What to Expect

As a team, home care workers can deliver most eldercare services that hospitals provide. Workers can be hired for complete caregiving needs, or they can provide respite (rest) for the person's spouse or other regular care provider. Most home care workers have the following job titles:

  • Health Care Aide
  • Registered Nurse
  • Companion or Homemaker

Physical therapists, social workers and other specialists make home visits too, as do charitable volunteers.

Home care has important benefits compared with alternatives. For example, compared with recuperating alone, receiving nurse-directed home care after hospitalization is associated with longer life and a lower risk of rehospitalization, according to a study in the Journal of the American Geriatrics Society. The same study found that because rehospitalization was less likely with home care, total medical bills for heart failure patients were about 35% lower.

Compared with moving to a nursing home or assisted living center, benefits of choosing in-home care tend to be:

  • Greater Convenience
  • Better Quality of Life
  • Lower Medical Bills

Examples of home care services include:

  • Monitoring heart rate and blood pressure
  • Caring for wounds from injury or surgery
  • Managing IVs and catheters
  • Providing physical and cognitive therapies
  • Educating patients and caregivers
  • Preparing meals and cleaning the home
  • Providing transportation
  • Providing companionship

Additionally some of the best home care agencies offer enrichment programs that are tailored to each customer or patient. For example, a senior's customized home care enrichment plan might include playing word games, painting, taking walks and attending church with her caregiver.

In This Article:
Who Gets Home Care? ↓
Costs of Home Care Services ↓
How to Pay for Home Care ↓
Hiring Home Care Workers ↓

Who Gets Home Care?

Home care helps a wide range of seniors and their families. People most commonly choose home care when they're ill or recovering from surgery, or when they simply need help with activities of daily living (ADLs) because of "normal aging."

  • Some seniors' caregiving needs are covered by professional homemakers, who provide companionship while also keeping house, helping with errands and preparing meals.
  • Other seniors need assistance from people with medical training, such as entry-level health aides or skilled nurses.

Memory care patients receive home care too. However, home care for dementia patients is usually respite care (support for the spouse or other regular caregiver). Memory care patients generally need 24-hour monitoring for safety, so home care costs can add up quickly.

Many home care agencies have four-hour minimum shifts. Still it's possible to get care for just an hour a day. Caregivers are also available for overnight stays.

Cost of Home Care Services

Home care costs for seniors range from $0 to about $40/hour. This range encompasses rates for most professional homemakers, health care aides, licensed practical nurses and registered nurses. Some healthcare professionals charge significantly more.

Factors influencing the amount charged for home care:

  • the local cost of living
  • the level of care required (skills needed)
  • the senior's financial assets
  • the senior's military status

Free respite care and meals are available in most communities thanks to government programs and non-profit groups. Three nationwide programs to learn about are:

  1. Lifespan Respite Care
  2. Meals on Wheels
  3. National Family Caregiver Support Program

Your state's Department on Aging can direct you to additional free and low-cost home care resources. When more than respite care is needed, seniors with financial need may get home care subsidies.

How to Pay for Home Care

Paying for home care might be easier than you expect. First, compared with 24-hour nursing home care, light to moderate in-home care is lower cost. Second, many payment strategies are possible with public and/or private funds.

Also keep in mind that the IRS lets taxpayers deduct certain medical expenses. Deductions depend on the total cost of medical care in relation to income.

Here we introduce common payment solutions. For the most up-to-date and personalized guidance, do work with a financial professional! Financial guidance is available for free through state Departments on Aging and various nonprofit groups.

Jump Ahead:
Private Pay ↓
Paid Family Leave ↓
Long-Term Care Insurance ↓
Medicare ↓
Medicaid & State Programs ↓
Veterans Administration ↓
Grants ↓

Private Pay

Many seniors pay privately for home care. They pay home care agencies or hire caregivers directly. The main advantage of privately paying for home care is freedom of choice in terms of:

  1. Who provides the care
  2. What services are available

Most taxpayer-funded programs give seniors less control over who provides their caregiving and what services are available. Private long-term care insurance companies have restrictions too.

Common funding sources for private payments are

Private Pay with Annuity Income

One strategy for stretching a nest egg is using savings to buy an annuity. When you buy a conservative annuity designed for retirement, you pay a lump sum to a financial institution, and they provide you with a predictable monthly income for life.

