AGENCY vs. PRIVATE HIRE

By Family Caregiver Alliance

It is easy for family and friends, as well as professionals, to suggest finding someone to help with housekeeping tasks and care responsibilities. Having someone else take on some of your housekeeping or personal care tasks might sound appealing to you too. But what does it mean to have someone in your house “to help” you? Where do you begin to find someone? Can you afford it? How do you respond to your loved one who proclaims that they don’t want “a stranger” in the house? We will help to guide you through the process of hiring help at home.

Do I Need Assistance?

Long-Distance caregiving, working full-time and caregiving and/or caring for someone 24 hours a day/7 days a week will take a toll on anyone. With a loved one who needs personal care and who can’t be left alone, you must be vigilant and “on duty” day and night. With constant care and companionship responsibilities, you may have very little time to yourself. If you are caring for someone who needs to be transferred from bed to wheelchair or out of a chair when sitting, you may be at risk for injuring your back. For those caring for a family member living with dementia, you may be also be dealing with challenging behavior, wandering risks, or actions that might be harmful or dangerous such as leaving cooking burners on. If you don’t have time to do the shopping, banking, and taking care of your own medical needs, you are at risk for stress-related illness. Are housekeeping routines and cooking being done with great difficulty or being left undone?

Consider your needs as a caregiver and the needs of the person you are caring for. Here are the main areas to assess:

Personal care: Bathing, eating, dressing, toileting, grooming

Household care: Cooking, cleaning, laundry, shopping

Health care: Medication management, physician’s appointments, physical therapy

Emotional care: Companionship, meaningful activities, conversation

Hiring help can relieve you of some of the tasks you are responsible for, freeing you to have some time for yourself. Having trusted help can give you the opportunity to run errands, go to the doctor for yourself, catch up on sleep, and socialize with friends. For long-distance caregivers and working caregivers, help can provide the care and assistance needed when you can’t be there on a daily basis yourself. Interestingly, caregivers have found that in some instances the person receiving care can be more cooperative with someone other than the primary caregiver, so that, for example, taking a shower might not be the battle that it can otherwise be. Engaging an attendant can help to preserve your relationship as daughter or partner, rather than always having to be the chore person or task master. Attendants come in fresh for a certain number of hours and therefore have the energy to be engaging and encouraging in a way you might be too exhausted to do around the clock.

Hiring help might not only be a necessity but a gift you can give yourself.

"My Loved One Only Wants Me to Help"

It can be hard for your loved one to accept help from a stranger. Initially, it will be important for you to be present to help the attendant and the care receiver to establish a successful relationship. You can show the attendant how you do things, so the help that is given will feel familiar and comfortable. Let your loved one know that YOU need help, and that this is something they can do to help you care for them. Reassure your loved one that hiring help does not signal that you are going to abandon them.

If your loved one lives alone, you might hear, “I don’t need any help.” Suggest that it will make YOU feel more comfortable knowing someone is there part of the day. You can also suggest that they “just try it for a week.” This will give your loved one some control in decision making and help them be open to having an attendant.

The transition to an attendant might be easier if the attendant shares a similar cultural background or language. The care receiver may have a preference for a male or female attendant. However, wonderful attendants come from all backgrounds, and being open to a caring, competent attendant from a different ethnicity or cultural background than your own can lead to rewarding bonds.

Sometimes the best way to get an attendant accepted is to hire a “housekeeper.” Care receivers are often more open to having someone come in and “help” with the housework before they are willing to accept someone to help with personal care. This gives your loved one time to become familiar with the attendant and build trust.

“I Don’t Want a Stranger in My House!”

We all react differently to interacting with someone we don’t know. For some people, meeting someone new is an enjoyable and interesting opportunity. But for others who are naturally more reticent or are feeling vulnerable due to their illness, there is great reluctance to exposing their private life and personal living space.

Hiring someone through an agency will give you some choice for attendant selection. Most agencies have done background checks and bonded the people who work for them—be sure to ask if this is the case. And if you feel uncomfortable with the person who is sent, you can always ask the agency to send someone else. But typically an agency will attempt to match the attendant to your specific needs and requests, so if you aren’t immediately comfortable with the attendant sent, consider giving it a day or two to warm up to them.

Care receivers often worry that their belongings will be stolen. This does happen, but it is much rarer than you might be led to believe. Lock up or take out of the house any especially valuable belongings, such as heirloom jewelry, just to make yourself less anxious about this happening. Keep track of cash and checks/checkbooks/credit cards. If hiring through a homecare agency report any concerns you might have. If hiring privately, schedule a time to discuss the concerns directly with the caregiver. If your loved one has dementia, they may report an item as “missing” when it is only misplaced or stashed away.

How Do I Find Help?

There are formal and informal ways of finding an attendant. The formal way is to contact a Home Care Agency located near to where your loved one lives. A long list of agencies will be available in most urban and suburban communities. This can make it difficult to figure out who to contact first. Far fewer agencies serve rural areas, limiting options for hiring care. People who can help you select the right agency for your needs include your doctor and their staff, your friends/family who have used an agency, and others in your community whom you trust, such as your faith community, your local senior center, etc. Also check for agency reviews from trusted online sources, and consider contacting your local Area Agency on Aging to ask whom they hold contract(s) with for their clients.

