New York Times; December 23, 2008

Home Health Aides: Why Hire From an Agency?
By Jane Gross
This is the first of a three-part series on home health aides, to be run on consecutive Tuesdays at The New Old Age.
Living out their lives at home, rather than in an assisted living center or a nursing home, is the overwhelming preference of the elderly and their adult children. Remaining at home often means hiring, paying for and supervising aides to help with shopping, cooking, bathing, dressing, eating, toileting and medication management.
This can cost upwards of $150,000 a year for someone who needs 24/7 assistance that is custodial, rather than medical, and thus not covered by Medicare, the universal health care system. Medicare pays for doctors, hospitalizations, surgery, diagnostic tests and medication for those 65-and-over — but not for what is commonly known as long-term care.
Only the impoverished elderly, in some states, are protected from this huge expense by Medicaid, a means-tested program that increasingly is looking for ways to pay for care at home. Medicaid has traditionally paid for care only in skilled nursing facilities, but patients’ preferences and the greater cost of institutional care are driving the trend toward home care coverage.
Marki Flannery of Partners in Care, part of the Visiting Nurse Service of New York. (Janet Charles)
The Visiting Nurse Service of New York is the nation’s largest not-for-profit provider of home health care. Some of the costs are covered by Medicare and Medicaid, and some by patients and families themselves, either directly out-of-pocket or with long-term care insurance policies, which themselves can be very expensive. These private-pay patients and families are clients of Partners in Care, an affiliate of the Visiting Nurse Service of New York that is run by Marki Flannery.
I asked Ms. Flannery to explain to our readers the value of hiring home health aides through a licensed agency, like Partners in Care, rather than in the so-called “gray market,’’ an over-the-back-fence approach that is far less expensive because there is no middleman, so to speak, but that lacks the protections and supervision provided by an agency.
Ms. Flannery also shares with us her advice on choosing an agency, determining the most economical set-up under the agency framework, what agency aides are paid and what you will pay for them. She will also address why agency adies are restricted in ways that gray market aides aren’t, how to insure a good working relationship and what the future holds for her industry as more and more people live longer and longer.
Today, she will talk about the reasons for using an agency and how to choose one. Her answers to other questions will follow, in posts on Tuesdays over the next two weeks.
Q. Why should someone hire a home health aide from an agency instead of hiring a person recommended by a friend?
A. There is a list of things people consider when they are faced with the need to hire a home health aide to help take care of someone. The list isn’t always in the same priority order, but the items on it are pretty much the same.
For most of us, that list includes:
Cost: What will I have to pay for each hour of care?
Flexibility in the job description.
Loyalty of the employee to me.
Consistency, meaning the same person comes to the home day after day.
Security: Can the person be trusted to do the right thing?
Expertise: Does the person really know how to provide the care he or she is being hired to give to my elderly parent, or my husband or wife?
It is possible that, through your personal network or through an ad you place in your local newspaper, you might find a person to work for you who is the solution to your needs. Many people — even people who work in the health care industry — go that route. Notice I say that you might find a person to work for you, but you aren’t going to find a certified home health aide. You probably aren’t going to find a person who has actually received formal training to do the job you need him or her to do.
And that right there is the difference between hiring a stranger recommended to you by a neighbor and hiring a home health aide who is part of an organization whose business is to properly train home health aides and send them to you when and where you need them, every day. Even more so, we are talking about an organization that is in the business of providing care to you for the long term, as your needs increase and the medical situation gets worse, which is often the case.
It’s sort of like getting an electrical problem fixed in your home. You can hire an unlicensed electrician to do the rewiring. The lights may work, but if you have all the lights on, plus the toaster, and the hair dryer, are you at risk for a blackout? Or worse, an electrical fire? Maybe. Maybe not. But would you take that chance on yourself and your family?
Let’s talk about the list and the things you should consider.
If the only thing you are concerned about is how much you are going to pay per hour, you certainly might be able to negotiate a better deal by hiring someone who used to be a nanny to now provide care to your 85-year-old mother. Hourly rates for this kind of babysitter vary across the country — in New York City, the going rate is about $12 per hour. Hiring a certified home health aide from Partners in Care is going to cost $18.50 an hour in New York City. So is an additional $6.50 an hour worth it to you?
