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When Toni Mandala's 84-year-old father was suffering with Alzheimer's disease—and its accompanying confusion, incontinence, and depression—she moved him into the house across the street to care for him herself. But when a neighbor spotted him walking down a highway searching for his favorite diner, Mandala knew she needed help. A nurse practitioner herself, Mandala went straight to a home health care agency. “The first person they sent out was a match,” she says. “She was attentive and my dad really liked her.”
Mandala was lucky—things don't always run that smoothly. Nevertheless, hiring help at home is usually a lot less expensive and more comfortable than putting your loved one in a nursing home or assisted-living facility, especially if he or she only needs a few hours of attention a day.
Think about what types of tasks you would like the aide to perform and write out a job description to use as a guide. “You should have some idea what you're looking for, but you don't want to create a rigid plan that might not work for the patient,” says Rona Bartelstone, licensed clinical social worker, certified case manager, and chief executive officer of Rona Bartelstone Care Management & Home Healthcare in Fort Lauderdale, FL.
Home health care typically falls into four categories: Registered nurses who can manage complex medical conditions, administer medications (including injections), and operate high tech machinery; certified nurse assistants who have training in first aid and can transfer patients from bed to wheelchair and help them bathe and go to the bathroom; personal care attendants who help with bathing, dressing, housework, and laundry; and homemakers who may have little or no medical training and whose tasks are usually limited to grocery shopping, housekeeping, cooking, making beds, and providing companionship.
Using a home health agency can lift a huge burden off an already overwhelmed family. With an agency you're paying for the package: A registered nurse to construct a care plan and supervise the home health aide; the aide to perform day-to-day care; and the agency to take care of background checks, emergency staffing, taxes, and payroll. Most agencies provide the full spectrum of care, from round-the-clock, licensed nurses to minimal companionship services.
To find out if an agency is licensed and certified, check with the state health department or visit medicare.gov . “Medicare evaluates agencies based on their quality of care and occurrence of adverse events, and posts the information on their Web site,” says Mary St. Pierre, vice president of Regulatory Affairs for the National Association of Home Care. You can compare a particular home health agency to others in the state and those nationally with a few clicks of a mouse. In addition to licensure and certification, some agencies are accredited, which is a good sign, according to St. Pierre: Because it costs an agency money just to have their operation considered for accreditation, “you know they're interested in providing the best care,” she says.
Too much work? If you have the money, hire a professional case manager who is either a nurse or a social worker to be your go-to person on an on-going basis. “It's very challenging to get the ‘Goldilocks effect’ and find just the right person,” says Bartelstone. “There's a better chance of getting it right sooner if you use a professional who can guide the family in the right direction and toward realistic expectations.”
Case managers not only deal with the agency and screen caregivers, they also manage the financial considerations of arranging care—for example, when is it best to use a limited long-term insurance policy? They can even mediate between family members who have differing views about what's best for mom or dad.
While hiring an aide on your own may involve more work, it does have at least two advantages: You'll have more control over duties, salary, and scheduling—and you'll save money. But you'll also have to check references, make sure your aide is a United States citizen, and pay state, federal, and social security taxes if your aide makes more than $1,000 a year. If you have long-term-care insurance, be sure to read the fine print. Some policies only reimburse you if you hire through an approved agency. And you'll need a back-up plan if your aide calls in sick or is otherwise unable to care for your loved one.
Still want to go it alone? Be prepared to keep detailed records. Documentation of your employee's work schedule and payments is required for tax purposes, and will come in handy if there are discrepancies about hours worked or payments due. And don't be afraid to audio- or videotape your aide in action. “Abuse and exploitation does happen,” says Bartelstone. “If someone is going to hire privately, the first thing they should do is take inventory of everything of value.”
Another option is to hire an aide through a nursing registry. You are responsible for supervising and managing the services and pay the worker directly, but the registry will provide a back-up if your assigned worker is unavailable—and in most cases the agency and its employees are bonded.
Whether you choose to go the agency route or on your own, interviewing potential home care aides is key. Your interview with the prospective aide should include a discussion of the patient's needs and a complete job description, preferably in writing. That way you can better determine whether the caregiver's skills and experiences match your loved one's needs.
“There are all kinds of cues you can pick up once you get a person talking,” says St. Pierre. “Ask about their former patients and experiences, and pay attention to what they reveal.” If dad has dementia, as in Mandala's case, ask if the aide has cared for such patients before and what challenges he or she encountered.
On a more basic level, make sure the aide clearly understands instructions. When you say, “Please put clean sheets on the bed,” be sure the aide understands that you want him or her to strip the old linens, replace them with clean ones, and make the bed—not simply throw a pile of clean, folded-up sheets on top of the bed. “If a person can't understand that request, personal care and hands-on tasks are going to be a lot more difficult,” says St. Pierre.
Once you are sold on a candidate, check their references. Letters are great, but they're not a substitute for a conversation with previous employers.
Once you've hired an aide, prepare a daily schedule of duties so expectations are clear. Visit frequently and at irregular times so you get an accurate picture of what their relationship is like. Make sure the house is clean, the refrigerator is full, and that your loved one is happy.
Ultimately, the aide and the care recipient need to get to know and trust each other, says Bartelstone, but it helps if you can facilitate the transition. Mandala visited her dad twice a day. Her goal was to make the adjustment easier for her dad and make his days go faster. While she was at work, the aide played simple games with him, took him for short walks, and played his favorite music and videos.
“Most people go into this field because they want to make a difference,” says Bartelstone. “They know they're not going to become rich doing this work. It's not just a livelihood—it's a calling.”
Is the agency licensed, bonded, and insured?
→ Are caregivers employees or independent contractors? Who will be responsible for taxes?
→ What are the hiring standards for the agency? What types of background check does the agency perform on caregivers?
→ Does the agency ensure that their staffs have valid professional licenses and meet education requirements?
→ Does the agency work with Medicare or your insurance company?
→ Do they have back-up systems in place for emergencies, holidays, and sick days?
→ Will the same person provide services every day?
→ Does the agency supply references for the professionals it employs?
→ How do their fees compare with those of other agencies?