What Level of Home Care is Required?

Figuring out how to select a care agency can be a little confusing because they differ in the level of care they provide. Non-medical in-home care agencies (usually referred to as “in-home care” or simply “home care”) provide companionship and supervision (especially important for the elderly with alzheimer’s disease or other mental impairments). They also offer in-home assistance with activities of daily living such as bathing, as well as offer help with meal preparation, housekeeping, and transportation.

Home health care agencies provide skilled nursing care for patients in need of significant medical attention. Other home health providers include specialists in hospice care, physical therapy, pharmaceutical and infusion therapy, and home medical equipment.

Non-Medical Home Care Agencies

These agencies are also referred to as personal care, custodial care, senior care, homemaker, companion, and private duty agencies. A professional in-home caregiver helps the care recipient with the activities of daily living (ADLs):

• Personal hygiene; bathing
• Dressing
• Transferring
• Toileting
• Eating
• Ambulating

In addition these caregivers assist with the instrumental activities of daily living (IADLs) which refer to tasks that enable an individual to keep living independently in their home:

• Managing personal finances
• Transportation; running errands
• Shopping for food, clothing, and other necessities.
• Meal preparation
• Housework and home maintenance
• Managing communication
• Taking medications

Care is provided by certified nursing assistants (CNAs), home health aides (HHAs), or personal care attendants (PCAs) also referred to as personal care aides, homemakers, caregivers, sitters or companions.

Unskilled care is usually paid for out-of-pocket, or in some cases by private long-term care insurance. Medicare sometimes covers non-medical care if certain conditions are met and the care is ordered by a physician. Licensure requirements and regulations for non-medical care agencies vary from state to state, unlike federally-regulated, Medicare-certified home health agencies.

Non-medical home care agencies play an increasingly important role, filling gaps in home care services that are not provided or covered under skilled care. Un-skilled home care services such as personal care assistance or cooking and cleaning help is often what is needed most in order for individuals to keep living in their own homes.

When hiring a non-medical caregiver there are several options, each with their pros and cons: hiring a caregiver privately, going through a referral agency, or using a full-service in-home care agency.

If You Decide to Hire a Caregiver Directly:

You will be responsible for checking a potential employee’s background and all employment paperwork (workers’ compensation, payroll taxes, insurance, etc.). In addition, you will need to be prepared with backup help if your regular caregiver can’t be there for whatever reason.

Using a Referral Agency:

Home care referral agencies, also called home care registries, can help match you to an independent contractor. These agencies do not employ caregivers; they simply collect a referral fee if you hire someone from their registry. Caregivers may or may not be well-screened depending on the agency, and, as when you hire a caregiver directly, you will become the employer of record and be responsible for all employment paperwork, taxes, and insurance.

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 screening and training their staff and will arrange for replacement caregivers when needed. They take care of all tax and insurance paperwork for their employees.

Medical or Skilled Home Health Care Agencies

Skilled Home Health Care Agencies

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

Skilled home health agencies provide professional medical care in the home. They often work with hospital discharge planners to provide wound care, training for new feeding tube or catheter care, medication and pain management, and rehab services.

Registered nurses, CNAs and HHAs are the typical caretakers, along with physical therapists, occupational therapists, speech therapists, social workers, etc. The home health agency sets up a team of care providers that will adhere to a physician-approved plan of care.

Home health agencies hire and supervise their personnel; they assume liability for their employees. They are also Medicare certified (meaning they have met federal guidelines) as well as being state-licensed. Some also offer a dedicated non-medical, in-home care service.

Hospice Care Agencies

Hospice care is indicated for individuals (of any age) who require pain management and compassionate end-of-life services. Most reimbursement sources require a prognosis of living six months or less if the illness runs its normal course. Hospice care involves a core team of skilled professionals and volunteers who provide all-around medical, psychological, and spiritual care when cure is no longer possible. Specifically, these services include pain management, palliative care, social and psychological support, and chaplain services for the patient and their family. Trained hospice professionals are available 24 hours a day. They help the family care for the patient, ensure that the patient’s wishes are honored, and keep the patient comfortable and free of pain. Most states require Hospice Agencies be licensed and Medicare certified. Hospice services are generally paid for by Medicare, as long as patients meet strict criteria for participation and payment authorization.

