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HEART Insight:
doi: 10.1097/01.HEARTI.0000432805.85850.2b
Features: Heart-To-Heart

No Place Like Home

Patton, Carol

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Families hire home care aides to keep loved ones safe at home

Casey O'Donnell understands the importance of proper introductions. As an experienced home health aide and certified nursing assistant at the Visiting Nurse Services (VNS) of Iowa Home Care, she believes how aides are introduced to patients can either create a smooth transition or a challenging experience.

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She recalls the first day she met her current patient, an 84-year-old woman with Alzheimer disease. A nurse at VNS who had already met the patient and her family made the introductions.

“It worked out better having the nurse introduce me,” says O'Donnell. “It made it a little more comfortable. I explained what I was going to be doing, coming every day to visit with her to help her out. She was very happy.”

Hiring home health aides or personal care aides, also called home care aides, is a cost-effective way to keep your loved ones safe at home. But the process involves addressing and monitoring dozens of details, ranging from health conditions and treatment plans to personal preferences. For example, does your mother want a female aide over the age of 40? Does your father prefer a nonsmoker or someone who likes dogs? Although the upfront work is often time-consuming, home care offers a realistic solution for helping loved ones maintain their quality of life in the comfort of their own homes.

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There are nearly two million home health aides and personal care aides in the country, according to the U.S. Department of Labor. While both deliver custodial care, such as helping patients bathe, dress or prepare meals, home health aides can also provide limited medical services like changing simple bandages or checking vital signs. However, some patients need skilled nursing care, often referred to as home healthcare services, which are delivered by nurses, therapists and other medical professionals. Because of our country's aging population, the Department of Labor projects that the number of home health aides and personal care aides will grow by 70 percent between 2010 and 2020.

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Selecting an agency

Which agency best matches the needs of your loved one? Ask the following questions, then compare responses:

* What types of services do you provide? Make sure they line up with your loved one's needs.

* How do you staff? Do you hire subcontractors or employees? This can make a difference. If using subcontractors, the agency may send a different nurse or aide every visit. That won't work well with certain patients, especially those with Alzheimer disease. Also ask about staff qualifications.

* Is someone always on call in case a problem develops? Medicare-certified agencies are required to have a 24/7 phone number.

* What kind of insurance do you accept? Not every agency accepts state assistance like Medicaid, and only a Medicare-certified agency can bill a Medicare program.

* How quickly do you respond to voice mail or email?

* How can I ensure that my loved one is getting appropriate care? Ask if they develop a personal treatment plan for each patient.

Source: Shannon Wilkins, home care director, Visiting Nurse Services of Iowa Home Care, Des Moines, Iowa.

Meanwhile, many family members who care for loved ones are working adults with children. Approximately 75 percent have worked while caregiving, according to Caregiving in the U.S., a 2009 survey conducted by the National Alliance for Caregiving and AARP. The same survey also revealed that 24 percent had a “very or somewhat difficult time” delivering care; 47 percent of care recipients live alone; and 38 percent want more information on how to keep their loved one safe at home.

“It takes an enormous amount of planning and running around and coordinating to plan for the care of people in their homes who have chronic illness,” says Shannon Wilkins, home care director at VNS of Iowa Home Care. “People have caregiver exhaustion and feel guilty about saying, ‘I need to have somebody come in and help my mom.’ Asking for help is not something you should feel guilty about. It could cut up to four hours of work out of your week.”

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Paint a picture

When talking with a home healthcare agency, they will need to know the following:

What health problems is your loved one facing? Maybe your mother recently started falling or your grandfather is having difficulty with his memory. The better informed the agency is, the more appropriate care it can deliver.

Who makes the healthcare decisions for your loved one? Who is the power of attorney? Is the patient able to make his or her own decisions?

What are the patient's likes and dislikes? For example, maybe your grandmother prefers nonsmokers. If she owns a dog or cat, make sure the aide isn't afraid of or allergic to pets. Mention anything that will make your loved one feel either more comfortable or stressed.

Source: Shannon Wilkins, home care director, Visiting Nurse Services of Iowa Home Care, Des Moines, Iowa

She explains that the purpose of home care is to help functioning people who simply need help with routine tasks safely stay in their homes. By explaining the needs of your loved one to home health agencies, they can tell you if a nurse or aide is needed (see Selecting an agency on page 9).

However, before setting up services, identify a family member or close friend to serve as the agency's key contact should a problem arise. Make sure that individual comes to your loved one's house during the admission process to help answer questions and fill out paperwork.

There is a lot of information to relay to the agency to avoid potential problems or future frustration. For example, where can the aide park her car when arriving? Which door should be used and will it be locked or unlocked when the aide arrives? Where should supplies be stored? If your mother isn't mobile, what items need to be placed within her reach? Do you want your father sitting in a chair or in bed when the aide leaves? Wilkins says families often forget the little stuff, which tends to build up frustration and jeopardize relationships with aides.

