En español | Family caregivers cannot do all things all the time. Recognizing when you need outside help is good for you, and for your loved one, too.
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.
A shift in long-term care from institutional settings like nursing facilities to people aging in place in their own homes and communities has fueled the growth, PHI says. The change is likely to continue as the population ages. The U.S. Census Bureau projects that the 65-and-older population will grow from 56 million in 2020 to 85.7 million in 2050.
Types of home care workers
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 (PCAs) 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 PCA 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 (HHAs) monitor the patient's condition, check vital signs and assist with activities of daily living, including bathing, dressing and using the bathroom. These aides also provide companionship, do light housekeeping and prepare meals.
HHAs 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 (LNAs) and certified nursing assistants (CNAs) 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.
They 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 LPNs 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 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.
They 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.
Who provides home care?
Nearly 2.3 million people provide paid, in-home care for older and disabled Americans, according to PHI, a nonprofit that works to improve job quality in the field. Who makes up that growing workforce?
- 87 percent of home care workers are women
- 62 percent are people of color
- 52 percent are 45 or older
- 30 percent are foreign born
Source: U.S. Home Care Workers: Key Facts 2019, PHI
Steps to hiring a paid caregiver
Assessing the need
Determine the level of assistance required. With your loved one, write down their needs and limitations, likes and dislikes, expectations and doctor recommendations.
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.
Choosing your search method
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?
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 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.
Once you have a list of promising agencies, arrange a consultation. AARP has a checklist of important questions to ask before signing a home health contract.
Working with an agency has pros and cons. The pluses 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.
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.
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.
Here are options for personalizing your search for in-home care.
- Ask friends and neighbors who have employed caregivers for recommendations, names, phone numbers and hourly rates of those they found to be outstanding. Get specifics, as your neighbor's priorities may not be yours.
- Consult the community. Look for recommendations or post a note about what you need on a private neighborhood social network such as Nextdoor. You might also make inquiries at local houses of worship and senior centers, or with employees and patrons at a gym or yoga studio you use.
- Contact your Area Agency on Aging and ask for recommendations. Use the federal government's Eldercare Locator to find your local agency, or call 800-677-1116.
Editor's note: This article, originally created in 2018, has been updated with more recent information.