of caregiving can become overwhelming.
Many working caregivers find that the demands of their job and
caregiving responsibilities conflict. When this happens it is
important to discuss your needs with your supervisor. Flex time,
job sharing or rearranging your schedule may help to minimize
your stress. Increasingly, companies are also offering resource
materials, counseling, and training programs to help caregivers.
You can also encourage your older children to become involved
in the care of your family member. Such responsibility, provided
it is not overburdensome, can help young people to become more
empathetic, responsible and self-confident and give you needed
Do not hesitate to ask other family members to share in the responsibility
of caregiving as well. Your siblings, if they live nearby, have
just as much reason as you to assist their aging parent. If you
are a caregiving spouse with siblings and/or adult children make
your needs known to them. A family conference can often help in
sorting out the tasks and schedules that other family members
are able to assume. And don't forget neighbors and friends who
may be willing to provide transportation, respite care, and help
with shopping, household chores and repair tasks.
The help provided by you, other family members, friends and neighbors
may still not be enough to enable an older person to remain independent.
In this case you will need to look for other avenues of support.
One of the first places you should contact is to your Area Agency
on Aging (AAA). If your family member has a limited income, he
or she may be eligible for services provided through the AAA including
homemaker home health aide services, transportation, home-delivered
meals, chore and home repair as well as legal assistance.
Area Agencies on Aging can direct you to other sources of help
for older persons with limited incomes such as subsidized housing,
food stamps, Supplemental Security Income, Medicaid or the Qualified
Medicare Beneficiary program which covers the cost of the Part
A and B insurance premiums for low-income elderly.
While your Area Agency on Aging may not be able to provide supportive
in-home services for older people who have higher incomes, your
AAA can provide a registry of home care workers that you can hire
directly. Your Area Agency also has information on home care agencies
and volunteer groups that provide transportation, chore, respite,
yard work and home repair services. In addition to these information
and referral services, many AAA's will also provide an assessment
of the older person's needs.
AAA's can also direct you to senior center programs which are
suitable for older persons who have minor problems with mobility
and activities of daily living and to adult day care programs
which serve older persons with serious limitations with mobility,
dementia, or medical conditions which require daily attention.
In addition to your Area Agency on Aging, good sources for referrals
to individual home care workers and home care agencies include
the Hospital or Nursing Home Discharge Planner or Social Worker,
if your older relative has been hospitalized.
If you decide to hire a home care worker, you will need to determine
how much help your older relative needs. Will several hours a
day be enough, does he or she need help all day until the family
returns home, or does your relative live alone and need round
the clock care? You also need to decide what type of home care
worker your relative needs. Following are descriptions of the
types of home care personnel available:
- A Housekeeper or Chore Worker is supervised by the person
hiring them and performs basic household tasks and light cleaning.
- A Homemaker or Personal Care Worker is supervised by an agency
or you and provides personal care, meal planning and household
management and medication reminders.
- A Companion or Live-In is supervised by an agency or you and
provides personal care, light housework, exercise, companionship,
and medication reminders.
- A Home Health Aide, Certified Nurse Assistant, or Nurses Aide
is supervised by an agency's registered nurse and provides personal
care, help with transfers, walking, and exercise; household services
that are essential to health care; assistance with medications,
and reports changes in the patient's condition to the RN or Therapist;
and completes appropriate records 9
Nonprofit and for profit home care agencies recruit, train, and
pay the worker. You pay the agency. Social Service agencies, in
addition to home care services, may provide an assessment of the
client's needs by a nurse or social worker, and help with the
adjustment or coordination of the care plan.
Home Health Care Agencies focus on the medical aspects of care
and provide trained health care personnel, such as nurses and
physical therapists. Their services may be paid for by Medicare,
if they are ordered by a physician.
When calling an agency be sure to ask:
- What type of employee screening is done?
- Is the employee paid by the agency or the employer?
- Who supervises the worker?
- What types of general and specialized training have the workers
- Whom do you call if the worker does not come?
- What are the fees and what do they cover?*
- Is there a sliding fee scale?
- What are the minimum and maximum hours of service?*
- Are there service limitations in terms of tasks performed
or times of the day when services are furnished?*
Questions starred with an asterisk should also be asked if you
are hiring the person directly.
Unless your older relative needs care for a limited number of
hours each day, the rates charged by private home care agencies
for homemaker home health aide services and van services for transportation
are often beyond the means of middle income families. There are
ways to obtain competent help at lower rates, however.
