Ultimate Guide to Senior & Personal Home Care Services

What is In-Home Care?

In-home care services can provide companionship, supervision and assistance with personal care in the comfort and convenience of a person’s own home–making it possible for them to live at home rather than move into a facility.

Care in the home may include some combination of skilled health care services and non-medical or assisted living services, but there is a distinction to be made: the term “home health care” is understood to mean licensed nursing care, while “in-home care” or “home care” refers to non-medical care, personal care, custodial care or domiciliary care. These differences are important because they help determine the appropriate level of care provided, which in turn will determine the actual cost of care and also the funding sources available to pay for care.

In-home care from a professional agency is appropriate whenever an individual prefers to stay at home, but needs ongoing care that cannot easily or effectively be provided solely by family and friends. As their physical and cognitive abilities diminish, a growing number of elderly are electing to keep living independent, non-institutionalized lives by receiving in-home care services. Most elderly seniors want to age independently at home while not burdening their families. Professional in-home care makes that possible. Families, meanwhile, are provided with peace of mind and assurance that their loved ones are well-cared for and comfortable in their own home.

What Is Non-Medical Home Care?

In-home, non-medical care services include supervision and help with personal care (see Activities of Daily Living, or ADLs, below), as well as help in the home with tasks such as meal preparation, medication reminders, laundry, light housekeeping, errands, shopping, transportation, and companionship. While there are differences in the terms describing aspects of in-home care or home health care, in reality, most elderly individuals needing one type of care, will eventually need both.

What is the Difference Between Skilled Home Health Care and Non-Medical Home Care?

The most familiar provider of medical home care services is the skilled home health agency. The main purpose of this type of agency is to provide skilled, professional care for medical treatment or rehabilitation services to homebound patients. Home health care professionals must strictly adhere to a physician-approved plan of care

Services provided generally include medical and/or psychological services, wound care, pain and medication management, disease management, nursing care services, oxygen services, medical supplies and equipment, physical therapy, speech therapy, occupational therapy and home health aide care.

The same agency may deliver different kinds of home care services through registered nurses, therapists, social workers, home care aides, medical equipment and supply dealers, and volunteers. Some agencies limit their services to nursing and one or two other specialties. If care is needed from more than one specialist, the home health agency will set up a team to provide care that covers the patient’s needs. Because home health agencies hire and supervise their personnel, they assume liability for their services.

Skilled home healthcare services generally are available 24 hours a day, 7 days a week. The home health agency is state-licensed and usually Medicare and Medicaid (Med-Cal in California) certified and may also accept other third party health insurances. Medicare certification means that the agency has met specific federal guidelines and criteria.

Many are also accredited by independent third-party review organizations such as JCAHCO, CHAPS or HHC. Services are generally paid for by Medicare, Medicaid, and private health insurance and patients must meet strict criteria for participation and payment authorization. However, some medical agencies also offer their medical home care services on a private duty or private pay basis. There are approximately 14,500 licensed home health agencies operating nationwide.

While the main focus of these agencies is medical care, some also offer a dedicated non-medical, in-home care service. Individuals often have ongoing personal care needs even though skilled home health care services are no longer required. With this home care component, the same agency can continue to provide personal and custodial care to their patients, but it will usually be on a private pay basis.

What are Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) and Why are they Important?

Activities of Daily Living (ADLs) refer to six specific tasks of basic self-care:

  • Personal hygiene including bathing, grooming, nail care, and oral care.
  • Dressing: choosing appropriate clothing and being able to physically dress and undress oneself.
  • Transferring i.e. being able to move from one body position or location to another.
  • Toileting: the ability to get on and off the toilet and cleaning oneself
  • Eating, meaning the ability to feed oneself.
  • Ambulating: walking or otherwise being able to get around independently (for example with a wheelchair).

Instrumental Activities of Daily Living (IADLs) are more advanced activities related to independent living:

  • Managing personal finances
  • Transportation, either by driving or by organizing other means of transport.
  • Shopping for food, clothing, and other necessities.
  • Meal preparation including cooking and safely using kitchen equipment and utensils.
  • Housework and home maintenance required to keep a tidy and hygienic place of residence.
  • Managing communication, such as the telephone and mail.
  • Taking medications in accurate doses and at appropriate times.

The number and severity of a person’s ADL and IADL needs are used to determine the level of assistance required, as well as to determine eligibility for long-term care insurance benefits. Long-term care insurance policies require justification and documentation that the insured individual needs help with at least two (sometimes three) ADLs in order for the benefit to be effective. The new Medicare benefit for non-medical care available only through Medicare Advantage Plans beginning in 2019 will most likely also require the same.

