Getting Care at Home – How to Find and Pay for it

As I get older I find that there are many fine attributes of aging. (Personally, I think wisdom is one of them - though my children seem to disagree).  Unfortunately, aging also increases our risk of frailty and illness and advances the potential that we may someday need the assistance of others to help us be able to remain at home.

Most seniors who need help with their daily care needs are able to live at home, either in their own home or that of a close relative. Their care needs are most often met through the unpaid help of family members. An estimated 16 percent of American adults, or 33.9 million adult caregivers, provide unpaid care to a recipient age 50 and older. (National Alliance for Caregiving Report, Caregiving in the United States).

According to a 2011 survey by the National Caregivers Association, more than two-thirds of caregivers are 45-64 years of age, nearly one-half have household incomes less than $40,000 and about one-third are employed full time. A typical caregiver is a married woman in her mid-forties, who provides 20 hours of care-giving per week, often while working full-time.

Despite the love, sacrifice and often heroic efforts of family, there may come a time when a care recipient’s needs overwhelm the unpaid family caregivers. The family may have to look to supplement the care it can provide with paid assistance. 

A family seeking paid in-home help to care for Mom or Dad faces a complicated array of issues and options.  Where do you start?  How can you find quality help?  How are you going to pay for it?

Assessing Needs

An early step should be to assess the situations of the senior and the family caregivers, and create a realistic plan. You may wish to seek the advice of the care recipient’s physician, and seek help from your local Area Agency on Aging (AAA). The government-funded AAAs will provide a care manager at no charge to assess the senior’s needs and help create a plan to provide in-home services. A listing of Pennsylvania AAAs by county is available here and at the Department of Aging website: www.aging.state.pa.us.

If the care recipient is being discharged from a hospital, limited discharge planning assistance should be available from the facility. In some localities, a private geriatric care manager (GCM) can be hired to help assess an older individual’s needs, create a care plan, and locate the assistance required to implement the plan.  Unfortunately, GCMs may be unavailable in more rural areas.

Finding caregiving services that are suited to your needs is complicated and requires thought and research. You can start by making a listing of which types of services will be needed. In searching for home care providers consider the level and quality of care they can provide, their availability and ability to provide the services you need, their training and experience, and how to pay for the care.

Finding Paid Caregivers

Once you have assessed needs and created a plan, the next step is to locate individuals and companies who can fill those needs. In some cases you will need to decide whether to try to hire help yourself or go through an agency. 

The main advantage of handling this task yourself is that privately hired caregivers are usually less expensive.  And you have the flexibility to hire family members or friends who are already known by the senior. But if you hire the home care worker yourself, you are responsible for the burden of dealing with employment rules and taxes. In some cases families choose to pay caregivers illegally “under the table.” This is not recommended.  

If you need help in locating paid caregivers, you may turn to either a home care registry or a home care agency. Both home care registries and home care agencies help supply families with paid caregivers who care provide “unskilled” assistance with needs such as:

• Assistance with self-administered medications

• Personal care such as assistance with personal hygiene, dressing, and feeding

• Homemaking such as assistance with household tasks, housekeeping, shopping, meal planning and preparation, and transportation

• Companionship

• Providing a respite for unpaid family caregivers

  

Registries are a kind of “matchmaker” that provide a list of names of people interested in providing home care services. The registry is typically paid a fee for its services but does not employ or supervise the worker. Those responsibilities remain with the family.  If you use a registry it is important to note that the workers you hire are subject to employment taxes for which you are responsible.  You may need an accountant’s help to set up your books. 

Home Care Agencies differ from registries in that agencies directly employ the care workers. This can free the family from bookkeeping and tax responsibilities and generally makes life easier for the family. Agencies handle all of the paperwork involving payroll and related taxes. The agency will find the workers, screen them, and monitor their work. If an agency offers a full range of services, the care may be better coordinated and more comprehensive. An individual care worker’s sudden unavailability can be better managed, since the agency can fill the gap.

In Pennsylvania, home care registries and agencies are both licensed by the Pennsylvania Department of Health and are subject to regulations.   

Although the names are confusingly similar, Home Health Care Agencies (also known merely as “Home Health Agencies”) are different from home care registries and home care agencies. A Home health agency can deliver skilled care like nursing, physical therapy, and occupational and speech therapy, along with unskilled assistance. Importantly, Medicare, Medicaid, and your private insurance plans may pay for services that are provided by a licensed home health agency. Payment will depend on whether the care is medically necessary and you meet qualification criteria. You may opt to pay out-of-pocket for services that are not covered by other sources. 

The Pennsylvania Department of Health website has a complete listing of licensed home care registries, home care agencies and home health agencies in each county: http://app2.health.state.pa.us/commonpoc/content/publiccommonpoc/normalSearch.asp

Your local Area Agency on Aging (AAA) may also be able to help the family locate and retain the services of paid caregivers.  Find a list of Pennsylvania AAAs here.

Paying for Care    

Seniors needing home care assistance can use private funds to pay for the care. Some commercial insurance policies may help with the cost of care. Some specialized “long term care insurance” policies specifically designed to pay for long term care may cover some home care costs.  But few seniors currently own this type of policy. 

Reverse mortgages may also provide a funding source for private payment of home care. A "reverse" mortgage is a loan against your home that you do not have to pay back for as long as you live there.

There are many publicly funded programs that may also help families pay for needed care.

Medicare – This program has some home health care coverage which can be of importance to seniors who require skilled care at home. Home health agencies are very familiar with Medicare and can help the senior qualify for any available benefits. The recipient must be homebound and require skilled care which is ordered by a physician. The official U.S. government booklet about Medicare home health care benefits for people with Original Medicare is available here. 

Medicaid – Medicaid is an increasingly important source of payment for home care for seniors. In addition to the services provided under regular Medicaid, Pennsylvania’s Aging Waiver program can provide home care to individuals over age 60 who would otherwise require institutional care in a nursing facility.  For those who qualify, there are no co-payments. Your AAA will have information available about the Aging Waiver and an elder law attorney may be able to help seniors qualify for Medicaid Aging Waiver benefits. 

Veteran’s Benefits – Unfortunately, these benefits are often overlooked. Older veterans (and the spouses of deceased veterans) may qualify for VA pension benefits even though they don’t have a service connected disability.  Benefits are increased if the veteran is homebound or in need of the aid and attendance of another person.

Office of Aging – several additional programs like Pennsylvania’s Caregiver Support program are operated through your local AAA. 

A combination of unpaid family care supplemented by privately or publicly paid services can allow a frail senior to remain in the home for as long as possible.  Publicly funded programs often have financial qualification limitations.  A knowledgeable elder law attorney can often help the senior find out about programs and meet qualification requirements.