Pharmaceutical and Infusion Therapy Companies

These companies deliver medicines, equipment, and nursing services to people who need intravenous (IV) fluids, nutrition, or treatments. They also give manage feeding tubes (G-tubes and NG-tubes). Nurses teach patients and family members to give these medicines, fluids, or feedings in the patient’s home. Some pharmaceutical and infusion therapy companies are certified by Medicare.

Home Medical Equipment (HME) and Medical Supply Dealers

These companies provide products ranging from respirators, wheelchairs and walkers, to catheter and wound-care supplies. They deliver these products, install or set them up, and teach patients and caregivers how to use them. Most of these companies do not provide physical care for patients, but a few offer pharmacy and infusion services. Some provide respiratory therapy services to help patients use breathing equipment. Those that bill Medicare are required to meet federal minimum standards. Some states require that these companies be licensed.

Choosing the Right Level of Care

(Does Someone in my Family Need Home Care?)

Knowing the ADLs and IADLs and looking for patterns of behavior and neglect within those areas can help determine the level of care needed. The IADLs (managing finances, transportation, shopping, meal preparation, housework, communication and taking medications) are usually the earliest to suffer, so look for difficulties with those first.

Watch for trouble with ADLs (personal hygiene, dressing, transferring, toileting, eating, ambulating) and for other warning signs including increased isolation and changes in attitude or in cognitive abilities.

Knowing exactly which activities you need help with will make it easier to choose the appropriate home care provider.

What Questions Should I Ask Prospective Home Care Agencies?

We make it easy for you to narrow your search by providing several prospective home care agencies that should generally fit your needs. Next you will want to ask each of them some specific questions. You’re about to select a caregiver who will come into your home on a regular basis and will potentially become quite close to you and your family, so it is in your interest to be thoroughly informed about the agency, the caregivers and the services they will be providing.

General Questions About the Agency

• What type of agency is your company? (i.e. home health care or non-medical home care)
• Does our state require your agency to be licensed and are you currently licensed by the state?
• What services does your agency provide? What services can’t or won’t your agency provide?
• Are services available 24 hours a day, seven days a week? Is management available 24/7?
• How long has your agency been providing services?
• Can you provide references that have used your services recently?
• How do I go about arranging for care to start?
• How soon can you start care?
• Do you have any minimum requirements regarding the length or frequency of care you provide?
• Is your agency, including your caregiver staff, insured and bonded?

Questions About Agency Caregivers

• What types of staff can your agency provide (e.g. CNA, HHA)?
• How do you screen and select your caregivers?
• Describe your typical caregiver to me? What kind of caregiver can I expect from your agency?
• What training and support will your agency provide to my caregiver?
• Are your caregivers employees of the agency? Or, would I as the client, be the legal employer?
• Are your caregivers bonded (insured against theft or loss to a home) through the agency?
• What is the procedure if my caregiver does not report to work when scheduled?
• Can a different caregiver be requested if I am unhappy with the worker the agency sent?
• How many caregivers do you have on staff available to care for me at any given time?
• Can I interview the caregivers before they work in my home?

Questions About Costs

• What is the cost of services? (Paying for home care)
• How are your prices determined?
• Do you require a deposit or any type of payment in advance?
• How often does your agency bill for services?
• Will your agency bill my long-term care insurance company directly?

Questions About Quality

• Does the agency have references or satisfaction reports for itself and staff?
• Is the agency reviewed by an outside organization?
• When was the last review and are the results available to clients?
• What kind of system is there for receiving client problems or complaints and resolving them?
• Is there a written plan of care for each client?
• Are clients and family members involved in putting the plan together or reviewing it?

Questions About Management

• Who owns the agency? How long have they owned the agency?
• Who is the manager in charge? What is their experience in the home care field?
• How can I get in touch with the agency and the manager on evenings and weekends?

Check References

Checking references is important when selecting an agency and caregiver. Although there are limitations on what a former employer can legally disclose about an employee (dates of employment, whether they are eligible for rehire or not, etc.) a person who has used an agency or a family member can tell you a lot about the agency’s performance and professionalism. Customer satisfaction is the best indicator of an agency’s ability to deliver the care you or your loved one deserves. Talk to former and/or current clients of the agency, including family members of the client (the client may not be cognizant of the entire experience with the agency). Ask them about their experience with the agency’s evaluation and on-boarding process, caregiver quality and replacement process, problem solving capabilities, responsiveness and professionalism, and the overall quality and value of their services.