When is Home Care Needed?

Home care is especially useful in the following scenarios:

Support for daily activities

When an individual needs assistance with ADLs and IADLs. Also when general supervision is needed for persons with dementia or other cognitive deficiencies.

Respite care

When regular in-home care is provided by family and close friends, respite care through a professional agency is a convenient and safe option for giving them a break from the emotional and physical demands of daily caregiving.

After a serious medical episode

Some medical episodes–falls resulting in a broken hip or femur, joint replacements, strokes, etc.–can result in prolonged recoveries, especially among the elderly. Hospital discharge planners and social service personnel are required to ensure that patients have adequate care at home before they can be discharged. Because hospitals are financially penalized if patients are readmitted within 30 days of discharge, they have a strong incentive to ensure that their patients are properly cared for at home. In the past, hospitals focused primarily on the clinical, medical care the patient needed in the home. Today, hospitals and insurers are increasingly focusing on the non-medical services that caregivers can provide. They want to ensure that their patients follow doctors’ orders, take their prescriptions, comply with diet restrictions, follow specific therapy regimens, and avoid falls or other accidents at home.

Short term disability or illness

Including situations such as a difficult pregnancy, or after a complicated childbirth.

For chronic conditions or illnesses such as:

    • Cancer
    • Alzheimerʼs & dementia
    • Parkinsonʼs
    • Chronic obstructive pulmonary disease (COPD)
    • Heart disease
    • Diabetes
    • Multiple sclerosis
    • Osteoporosis

Most elderly, especially the frail elderly, will have co-morbidity diagnoses, meaning they will be diagnosed with two or more serious health conditions. It would be quite common, for example, for an 85 year-old woman who suffered a stroke to also have diabetes, osteoporosis and dementia. She would most likely have multiple prescription medications and have been given important dietary restrictions–often ordered by different doctors. After her 3-5 day stay in the hospital for her stroke, she would go to a short-term rehab facility for 10 days before being discharged home. Without constant, capable care and assistance at home, there is a high degree of probability that she could sustain a serious fall, sending her back to the hospital for a broken hip or femur–where she could in turn catch pneumonia or another infection, worsening her chances of full recovery. Hospital discharge planners, case managers, and professional geriatric social workers face the reality of this scenario constantly. The need for in-home caregivers, especially those experienced in condition specific co-morbidity care for the frail elderly, has never been higher.

Does Someone in my Family Need Home Care?

Fearful of losing their independence, aging individuals will often mask or cover-up the signs and symptoms indicating they might need assistance. Younger adults and children with disabilities or who are recuperating from acute illness may also benefit from in-home care.

Knowing the ADLs and IADLs and looking for patterns of behavior and neglect within those areas can help pinpoint whether a loved one needs in-home care. The IADLs are usually the earliest to suffer, so look for difficulties with those first:

  • Unpaid bills, irresponsible spending, susceptibility to scams.
  • Inability to drive safely or to access other means of transportation.
  • Low supplies of fresh food and other necessities; spoiled food in the fridge; evidence that only canned food is being consumed.
  • Messes left untidied, laundry piled up, home care and maintenance neglected.
  • Telephone calls unanswered, mail unopened.
  • Unfilled prescriptions; medications not being taken as directed.

Next look for evidence of trouble with ADLs:

  • Infrequent bathing, unusually sloppy appearance, bad body or mouth odor.
  • Inappropriate clothing choices or not being able to physically dress and undress oneself.
  • Difficulty standing up, sitting down, or getting in and out of bed.
  • Incontinence or difficulty cleaning oneself after using the toilet.
  • Weight loss, appetite changes, difficulty swallowing, dehydration.
  • Inability to walk or otherwise be able to get around independently.

In addition, look for the following warning signs:

  • Burns or bruises.
  • Hearing loss.
  • Spilling or dropping things.
  • Fatigue; sleeping too much or too little.
  • Isolation; lack of interest in friendships, hobbies, or activities; curtains drawn day and night.
  • Change in attitude; sadness or feelings of depression and despair; abuse of alcohol or drugs; paranoia; refusal to communicate or unusual argumentativeness; verbal abuse.
  • Diminished cognitive abilities; forgetfulness about where things are, getting lost walking or driving, confusion, loss of reasoning skills, difficulty answering questions, inability to find the right word or complete a sentence, repetitive words or phrases, wandering, loss of sense of time or season, forgetting how to use ordinary things, consistently forgetting to turn off the stove, close windows, or lock doors.