  • Immediate annuities may start paying in as little as 30 days.
  • Deferred annuities are meant for payoffs further into the future.

Advantages of retirement annuities are:

  • the security of a guaranteed income
  • the shielding of savings from Medicare/Medicaid consideration
  • cost-of-living protection (optional)

A possible disadvantage of putting cash into a deferred annuity is the penalty for accessing the funds early. Also, not all annuities provide guaranteed income! Some are vulnerable to market volatility and aren't intended as retirement security.

Paid Family Leave for Home Care

State laws for paid family leave let eligible workers receive part of their usual work income while caring for family. This financial benefit is sometimes called wage replacement. It's funded with employee-paid payroll taxes and managed through a state's employment disability office.

Three states and Washington, DC have family leave laws in effect in 2017:

The New York Paid Family Leave Benefits Law (PFLBL) will take effect incrementally starting on January 1, 2018. In 2017 members of Congress have proposed federal laws for paid family leave as well.

State family leave laws differ in terms of:

  • worker eligibility
  • maximum payment amounts
  • maximum time allowed away from work

The main advantage of choosing paid family leave is that a loved one provides caregiving. A disadvantage is that job security is not necessarily guaranteed.

Long Term Care Insurance

Long term care insurance pays for health care and personal care in different settings such as private homes, nursing homes and adult daycare centers. Most policyholders use their benefits to pay for home care. According to the American Association for Long-Term Care Insurance,

about 7.5 million Americans get in-home care but fewer than two million Americans are in nursing homes.

The definition of "long term" varies from policy to policy: The maximum length of time for receiving benefits could be capped at two years or five years, but it could be unlimited. Long term care insurance policies also differ in term of maximum payout per day. A low-cost plan might pay about $100/day. A pricier plan could pay $250 or more.

Long Term Care Insurance Tips:

  • Financial planners recommend buying long term care insurance long before it's likely to be needed. Insurance costs more when an individual is already in need of care. Plus, the younger you are when buying a policy, the lower your premiums.
  • Before choosing an insurance provider, research their yearly rate changes. If rates have jumped, you have reason to be cautious.
  • Including inflation protection on your insurance policy can help ensure that your benefits align with the cost of living.

Medicare

For short time periods Medicare may cover up to 100% of home medical care costs for seniors with low income. Medicare will also pay for in-home assistance with activities of daily living (ADLs) such as bathing and dressing -- but only if skilled nursing or therapy is also needed following a hospital stay.

Overall the Medicare eligibility requirements are:

  • Initially needing hospitalization for three nights or more
  • Being homebound (either in a wheelchair, or having great difficulty leaving home) after discharge from the hospital
  • Requiring skilled nursing or skilled therapy as prescribed by a doctor
  • Having a doctor's plan for care that includes a projected end point (an estimate of when recovery/rehab services will no longer be required)

When seniors are ineligible for standard Medicare, they might still get in-home assistance with ADLs via a Medicare-Medicaid partnership called Program of All-Inclusive Care for the Elderly (PACE).

Medicaid & State Programs

Medicaid benefits differ from state to state. Some state Medicaid programs pay for home care. Others deny home care coverage but pay for nursing home care, which costs twice as much! Someday federal law might make Medicaid home care coverage mandatory… but for now you'll need to get state-specific Medicaid benefits info.

States have different ways of providing Medicaid funds for home care. Most common is using an "HCBS Waiver" or Medicaid Home and Community Based Services Waiver.

Additionally many states have non-Medicaid assistance programs. Some are specifically for people with low income. Others are tailored for memory care. You can learn more about non-Medicaid senior care options from your regional Agency on Aging.

Veterans Benefits

The Veterans Administration or VA offers a variety of subsidized home care services for veterans and their families.

Families in most parts of the US can also take advantage of VA respite care for up to 30 days a year. For VA home care a "day" is a maximum of six hours. In rare cases the care maximums may be extended. The cost is covered partially or completely by the veteran's basic Medical Benefits Package.

When more care is needed, impressive flexibility comes with the VA's Veterans Directed Home and Community Based Services (VD-HCBS). This program lets veterans who are candidates for nursing homes instead hire home care. Veterans receive VA funds to essentially become employers; they can interview, hire and fire their home care workers.