If an older person is discharged from a hospital and receives
skilled health care services at home, such as nursing or physical
therapy, they are usually eligible for homemaker-home health aide
services from home care agencies paid for under Medicare. When
Medicare coverage ends, it is often possible to hire these same
aides privately for a half to two-thirds of the cost charged by
the home care agency.
Other avenues for finding aides who charge lower fees include
churches, senior employment services, and agencies that assist
displaced homemakers and others entering the employment market.
If you advertize in the papers for help, screen the applicants
carefully. Ask for identification and check their references.
Regardless of who cares for your elderly relative, protect their
private papers and valuables, make arrangements to pick up the
mail yourself, and check the phone bill for unauthorized calls.
Stealing and fraud are on the rise among caregivers for the elderly
so it is best to "play it safe."
When hiring the worker yourself, be sure that the home care worker
has the necessary qualifications and/or training. Ask to see training
certificates, particularly if the older person has special medical
needs such as insulin injections. If the older person needs to
be transferred from a wheelchair make certain that the aide knows
how to do this safely. If the prospective aide does not know how
to bathe a person in bed or transfer, but seems to be otherwise
qualified, they can be trained in these and other necessary procedures.
If your older relative needs a considerable amount of help or
round the clock care, consider hiring live-in help. In exchange
for room and board, these home care aides will usually work for
a salary that is far lower than that charged by aides who come
in for a few hours, or during the day.
Check with your insurance company about coverage for a full-time
home care worker, and contact the appropriate agencies concerning
social security taxes, unemployment insurance, and workmens compensation.
If you do not want to deal with these somewhat complicated withholdings
from the employee's salary, accountants and companies that specialize
in doing payrolls will issue the employee's check with the necessary
If public transportation is not available and the older person
is not eligible for free or low cost transportation, try to hire
someone who drives, since this can save you substantial amounts
of money in taxi or commercial van ride fares. If the home care
worker is going to drive the family car, be sure to check with
your insurance company concerning any limitations on your policy.
Your interview with the prospective home care worker should include
a full discussion of the client's needs and limitations; as well
as the home care worker's experience in caregiving and her expectations.
Also ask for the names, addresses, and phone numbers of people
who have previously employed the home care worker and be certain
to contact them.
Once you have hired a home care worker, make sure that the lines
of communication are fully open and that both you and the worker
have a clear understanding of your responsibilities to the older
person and to each other. Explain what you want done and how you
would like it done, keeping in mind that the home care worker
is there to care for the older person and not the rest of the
family. If the home care worker lives in, try to ensure that he
or she has living quarters that give you, the older person and
the worker the maximum amount of privacy possible. Be clear about
the worker's salary, when he or she will be paid, and about reimbursement
for money the worker may spend out of pocket for gas, groceries
etc. If the home care worker has a car, discuss use of the worker's
car on the job, insurance coverage for the worker's car or other
Be certain to discuss the subject of vacations, holidays, absences
and lateness as well as the amount of time each of you should
give if the employment is terminated. If you work and are heavily
dependent on the home care worker, emphasize the importance of
being informed as soon as possible so that you can make alternative
arrangements, if the home care worker is going to be late or absent.
You should have a list of home care agencies, neighbors, or family
members who can step in should the home care worker be late or
absent from work.
Finally, inform the worker about the older person's dietary restrictions,
provide a list of contacts in case of an emergency, review security
precautions and keys, and discuss the medication requirements
of the older person.
Once the home care worker is on the job, periodic and/or ad hoc
meetings can be held to discuss any problems the home care worker
or the older person may have with the arrangement and to find
ways to resolve them. Be positive and open in your approach to
resolving difficulties. In most cases, they can be corrected.
However, if, after repeated attempts, you find that major problems
are not resolved satisfactorily it may be best to terminate the
relationship, and seek another home care worker. During this time,
it may be necessary for your older relative to temporarily reside
in a long-term care facility or for you to hire a worker through
an agency, so it is best to have reserve funds on hand should
such an emergency arise.
Another possible avenue of temporary help is respite care. As
applied to home care, respite refers to care that provides a needed
break for the primary caregiver, ranging from a few hours to days
or weeks. Respite care services can be arranged through your Area
Agency on Aging. The service offers assistance with meal preparation,
dressing, grooming, feeding and light housekeeping, and may include
some personal care. A four-hour session is usually the minimum,
with an 80 hour annual maximum.
While home care may not necessarily be less expensive than nursing
home care or assisted living, it offers older people and their
families the opportunity to remain at home and together. What
is more, it affords a degree of flexibility and choice for the
at-risk elderly that few other living arrangements can offer.
Information provided by NIH.