Tips for choosing the right caregiver for your loved ones

A private-duty caregiver, whether professional, friend or family, is someone who helps another person in need. Some of the conditions and circumstances that call for care are:

• An acute or chronic illness
• Recovery from surgery or hospitalization
• Age-related decline
• Dementia or Alzheimer's disease
• Childhood developmental disorders such as autism, cerebral palsy, spina bifida and down syndrome
• Mental health conditions such as depression, anxiety or psychotic conditions

The tasks of caregiving can be simple or complex. Many are expected to perform medical duties for loved ones after discharge from the hospital. Professional private duty caregivers may be prohibited from assisting clients with these medical-related tasks due to state regulations. Here are some of the more common duties:

Activities of daily living are all the tasks that most of us take for granted to get through a typical day. It is not unusual for someone to need help with some of these tasks but not all. Others require maximum assistance with all activities of daily living.

One way to look at ADLs is to consider what your loved ones can do for themselves and what they cannot. For example, if your family member requires assistance transferring safely or meal prep, they could need a caregiver several times throughout the day unless other family members can help.

Vitals checks

Checking vitals is something most professional caregivers can do. They can check blood pressure, temperature and oxygen levels. Other tasks such as diabetic checks or injections, may or may not be allowed by state regulations.

Shopping and cooking

Shopping for groceries and other necessities is a big part of what caregivers can do to improve quality of life and take the stress off you, giving you peace of mind. Good nutrition is a critical component of recovery and continued good health.

Transportation

Most people think of transportation when it is time for a doctor's appointment. Some older adults give up driving (or should) and need reliable and safe transportation to doctor's appointments or to visit friends. Not having to take time off from work and knowing that your loved one will make it to an appointment is a huge relief.

Companionship

Loneliness is a big concern for older adults confined at home. Lack of social contact can contribute to depression and anxiety and worsen symptoms of dementia. Providing companionship is doing more than keeping someone company. They are improving your loved one's quality of life and assisting them to be more independent.

A caregiver can also help an older isolated adult learn technology, opening a new world of social contact and information. They can take someone out to cultural events or the senior center.

Bathing

Bathing can present a safety hazard for older adults with mobility or cognitive problems. They can bathe someone or provide standby assistance.

Dressing

Caregivers assist individuals who struggle with getting dressed and undressed after surgery or due to neurological disorders and general physical decline.

Transfers

Getting in and out of bed or a chair can present a fall risk for people with weak upper and lower body strength — the caregiver assists with safe transfers to a walker or wheelchair.

Hygiene

Hygiene consists of brushing teeth, shaving, bed baths, continence care, hair care and other personal requests for cleanliness.

Toileting

Challenges with getting to the toilet are usually solved by using briefs, but some people choose to get to the bathroom with assistance from a caregiver.

Instrumental activities of daily living are generally considered more complex tasks requiring a higher level of thinking and judgment. There is no hard and fast rule about what constitutes IADLs, but in general, these are the tasks that an independent person can do without assistance:

Communicate

Communication involves the ability to express and understand one's native language. It also entails the ability to access communication devices such as a phone. Caregivers can assist with communication by teaching clients how to use communication devices and sharing important information about physical and mental health needs with the family.

Managing finances

Managing finances requires the ability to pay bills, understand bank accounts and investments, and recognize and avoid scams. Professional caregivers do not manage finances but can help an older adult identify fraudulent behavior.

Home maintenance

Maintaining a home involves ongoing efforts to keep the house clean and free of safety issues. Most professional caregivers will do light housekeeping and minor home maintenance tasks such as changing lightbulbs and informing family members of more serious problems.

Managing medications

Although state regulations prohibit many caregivers from dispensing medications, they can give reminders and monitor medication compliance.

Caregivers work in different senior care industries, and their responsibilities may vary depending on where and who they work for. Training requirements for caregivers differ from state to state, and agencies will dictate training guidelines.

Here are the four main types:

1. Informal caregivers

   Informal caregivers refer to any caregiver that does not work for a company or senior industry. They could be family, friends or people who are referred by someone you know. They can work well for some people, but there is a significant liability in terms of theft, abuse or exploitation.

2. Independent caregivers

   Independent caregivers advertise on sites such as Care.com or Carelinx.com and can negotiate their fees with the customer. Some online sites offer background checks and payroll services. Generally, they make more per hour, and the client pays less than through an agency that has overhead.

3. Agency caregivers

   Most families choose to hire a caregiver through an agency. The reasons? Agencies are licensed, bonded and insured. They will try to replace a caregiver if they quit or call in sick. The downside is the cost, which can be significant if your loved one requires several hours a day of care.