Another home care payment option for veterans and their surviving spouses is an increase in their Aid and Attendance pension. For eligibility a person needs to be homebound or require significant assistance with personal or medical care. A related Housebound VA pension increase is for vets who are housebound with a permanent disability. You can apply for Aid and Attendance or Housebound pension increases at your regional  VA benefit office or by writing to your state's Pension Management Center (PMC) for an application.

Grants

Grants from nonprofit groups can help pay for in-home care. Often these grants are disease-specific. For instance, they might focus on home care for patients with diabetes. Best known are the respite care grants offered for families managing Alzheimer's or other dementia.

You can learn about respite for Alzheimer's caregivers by contacting the Alzheimer's fundraiser Hilarity for Charity, the Alzheimer's Association or the Alzheimer's Foundation of America.

Hiring Home Care Workers

To set up home care for an older adult, you can work with an agency or hire caregivers directly. Here we describe different kinds of home care agencies and suggest questions to ask when meeting with an agency director or interviewing home care workers.

In This Section:
Types of Home Care Agencies ↓
Questions to Ask Home Care Agencies ↓
Questions to Ask Home Care Workers ↓

Types of Home Care Agencies

Home care agencies in the US fall into four main categories. Comparing the categories, you'll see they vary in terms of licensing, services and accepted payments.

Categories:
  1. Medicare Certified Home Health Agencies
  2. State Licensed Home Health Agencies
  3. Non-Medical Care Agencies
  4. Home Care Employment Agencies

Medicare Certified Home Health Agencies (CHHAs)

Medicare is the USA's federal health insurance program for adults 65 and older. It also insures younger adults with kidney disease and children with disabilities. When Medicare patients receive home care, Medicare will only pay if a Certified Home Health Agency (CHHA) provides the services. Agencies eligible for certification provide skilled nursing and at least one therapy.

Each Medicare Certified Home Health Agency directly employs skilled nurses. (Direct employment means that the work isn't subcontracted.) Additionally each CHHA directly offers at least one of the following services and may subcontract others:

  • home health aide services
  • medical social services
  • occupational therapy
  • physical therapy
  • speech therapy

Some CHHAs offer personal care support that's subsidized by Medicare or Medicaid.

A complete list of Medicare Certified Home Health Agencies is posted at data.medicare.gov.

State Licensed Home Care Agencies

While the federal government certifies home health care agencies for Medicare, many state governments set agency licensing standards to help protect consumers. When states do not issue special licenses, the agencies only need standard business licenses for legal operation.

States that license their home care agencies may have more than one type of license available. The biggest distinction is whether a license approves medical care or non-medical care. Many home care agencies hold multiple licenses in order to offer a wide range of home care services.

Because each state sets its own standards, the laws governing home care agencies are quite different from place to place. Some states have rigorous licensing standards for home care agencies. Successful applicants provide:

  • Business plans and names of investors
  • Copies of criminal background checks for all intended workers
  • Proof of liability insurance and property damage insurance
  • Other evidence of readiness to effectively serve the community

States may also stipulate that licensed home care agencies have two administrators rather than one, and they may require than an RN be available 24/7. States also have the leeway to require that administrators have specific experience in healthcare management.

Some states have easy-to-meet licensing standards. It's important to know that states sometimes grant licenses based solely on paper applications. This lets new agencies run for several months or longer before the facilities are actually inspected by the government.

A minority of states lack industry-specific licenses. At last check the list included:

  • Alabama
  • Iowa
  • Massachusetts
  • Michigan
  • South Dakota
  • Vermont
  • West Virginia

Home health agencies in the above states can legally operate with the same licensing required of any standard business or employment agency.

Whatever your state's licensing standards might be, knowing the best practices can help you choose wisely. For instance, if you live in a state without licensing for home care agencies, then specifically look for a center that conducts full criminal background checks on all its employees. With the following links you can see laws and license applications to get a sense of what state governments have deemed important.

