Stepping Stones to a Positive In-Home Care Experience

As a loved one ages, the family caregiver often realizes that their home care needs are greater than anticipated or require more advanced care-giving than they are able to provide.

These situations range from serious, such as a parent who requires skilled medical care after being hospitalized, or as simple as a modest parent who needs assistance with bathing and personal hygiene.

Whatever the reason, family caregivers are likely to find numerous care-giving choices available to them. It is certainly easy to become confused as to which type of service is needed and how to go about selecting the best agency or private caregiver for their circumstances.

The first step is to clearly identify what the patient’s care needs are and which type of care-giving service corresponds to those needs. The two basic types of in-home care are skilled medical/home health care or nonmedical home care. There is a significant difference between the two.

Skilled medical/home health care is usually required when it is determined that the patient needs physical therapy, ongoing treatment, or is recovering from an illness. These services are provided by medical professionals such as doctors, nurses, therapists, home health aides and certified nursing assistants. Basic services you could expect from a skilled medical/home health agency include:

  • managing pain,
  • caring for wounds,
  • changing bandages,
  • checking vitals,
  • administering medications,
  • providing physical therapy,
  • assisting with medical equipment.

Nonmedical home care agencies provide services through home care aides who assist your elder with their normal activities of daily living (ADLs). These services do not involve any form of medical care. Typically, you could expect them to assist with the following:

  • bathing and dressing,
  • assisting with mobility and safety while moving around and getting in and out of the shower, bed or chair,
  • reminding your loved one when to take their medications,
  • helping with household chores such as light cleaning, vacuuming and laundry,
  • running errands like grocery shopping or picking up prescriptions,
  • providing companionship for isolated or homebound seniors.

As you can see, there is a distinct difference in the type of care each agency provides.

When making your decision on the type of agency, keep in mind that it might be possible for a skilled medical/home health care agency to provide not only the skilled medical care, but also the basic services that a nonmedical home care agency can provide. However, a nonmedical home care agency cannot provide the medical services a skilled medical/home health care agency can.

Another option available to you is hiring a private caregiver who is not affiliated with an agency. Many families choose this option because they often charge less. However, along with the financial benefits come certain responsibilities.

It is important to understand that when hiring a private individual, you will need to decide whether they are considered an employee or an independent contractor. Each has their own set of considerations.

As an employer, you will have to verify if they are legal to work in the United States, be responsible for payroll taxes to the government and comply with all federal and state wage and hour laws as well as paying for state unemployment insurance. Employed caregivers fall under federal guidelines of household employees as defined in IRS Publication 926.

If your private caregiver is an independent contractor, you may find that you have less control over the hours they work or the services they provide. As an independent contractor, they have control over their schedule and how they provide services. They do not take direction from the client, which can limit your input in your loved one’s care. However, these issues can be discussed and clarified in a working agreement.

With any of these three options available to you, it is important to realize possible risks. There is always the possibility of hiring someone who will take advantage of those who are vulnerable, especially if your senior is frail, functionally limited or has cognitive impairment. With an agency, you have the ability to file a complaint, request an investigation in to the matter and seek resolution. With a private, non-agency caregiver, it may be harder to pinpoint if there is a transgression or to find a solution to your concerns.

Once you’ve made the decision to ask for help and know which type of agency or caregiver would be the best fit, what happens next?

With a professional agency, you would set up an assessment/evaluation with the agency’s nurse, intake coordinator or other appropriate staff member to formally identify your loved one’s needs and desires and establish a care plan. This involves the agency meeting with you and/or your elder. During this assessment, you can discuss any particular concerns regarding who will be coming into the home to provide assistance. While each agency has their own policies and procedures, it is possible that they would allow you to meet this person before agreeing to bring them on as part of the care team.

