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Ecology of Money

How to Vet a Home Care Agency

Contributor John Wasik reviews home care options for the elderly with an eye on pricing and useful resources.

When my father, now 91, was no longer able to fully care for himself, his emerging needs unfolded slowly. At first, we noticed unpaid bills began to stack up, which my younger brother and I took over managing. Then there were other daily details of his life, such as cleaning and eating, that began to deteriorate.

Since my father had no intention of moving into assisted living--he rejected the places we toured--yet couldn't continue to be completely on his own, the third option, which we knew little or nothing about, was home care.

For years, options for long-term care were limited to taking an older relative into your home or placing him or her in assisted living or a nursing home. For working families, the first choice can be difficult, and the second option can be prohibitively expensive.

But as America ages, the home healthcare industry is evolving, providing lower-cost alternatives to residential assisted living. More than one million jobs will be created to meet this growing need through 2020, according to the U.S. Bureau of Labor Statistics.

How can you know if home care is a viable option for yourself or a loved one?

Home Care Basics
There are several layers of home care, and you can order them a la carte. Basic services, such as home cleaning or homemaking, are the least expensive and are a good place to start. More personal services, such as companion care and health aides, perform nonmedical tasks, such as transportation to doctors and checking on medication. The top level of care is skilled nursing, where registered visiting nurses come into the home to provide basic medical services.

How do you know which services to order? Start with a needs assessment before contracting with a home care company. Is the house being cleaned on a regular basis? Is the laundry getting done? Are meals being cooked? Sometimes asking may not provide all the information you need, however.

My father, for example, had stopped cleaning, cooking, and paying his bills. However, he didn't come out and tell me these things; he didn't want me to know that he couldn't live independently, which is all too common among the elderly. I literally had to see the state of his home to realize that he needed immediate help.

What Will it Cost?
The great advantage of home care is that you order what you need, which makes it much less expensive than a senior living facility. The home care agency that I found charged in minimum increments of three hours, which is typical.

Homemaker services, which include "hands-off" tasks such as cleaning and laundry, average around $21 an hour, according to the Genworth Cost of Care Survey. The next level up, home healthcare aides, who provide things like medication monitoring but not skilled nursing, cost slightly more--$22 an hour on average. Compare that to assisted living, which averages nearly $4,000 per month, or nursing homes, at around $235 per day, and your savings by providing in-home services could be considerable.

What you ultimately spend depends upon the medical and personal needs of your loved one, which should be tailored to what they can and can't do by themselves. For acute care that requires tests, intensive treatments and procedures, you'll need to consult your medical care providers. In any case, you need to take your time to involve professionals who can best evaluate what can be delivered in home. Most home care agencies can do this for you, but you'll need to do your own legwork to determine what's needed.

"The types of agencies, array of services and prices they charge varies dramatically around the country," notes Dr. Katy Votava, a nurse, research economist and president of Goodcare.com, a healthcare consulting firm. "These variables differ at the state, region and county level.  Folks are best served by finding local information and referrals to meet the needs or those of the person they are caring for."

Where to Find Home Care Help
The simplest way to begin is to do an online search for home care with your ZIP code. Although this will yield national or franchise firms' ads, it's a good place to start. You can see what they offer and how much their services cost.

When searching for home healthcare agencies, start with Medicare's home health compare. You can search by agency and zip code and receive quality and patient survey "star" ratings.

Another good place to start is Eldercare.gov, which is the federal government's search engine for elder services. You can enter your ZIP code and specifically search for the kinds of services you need, ranging from Alzheimer's care to transportation. You can also contact a professional counselor through the service.

"I recommend that people reach out to the national Eldercare locator service as their first stop to find eldercare resources, including home care information, in every U.S. community," Votava says. "Eldercare locator gives people access to trained professional counselors providing information and referral assistance free of charge."

You can also try OnlyBoth Home Health Agency. You can find agencies by ZIP code and see how they rated in Medicare's quality evaluations.

Note that medical services, which can be covered by Medicaid and, to some degree, Medicare, have much more rigorous licensing and standards than nonmedical care. Most basic home services, unfortunately, are covered out of pocket, unless you qualify for Medicaid, veteran's benefits, or a limited Medicare skilled nursing benefit.

How to Ensure Quality Care
This is where you need to be proactive. You'll need to vet any services or aides carefully. They should have gone through background checks and have bonding, training, and proper certification. National home health agencies do this work for you, but you still need to ask some questions.

Here are some important questions, according to Eldercare Locator:

  • How long has the agency served this community?
  • Does the agency have a current license to practice (if required by the state)?
  • Does the agency offer a "bill of rights" that describes the rights and responsibilities of both the agency and the person receiving care?
  • Does the agency prepare a care plan for the patient (with input from the patient, his or her doctor, and family members)?
  • Will the agency update the plan as necessary?
  • How closely do supervisors oversee care to ensure quality?
  • Does the agency have a nursing supervisor available for on-call assistance at all times?
  • How are agency caregivers hired and trained?
  • How does the agency screen prospective employees?
  • Will the agency provide a list of references for its caregivers?
  • What is the procedure for resolving problems, if they occur? Who can I call with questions or complaints?

Keep in mind though, that not all home care services or aides are equal. Some workers may unreliable, while others may be dishonest. One "caregiver" who approached my father (unsolicited) offered to move in with him to provide care. We were suspicious, and when we asked for references (which she wouldn't provide) and we interviewed her, she was evasive. We never heard from her again.

Also important is to know the limits of home care. While many elderly would prefer to stay in their own home, many can't without 24/7 supervision. When my father's dementia and risk of falling progressed to the point that three shifts of home care aides weren't adequate to ensure his safety and well-being, it was clear he couldn't continue to live at home. At the very least, someone--an appointed family member or professionals--need to closely monitor every home care situation.

Note: This is my last column for Morningstar. It's been a privilege serving the Morningstar community for the past half decade. I wish the best to you in your journey. You can read my archived columns here.

John F. Wasik is a freelance columnist for Morningstar.com and author of 17 books. The views expressed in this article do not necessarily reflect the views of Morningstar.com.