Hiring In-Home Help

It is easy for family and friends, as well as professionals, to suggest finding someone to help with housekeeping tasks and care responsibilities. Having someone else take on some of your housekeeping or personal care tasks might sound appealing to you too. But what does it mean to have someone in your house “to help” you? Where do you begin to find someone? Can you afford it? How do you respond to your loved one who proclaims that they don’t want “a stranger” in the house? This fact sheet will help guide you through the process of hiring help at home.*

NOTE: FCA refers to unpaid family, partner, friends, family members, and others as caregivers. For purposes of clarity, this fact sheet will refer to hired care providers as attendants. Other terms that are used are home care attendant, home care provider, care worker, and hired help.

Do I Need Assistance?

Long-Distance caregiving, working full-time and caregiving and/or caring for someone 24 hours a day/7 days a week will take a toll on anyone. With a loved one who needs personal care and who can’t be left alone, you must be vigilant and “on duty” day and night. With constant care and companionship responsibilities, you may have very little time to yourself. If you are caring for someone who needs to be transferred from bed to wheelchair or out of a chair when sitting, you may be at risk for injuring your back. For those caring for a family member living with dementia, you may be also be dealing with challenging behavior, wandering risks, or actions that might be harmful or dangerous such as leaving cooking burners on. If you don’t have time to do the shopping, banking, and taking care of your own medical needs, you are at risk for stress-related illness. Are housekeeping routines and cooking being done with great difficulty or being left undone?

Consider your needs as a caregiver and the needs of the person you are caring for. Here are the main areas to assess:

Personal care: Bathing, eating, dressing, toileting, grooming
Household care: Cooking, cleaning, laundry, shopping
Health care: Medication management, physician’s appointments, physical therapy
Emotional care: Companionship, meaningful activities, conversation

Hiring help can relieve you of some of the tasks you are responsible for, freeing you to have some time for yourself. Having trusted help can give you the opportunity to run errands, go to the doctor for yourself, catch up on sleep, and socialize with friends. For long-distance caregivers and working caregivers, help can provide the care and assistance needed when you can’t be there on a daily basis yourself. Interestingly, caregivers have found that in some instances the person receiving care can be more cooperative with someone other than the primary caregiver, so that, for example, taking a shower might not be the battle that it can otherwise be. Engaging an attendant can help to preserve your relationship as daughter or partner, rather than always having to be the chore person or task master. Attendants come in fresh for a certain number of hours and therefore have the energy to be engaging and encouraging in a way you might be too exhausted to do around the clock.

Hiring help might not only be a necessity but a gift you can give yourself.

My Loved One Only Wants Me to Help

It can be hard for your loved one to accept help from a stranger. Initially, it will be important for you to be present to help the attendant and the care receiver to establish a successful relationship. You can show the attendant how you do things, so the help that is given will feel familiar and comfortable. Let your loved one know that YOU need help and that this is something they can do to help you care for them. Reassure your loved one that hiring help does not signal that you are going to abandon them.

If your loved one lives alone, you might hear, “I don’t need any help.” Suggest that it will make YOU feel more comfortable knowing someone is there part of the day. You can also suggest that they “just try it for a week.” This will give your loved one some control in decision making and help them be open to having an attendant.

The transition to an attendant might be easier if the attendant shares a similar cultural background or language. The care receiver may have a preference for a male or female attendant. However, wonderful attendants come from all backgrounds, and being open to a caring, competent attendant from a different ethnicity or cultural background than your own can lead to rewarding bonds.

Sometimes the best way to get an attendant accepted is to hire a “housekeeper.” Care receivers are often more open to having someone come in and “help” with the housework before they are willing to accept someone to help with personal care. This gives your loved one time to become familiar with the attendant and build trust.

“I Don’t Want a Stranger in My House!”

We all react differently to interacting with someone we don’t know. For some people, meeting someone new is an enjoyable and interesting opportunity. But for others who are naturally more reticent or are feeling vulnerable due to their illness, there is great reluctance to exposing their private life and personal living space.