With the advent of professional in-home care agencies, families can easily help their elderly or disabled loved ones to stay in the comfort and security of their own homes, while still receiving the care and assistance they need to be safe.

How do I Find a Professional Caregiver or Home Care Agency?

Traditionally, much of the care in the home was provided by families and friends or by independent or freelance caregivers, even though there are significant labor and liability risks associated with directly hiring a caregiver. That course is changing due to the emergence of widely available, capable and affordable in-home care agencies.

Many people looking to hire professional care for a loved one will ask a relative or trusted friend, advisor or clergy if they know of any caregiving services and options. Some families would rather hire a caregiver privately. There may be some potential cost savings in going this route, but if you are considering this, you must be aware of the additional responsibilities and liabilities involved.

If You Decide to Hire a Caregiver Directly:

  • You must do a substantial background check to ensure that the employee has no record of criminal activity or abusive behavior and that they, in fact, have the experience and training necessary to meet your care needs.
  • You, as the employer of record, are responsible for all the employment paperwork–payroll taxes, proper withholdings and filings, worker’s compensation insurance, etc.–necessary to comply with all federal, state and local labor, tax and insurance laws.
  • You will need to arrange for a suitable substitute or relief caregiver if your caregiver is ill, needs time off or simply abandons you.

Using a Referral Agency:

Home care referral agencies, also called home care registries, can help match you to an independent caregiver. These agencies do not employ caregivers; they simply collect a referral fee if you hire someone from their registry. Referral agencies vary widely in the quality of the screening they do, and they do not generally offer professional liability or workers’ compensation insurance. When you hire a caregiver, you will become the employer of record and be responsible, as above, for complying with all federal, state and local labor, tax and insurance laws.

Using a Licensed Home Care Agency:

Full service, licensed home care agencies (also called home care organizations) specialize in recruiting, hiring and supervising their caregivers. They are responsible for performing background checks, handling all payroll taxes, withholdings and filings, worker’s compensation insurance, and arranging replacement and back-up staff for time-off, sick-time and emergencies. Indeed, they lighten the burden of hiring a caregiver and provide peace of mind to the patient’s family.

Benefits of Using a Licensed Home Care Agency:

1. Convenience

InHomeCare.com makes it simple and easy to find a reputable in-home care company serving your area. You’ll work out a schedule and the list of duties your caregiver will perform when you meet with your selected company. The company will choose the best caregiver for you to ensure that the care you receive is personalized to meet your exact needs.

2. Comfort

You or your loved one is able to continue living as independently as possible, in familiar surroundings and in the comfort of home.

3. Companionship

In-home care services can also provide something that we all need, companionship. Most in-home care companies will match a caregiver to your personal care needs and to your personal interests.

4. Cost-Effectiveness

You’ll receive the one-on-one care and attention from your caregiver that you can’t get in a facility. That means greater value for every dollar spent on care. Plus, your caregiver may perform tasks previously handled by an errand service, a housekeeper, a transportation service, etc.–saving you more money and time, too.

5. Security

Having a professional caregiver in your home can provide an additional level of security. However, when contacting an in-home care company, be sure to ask how the agency screens caregivers and manages their staff. Make sure your selected agency is properly licensed and insured, and that its caregivers are fidelity bonded.

6. Assurance

In-home care assures you and your family peace of mind. Many adult children of aging parents can’t regularly pop-in to check on their loved ones or tend to their every need. With a caregiver in the home, families are regularly updated as to the well-being of their parents. Having a personal, caring, professional caregiver in the home provides everyone peace of mind.

Care Needs Checklist:

Non-medical home care agencies provide some personal care that skilled home healthcare agencies do not; conversely there are needs that can only be provided by skilled healthcare personnel. Although these tasks vary by state because of license regulations, the following are some general guidelines:

