Rosalyn Carter once said, “There are four kinds of people in the world – those who have been caregivers, those who are currently caregivers, those who will be caregivers, and those who will need caregivers.” Sooner or later, as we age, we will all need some type of care. Those of us who are in good health may only start needing a little help, perhaps a few hours a week, by our mid to late seventies. By then, even if we don’t have any challenging physical or mental health conditions, we could still use some assistance to run chores for us both indoors and outdoors, to have decent meals prepared, and to keep us company.
Others need more care and assistance. Whether because of bad knees, Alzheimer’s disease, or other health conditions, individuals will start leaning increasingly on family members for help or, if money is not an issue, they will likely look to hire professional caregivers. The following article provide some information on finding a professional caregiver and the tasks and duties that caregivers typically handle.
When your budget permits, there are several ways to find an appropriate caregiver.
You can save money on their salary by hiring an aide or certified nursing assistant (CNA) directly for your parent or spouse. Personal recommendations from friends or family who have used the aide and know his or her abilities is one way. However, you would have to conduct the searching, screening, interviewing, vetting and, finally, the hiring.
In addition, every time the caregiver needs time off, you would need to fill-in, either personally, or with another aide or CNA. If your parent ought not be left unattended for long periods of time, you would be doubly challenged, for emergencies in the lives of your aides will be inevitable, and you need to ensure that you or someone else is can rapidly fill in and do the job if necessary.
Home care agencies cost considerably more than hiring a CNA privately. However, a good agency would assume the responsibility for most of the mentioned tasks. Here is what a home care agency does:
- They continually recruit new aides and CNAs so that when you require an aide, chances are they would have someone who lives close to your parent or spouse, and for whom the required number of hours a day match their own preferred schedule.
- They insure and vet their caregivers: eligibility to work in the U.S., professional and state certifications, criminal background and reference checks, CPR, TB tests, and more.
- They match your parent or spouse with an appropriate caregiver, in terms of skills and temperament, change the caregiver if your parent does not get along with her, and fill in for caregiving time off.
- They supervise their aides and CNAs regularly, give them periodical orientations, support them in times of personal crisis, pay their salary, and take care of their other employment benefits and taxes, all of it to ensure that they do a good job while on assignment.
- At the end of that trail, the home care agency finally bills you.
Referral agencies end up costing you less than a home care agency, screen and vet your prospective CNA or home health aide (HHA), and allow you to interview her for employment at your parent’s home. In the end, the CNA becomes your own employee, and while some agencies offer payroll services, you must pay their salary with the appropriate taxes withheld.
While the vast majority of professional caregivers work on an hourly basis, some caregivers live with care recipients and thus work by the day. Needless to say, hourly and live-in caregivers provide the same services: companionship, homemakers, and personal care.
Live-in services work best for care recipients who benefit from the presence of an aide day and night. Here are some of the benefits of hiring a live-in caregiver:
- For someone who needs to have an aide day and night, live-in arrangements cost considerably less than 24-hour care by way of hourly personnel.
- Live-in arrangements are ideal for convalescing from illnesses or surgery since they avoid the three-times daily commotion and nervousness associated with shift changes.
- For the rest of the family, it is very comforting to know that their loved one is attended for by the same CNA or HHA day and night. Whenever they call for reassurances or updates, they know they can speak to the same aide.
- Finally, it is a well-known factor in caregiving that once the caregiver and care recipient settle down to a live-in relationship, these can last a long time, avoiding the nerve-wracking business of a high turnover in caregivers.
In live-in schedules, it is expected that the caregiver can get a good portion of the night with uninterrupted rest and sleep. Unlike hourly caregivers, live-in caregivers are given food and beverages at the care recipient’s expense. They typically share in the meals and snacks that they prepare for their client.
Safe transfers are one of the most important caregiver jobs. An experienced CNA or HHA has a working knowledge of body mechanics and is able to safely move her patient from a chair or wheelchair to the toilet, the bed or even into a car. They should know how to use a gait belt if necessary.
Maintaining senior and caregiver safety is one of the most important caregiver jobs. Thus, any caregiver who is assigned to in-home care with a senior who needs to be transferred back and forth needs to be proficient in those tasks. He or she would also need to be of sufficient build and weight to be able to endure the continuous need to lift the care recipient in and out of different sitting or lying positions.
A major problem with older adults has to do with the consistency of taking their medications as doctor-prescribed and in timely fashion:
- Many seniors simply forget or neglect to take their meds
- Others self-medicate and decide they no longer need a particular med, or they double the dosage of some medication
- Yet others get confused and take the wrong dosages
- Or they mix medications in a non-prescribed and hazardous manner
Before you hire an in-home caregiver, you would do well to inquire about the degree of responsibility she can assume in this regard. If you are hiring privately, there are no legal restrictions to what the aide can do with regard to managing and administering your loved one’s medications.