Alaska Kentucky North Dakota
Arizona Louisiana Oklahoma
Arkansas Maine Oregon
California Maryland Pennsylvania
Colorado Minnesota Rhode Island
Connecticut Mississippi South Carolina
Delaware Missouri South Dakota
District of Columbia Montana Tennessee
Florida Nebraska Texas
Georgia Nevada Utah
Hawaii New Hampshire Virginia
Idaho New Jersey Washington
Illinois New Mexico Wisconsin
Indiana New York Wyoming
Kansas North Carolina  

Non-Medical Home Care Agencies (Companion Agencies)

Non-medical care agencies, or companion agencies for eldercare, are not subject to federal or state licensing. Workers are paid to provide friendly companionship and help their clients accomplish chores and errands. These services are not covered by public or private insurance.

Employees' qualifications are extremely varied. For safety's sake, work with agencies that show proof of up-to-date criminal background checks. Also check an agency's reputation with the Better Business Bureau.

Home Care Employment Agencies

Home care employment agencies give referrals to people seeking home care nurses and health aides. Clients may contact, hire and pay caregivers directly.

When you directly hire home care workers, the advantage of working with a reputable home care employment agency is that they've screened each person in their database. Additionally home care employment agencies may provide worker training and occasional on-the-job supervision.

Questions to Ask Home Care Agencies

Ideally a home care agency becomes a family's trusted partner for senior care. When you meet with the administrator, getting answers to the following questions can help you avoid choosing a mismatch or substandard care.

  1. What is the administrator's background? Ask the question in a friendly getting-to-know-you manner. All sorts of people direct home care agencies, and some are more qualified than others! A director's duties are important and diverse: setting the agency's policies, managing the employees, negotiating with insurance companies, ensuring compliance with healthcare laws, and more. Many states require that two people serve as an agency's administrators.
  2. The most appropriate educational background for a home care agency leader is in healthcare administration or public health. Typically an administrator has a master's degree, but competence for the role is certainly possible with a bachelor's degree plus work experience. Longtime healthcare professionals such as RNs and psychologists also move into administrative positions.

    The best home care agencies are led by people with relevant training and a genuine commitment to human well-being. If you get the sense that money is the manager's main motivator, then it's time to wiggle out of the interview.

  3. Is the agency Medicare certified? To receive Medicare coverage for home care, a patient needs to work with a Medicare Certified Home Health Agency (CHHA).
  4. Is the agency licensed by the state? Not all states have industry-specific licenses for home care agencies. If your state has the option, choose a state licensed home care agency for assurance that state standards are met.
  5. Does the agency carry insurance? Choose an agency that has its caregivers bonded and insured. A well-run agency also has professional liability insurance and general liability insurance.
  6. What services are available? Home care agencies may provide medical services, non-medical services or both. Confirm that the desired services are available. For example, not every state-licensed center has an RN on call 24/7. Some but not all have caregivers trained in speech therapy, physical therapy, Alzheimer's therapy or memory care, and other healthcare specialties.
  7. How are the caregivers trained? The best home care agencies have extensive orientations for caregivers and provide continuing education. One essential part of caregiving is effectively handling emergencies, so be sure to ask if emergency training is included in employee orientation. (Are employees trained in fire safety? Do they know the Heimlich maneuver and CPR?) Continuing education lets caregivers build their healthcare skill sets and stay up-to-date with best practices in home care.
  8. How thorough are the agency's background checks? Effectively vetting a potential employee involves talking with their previous employer and other references. It also involves getting a full criminal background check to be aware of any felonies, misdemeanors and driving violations.
  9. How many caregivers are assigned to each client? The best home care agencies assign more than one caregiver to each client. Because two or three people become regular visitors, a worker familiar to the senior is available even if one person takes time off or leaves the agency.
  10. If the senior is unhappy with a caregiver, can another worker take the shift? You might also ask the director to explain their procedure for matching clients with caregivers.
  11. How are caregivers managed? When caregivers are treated well, their patients can benefit. Before hiring a home care agency, observe how the management interacts with staff. Ask the director how the agency motivates its workers and recognizes great work.

Also ask about employee supervision and evaluation. Directors should occasionally observe their employees in the field -- preferably unannounced to help ensure quality control.

Questions to Ask Home Care Workers

The following tips and interview questions may be helpful as you hire home care workers.

Before You Interview…

First things first! Protect your family's assets. Before letting people into the senior's home, verify that the space is insured against accidents. Renter's insurance and homeowners insurance can cover expenses in case of accidents that injure household employees.

Next, clarify your needs before interviewing caregivers. Here are three steps.