“Don't let little things build up,” she says, adding that sometimes, families don't realize that an aide's actions that may seem inappropriate—like answering the phone during meal time—may be based on agency policy. “The first time something bothers you, talk directly to that worker. If you're not comfortable with the direct approach, call the agency.” See Paint a picture, at left, for more information.

Other times, Wilkins says patients are skeptical or resistant to home care, especially if their Medicare benefits are paying for such services.

“[Patients] feel guilty using their Medicare dollars,” she says, explaining that many believe they are exploiting the government program. “We run into that a lot. Reassure them that they worked their entire lives to have a Medicare benefit and it's OK to use it.”

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Any relationship, including those between aides and patients, can offer unique challenges. Consider loved ones who are resistant to receiving external help or assistance. One way to minimize their fears or anxieties is to tell them that you're asking a trained professional to come into their house to help them with daily tasks so they can remain at home. Ask them to just try it for two weeks, says John Buck, executive director at Visiting Homemaker Service of Hudson County in Jersey City, N.J., which provides home care aides to roughly 1,500 families.

“[Patients] see it as a step closer to having to leave their homes,” he explains. “It's actually the reverse. It's a step to keep them from leaving their homes. In most cases, after the two weeks, they won't give it up and realize how helpful it is.”

Before selecting an agency, Buck suggests visiting its website to get a flavor of its staff and operations. Check to see if it's either licensed—not every state requires licensure—or accredited by organizations such as the National Association for Home Care & Hospice or the Community Health Accreditation Program.

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Costly or cost effective?

Compare these national, average rates for healthcare services:

Nursing home: daily rate for a private room, $248; semi-private room, $222

Assisted living facility: daily rate, $118.33; monthly base rate, $3,550

Adult day services: daily rate, $70

Home health aides: hourly rate, $21

Source: 2012 MetLife Market Survey of Nursing Home, Assisted Living, Adult Day Services and Home Care Costs

“Be a smart consumer,” he says. “You want some kind of oversight, either licensure or accreditation. There are an awful lot of people who are out there just because they think they can make some money at this.” Choose an agency carefully.

Make sure the agency you choose develops a plan of care that identifies all the tasks or services being performed for your loved one and specific times and days they are delivered. Keep in mind that if the aide is hired to help your mother, your grandparent who is living in the same home cannot ask the aide for any assistance with routine activities. If more than one person needs help, tell the agency so it can develop a plan that accommodates everyone's needs.

Typically, agencies will place the same aide in a home to ensure a consistency of services and help build relationships between aides and patients. But sometimes, personality conflicts develop. If differences persist and can't be reconciled, call the agency. Inform your contact about the situation so another aide can be assigned. When situations like this occur, Buck says his agency sometimes places several aides in the home over the course of a month to offer patients a choice.

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If your loved one is eligible for Medicaid, Buck says every state has Medicaid programs that will pay for a home care aide. Contact your local Medicaid office for more information.

However, Medicare operates very differently. He says it will only cover services delivered by a Medicare-certified agency. Likewise, the patient must be homebound and in need of temporary skilled care from a nurse, therapist or other healthcare professional.

Under such conditions, the aide can only perform household chores that are incidental to the personal care being delivered, says Wilkins. For example, if an aide helps your mother bathe or shower, she can clean out the tub or shower stall, wipe the floor and wash the towels. But if your mother doesn't require help with bathing, the aide is not allowed to perform those additional tasks. Once your loved one's condition reaches a level of custodial care, Medicare will no longer cover home care.

The cost for ongoing services provided by aides is generally paid out of pocket, unless it's covered by the patient's long-term disability policy. Jeff Huber, president at Home Instead Senior Care in Omaha, Neb., says 95 percent of his patients are private pay. The company operates in 17 countries and supports 650 franchises throughout the United States and Canada.

People need to plan for such services in advance, “when emotions aren't so high and you can think more clearly about things,” Huber says, citing the company's 40–70 Rule, which encourages families to begin these conversations when parents are in their seventies and children are in their forties.

What's surprising, however, is that most people tend to overestimate the cost of home care by as much as 30 percent and cross it off their list of options, says Buck, pointing to recent research conducted by his company. (See Costly or cost effective?, above.)

Even if families haven't planned for such services, options are available. Try contacting the U.S. Department of Veterans Affairs if your loved one is a veteran or check with religious organizations, such as local churches, mosques or synagogues. Another source is your local Area Agency on Aging, which can identify federal, state or local programs that offer financial assistance.

Still, more can be done. Maximize the dollars spent by scheduling aides during key hours. Maybe your mother doesn't need someone eight hours each day. Perhaps an aide can visit from 10 a.m. to noon, then again from three to five in the afternoon. Family members can also assume specific responsibilities, like filling Dad's pillbox for the week, which reduces the number of tasks an aide needs to perform and cuts down on the number of work hours needed. Huber says some agencies are more flexible than others by allowing split schedules or offering a two- or three-hour service minimum.

“Being proactive is the best thing to do,” he says. “People should not eliminate options before they've had a chance to adequately investigate them, [otherwise] they might be leaving some great options off the table.”

© 2013 by the American Heart Association