Hiring someone through an agency will give you some choice for attendant selection. Most agencies have done background checks and bonded the people who work for them—be sure to ask if this is the case. And if you feel uncomfortable with the person who is sent, you can always ask the agency to send someone else. But typically an agency will attempt to match the attendant to your specific needs and requests, so if you aren’t immediately comfortable with the attendant sent, consider giving it a day or two to warm up to them.

Caregivers and care receivers often worry that their belongings will be stolen. This does happen, but it is much rarer than you might be led to believe. Lock up or take out of the house any especially valuable belongings, such as heirloom jewelry, just to make yourself less anxious about this happening. Keep track of cash and checks/checkbooks/credit cards. If hiring through a home care agency report any concerns you might have. If hiring privately, schedule a time to discuss the concerns directly with the caregiver. If your loved one has dementia, they may report an item as “missing” when it is only misplaced or stashed away.

How Do I Find Help?

There are formal and informal ways of finding an attendant. The formal way is to contact a Home Care Agency located near to where your loved one lives. A long list of agencies will be available in most urban and suburban communities. This can make it difficult to figure out who to contact first. Far fewer agencies serve rural areas, limiting options for hiring care. People who can help you select the right agency for your needs include your doctor and their staff, your friends/family who have used an agency, and others in your community whom you trust, such as your faith community, your local senior center, etc. Also, check for agency reviews from trusted online sources, and consider contacting your local Area Agency on Aging to ask whom they hold contract(s) with for their clients.

Key questions to ask:

Is the agency licensed by the state? (Many but not all states require licensing to operate a Home Care Agency). Ask how long they have been in business.
Are the workers licensed and insured? How does the agency train, supervise, and monitor their workers?
Request that the agency send you a packet of information that describes their services, fees, and a list of references. This will give you an opportunity to review the information before sitting face to face with an agency representative.

Home Care Agency Pros and Cons

Pros:

Screening, hiring/firing, pay, taxes are handled through the agency
Note: Some agencies work as “employment agencies,” and their workers are contractors, not employees of the agency. Be clear on what the agency covers, e.g. payroll, liability insurance, workmen’s compensation insurance, unemployment insurance. Ask for evidence of their insurance.
Can offer attendants with a variety of skills and match you with a staff member who can provide the care or help that you need
Able to accommodate variable schedules that might be inconsistent or unpredictable at times
If worker is sick/goes on vacation, agency will provide a substitute
If worker is not the right fit, can send an alternate choice
Can help settle disputes with you/attendant
Often covered by long-term care insurance

Cons:

May schedule more than one attendant if work hours are not consistent, needing to separately orient and adjust to each new person
May experience more staff turnover
May limit or charge more for certain tasks
Typically more expensive than private hire

The informal way of finding help is to hire an attendant privately. This entails your finding your own attendant and being responsible for hiring/firing/payroll taxes, and all aspects of being an employer. Attendants are most often found through word of mouth—friends, your community, and some non-profit senior organizations. Attendants available for work may also list their services on online listing services and on bulletin boards in Senior Centers and other places. Local colleges and in particular nursing programs, community college HHA (Home Health Aide)/CNA (Certified Nursing Assistant) programs are good sources of available talent. If you are hiring privately, it is essential that you do a background check (See FCA fact sheet Background Checking: Resources That Help). Check your homeowners or apartment insurance for liability coverage. You may need to add it and also get workmen’s compensation insurance.

Key questions to ask:

What are the aide’s credentials? Check with the credentialing body to confirm.
Where has the aide worked previously? Ask for two to three references from former or current employers.
Always contact the references asking about the care competency, compassion, and reliability of the worker.
Is the aide legally eligible to work in this country? Ask to see verification (passport, green card, etc.)

Private Hire

Pros:

You choose the person you want from a pool you have screened, and you are the “boss”
More flexibility in tasks that can be performed
Typically less expensive than going through an agency
Greater opportunity to build a long-term relationship with the attendant(s)

Cons:

If worker is sick, it is your responsibility to find alternate help
You are responsible for all aspects of being an employer: hiring/firing, payroll, taxes, insurance, and employee disputes
May not be covered by long-term care insurance

What Will It Cost?

