National Family Caregivers Association

Friday May 16, 2008

A Home Healthcare Primer

From the Editors of Take Care!

What is home care? Home care is a general term that represents a wide range of community-based services to support someone who is recuperating from an acute situation, such as a hip fracture, or needed by persons with ongoing chronic conditions, such as stroke or cerebral palsy. The skills and duties of home care personnel vary, but all have one thing in common-they make it possible for care recipients to remain at home in a safe environment and in some cases have more independence than they did before. In the process, they also provide family caregivers with a chance to replenish their depleted physical and emotional reserves.

Home care personnel include:

Registered nurses (RNs) who provide skilled nursing care according to a doctor's medical plan of treatment, including assessment and monitoring of vital signs, complex wound care, administration of intravenous and other medications, and teaching family caregivers how to perform procedures including the use of certain equipment in the home.

Therapists who work with patients to restore or maintain their motor and mobility function, speech and communication, and cognitive skills.

Home care aides who provide personal services such as bathing, dressing, toileting, preparing light meals, and who in some cases may accompany or transport patients to the doctor.

Companion/homemakers who help with homemaking chores such as shopping, meal preparation, and housekeeping, but who usually do not perform personal care duties for the recipient of services.

Getting Started with Home Care

If you are considering getting home care help to assist you with your caregiving responsibilities and/or to get some time for yourself, there are a number of things you need to consider, and also things you need to know.

The first step is to make sure you and your loved one are comfortable with the idea of someone else taking on some of the tasks that you've been doing by yourself. There are many care recipients who are totally opposed to the idea, and some negotiations will need to occur before any plan can be put in place. It is important for all concerned to understand what is prompting the need for home care and the personal issues that lie beneath refusal to consider it. Getting beyond objections isn't necessarily easy and you might need some guidance on how to go about it, perhaps from other family caregivers who have dealt with the issue or from professionals who counsel family caregivers.

Defining the tasks that need to be done by the home care worker will help you determine exactly what type of home care is most appropriate in your situation. Do you need a nurse to clean and bandage wounds and monitor equipment, a home care aide to help your loved one get showered and dressed, or would a companion/homemaker be more appropriate in your circumstance?

Once you know what type of assistance you need, and all parties agree that it is necessary or desirable, the inevitable questions about where to find home care services, how much they will cost, and whether any of the cost is covered by insurance or provided by government programs must be asked and answered. Some federally-funded programs, insurance companies, and health maintenance organizations (HMOs) do provide for some home healthcare services, but the coverage provided may not meet your needs. To determine whether or not you have any coverage at all, it is imperative that you review your insurance benefits.

If you're like the majority of family caregivers, you need the most help with personal care tasks-the very type of care that is not covered by private health insurance programs or Medicare. So unless your loved one had the foresight and the funds to purchase long-term care insurance prior to becoming ill, your access to home care will be limited by what you can afford. You may be able to get some help from state programs that take into account your ability to pay and the age or extent of disability of your care recipient, but the sad reality is that more often than not the costs of home care services will have to come out of your own pocket.

Choosing the Right In-Home Care

How do you find the right home care solution for your family, the one that provides the services you need at a price you can afford? There are several ways of tapping into the home care network. Here is a look at some of the most common ones and what you need to think about when considering them:

Home Care Agencies are companies in the business of meeting home care needs. Not all home care agencies provide the same variety and level of service, however, so make sure the agency you are considering can provide all the services you need. The issue isn't bigger or smaller but rather which one meets your criteria.

If your care recipient is approved for skilled care that Medicare will pay for, it's vital that the agency be Medicare certified. This ensures that the agency has met minimum federal requirements. If your loved one only requires personal care or companion/homemaker care, Medicare certification need not be a factor in your decision. Some companies may have separate departments that provide Medicare-covered services as well as private pay/private duty services.

Some agencies are accredited in addition to being certified. Well-known accrediting organizations are the Community Health Accreditation Program, the Joint Commission on Accreditation of Healthcare Organizations, and the Home Care Aide Services Accreditation of the National Association for Home Care. This type of credential tells you that the agency conforms to national industry standards, and there is always comfort in knowing you are dealing with an organization that has proven its worth to its peers.

What do home care services cost through an agency? Some agencies charge flat fees ranging from $100 to $120 per visit. Others have a minimum two- or four-hour fee. The actual hourly rate will vary depending on the services you require and the part of the country you live in, but don't be surprised to find rates ranging anywhere from $13 to $35 per hour.

Questions to Ask Any Agency With Whom You Are Thinking of Working:

Is the agency certified for participation in Medicare and Medicaid programs (where applicable)?

How long has the agency been serving the community?

Is the agency accredited by the Joint Commission On Accreditation of Healthcare Organizations (JCAHO), or the Community Health Accreditation Program (CHAP), or other recognized accrediting body?

Does the agency provide an initial assessment to determine if the patient would be appropriate for home care and what those services might be?

Does the agency provide all of the services you need? Can it provide flexibility to meet the patient's changing health care needs?

How does the agency choose and train its employees? Are background checks made? Does it protect its employees with written personnel policies, benefits packages, and malpractice insurance?

Does the agency provide literature explaining its services, eligibility requirements, fees, and funding?

Does the agency have arrangements in place for emergencies? Are the agency's caregivers available 24 hours a day, seven days a week? How quickly can they start service?