Key questions to ask:

Is the agency licensed by the state? (Many but not all states require licensing to operate a Home Care Agency). Ask how long they have been in business.

Are the workers licensed and insured? How does the agency train, supervise, and monitor their workers?

Request a Free Assessment from the agency and discuss their services and fees. This will give you an opportunity to get to know your Care Manager and for the agency to assess the Care Plan.

Home Care Agency Pros and Cons

Pros:

Screening, hiring/firing, pay, taxes are handled through the agency
Note: Some agencies work as “employment agencies,” and their workers are contractors, not employees of the agency. Be clear on what the agency covers, e.g. payroll, liability insurance, workmen’s compensation insurance, unemployment insurance. Ask for evidence of their insurance.

Can offer attendants with a variety of skills and match you with a staff member who can provide the care or help that you need

Able to accommodate variable schedules that might be inconsistent or unpredictable at times

If worker is sick/goes on vacation, agency will provide a substitute

If worker is not the right fit, can send an alternate choice

Can help settle disputes with you/attendant

Often covered by long-term care insurance

Cons:

May schedule more than one caregiver if the schedule is not consistent, needing to separately orient and adjust to each new person.

Typically more expensive than private hire

The informal way of finding help is to hire an attendant privately. This entails your finding your own attendant and being responsible for hiring/firing/payroll taxes, and all aspects of being an employer in California. You have to track sick hours, retirement contributions, worker's comp contributions and other indirect costs. Local colleges and in particular nursing programs, community college HHA (Home Health Aide)/CNA (Certified Nursing Assistant) programs are good sources of available talent. If you are hiring privately, it is essential that you do a background check (See FCA fact sheet Background Checking: Resources That Help). Check your home owners or apartment insurance for liability coverage. You may need to add it and also get workmen’s compensation insurance.

What Will It Cost?

The rules for hired help vary from state to state, and sometimes city to city. Start with state Department of Labor. You will need to familiarize yourself the regulations in the municipality where the help or care will be provided. First, find out what the minimum wage is in your area. Second, determine how many hours of help you require. In some states, if someone works more than 8 hours/day, they are eligible to be paid time and a half for 8–16 hours, and double time for 16–24 hours. If you have live-in help, some states require that the attendant get 8 hours of uninterrupted sleep. So, if you have a loved one who is up a lot at night, you might have to hire a nighttime attendant in order to give the daytime attendant a break. Also, if you hire privately, you will need to set up a payroll (see above). Some attendants prefer to be paid with a 1099 at the end of the year. This means they will be responsible for their own taxes. Be sure that they meet the local requirements for an independent contractor. Finally, some attendants will accept payment only in cash.

If you hire a Home Care Agency, they will establish the pay rate. Agencies will charge a different amount, depending on the kind of care that is needed, e.g. personal care versus dementia care. Also, an agency might have a minimum number of hours. We have 6-hour shift minimum on weekdays and 8-hour minimum on weekends. For people who need full-time care, the options are a “live-in” who does the full 24 hours, a live-in plus an 8-hour shift for someone who needs someone to be awake and available during the night, two 12-hour shifts for people who may need someone awake at night, or three 8-hour shifts for someone who may need extra help due to heavy care needs.

Care recipients often ask whether they should pay the attendant if they take a vacation. Or if they should give a monetary or physical gift at holidays. Are yearly bonuses expected? If the attendant is terminated, not for cause, should they pay severance? These are individual decisions but important things to think about so you are not burdened with trying to figure them out when the time comes.

How Can I Afford It?

Hiring in-home help can be expensive, particularly if you need full-time help. However, if you only need six hours twice a week, it can be more affordable—the hourly cost varies depending on the care needs and care providers

If the care receiver has a long-term care insurance policy and the service provided meets the policy criteria, the benefits can offset the cost. Check the policy for how many days of care are required before the policy will start to pay. Determine whether there is coverage for hiring someone privately, or only for hiring through an agency. Some policies require that the attendant be a HHA, LVN (licensed vocational nurse) or CNA, and others do not. Also check your Life Insurance policy for Home Care rider. Some policies have that component.

The cost of a hired attendant might be tax deductible if it is considered medically necessary. Check with your tax accountant to see if this is the case in your situation.

If the care receiver is low income and qualifies for Medicaid (Medi-Cal in California), they may be able to get help through an in-home program called In-Home Supportive Services (IHSS). Check with your local Medicaid office to see what services are available in your area. Medicaid benefits differ by state.

This type of care is an appropriate expenditure for use of the care receivers’ personal savings. Often family will also contribute as needed to help cover the cost. Holding a family meeting to discuss the need for the home care service, the cost of the care, and the means available to cover the cost can help surface concerns from family members, and gain support to help cover the expense.

Also look into Non-profit organizations for Grants and Special programs.

Such as: Institute on Aging, By the Bay Health, Kaiser Foundation, Sutter Health and Hospice, VA Services, JFCS, Catholic Charities and many others in your area.