Finding a Home Aide Can Be a Challenge

EDITOR'S NOTE: This article was originally published in the September 2007 issue of Kiplinger's Retirement Report. To subscribe, click here.

When Richard Foye, of South Newfane, Vt., was looking for a home health aide to live with his 97-year-old mother, he found the search daunting. One applicant was bipolar and admitted that she didn't always take her medication. Another was afraid to stay overnight alone with his mom. Finally, Foye found a caring and capable aide. "It was a struggle," he says.

Care at home can be a lot less expensive than a nursing home or an assisted-living facility, especially for seniors who need only a few hours of help a day. And staying in familiar surroundings can be much more comfortable than living in an institution. That's why the government's Medicaid program and private long-term-care insurance are beginning to cover home care. As Foye learned, hiring an aide is not easy, but with perseverance, it's a manageable task.

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To start, think about the level of help your parent or spouse will need. For the most seriously ill, there are registered nurses, who can manage many complex medical conditions, administer medications and operate sophisticated equipment. At the next level are certified nursing assistants, who have training in first aid and in helping patients bathe, go to the bathroom and transfer from a bed to a wheelchair. For those who don't need skilled assistance, there are companions and homemakers, who may have little or no medical training.

Once you settle on a level of care, decide how many hours of assistance you'll need. Does your mom need someone to come in just a few mornings a week to help her cook, clean or perhaps bathe? If Mom needs constant care, you can hire aides to work 8- or 12-hour shifts. Hiring a live-in aide would be a lot less costly. But you can't expect a live-in to be on call 24 hours a day. If your loved one needs to be turned in bed every few hours, you'll need to use shift workers.

The biggest area of conflict between aides and clients is confusion over what services will be provided, says Susan Rogers, president of Capital City Nurses, a home-care agency in Chevy Chase, Md. For instance, families often expect aides to administer medications. But in most states only nurses can dispense drugs. "We define those expectations right up front," Rogers says.

Navigating the Aide Maze

You can hire an aide in one of three ways. The simplest but most expensive option is to hire an employee of a home-health agency. The agency will take care of the aide's withholding taxes and any benefits, and it will find a fill-in on days your aide cannot come. The agency may also provide insurance and arrange ongoing training. In many cities, the going rate is $20 an hour for a certified aide who is an agency employee. A registered nurse will likely cost twice as much.

A second option is to hire an independent aide through home-health agencies called registries. These firms act like an old-fashioned hiring hall. They may check aides for competency or a criminal record, but the level of screening differs by firm. Aides hired through a registry may cost an average of $15 an hour.

To find a good agency, check with a local information-and-referral service. (You can find a service through the Alliance of Information & Referral Systems at www.airs.org.) The federal government's HomeHealth Compare at www.medicare.gov provides broad quality ratings for Medicare-approved agencies. But Medicare itself will only pay for very limited home care after a hospitalization.

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Call several companies, and ask many questions. How long has the firm been in business? Is the firm insured? How does it handle complaints? Most important, you'll want to learn all you can about the individual aide you are getting.

You can save money by hiring an aide on your own. You may find one through a newspaper ad, an online service such as Craigslist.org or a friend. You'll negotiate your own price, but expect to pay about $10 to $12 an hour. If you go this route, you will be an employer. You'll have to pay Social Security taxes, check references and make sure that an immigrant worker has a green card.

If you have long-term-care insurance, read the policy carefully and contact your agent. Some policies will only reimburse you if you hire through an approved agency. Medicare and Medicaid, which pays for long-term home care only if you meet strict income and asset tests, may also require you to hire through an approved firm.

Before choosing an aide, conduct an in-home interview. Most reputable agencies will conduct a formal assessment of your loved one's needs either by phone or by sending a registered nurse, along with the prospective aide, to the patient's home.

Ask the aide about his or her experience. If Mom has dementia or other special needs, see if the aide has cared for such patients before. Find out if the agency or the aide has malpractice insurance. Who will cover if the aide is out sick or takes a few days off?

After you hire someone, prepare a daily schedule of duties, so that expectations are clear. Visit frequently, and at irregular times. See that the house is clean, that the refrigerator is full and that Mom is doing well -- that she's up and dressed (if that is possible) every morning. If she is confined to bed, check for bedsores. Have the aide keep a log of what she does each day.

Many aides are immigrants. Some may speak English with a heavy accent, and if Mom has difficulty hearing, communicating can be a challenge at first. But if the aide seems caring and competent, give it a few weeks. You'll be surprised at how well they'll be able to work things out.

It is crucial that you communicate with the aide. If an aide is doing a good job, offer your thanks. If there are problems, talk about it. Sometimes an aide is capable, but personalities can clash. You can ask an agency to send someone else. Remember, this is a difficult situation for everyone. A little patience can go a long way.