The rules for hired help vary from state to state, and sometimes city to city. Start with the state Department of Labor. You will need to familiarize yourself with the regulations in the municipality where the help or care will be provided. First, find out what the minimum wage is in your area. Second, determine how many hours of help you require. In some states, if someone works more than 8 hours/day, they are eligible to be paid time and a half for 8–16 hours and double time for 16–24 hours. If you have live-in help, some states require that the attendant get 5 hours of uninterrupted sleep. So, if you have a loved one who is up a lot at night, you might have to hire a nighttime attendant in order to give the daytime attendant a break. In other states, you can hire someone for a “per diem” or “shift” rate, for example, $250/day for someone to be there 24/7, instead of an hourly rate. Third, if you hire privately, you will need to set up a payroll (see above). Some attendants prefer to be paid with a 1099 at the end of the year. This means they will be responsible for their own taxes. Be sure that they meet the local requirements for an independent contractor. Finally, some attendants will accept payment only in cash.

If you hire a Home Care Agency, they will establish the pay rate. Agencies will charge a different amount, depending on the kind of care that is needed, e.g. personal care versus dementia care. Also, an agency might have a minimum number of hours, for example, only 4-hour shifts. Or they will do a 2-hour shift but charge more per hour. For people who need full-time care, the options are a “live-in” who does the full 24 hours, a live-in plus an 8-hour shift for someone who needs someone to be awake and available during the night, two 12-hour shifts for people who may need someone awake at night, or three 8-hour shifts for someone who may need extra help due to heavy care needs.

Caregivers often ask whether they should pay the attendant if they take a vacation. Or if they should give a monetary or physical gift at holidays. Are yearly bonuses expected? If the attendant is terminated, not for cause, should they pay severance? These are individual decisions but important things to think about so you are not burdened with trying to figure them out when the time comes.

How Can I Afford It?

Hiring in-home help can be expensive, particularly if you need full-time help. However, if you only need four hours once or twice a week, it can be more affordable—the hourly cost varies depending on where you live in the United States.

If the care receiver has a long-term care insurance policy and the service provided meets the policy criteria, the benefits can offset the cost. Check the policy for how many days of care are required before the policy will start to pay. Determine whether there is coverage for hiring someone privately, or only for hiring through an agency. Some policies require that the attendant be an HHA, LVN (licensed vocational nurse) or CNA, and others do not.

The cost of a hired attendant might be tax deductible if it is considered medically necessary. Check with your tax accountant to see if this is the case in your situation.

If the care receiver is low income and qualifies for Medicaid (Medi-Cal in California), they may be able to get help through an in-home program called In-Home Supportive Services (IHSS). Check with your local Medicaid office to see what services are available in your area. Medicaid benefits differ by state.

This type of care is an appropriate expenditure for use of the care receivers’ personal savings. Often family will also contribute as needed to help cover the cost. Holding a family meeting to discuss the need for the home care service, the cost of the care and the means available to cover the cost can help surface concerns from family members, and gain support to help cover the expense.

Some communities have a sliding scale or low-cost home care through specialized funding. Contact your local Area Agency on Aging (AAA) to see what is available in your community. The Medicaid In-Home Supportive Services (IHSS) office may have a registry that is open to the public and can give you referrals for pre-screened attendants. Under Title IIIE of the Older Americans Act, funding distributed through your local Area Agency on Aging (AAA) offers help paying for respite care (temporary relief) and other caregiver related services. Faith communities and some senior service agencies also might be able to help you find lower-cost attendant care in your area.

How Do I Find the Right Person?