Well, to answer that question, you have to answer some other questions that address the rest of the items on that list:
Will the home health aide be caring for someone with a diagnosed medical condition?
If my mom hates the person I hire, can I quickly find a replacement — or even a replacement for the replacement?
If this person calls in sick or plans a vacation, am I able to work from home to provide care?
Can I trust this person to do the food shopping for my dad and only buy what he needs and not extras?
Am I worried that my mom might fall and break her hip — again — and then need to be hospitalized, or do I have an aide who is trained to prevent falls?
What is the chance that my situation becomes one of those awful newspaper stories of “elder abuse” or financial fraud?
If my dad’s condition worsens and more medical attention is needed, can I get a registered nurse to come to the home? To talk directly to his doctor? To arrange a plan of care?
And finally: Do I need help understanding the health care system in this country and who pays for what?
I am the president of a licensed home health care agency and have been in this business for more than 25 years. So, there is no doubt in my mind that the best answer to each of these questions comes when you hire professionals. Time and time again, we’ve seen people start with the babysitter approach and wind up with a catastrophe that costs more and causes harm to loved ones. But we know the informal workforce will always be there — even more now as jobs are harder to find and to keep.
The equation for you is about risk and return. A licensed home health care agency won’t beat the cost on an hourly basis, but if all you are considering is dollars and cents then the risk factor in your equation has just increased. However, considering all the other items on the list will increase your return.
Licensed agencies can find substitutes or replacements for you so you never have to miss a day of work or skip an evening out with friends.
Licensed agencies are in the business of satisfying you, the customer. They don’t want to lose you, so they will work very hard to accommodate your needs.
Licensed agencies offer you the same home health aide day-after-day, provided that is what you want. Licensed agencies work to make the match between you and the home health aide as perfect as possible — so the needs of the patient are understood, the right language is spoken, the right foods can be cooked and the right respect for customs and preferences is shown.
Licensed agencies assign a registered nurse to each patient, and that nurse supervises the aide, monitors the patient’s condition and medications, confers with the physician and is an information resource for you.
But perhaps most importantly, licensed home health care agencies provide you with highly trained expert aides who know how to do their job well before they enter your home. They don’t learn at your expense. Our aides, for example, have been thoroughly interviewed and screened, have had reference checks, and have spent more than 114 hours learning the skills to provide quality care to the people you love. One hundred and fourteen hours of training is a lot of training. And our home health aides have “refresher” training each year.
Q. What factors should we consider when choosing among the different home health care companies?
A. If you have decided to hire a licensed home health care agency to provide a certified home health aide to help you care for your elderly parent, your next logical question is which home health care agency should you hire? Likely, you will ask yourself questions such as: do they all offer the same services; do they all charge the same prices; does one have a better reputation than another?
Part of the answer lies in understanding that there are for-profit home health care agencies and not-for-profit agencies. The biggest difference between those two types of organizations is how they make business decisions. For-profit companies often select the kind of cases that will make them the most money and turn away other cases. Or, they don’t employ certified home health aides at all. Their people are not trained to do the same things for you as are certified aides. A not-for-profit agency doesn’t turn away cases. At Partners in Care, we take short-term cases and long-term complex cases, and we staff them properly to match your needs.
It is also important to learn about the full set of resources that a home health care agency can offer you because health care situations can change overnight. Partners in Care is part of the Visiting Nurse Service of New York, the country’s largest not-for-profit certified home health care organization.
So, if your elderly mom’s condition worsens and care is needed that will be covered by Medicare, we coordinate that care so your mom gets the medical attention she needs and Medicare covers the cost. Or, if your mom needed care that was initially covered by Medicare but now her condition has improved and Medicare will no longer pay, you can transition your mom to care you pay for privately while keeping the same home health aide.