Non-medical CareSkilled Healthcare
Household Tasks
Light Housekeeping: clean and keep tidy all living areas
Laundry: wash and change bed linens and launder clothing, etc.
Meals: cook, grocery shop, prepare food ahead for later meals
Organization: schedule daily tasks and appointments, sort mail, etc.
Transportation, Companionship, General Safety
Drive and escort on errands, shopping and doctor appointments
Encourage social participation, escort on outings and to recreational events, everyday stimulating conversation, phone call assistance
Supervise in home to avoid falls, household accidents and ensure easy access to emergency contacts
Personal Care
Eating: assist feeding, provide nutritious meals and adequate fluids
Bathing: assist bathing, transferring in/out of tub/shower, bed-baths as needed
Dressing & Grooming: assist dressing, glasses, hearing aids, special orthotics (i.e. braces), hair care, shaving, oral hygiene
Ambulation: assist walking, safe use of assistive devices, range of motion and strengthening exercises
Toileting: assist to bathroom, bedside commode, urinal, bedpan usage
Incontinence: assist changing diapers, undergarments, pads, related skin care
Therapy: assess, plan, implement and evaluate therapy to regain speech, breathing and swallowing function
Teaching: instruct speech therapy regime, evaluate technique and compliance
Assistance: help to perform prescribed exercises, report progress to supervisor
Referrals: identify and arrange local resources for home care services, adult daycare, respite, financial assistance and support groups
Intervention: identify and arrange local resources for family and individual counseling and crisis intervention
Wounds and Bedsores
Assess wound, incision or bedsore; evaluate signs and symptoms of infection and monitor response to treatment
Teach Care: instruct wound or bedsore regime, evaluate technique, compliance
Treatment: perform wound/bedsore care per prescribed regime; report signs & symptoms of infection
Alzheimer’s and Dementia
Home Safety: closely supervise for safe environment, secure area with use of monitoring alarm devices to avoid wandering
Emotional Support: provide structured activity at appropriate cognitive level to minimize confusion
New Diabetic: teach specialized skin care, insulin injection technique, blood glucose monitoring, hypo/hyperglycemia symptoms and related emergency protocol
Glucose Monitoring: remind to check blood glucose per orders, report results to supervisor
Insulin: remind to inject insulin per prescribed regime, follow-up and report compliance to supervisor
Diet: prepare special prescribed diets, encourage compliance with restrictions
Ostomies: Colostomy, Urostomy
New Ostomy: teach ostomy care, preventive skin care, troubleshooting
Care: assist with ostomy changes, monitor peristomal skin blood work and report results to physician
 Feeding Tubes: G-Tube, NG Tube
New Tube: teach proactive skin care, dressing changes and troubleshooting problems with blockage, tube placement, skin infections
Tube Changes: insert new tube per authorized plan of care and as needed
Feeding: teach tube feeding regime, evaluate competency and compliance
Care: perform daily and as needed dressing changes and skin care to tube site
Catheters: Foley Indwelling and External
New Catheter: teach drainage bag changes and cleaning, securing tubing, troubleshooting dislodged catheters, placement, blockages, drainage amounts
Catheter Changes: insert catheter per authorized plan of care and as needed
Care: perform daily and as needed catheter care including emptying drainage bag, monitoring intake and output, cleaning and securing tubing and bags
Basic Health Monitoring
Skin: monitor for signs of breakdown, apply pressure reduction measures
Nutrition: monitor weight, nutritional intake, adhere to dietary restrictions
Intake/Output: encourage adequate fluids, monitor fluid intake and urine output
Vital Signs: take blood pressure, temperatures, pulses and report changes
Lab Monitoring: perform prescribed blood work and report results to physician
Medication Management
Remind to take medications and follow-up
Administer oral medications
Teaching: instruct new medications or monitor changes in regime per plan of care, assess response, side effects, and adverse reactions
Injections: administer prescribed injections per authorized plan of care, report side effects, adverse reactions
Supplies: manage supply of prescriptions to have all meds on-hand
Home Assessment: evaluate home safety needs, arrange for adaptive equipment
Therapy: assess, plan, perform and evaluate physical therapy to regain strength and maximal activities of daily living plan
Teaching: instruct prescribe exercise regime and safe ambulation with/without assistive devices
Assistance: help perform prescribed exercises, report progress to supervisor

Who comes to my home to provide the care?

Certified nursing assistants (CNAs), home health aides (HHAs) and personal care attendants (PCAs) perform similar but distinct roles in the home care community. Because they are able to offer much of the personalized care needed without being registered nurses, these care professionals play an important role in reducing healthcare costs, especially among seniors. CNAs, HHAs and PCAs have the ability to help reduce patient falls and readmissions, and improve outcomes by helping patients adhere to doctors’ orders and to comply with prescriptions, diets and exercises.

CNAs, HHAs and PCAs can all provide companionship and basic personal care to patients, but they have different levels of education, training, and certification. They also differ in the level of medical care they are allowed to provide without supervision from a doctor or nurse.

Certified Nursing Assistant (CNA)

CNAs are state-licensed nursing assistants who have received classroom and hands-on training, as well as passed an exam. Requirements vary by state, but generally certification must be renewed every few years and requires additional hours of training. The basic health care training that CNAs receive qualifies them to work in a hospital, Skilled Nursing Facility (SNF), Assisted Living Facility (ALF) or with a home health or in-home care agency.

