I want to Stay in my Home – In-home Care

This week’s blog continues the discussion of an aging adult who wants to stay in his or her home.  The introductory installment (on February 11, 2016) discussed the emotional turmoil that can face the adult children in deciding whether to accede to the aging parent’s wishes to stay home.  The February 18, 2016 installment discussed home modifications that may make it easier for an aging adult to stay home.  The February 25, 2016 installment discussed medication management.  Today’s installment will discuss hiring someone to help with activities of daily living.

When an older adult is no longer able  to perform the routine daily tasks that he or she could easily perform when younger, it is time to consider how to help the older adult.  The routine daily tasks that people who work with seniors usually considers are:

  • bathing,
  • grooming,
  • toileting (including bladder and bowel control and cleaning up afterward,)
  • moving around (often broken down into “transferring,” meaning the ability to get into and out of bed or a chair, and “ambulating,” meaning the ability to walk around,)
  • eating (not cooking, but the actual ability to put food into one’s mouth,) and
  • dressing.

These “activities of daily living” or ADLs are crucial in allowing someone to maintain health and hygiene.  When someone has trouble carrying out one or more of these activities, it is time to figure out how the family can make sure that the senior gets help performing them.

Someone who is trying to stay in his or her home but is having difficulties with one or more activities of daily living can hire help.  Professional caregivers are available who will help someone with these activities.  Such caregivers can be found through a commercial home care agency, and there are many such agencies.  Such caregivers can also be hired directly by the aging senior or by his or her family.

Commercial home care companies can be expected to provide oversight of the caregivers as well as to manage the business relationship with the caregiver.  The caregiver should be an employee of the company, so the company handles insurance, bonding, payroll, taxes, and accident liability.  The actual person who acts as caregiver may change from time to time.  Commercial home care companies are currently watching a Department of Labor proposal that would force higher pay for the caregivers because of the application of rules on length of the work day and overtime pay.

When the older adult or family hires the caregiver directly, the adult or family must manage payroll and taxes.  The adult and family takes the risk that the caregiver is not up to the task of providing care or is not trustworthy.  Admittedly, many (maybe even most) directly hired caregivers are friends (especially church friends) willing to help out.  In addition, much of the pay for directly hired caregivers is done “under the table,” without proper tax and payroll compliance.  (I cannot recommend such an evasion of tax and labor laws.)

For some older adults, the Medicaid program and/or the Veterans Administration’s Pension (more commonly called Aid and Attendance) program can help pay for such home care services.

Please note, despite what TV shows and literature, these home caregivers are rarely nurses.  They may be most often called home health aides.  Nurses provide medical care (in the way that “medical” is used by hospitals, doctors, and health insurance companies.)  Home health aides provide more personal care or “custodial” care.  Nurses in the home are more highly paid priced than aides, but their costs are usually covered by Medicare and health insurance.  Home health aides are paid less than nurses and are rarely covered by insurance (other than long term care insurance.)

(As an aside, I try to call nursing services “skilled care” and call home health aides “non-skilled care.”  I do not want to imply that home health aides are not skilled.  They are great!  Often, people who work with seniors call them “medical home care” and “non-medical home care.”  I try to avoid the “non-medical” label because of the rules for VA Pension.

The VA Pension program covers “medical” costs for certain veterans and surviving spouses of certain veterans.  The rules for VA Pension defines “medical” costs in a way that includes the services of home health aides.  Some of my friends who help with VA Pension applications have encountered difficulties with the review of applications if the home care provider describes itself as a “non-medical” provider.  (This description has most often been in the letterhead of the care provider.  The VA sees the letterhead because the paid care provider must provide a letter explaining the services that it provides or the Pension applicant.)  A reference to “non-skilled” care does not seem to trigger the same difficulties in the application process.)

If the older adult has funds available to pay for home care services and is willing to accept a “stranger” coming to the house, home care support can allow the older adult to stay in his or her home.

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