If you are hiring through a home care agency, the responsibility for administering medications can be a tricky job, particularly if your loved one lives alone and cannot successfully handle their own medications. In that regard, different states have different rules, many state laws forbidding caregivers, even CNAs and HHAs from actually taking medication out of a bottle, mixing meds, or in any other way dispensing meds. In such states, the most that an in-home aide can do is remind their senior patient to take their meds on time. In such states, only a licensed practical nurse (LPN) or registered nurse (RN) can actually handle and administer meds.
These regulations do not apply to family members or friends and neighbors, i.e. people who are frequently tasked with coming in once or twice a day to administer a medication. Privately hired in-home aides are also excluded from these regulations. They are treated as family members and can do their job without undue hindrance from the state licensing boards.
In-home CNA and Home health aide duties that might be considered invasive or medical in nature, such as finger sticks for diabetics, enemas or wound care are frequently not allowed. It is therefore important for you to inquire to make sure your parent or spouse will get this job covered.
Another caregiving job has to do with grooming and bathing. A good in-home personal care aide or home health aide will assist in making bathing a pleasant experience while embracing their client’s preferences, e.g. whether to have a shower or bath, or the time of day to get cleaned up.
The first and foremost consideration, particularly when the patient is cognitively impaired, is for the caregiver to make sure the patient is kept warm and safe, and to be considerate of their client’s right to privacy. The in-home caregiver should discuss with the family or agency care manager the need for safety equipment like a bath seat, grab bars, and non-slip floor mats.
Here are a few other considerations:
- Skin condition: Redness or skin breakdown should be reported either to the family or to the agency supervisor, and an appropriate barrier cream used.
- Moisturizers: Applying a moisturizer all over after bathing to both male and female patients helps protect the skin and feels good. There are a number of scent-free and hypoallergenic moisturizers.
- Incontinence: Special attention should be paid to the genital area in individuals who are incontinent.
- Mouth Care: The caregiver should assist in brushing the teeth if necessary, and they should provide daily cleaning for dentures.
- Hair: Shampooing, massaging the scalp and then drying should be done at least once or twice a week.
- Shaving: For men, being clean-shaven often feels better. For the ladies, a bit of lipstick can help finish the look and inspire confidence.
- Nail care: Following a bath might be a good time to check fingernails and toenails. While the filing of nails is allowed for caregivers, actual nail cutting may be disallowed in certain states. If you are hiring through an agency, you might want to inquire about that. If you are hiring privately, your only concern would be that the caregiver does that safely. In addition, care of the feet of diabetics should be done by a licensed podiatrist, many of whom make home visits for older adults.
- Dressing: A clean body and clean clothes are important both physically and emotionally. A favorite flannel shirt or a spring-like floral dress can add comfort, a sense of familiarity or even improve the client’s mindset and outlook. It is incumbent on the caregiver to ensure that there is always an adequate supply of fresh clothing, and that their care recipient’s preferences are taken into consideration.
Toileting or incontinence care may be embarrassing to the care recipient. However, regular elimination is important to avoid infection or other complications such as constipation or impaction. If physically or mentally disabled, the caregiver should assist their client to the toilet.
Moving around every two hours is not only good for bladder and bowel routines but gives the individual some exercise. Constipation should be reported immediately as should painful or abnormally frequent urination, or a sudden strong-smelling odor.
Incontinence garments are made to pull moisture away from the skin, but they cannot prevent all irritation or skin breakdown. It is recommended that the caregiver check for incontinence every two or three hours and clean the genital area carefully, using barrier cream as needed.
Your caregiver should be able to plan and prepare appetizing and nutritious meals that appeal to the average client. Here are a few considerations:
- Dietary restrictions: The caregiver should be made aware of any dietary restrictions and asked to follow them.
- The client’s preferences: It is naturally important that your loved one’s preferences be considered. If the client insists he or she hates spinach, don’t try to serve it no matter how good it may be for them.
- Spicy or ethnic foods: These should be avoided, unless specifically requested.
- Physical capabilities: The caregiver should consider physical capabilities. Can they successfully use utensils? Can they chew food adequately? How much or how little are they eating, and why?
- Leftovers: Leftovers should be identified, dated, and, if applicable, refrigerated. Expired items should be checked for and disposed of regularly, and a quick wipe-down at the end of each week will keep things fresh.
- Grocery shopping: Some caregivers are expected to do grocery shopping as part of their duties. In such cases, caregivers should check before purchasing unusual food items or products that only the caregiver would eat or items that are beyond the normal budget.
The definition of “light” housekeeping means different things to different people and can create a misunderstanding as to what a caregiver’s duties entail.
Basically, the caregiver’s housekeeping duties include what any tidy and responsible person would like to do or see done in their own home. In the case of caregivers, the emphasis is not only on cleanliness, but also on safety factors around the house, i.e. keeping the home clutter-free, taking trash out regularly, and removing hazardous objects such as telephone or electrical lines running across rooms. These types of precautions can help reduce falls and other injuries.