  1. List the specific areas in which help is needed. Some possibilities:
    • Personal Care: bathing, dressing, eating, dressing, using the toilet, lifting out of bed
    • Homemaking: preparing meals, cleaning, washing laundry, buying groceries
    • Medical Care: managing medication, intravenous treatments, dialysis, physician's appointments, physical therapy
    • Emotional Care: companionship, conversation, enriching activities
  2. Calculate how many hours of care are needed daily or weekly. How long is each visit? What are the best time windows?
  3. Decide how much you will pay per hour. Also list any special benefits of the job.
    • For help determining your pay rate, research the wages offered by local home care agencies.
    • Also put yourself in a worker's shoes… because paying the local norm isn't necessarily fair to the employee, which doesn't serve your loved one's best interest.

Living on market rates can be especially stressful for entry-level home care workers. If the market rate is just $10 in your town, then a full-time worker would take home just $1600/month before taxes. Their annual income would be so low, they'd qualify for federal assistance.

If home care workers sense that they're "living on the edge," they can't keep up a high level of care for long! When setting a rate, put yourself in the worker's shoes.

Employment benefits can make your job offer more attractive. Home health care agencies typically offer health care and other benefits to their employees. A few examples of benefits you might offer:

  • Meals
  • Paid vacation days
  • Paid sick days
  • Dental insurance
  • Health insurance
  • Travel opportunities
  • Tuition for healthcare education

Figure out how you'll make payments and comply with the law. When you hire home health workers directly, you need to report the expense to the Internal Revenue Service. Reporting the work may bring tax deductions, plus it gives social security benefits to the employee. For details you can see the IRS publications "Hiring Household Employees" and "Independent Contractor (Self-Employed) or Employee?"

Finally, start writing a job contract to protect yourself and your employees. A sample home health care contract is posted at RocketLawyer.com. It's wise to first have a trial agreement, e.g., for 30 days.

Preliminary Interview by Phone

Before meeting a job applicant in person, interview him or her by phone. This can be a great timesaver. Covering the following topics might rule out an applicant.

  • Work hours
  • Relevant training and work experience
  • Access to transportation
  • Why the person is interested in the job

If the phone interview is to your liking, then arrange to meet in person.

  • Agree to meet in a public place unless you already trust the individual based on a friend's recommendation.
  • Ask the applicant to bring a photo ID, their job history or resume, and contacts for references.

Full Interview in Person

Below are ten interview questions for home health care workers. Remember that the main tasks of your interview are:

  • Presenting your needs
  • Explaining the compensation  
  • Deciding whether the applicant is a good match for your family

If possible, have the senior participate in the interview.

  1. Why are you working in home eldercare?
  2. What is your work experience as an in-home caregiver?
  3. What do you like about home care?
  4. What are the greatest challenges of home care work?
  5. Why did you leave your previous job?
  6. Are you insured to provide in-home care?
  7. Can you provide documentation of your health status including immunizations?
  8. Can you provide documentation of your relevant training?
  9. Are you certified in CPR or willing to become certified?
  10. How do you prefer to receive feedback? Would you be comfortable with a weekly or monthly check-in about progress and any problems?

After the Home Care Interview...

Following a positive interview, here are steps you can take to help ensure an effective home care agreement.

  1. Call the job applicant's references. Previous employers and other references might confirm your impressions of the individual, or they might share "red flags" that you missed. When you speak with other employers, ask about the worker's punctuality and work quality. Ask why the person no longer holds that job position.
  2. Pay for a criminal background check. Ask your local police station for guidance to get an accurate report. Many companies offer background checks via smartphone apps or the web, but their reports can be misleading.
  3. Make the job offer. If the candidate accepts, then put your agreement in writing. Include mention of a trial period before the job position is considered permanent. A contract for home care should also include:
    • Job duties
    • Wages
    • Payment schedule and method
    • Start date
    • Time off and other benefits
    • Termination policy

    When setting up employment, schedule a regular time to meet with the employee to concerns about the job duties or the senior's status.

Consider hiring a backup worker. You are hiring a human, not a superhuman! Be prepared to cover home care without stressing in case the employee falls ill or otherwise needs to skip a visit.

Check in during home care. When the work arrangement is new, spend time at the senior's home to familiarize the caregiver with the senior's needs. Periodically drop by unannounced during a shift to ensure that all is well.