October 28, 2010
What is a home care aide?
At-home caregivers generally fall into three categories: certified nursing assistants, home health aides, and personal care attendants. Certified nursing assistants (CNAs) have some medical training and must pass an exam to get a license. They generally work under the supervision of registered nurses. CNAs can check vital signs, care for wounds, and help with everyday activities such as bathing and eating (you'll often hear these referred to as "activities of daily living," or ADLs).
Home health aides generally assist with ADLs. And personal care attendants (PCAs), also sometimes called personal companions, assist with household chores like cooking, cleaning, and shopping. The job descriptions of these caregivers can overlap considerably, and they're often referred to interchangeably.
Your first hiring decision: agency versus independent
Hiring a home care aide through the classifieds or word of mouth is usually the least expensive option. But you should know that it might create unexpected liabilities for your family, which legally becomes the employer. For example, you'd be held liable for any costs related to an injury that happens on the job, including medical expenses and disability payments. This may not apply if you hire your worker as a contractor, but having a "freelance" aide rather than an employee may not create the long-term solution you're hoping for -- high turnover plagues this industry. That said, hiring someone on your own can be a good idea if you have a personal connection or a strong endorsement from a friend.
If you hire an at-home caregiver through an agency, hourly rates tend to be higher (often significantly higher), but the agency will pay the FICA taxes, cover the worker's liability insurance, and fill out the W-4 and W-2 forms. "Once you factor in taxes and insurance, it really comes out to close to the same price," says Jacqueline Dollar, a geriatric care manager in Des Moines, Iowa.
Also, because an agency has a stable of caregivers, you might be able to try out a few and find just the right aide for your situation. "With an agency, you also have the right of refusal," says Anita Silverman, a geriatric care manager in Lake Worth, Florida. "The agency can replace the person if the arrangement doesn't work out." An agency may be able to provide a substitute caregiver if your primary home aide is out sick or on vacation, which can save you a lot of frantic last-minute phone calls.
Keep in mind that agency caregivers are bonded and insured, and they're trained in the basics of care. They often have training in CPR and first aid, as well. Agency employees are expected to abide by an ethics policy and company rules. And agency CNAs may also have nurses checking in on them to make sure all is well and to offer advice.
If you live far from where the care will be needed, or don't want to get involved with supervising an at-home caregiver day-to-day, an agency can be a good option for your family.
Finding a gem of an at-home caregiver
Whether you choose to hire independently or go through an agency, doing some homework on your candidates will help ensure that you hire a reputable worker.
An excellent way to find a high-quality agency is Medicare's new Home Healthcare Compare tool, which allows you to search for agencies in your area that have met with Medicare's approval. The site gives a summary of statistics on the quality of each agency, such as "percentage of patients who get better at walking around," that you can use to guide your decision.
Also look for an agency that's licensed (if state law requires it) and that has liability insurance. Check to make sure the agency's caregivers are bonded and insured.
If you hire someone yourself, it's a good idea to find an individual who has (or who once had) a home health aide license, so you know a registered nurse has trained the person in the basics of care. Also get a criminal record check from a service such as Intelius or SentryLink and always call references. There are always a few bad apples who'll take advantage of vulnerable clients -- make sure you don't unwittingly hire one. "If the person doesn't want to submit to a reference check, that's not the person you want -- it's a big red flag," says Dollar.
It's important to find an at-home caregiver your family will be comfortable with. When you're interviewing caregivers, include your parents (or whomever will need the care) and make sure they interact well with the aide. Do they communicate well with each other? Are there language barriers? Do your parents enjoy the person's company? "Having shared interests can make a big difference," says Dollar. "One of my clients loved NASCAR and found a home health aide who did, too. They immediately hit it off."
Navigating the paperwork
If you choose to hire an at-home caregiver independently, the first thing you need to decide is whether to treat the person as an employee or as a contractor. If you hire an employee, you'll be legally responsible for paying taxes and benefits such as Social Security and Medicare (FICA), income tax withholding, and unemployment tax. Payroll preparation agencies such as Paycycle and SurePayroll can help you with the accounting and paperwork.
If you hire the worker as a contractor, you'll still have to file a 1099 form with the IRS on any wages you pay over $600 per year. However, the aide would be responsible for paying her own taxes. If you choose to hire independently, you may want to consult a lawyer and an accountant to make sure you're meeting your legal and financial obligations to the employee and to the state and federal governments.
Forming a tag team
If your parents or other family members need full-time care, you'll need to hire at least two caregivers. Nobody wants to work seven days a week, complications will arise in any aide's schedule, and turnover is really high in this field. Also, if you hire two at-home caregivers, they can trade off and you can protect yourself from being left in the lurch with no help. One way to ensure a smooth handoff is to schedule a half hour of overlap between their shifts so that they can debrief each other on any issues that may have come up during the prior day or shift. If they work on different days, ask them to keep notes in a designated notebook about changes in routine or any concerns.
If you hire the caregiver through an agency, ask about backup provisions for when your aide is sick or on vacation -- or if he or she quits the agency. Does the agency provide an alternate? Is there an extra charge for this service?
Setting clear expectations
"One big mistake people make when hiring an aide is to say, 'Your job is to take care of Dad,'" says Dollar. "That's not good enough -- you need a detailed job description." Do you expect the aide to cook? Clean? Do laundry? Pick up medications from the pharmacy and run errands? Will she bring her own lunch or cook and eat with your parents? Make your expectations clear. It's also important to tell the aide when her routine evaluations and raises will occur. If you put all these details in writing, you won't run the risk of disappointment once you've hired your aide, and you'll have better luck keeping her on board.
"You should also enlighten your parents or other family members about what they should -- and shouldn't -- be asking for," says Silverman. If the contract doesn't say the aide will wash the floors, don't expect it.
Setting clear rules about food and cooking is also important, says Silverman. "One problem I often see is that the way the aide eats may not be the way the parents eat. You need to make sure an aide will shop and cook for your parents' dietary needs, not according to her own habits."
Keep in mind that aides are employees; don't try to make them your friends. "People are so happy to have help that they often treat the employee like a friend, and that creates problems down the line," says Dollar. If your employee thinks of herself as your pal, she may be more likely to take liberties such as bringing her kids or pets to work, or she may bridle when you assert your authority and request a change. The bottom line: Keep it professional.
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