An appreciation
By Sara Myers

Definition, caregiver: A person with knowledge of, the patience for, and an interest in taking care of old or disabled adults and who does so with kindness and compassion. Not everyone who takes care of an old or disabled adult is a caregiver.

It’s bad form to say to a caregiver, “I don’t know how you do this job. I could never care for demented people.” That kind of comment belittles the work and disrespects the caregiver. However, the truth is, I am constitutionally ill suited to spend my day with demented people. Miraculously—and fortunately for all of us—lots of fine men and women find satisfaction in sheltering, supervising, and protecting human beings who are unpredictable and often bizarre and combative.

A couple of days ago I visited Gaffney House, my mother’s assisted living facility, and walked in to find Ula swinging away at Ashu, who was trying to get her to sit down in a chair. It’s entirely possible that Ula was a friendly person before contracting dementia, but maybe not. Maybe she has always been a bitch, as my mother calls her. My mother never called anyone a bitch before she became demented. That’s the unfortunate deal with dementia: it seldom improves one’s behavior or outlook. (Below: Gaffney House caregivers Amelewrk, left, and Ashu, right.)

If I had the power, I would declare a National Caregiver Day in honor of every caregiver who accompanies and shepherds demented people through to the end.

By Sara Myers
A Good Enough Daughter Blog

Home care services can be paid for by:

patient and family
public third-party payers such as Medicare, Medicaid, and the Veterans Administration (VA)
private third-party payers such as health insurance companies and managed care groups
For most home care to be covered by public and private payers it must be considered medically necessary. You must also meet certain coverage requirements. Different private insurance plans have different policies, and you may need to call them to find out about what they cover. Medicaid coverage varies based on the state where you live.

For services that are not covered by insurance, you may choose to pay out of your own pocket. Some agencies receive money from community groups or local and state governments to help patients pay for their care when they have no other way to get it. With support from donors or charitable groups, some agencies provide care to all that need it, whether or not the patient is able to pay.

Public Third-Party Payers

To qualify for the Medicare Home Care Benefit: Most Americans over age 65 are eligible for the federal Medicare program. Some people under the age of 65 may be eligible due to disability. To qualify for home care, a person with Medicare must meet all of the following conditions:

Your doctor must decide that you need medical care at home and make a plan for your care at home.

You must need at least one of the following on a part time or intermittent basis: skilled nursing care, physical therapy, speech-language therapy, or occupational therapy.

You must be homebound and generally unable to leave the house without help. To be homebound means that leaving home takes a good deal of effort, although leaving home for medical treatment or occasional short non-medical trips (such as for haircuts or religious services) do not usually disqualify you.
If you meet all the above requirements, you may be eligible for services provided by a Medicare-certified home health agency. Depending on your condition, Medicare may pay for:

skilled nursing visits
physical, occupational, and speech therapies
medical social services
medical equipment and supplies
If one of these skilled services is required, home care aide services may also be provided as part of home care for the illness.

The doctor who refers you for home care must authorize and perform a regular review your plan of care. Except for hospice care, the services you receive must be part-time and provided through a Medicare-certified home health agency in order to qualify for payment. For more information on Medicare and home care, you can order the booklet, Medicare and Home Health Care by calling 1-800-MEDICARE (TTY call 1-877-486-2048). The booklet contains a checklist to help you choose an agency and a second checklist to help you evaluate its quality.

Not all home care agencies are certified to provide care to people with Medicare. Those that are certified have met federal minimum requirements for patient care. This allows them to provide home health services to patients covered by Medicare and Medicaid. Due to legal requirements, the agencies must report to Medicare, and their services are watched and controlled.

Medicare also covers hospice services for people with cancer who are expected to live for 6 months or less. For hospice coverage, you are not required to be homebound or in need of skilled nursing care. Call 1-800-MEDICARE or visit their web site (see Additional Resources section of this document) to find out more about the Medicare Hospice Benefit.

To qualify for Medicaid coverage of home care: States are required to provide health services to individuals who receive money from federally assisted income programs, such as Social Security and Temporary Assistance for Needy Families (TANF). The TANF replaced Aid to Families with Dependent Children (AFDC) as a result of welfare reform legislation (The Personal Responsibility and Work Opportunity Act of 1996).

Others who may qualify for Medicaid help include “categorically needy” people. These are people who meet the income and resource requirements for TANF but who are not getting it (for example, certain children under the age of 21, and some elderly, blind, and disabled persons whose income is below certain levels).

Under federal Medicaid rules, coverage of home health services must include part-time nursing, home care aide services, and medical supplies and equipment. At the state’s option, Medicaid may also cover audiology (hearing services); physical, occupational, and speech therapies; medical social services; and hospice.

Department of Veterans Affairs: Different types of services are available in different areas of the United States. Most Veterans Affairs (VA) regions pay for skilled home care (SHC) and hospice, although the VA may not directly provide these services. The veteran must be referred by a VA doctor and meet medical requirements to qualify for skilled home care or hospice. The Social Services department of your local VA medical facility will be able to answer questions about eligibility in your area.

Older Americans Act (OAA): The OAA provides federal funds for state and local social service programs that help frail and disabled older people to remain independent in their communities. This funding covers home care aides and personal care, household chores, escort, meal delivery, and shopping services for those aged 60 and older with the greatest social and financial need. These services are often provided through a local area Agency on Aging. The OAA was recently reauthorized by Congress from 2006 through 2010. At that time, the OAA must report to Congress before it is authorized again. To find your local Agency on Aging, you can contact the National Association of Area Agencies on Aging (see Additional Resources section of this document).