It is always a plus when your loved one can meet potential care providers, and you can see if there is a possible connection between them. However, if you cannot meet the prospects in person before hiring them, be sure to be as open and honest as possible as to what type of person your loved one responds best to. Be sure to ask about their policy for rejecting an individual's services or requesting a better fit. For instance, if your mother would be uncomfortable having a male caregiver or would prefer someone of the same nationality so that they have more in common, please speak up. Many elders wish to have someone in the house that is familiar with their own customs, cuisine and even language. The agency cannot select the proper caregivers if they are not aware of any potential red flags.

Now that someone has been hired, how do you manage that first few days or weeks as a stranger is being introduced in to your loved one’s home and life?

If it is at all possible, a family member should be present for the first few days or readily available for reassurance during this transition. Just remember you need to allow the caregiver to do their job. The biggest mistake you could make is to step in and take over while the caregiver and your loved one are getting to know each other, establishing a daily routine and interacting with each other. Like any new situation, it may take some time for your loved one and the family to develop a level of comfort and trust in their skills.

Unfortunately, there are those instances when a certain caregiver may not be a good fit. Just make sure that the reasons you cite as problematic are not a result of personal feelings clouding your judgment. It is easy to claim a poor fit if you are feeling anxious or guilty about your decision to accept outside help, uncomfortable about having a stranger care for your loved one, or in denial as to whether professional help is even necessary. If you truly feel that the care needs are not being met, or the caregiver is not the right person for the job, speak up! Talk with the agency and be as clear and direct as possible in order to give adequate information to help them understand why their selection is not working out. This way they have a better likelihood of selecting an appropriate candidate the second time around.

Bringing someone in to your or your loved one’s home to provide sometimes very personal services can be a nerve-wracking or even frightening experience. There are some steps you can take to make it easier on all involved. If you decide to work with an agency, these guidelines should be discussed on the first meeting before any hiring or placement occurs. If you are selecting a private, non-agency caregiver, it could be part of the interview process and their employment agreement. Some things to address might include:

  • Establishing boundaries if there are private areas in the house that are off-limits.
  • Deciding how and when they will be able to receive meals and drinks during their time at the home. For instance, may they bring food and beverages into the home, or if they cook meals for your loved one, would they be welcome to join in the meal?
  • May they smoke? If yes, then where?
  • How often will they take breaks and where?
  • Defining how guests should be handled. Are they allowed personal guests at your loved one’s home and/or should they allow others into the home to visit your senior while they are on duty?
  • Are they allowed to make or receive personal phone calls while on duty or during breaks?
  • If your loved one is sleeping, occupied with a book or any other situation that may result in down time, how would you prefer them to handle this time? May they watch television or talk on the phone, or maybe you would prefer that they spend any time not providing direct personal care by cleaning house, cooking meals to freeze, etc?

Finally, ensure that all parties are in agreement with these conditions.

Open communication and shared expectations are the keys to a successful relationship between the family, their loved one and the caregiver. Seniors can often be overwhelmed with anxieties or fear of the unknown.

Once you’ve established who will be providing care and what their responsibilities will be, make sure you have a detailed conversation about these matters with your loved one. However, if your elder has cognitive impairment or dementia, you may not be able to fully prepare them as to what will happen when the caregiver begins providing services. Most professionals are trained in this area and their experience would be a topic of discussion before hiring.

By hearing what is going to occur and what they should expect, your loved one may relax and be more open to the changes ahead, which will help promote a more positive care-giving experience for everyone. There are many kind and qualified caregivers who truly enjoy providing these services; If you are thorough and diligent in seeking references and engage in candid discussion, a good fit will be found.


Author and Eldercare Consultant Becky Feola has founded two eldercare businesses and authored "The Eldercare Consultant, Your Guide to Making the Best Choices Possible." She has been a guest lecturer at colleges in the Greater Phoenix area along with providing public seminars on the subjects of eldercare and caregiving. Feola has also been featured on local television, local and national radio programming, and in local and regional newspapers and publications. Visit for more information.