Are references from former clients and doctors available?

What types of programs does the company have in place to assure quality care is provided?

Will the agency go to bat for you if your insurance company or Medicare fails to cover a claim you and the agency thought should be covered?

Homecare Resources

"How to Choose a Home Care Agency: A Consumer's Guide" is available for free by sending an self-addressed stamped letter to the National Association for Home Care, 519 C Street NE, Washington, DC 20002-5809.

"Managing Your Personal Assistance Worker," written by Consumers in Action for Personal Assistance in 1998, includes information on worker management, communication skills, hiring skills, and many other topics. The handbook is free to In-Home Support Services (IHSS) consumers in San Francisco. Others are charged $6 to offset some of the cost of printing and mailing. Call 415/243-4477 or email info@sfihsspa.org.

"Caregivers and Personal Assistants: How to Find, Hire and Manage the People Who Help You (or Your Loved One!)" by Alfred H. Degraff, MA, SEA, from Saratoga Access Publications is $24.95 and can be ordered online at www.saratoga-publications.com or by calling 970/484-5595.

Privately Employed Home Caregivers

Instead of using a home care agency, you may wish to hire a home care worker on your own, especially if you are not looking for skilled medical care, but rather for someone to act as a companion or personal aide on a regular, long-term basis. In those situations, bypassing commercial agencies can often result in significant financial savings. You can start your search by putting the word out to friends and neighbors that may know of a home care worker. Also check with the nursing staff in your doctor's office, a hospital discharge planner, or community-based social service agencies for reliable candidates.

If you are considering hiring privately instead of using an agency, it is essential to consider some of the drawbacks: (1) you yourself must do substantial background checks to ensure that the person has no record of criminal activity or abuse; (2) you must be prepared to do all the paperwork necessary to comply with tax and insurance laws affecting employees; (3) you may not get candidates with the same level of training and licensure as those who work for home care agencies; and (4) you do not have the guarantee of substitute help if your home caregiver is ill or on vacation.

Home Care Registries

A good middle ground between home care agencies and hiring help on your own is a home care registry. Registries are somewhat like an employment agency. They screen, interview, and reference-check workers they refer to clients, so you don't have to, but just as with home care agencies, you need to ask a lot of questions to assure yourself that they can provide the right personnel to meet your needs. Because members of a registry are independent contractors, their services are available at prices that are usually lower than agencies.

Government In-Home Aide Services

Many states and counties offer home care services to residents who are aged or disabled. Some even offer services to family caregivers. Applications for aid are evaluated by state social workers who rank a candidate's needs according to a number of objective criteria, including whether the care recipient lives alone and what activities he or she can perform. Care recipients who qualify are provided with home care aides who can give personal (not medical) care, do light cleaning, change linens, prepare meals, and transport or escort the patient to the doctor.

The aides are trained and licensed by the state. Fees are usually set on a sliding scale and can range anywhere from $1 to $20/hour, depending on the care recipient's ability to pay. To find out what services your state offers, call your state Department of Human Resources or state Health Department. But be forewarned: usually these agencies are overwhelmed with applications and the waiting list can be long.

Hospice

If you are caring for a loved one with a terminal illness, Hospice offers a number of services that can help. To qualify for in-home hospice care, you must have a doctor certify that your loved one is no longer seeking curative treatments and that he or she has "months rather than years to live." Depending on your situation, hospice will provide a social worker, a nurse who comes regularly to check medicines and vital signs, volunteers to sit with your loved one while you run errands or just get some rest, and home health aides who will bathe and clean the patient, tidy up the room, and fix a meal if necessary. Payment is usually through Medicare or private insurance. When you call your local hospice office, a home health care coordinator will work with you to arrive at the best combination of services for your situation.

An Ever-Changing Landscape

There are no easy answers to the search for home care services, especially personal care services, but a number of changes are taking place that are likely to offer caregiving families more flexibility in finding assistance. For instance, Medicare patients may now attend adult day services and still receive Medicare-covered home health services, thereby not forcing families to choose between one and the other.

Reimbursements to Medicare-certified home care agencies are being cut, and therefore agencies are rethinking how to meet the needs of clients and stay in business. At the same time, the population is aging and the incidence of chronic illness is increasing. Therefore, there is at least the beginning of grass roots interest and discussion about how to make assistance available to a wider spectrum of people. Pilot projects are underway with government programs to test the concept of consumer-directed care that would allow families to decide what sort of services they need rather than only being allowed to get services that have been pre-determined by government agencies. The Supreme Court's Olmstead decision (June 1999) mentioned on page 13 in this issue of Take Care! is starting to have an effect on the availability of home- and community-based services. With the passage of the National Family Caregiver Support Program last year, Area Agencies on Aging have more money to spend, and some of it can be used to provide respite care.

But while all of this is going on, caregiving families struggle to find home care solutions that work for them-economically, psychologically and logistically. The perfect solution may not exist, or be available, but we must continue to try to create a fabric of support for ourselves and our loved ones. Hopefully, the information in this article will make it a little easier to do.

The following organizations provided the information that made this article possible: American Federation of Home care Providers, Silver Spring, MD; Family & Nursing Care, Silver Spring, MD; Gentiva Health Services, Melville, IL; National Association for Home Care, Washington, DC; and Prime Care Services, Detroit, MI.