Social Services Block Grant Programs: Each year states receive social services grants from the federal government. Part of the money is usually used for programs who offer home care aides and homemaker services. Patients can contact their state health departments or local area Agency on Aging to learn more (see Additional Resources section of this document).

Community organizations: Some community groups, along with state and local governments, provide funds for home health and personal care. Depending on a person’s eligibility and financial circumstances, these groups may pay for all or part of services. Hospital discharge planners, social workers, local offices on aging, the United Way, and your American Cancer Society are excellent sources for information about what’s offered in your community.

Private Third-Party Payers

Commercial health insurance companies: Most private insurance policies include some home care service for acute, short-term needs, but benefits for long-term care vary from plan to plan. Be sure to inquire about your insurance coverage not only for home care but also for home hospice care.

TRICARE standard: Previously known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), TRICARE covers home care services on a cost-shared basis for dependents of active military personnel and military retirees, their dependents and survivors. TRICARE offers hospice benefits that cover nursing, social work and counseling services, personal care, medicines, and medical supplies and equipment.

Managed care organizations: These group health plans sometimes cover home care services. Managed care organizations that have contracts with Medicare must provide the full range of Medicare-covered home health services available in a particular part of the country. Coverage may be limited to doctor-directed medical services and treatments. Your choice of agency, however, is restricted. Be sure to inquire about your plan’s specific coverage. If you have problems with a Medicare Health Maintenance Organization, you can call the Medicare Rights Center at 1-888-466-9050 to appeal.

Private pay or self-pay: If insurance coverage is not available or does not cover all that is needed, you and your family can engage providers and pay for services out of pocket.

theHomecareDirectory.com

A Caregiver by Beth Witrogen McLeod
Taking care of an aging parent can cause fatigue, stress, even depression. But you can find help — if you know where to look.

Ten years ago, Margo Aparicio rescued her widowed mother, Genevieve, from near death because of a neglectful aide. Although she did it out of love, Aparicio never imagined the toll caregiving would take on her health and emotions.

Genevieve suffered not only from diabetes, incontinence, and dementia but also severe emotional problems: She needed to know that someone cared. So Aparicio relocated her mother from 150 miles away into an apartment above her own in San Francisco. For four years, Aparicio bathed her mother, fed her and cleaned up after her, while also working full time. Then depression descended — without warning. “I would wake up realizing my day was going to be nonstop horrific with no relief in sight,” says Aparicio, 45. Soon, Aparicio grew so depressed she became isolated and angry. “When I found myself screaming at my mother and blaming her, I realized I needed help.”

Aparicio is not alone: A new survey from the National Family Caregivers Association shows that the number of persons who provided care for an elderly, disabled, or chronically ill friend or relative during the past year is more than twice as large as had been previously thought. Survey results indicate 26.6% of the adult population was involved in caregiving during the past 12 months. That translates to more than 54 million people.

Most caregivers are women, many of whom also juggle work and child care. Some do the occasional grocery shopping for their aging parents; others provide round-the-clock care. And although most of these women have taken on this role willingly, the unrelenting demands exact a high toll. Some 60% of caregivers say they experience depression, according to an earlier survey by the National Family Caregivers Association. The rate is even higher — up to 76% — among those caring for loved ones with dementia, such as Alzheimer’s disease.

The price of such depression and burnout is high both for the caregivers and their aging parents. Caregivers suffer more stress-related illness than others their age, according to the association. And, ironically, burnout is the leading reason caregivers say they eventually put their loved ones in nursing homes.

But there is good news. Experts say family caregivers can often protect themselves from depression — if they recognize the signs and seek support.

The greatest danger to health is in ignoring the warning signs of depression, says the National Mental Health Association. Their experts advise caregivers to watch for feelings of persistent sadness, anxiety, or fatigue. People suffering depression often feel guilty or worthless and have difficulty concentrating.

The key to prevention is realizing that you are not alone and you should not try to take on this responsibility alone. “This is the other mid-life crisis, but there’s a lot of good help out there,” says geriatric social worker Joan Booty. “There are community resources and support groups — people have a huge ability to help one another.”

Booty recommends caregivers call their county’s Area Agency on Aging for information and referrals to local programs, such as Meals-On-Wheels, adult day care centers, in-home health aides and transportation assistance. Some programs will even help caregivers with home repairs or offer friendly visitors who stop by occasionally. Hospital discharge planners, doctors, and nurses can also refer caregivers to helpful programs. And, of course, caregivers should look for counseling and support groups for themselves, as well. If you don’t take care of yourself, you can’t take care of your aging parent or spouse.