Keeping the bedroom, bathroom and kitchen clean on a regular basis is essential. In the bedroom, the bed has to be made, and linen changed, laundered and folded, usually once a week. The bathroom and kitchen need to be mopped at least twice a week.
Caregivers are not expected to do heavy cleaning such as scrubbing or waxing floors, washing windows, or shoveling snow. If family members live in the home, caregivers should also not be required to do their laundry, cook for anyone other than the care recipient, or babysit.
If your caregiver is going to assume the responsibility to drive mom or dad to appointments, it is naturally important to check that they have a valid license, a clean driving record, and that they are insured. Insurance can be a complicated matter that requires looking into. Insurance companies may feel that a caregiver driving a client around is of a commercial nature, requiring special coverage. If the caregiver will be driving a family car, the insurance agent should be notified to make sure their name and driver’s license are included on the family policy. Caregivers should be instructed that the auto is for client use only and not for their personal use.
Of all the non-medical services that a caregiver offers, perhaps none is more precious to our loved one than the friendly face and easy-going support that a caregiver provides. He or she is there to hold hands, provide a comforting word, hold a conversation, keep curiosity alive, and lift the spirit. Caregivers can achieve most of that by indulging in joint activities with their clients, such as board games, listening to music, magazine and bible reading, and all the outdoor activities that the care recipient’s health permits, such as trips to church, restaurants, malls and parks.
A caregiver should be warm, compassionate and easily understood, and they should be able to maintain professional boundaries but still relate to their client’s personality. Furthermore, in their capacity as companions, caregivers should respect their care recipients’ confidentiality, their belongings, and the integrity and sanctity of their home.
The withdrawal and isolation many older adults experience can have a direct negative impact on their health. Companionship should attempt to mitigate loneliness by providing opportunities for stimulating social engagement and interaction.
Clients are known to eat more when in the company of their caregivers, and they are less likely to resist exercise. They tend to also experience less stress and anxiety when they know that someone is there and available to talk to. These and many others are attributes credited to a good companion.
Just as every employee is different, every home care job or caregiving situation is also special. Some care recipients have memory issues, while others have physical challenges or both. The caregiver you hire has to be able to adapt to these and respond appropriately, follow instructions, and monitor changes. A good care plan, usually crafted by the loved one’s physician or the agency’s nurse, provides a comprehensive guide to the caregiver’s duties, including special instructions such as diet, medical issues, exercise, medication, and issues that are specific to your loved one’s conditions.
Documentation can be as simple as a small notebook, or more elaborate such as an agency-provided form for daily activities. Documentation should point out significant changes in the care recipient’s condition, unusual occurrences, and issues to bring up with family or supervisors. Good documentation and follow-up phone calls give agency or medical personnel a clearer picture of the care recipient’s updated condition and how their activities of daily living (ADLs) are progressing.
Choosing and hiring a home care agency or caregiver is a critical and intimate job, particularly in your loved one’s life, though also for the rest of the family. If that process is handled successfully, the caregiver can become “part of the family.” However, this person is a professional who should be promptly made aware of their duties and boundaries right from the start.
Whether part-time or full-time, make your preferences known upon hiring and orienting the new caregiver. Alert them to areas of the home that are off limits or items that should not be moved or touched. Remember that they can’t know what you want if you don’t brief them.
For example, you should be strict about the daily caregiver arriving on time per the agreed upon schedule, and that he or she should be bringing his or her own meals and snacks. They should not expect any personal favors such as loans, the use of the family car for personal errands, overnight stays, or bringing others into your loved one’s home.
Your caregiver’s duties should be well defined at your first meeting. This allows you both to understand what is needed and what a caregiver can or cannot or should not be asked to do while she assists the patient. It also avoids later misunderstandings.
A caregiver is a professional who should be treated as one. Neither of you should be divulging too much personal information about yourselves. Avoid confiding in complaints about your loved one and difficulty you had caring for them, for the caregiver may pick up on these trends and go into caregiving responsibilities biased.
Finally, make sure to pay (or have paid) your caregiver promptly, methodically, and without a fuss. Wages, work schedules, and job descriptions should ideally be in writing, though this is not an absolute must. Gratuities should be avoided, and reasonable gifts restricted to very special occasions.
Your loved one’s caregiver is a critical part of your daily life. Every effort should be made to start the relationship on the right foot and to nourish it with appropriate kindness and respect. The last thing you want is a high turnover in your loved one’s caregivers, so act with diligence, and if you are asked to mediate on occasion between your loved one and the caregiver, use your best judgment in being fair to both sides and in measured ways. Hopefully this information is useful as you think about hiring a caregiver for a family member. Additional resources that may be helpful include our articles on Dementia Care Communication Strategies, Dementia Help and Support, Common Dementia Behaviors and Solutions, and Activities for Persons with Dementia.