4. Senior living and health care resources

   Without professional caregivers, senior living communities could not operate. By senior living, we mean assisted and independent living, nursing homes and short-term rehabilitation skilled nursing. Home health and hospice also rely on professional caregivers to help with daily living activities. In many settings, they will need to be certified nursing assistants (CNAs) to provide some medical assistance to residents or under Medicare services such as home health and hospice.

Now the hard part. Choosing the right caregiver is part luck but a lot of effort and flexibility. The reality of professional caregiving in the U.S. is that the turnover rate is exceptionally high. In 2021 the turnover rate was 64%.

This means that the great caregiver you hire and want to keep may move on to school, another agency or a higher-paying job. But let us start with the first steps and identify possible challenges along the way.

Step 1: Decide on agency vs. private hire

If your loved one is in senior living, you will not have a choice of caregivers. Most senior living communities are severely understaffed, and you get who you get. However, for home care, the first step is deciding whether you want to hire through an agency, online or informally through referral. Make sure you understand the responsibilities entailed with hiring on your own such as backup, liability insurance and payroll.

Step 2: Interview

Interview prospective caregivers and arrange a meet and greet if possible. With a local agency, they should be happy to arrange for any caregiver to meet your loved one before deciding. But it can be challenging to predict compatibility. If your family member is more of an introvert, they may not want someone who is chatty, but someone outgoing may prefer one that engages more.

Step 3: Identify skills

If your loved one has Alzheimer's, you will want to choose a caregiver with experience working with individuals with cognitive impairment. Learning on the job is probably not a good idea. If, on the other hand, your loved one has several care needs, you will want to know what the caregiver's skill level is in providing baths, transfers and continence care. Ask them if they have additional certifications or training in specific areas.

Step 4: Be flexible

When you find what you think is the perfect caregiver, they quit or are not compatible with your loved one. Unfortunately, this is normal, and you will need to be flexible and roll with the changes the best you can. Remember that if you need several hours of care each week, you will likely be dealing with two or more. At some point, you may need to request a different caregiver, which is your right to do.

Step 5: Determine the financial cutoff point

If money is no object, you can incur the cost of caregiving without worry. However, most people have limited financial resources, and the cost of in-home care could exceed the cost of assisted living. Assisted living might make the most sense despite your loved one's desire to age in place. Talk over the possibility and tour several communities to get an idea of cost based on levels of care.

Finding private duty caregivers will depend on whether you choose an agency, go online or opt for an informal referral system. Some people like the control of finding one by reviewing resumes and choosing someone online. Others prefer the security and reliability of an agency.

Typically, online and informal referrals will cost you less per hour. But other factors affecting cost are the state where you live, how many agency choices you have, and the number of hours of care you need. Genworth estimates the median hourly cost of a home caregiver in 2022 to be $26.78. However, this is only a median estimate, and your costs could be more.

Choosing a caregiver recommended by a friend or neighbor works well for some families but can be risky. You may love the hourly price they quote you but remember you have virtually no protections.

Live-in caregiving can be a reasonable option for families but can get complicated. Agencies often provide live-in caregiver services for elderly family members and must comply with federal regulations regarding the number of hours worked, overtime pay and sleep requirements. What this means in terms of the live-in situation for your family is that you are likely to have two or more caregivers covering so that each has time off.

If you decide to hire a live-in caregiver informally, you are still bound by federal regulations regarding pay and sleep requirements. Do families avoid these requirements? Yes, they do, but the risk of getting sued is not worth saving money or the convenience of not complying with fair labor law requirements.

The other possible live-in situation is for a family member to move in with your loved one to provide care. If they are not being paid, there is nothing for you to do. However, if you or some other family member pays them, you will want to consult an attorney, draw up a contract for services, and determine who will pay taxes.

Medicare has strict requirements for the services they provide to older adults. You either have original Medicare with a secondary or a Medicare Advantage plan. Let's look at each plan and what caregiving services they cover and those they don't.

Original Medicare

Original Medicare does not pay for private-duty home care caregivers under any circumstances. However, if your loved one is in home health, hospice or skilled nursing rehab, the caregivers contracted by the home health agency or rehab are covered by Medicare. But these caregivers can only assist with activities of daily living for limited periods of time. Under Medicare, caregivers cannot shop, cook, clean or provide transportation.

Medicare Advantage

Medicare Advantage plans, also called Part C or MA plans, are provided by private insurance companies approved by Medicare. Medicare Advantage plans have lower premiums but limit your choices. Each plan is different, but some MA plans offer in-home services under specific circumstances. MA plans, like original Medicare, will also cover home health and hospice caregivers.

Now you can see there is much to consider when choosing the best caregiver for your loved ones. Family caregivers provide most of the care for loved ones in the U.S. Finding professional caregiving help can offset the stress and strain of personal caregiving.

To ensure success, take your time, understand the risks and be willing to change course if necessary. Involve your loved one in all decisions and take a compassionate view toward what will be an unpredictable journey.