When hiring help, it is important to be clear about what it is you want the attendant to do. Write a job description that spells out the things you need help with and make a detailed list of the tasks you want to be done. Clarity is essential to effective communication and mutual understanding. For example, if you want help with housekeeping, list the kind of housekeeping duties that need to be performed—vacuuming, cleaning the bathroom, washing dishes, doing the laundry, etc. Be clear about any specific ways that you want these duties performed, e.g. wash white items and colors separately. If you want personal care, does the care receiver need help with dressing, grooming, bathing, toileting, transferring? If you want someone to just “be there,” does the care receiver like to take walks, watch TV (what shows?), talk, go out to lunch, play golf, read, be left alone (some people like chatty attendants and some people do not)? If there is a pet, does it need to be taken for a walk, do you want the poop in the backyard cleaned up, the kitty box cleaned out? (Check with the attendant for allergies to pets or fear of certain animals.). It is very important to find out the attendant’s experience with dementia if you are hiring someone to care for a loved one with cognitive impairment. Give examples of situations you face and ask how they would handle them. (See below: “Write a Job Description”)

Three general certifications exist for home care attendants. One is an HHA—home health aide, the second is a CNA—certified nursing assistant, and the third is an LVN—licensed vocational nurse. They are trained to provide most levels of care in the home except for care requiring a registered nurse, e.g. giving an injection. Each state has different laws on what attendants can and cannot do, such as dressing changes on a wound or giving medications. In most settings, an attendant can put the medications in the care receiver’s hand, but the care receiver must take the medications on their own. However, there might be rules on who can set up the medi-set with the pills in it, and whether or not the care receiver must take them out of the medi-set on their own.

Always check references. Always do a background check.

(See FCA fact sheet Background Checking: Resources That Help)

Write a Job Description

Once you have identified the types of help you need, write a job description. (See FCA fact sheet Personal Care Agreements) In addition to including the tasks you have identified, also be specific about:

Training desired: CNA (certified nursing assistant), LVN (licensed vocational nurse), HHA (home health aide)
Driving: Do you want help transporting care receiver? Their car or yours? Reimbursement for mileage? Check with the DMV to confirm their driving record.
Transferring skills: Getting someone out of bed, chair, using Hoyer lift
Experience with people with memory or other cognitive impairments
Language skills: Especially for people who are hard of hearing, or whose primary language is not English.
Housekeeping: What sort of housekeeping do you want in addition to care for the care receiver? Cooking? If so, what kind of foods? Can the attendant accommodate a special diet?
Pets: What kind of care do they require, and what do you expect the attendant to do?
Smoking: Does the care receiver smoke? Does the attendant smoke? If so, is this ok? Where is smoking permitted?
Hours: What times/days are you hiring for?

If hiring privately, also consider:

Wages: Hourly or shift payment? Holiday, vacation, or sick pay (most states now require three paid sick days/year)? How will the attendant be paid, including withholding and taxes (Social Security, Medicare, disability, unemployment)? Cash or check? Weekly, semi-monthly, monthly? Employee or contract worker (W-2 or 1099)? For a fee, an accountant or household employee payroll service provider can assume this responsibility.
Are you providing food for meals, or does the attendant bring their own food?

Interviewing

If you are hiring through an agency, you can shorten this process. If you need help right away, always go through an agency, as hiring privately takes time and energy to secure the right person or team of people. Often an agency representative will come to the house and interview you to find out what type of help you are seeking and will try to match you with the person in their employee pool who best meets your needs. However, having your job description will still be helpful in working with the agency.

Initial interview/screening can be done by phone. Ask for a resume and references. With those who seem like they would be right for your situation, you can set up an in-person interview either at your loved one’s home or at a nearby coffee shop if you prefer. If appropriate, the care receiver should be present at the interview, as their input is important. Other family members or concerned individuals may also be present. Their input can help you make a good decision. The job description can be emailed to the applicant as a way to start the conversation.

Here are some initial questions for the interview:

Why are you interested in this position?
Tell me a little about yourself.
Where have you worked before?
What were your duties? Here is the job description for this position.
What is your favorite kind of client? What pushes your buttons?
Is there anything in the job description that you are uncomfortable doing?
How do you deal with someone living with memory problems? Give an example.
Describe your experience making meals for other people.
How do you handle people who are angry, stubborn, and/or fearful?
Do you have a car? Would you prefer to drive your own car or our car in transporting? I’ll need to see proof of insurance and a current driver’s license.
What is your experience transferring someone out of bed or chair and into a wheelchair?
What is your availability? Days? Hours?
Can you give me two work-related and one personal reference I can contact?
I’ll need personal identification that verifies that you can work in this country. Please bring it with you so that I can make a copy.