In addition to assisting with personal care needs, CNAs help monitor their patients’ medical conditions. They can monitor and record vital signs and symptoms to share with the supervising nurse or doctor, and in some states they are allowed to

administer medication. They may also assist with basic medical care such as changing dressings, etc.

Home Health Aide (HHA)

HHAs are also state-licensed and must meet the same kinds of requirements as CNAs, however their health care training is very limited. Home Health Aides will usually work in an Assisted Living Facility (ALF) or with a home health or in-home care agency.

HHAs rarely provide any kind of medical care, although this can vary by state. They assist with all personal care, prepare meals, perform light housekeeping duties, and provide transportation.

Personal Care Attendant (PCA)

Also referred to as personal care assistants/aides, or homemakers, PCAs make up the majority of individuals providing care to seniors or the disabled in their home. There are no formal education requirements necessary to become a PCA, but many states now require all professional in-home caregivers to obtain a certain number of supervised training hours.

Many of these caregivers started their careers by taking care of a relative; nearly all obtain their caregiving skills and knowledge through hands-on, on-the-job experience. Some have supplemented their experience with additional training. Training usually includes basic personal care principles, common diseases and health conditions, sanitation practices and safety precautions, communication and cultural sensitivity, privacy and ethics, and transfer assistance.

As with HHAs, PCAs primarily provide companionship and assistance with basic personal care, homekeeping and transportation.

Paying for home care

How Much Does Home Care Cost?

The cost of care varies widely. Factors include the type and number of hours of care needed and the geographic location. On average, the cost of light companionship care is between $17-$21 per hour. The cost for total care can range from $28-$40 per hour. Someone needing a moderate amount of in-home care services could expect to pay around $22-$28 per hour.

The payment rates, terms and types of programs offered by agencies vary. Rates may be priced on an hourly, per day, or per shift (including a “live-in”) basis. Some determine their charges based on the level of care needed, while others charge a flat rate per hour or day regardless of the care needed. Paying an upfront deposit is common in the industry. Agencies usually bill twice each month or on a monthly cycle. Payment by check is still the most common form of payment although many agencies are set up for automatic debit payment. More and more accept major credit cards as an additional form of payment.

How Will I Pay for Home Care?

Private Pay

There are several sources of funding for non-medical, in-home care services. However, the vast majority of care is paid from the savings and resources of the individual receiving care or from their family. This type of payment is commonly referred to as private pay or as out-of pocket payment.


Medicare does not presently cover non-medical care except when certain custodial services are part of a doctor authorized plan of care. In this case the licensed home care agency must be approved and, of course, the patient must be Medicare eligible and must meet Medicare’s definition of “homebound.”

In 2019, the federal Medicare program will include a benefit for non-medical, in-home care under certain conditions, only if the Medicare beneficiary is enrolled in a Medicare Advantage Plan. The specific details of the new Medicare in-home care benefit will soon be unveiled and should include the conditions and limitations that will apply.

Long-Term Care Insurance

Long-Term Care Insurance (LTC) carriers currently pay for about 20% of the in-home care in the U.S. LTC companies generally pay a fixed benefit per day and have a maximum benefit they will pay for in-home care. Most home care agencies will assist you in complying with the requirements of your LTC carrier. They will usually verify policy benefits, perform a pre-evaluation, obtain a doctor’s order, and complete daily care notes and itemize bills for services rendered. It is generally your responsibility to pay the care agency and then to submit the claims to your LTC insurance carrier for payment on your policy. Some agencies do accept assignment of benefits, meaning they do all the paperwork and get paid directly by your LTC carrier.

Other Options

There may be other options to consider which might assist in paying for care including:

  • Paid Family Leave
  • Medicaid & State Programs
  • Veterans Administration
  • Grants

In-Home Care Costs vs Continuing Care in a Facility

The cost of care in a facility depends on many factors including the type of facility (Short-term Skilled Rehab vs Chronic Long-term Care Facility, or Skilled Nursing vs Assisted Living), the health and care needs of the patient, private room vs semi-private, the quality and location of the facility, etc. Cost varies widely: anywhere from $350 to $1,200 per day.

Because a patient does not receive one-on-one care in a facility, a patient or resident in a facility may also elect to hire, at additional cost, an outside care agency or caregiver to supplement the care provided by the facility. In these cases, the agency and caregiver must comply with all rules and regulations of the facility.