Experts recommend the following six tips for warding off depression:

Accept that you may need help from others, including family, friends, neighbors, community programs, medical societies, and religious and fraternal groups.

Talk regularly with family, friends, or mental health professionals. Find a support group, locally or on the Internet, so you can share your feelings before they escalate into problems.

Set limits. It is OK to say “no” to taking on more than you can handle — physically and emotionally.

Eat nutritiously, exercise regularly, and get enough sleep.

Let go of unrealistic expectations and demands, including martyrdom.

Keep a sense of humor.

Looking back, Aparicio realizes that she lost emotional balance in those first years she cared for her mother. “I was taking care of somebody else and their problems and had little time for my own,” she says. “It was a vicious cycle: I was angry and under constant tension.” Eventually, she became disabled with chronic back pain and had to stop working for a while.

But now, a decade later, both she and her mother are doing well. Genevieve recently turned 83. They employ home health care aides while Aparicio is at work, and Genevieve attends an adult day care center three times a week. Aparicio has returned to work and participates in an Internet support group with other caregivers who share the best and worst of stories.

“It took years to get to this point,” Aparicio says ruefully. “It’s so important to get outside support. The reward is seeing my mother live as fully as she is capable — there’s vibrancy, there’s laughter. You can’t give up; we should never underestimate the power of love to heal the body as well as the soul.”

This article originally appeared in “Family Circle” April 2000

Beth Witrogen Mcleod
Beth Witrogen McLeod is an author, journalist, speaker and consultant on caregiving, end-of-life issues and renewal at midlife, especially for women. She is a double Pulitzer Prize nominee, and has won many national and regional awards for her work. She has written for Good Housekeeping, SELF, Family Circle, and The Wall Street Journal, among others. Her latest book is Caregiving: The Spiritual Journey of Love, Loss, and Renewal www.Witrogen.Com

Her expertise grew out of personal experience caring for her parents who were simultaneously terminally ill 1,200 miles away. With a father dying of a rare form of cancer and a mother with Lou Gehrig’s disease and dementia, McLeod learned firsthand about the traumas and blessings of this mid-life rite of passage. She turned her experiences into a passion for public service, first writing and producing an award-winning newspaper series, “The Caregivers,” for The San Francisco Examiner in 1995. It was nominated for a Pulitzer Prize. She developed a weekly column for The Examiner that often appeared on the New York Times Syndicate Web site. Honors for the series included National Hospice Organization, Pew Charitable Trusts, American Legion Auxiliary, Society of Professional Journalists, and many regional and local social service organizations.

Web Site: http://www.witrogen.com

According to the US Department of Health and Human Services, in 2008, the average cost of hiring a home health care provider in United States is $29 an hour. The cost may vary depending upon where you live, however. Those in Los Angeles, may have to pay $29/hour for a home health aide, but those in San Jose, may need to pay $50/hour for the same in home care.

The table below shows average hourly rates of home healthcare services state-wise. Average state hourly home health aide rates in USD ($) (Source: 2008 Cost of Care Survey, Genworth Financial, March 2008)

State by State Cost of US Home Health Care

Alabama 46.00
Alaska 49.00
Arizona 29.00
Arkansas 21.00
California 36.00
Colorado 27.00
Connecticut 25.00
Delaware 31.00
District of Columbia 20.00
Florida 20.00
Georgia 42.00
Hawaii 32.00
Idaho 25.00
Illinois 30.00
Indiana 21.00
Iowa 28.00
Kansas 22.00
Kentucky 16.00
Louisiana 41.00
Maine 38.00
Massachusetts 28.00
Michigan 26.00
Minnesota 26.00
Mississippi 44.00
Missouri 25.00
Montana 23.00
Nebraska 23.00
Nevada 37.00
New Hampshire 32.00
New Jersey 26.00
New Mexico 23.00
New York 25.00
North Carolina 28.00
North Dakota 24.00
Oklahoma 29.00
Oregon 33.00
Pennsylvania 24.00
Rhode Island 22.00
South Carolina 29.00
South Dakota 20.00
Tennessee 30.00
Texas 28.00
Utah 24.00
Vermont 24.00
Virginia 25.00
Washington 45.00
West Virginia 32.00
Wisconsin 25.00
Wyoming 24.00