If the care receiver is present, watch the interactions between the attendant and the care receiver. Do they only respond to you, or do they include the care receiver in their answers? If the care receiver is not present, you might want to invite a top candidate back to meet the care receiver before making a final job offer.

Immediately after the interview, write down your impressions. Include input from the care receiver, if they were present, as well any other family/friends who were a part of the interview. Check your gut. How you feel about someone can go a long way in your finding the right person. Check the references. Have a list of questions to ask about their experience in working with this attendant.

If someone is looking for work, they are probably interviewing with others. Do not wait too long to make a job offer, as the person may have taken a different job. Arrange to meet to sign the contract and establish a start date.

Writing a Contract for Hiring Help

If hiring privately, you will need to develop a contract. Use the job description as the basis of the contract. Alternatively, contact an attorney to help draft a simple agreement. The contract formalizes the agreement between you, the employer, and the attendant, the employee. It is signed by both of you. If problems should arise, either party can refer back to the written agreement to help negotiate solutions. In addition to the job description, the contract should have the following:

Your name: The employer

Attendant’s name: The employee

— address, phone number, Social Security number

Wages: (see job description)

— Also include criteria for reimbursement, e.g. is there a petty cash fund for incidentals that the attendant buys?
— If using their own car, will the attendant be paid mileage?
— Get a copy of driver’s license and car insurance

What kind of paperwork do you want the attendant to keep?

— Daily log?
— Medication administration list?

Expectations for behavior: Use of phone, smoking, being late

Grounds for termination: Notice with cause/notice without cause

Date and sign the contract: You and the attendant

What Are the Employer’s Responsibilities?

Significant legal and financial considerations exist for employers. (See also Resources at the end of this fact sheet.) Check your renter’s or homeowner’s insurance to see that it covers household employees. Be informed about your tax responsibilities if you have a hired employee. All U.S. employees must complete an Employment Eligibility Verification form I-9. This form verifies that the person is legally entitled to work in the United States. A W-9 form is also completed by the employee to set up payroll. You will also have to apply for an employer ID number.

Local services are often available to seniors who need assistance in filing tax statements for household employees, as well as help with doing the payroll. Check with your local Area Agency on Aging to find out what is available in in your area.

Communication

Your relationship with the attendant, the care receiver’s relationship with the attendant, the attendant’s relationship with you, and the attendant’s relationship with the care receiver are all very important. Good communication is essential for a good relationship. Schedule regular times to meet and discuss concerns, problems, and/or changes. Changes in care needs are to be expected. If there are added responsibilities or changes in who is living in the house, for example, these need to be discussed with the attendant. It is important to make expectations clear and to provide adequate training to meet those expectations. If there are problems, write out what is not working and come together on solutions that both of you sign. Keep communication current; address problems as soon as they arise. If you hire an attendant privately, it is important you feel comfortable both providing training and firing the worker if necessary. The higher the trust, the better the relationship. Trust comes through honest and open communication. If the attendant is doing a great job, be sure to tell them. A smile and well-deserved praise can make a big difference. None of us likes to feel our work is not appreciated. When you find the right person for your caregiving needs, they are worth their weight in gold. Wishing you success in finding the best help to match your caregiving situation and make your journey as a caregiver more manageable and fulfilling.

Resources

Family Caregiver Alliance
National Center on Caregiving
(415) 434-3388 | (800) 445-8106
Website: www.caregiver.org
FCA CareNav: www.fca.cacrc.org/login
Services by State: www.caregiver.org/connecting-caregivers/services-by-state

Family Caregiver Alliance (FCA) seeks to improve the quality of life for caregivers through education, services, research, and advocacy. Through its National Center on Caregiving, FCA offers information on current social, public policy, and caregiving issues and provides assistance in the development of public and private programs for caregivers. For residents of the greater San Francisco Bay Area, FCA provides direct support services for caregivers of those with Alzheimer’s disease, stroke, traumatic brain injury, Parkinson’s, and other debilitating health conditions that strike adults.

FCA Fact and Tip Sheets

A listing of all FCA Fact and Tip Sheets is available online at www.caregiver.org/caregiver-resources/all-resources

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