Live-In Caregivers

Article Highlights

• There are distinct differences between Live-In Care and 24-Hour Care
• Live-In Care has many benefits including lower cost, easy transitioning, better communication, and greater reliability
• Privately hiring a caregiver allows one to save costs as opposed to hiring through an agency
• To ensure proper care one must prepare care guidelines, employee classification, caregiver vetting, a written care plan, and more

What is Live-In Care?

The terms “Live-In” and “24 Hour Care” are often used interchangeably. They are, however, two entirely different types of care. In “Live-In” Care, the care provider resides in the elderly client’s home. Although they sleep there at night, they are permitted at least eight to ten hours of rest and sleep. In those hours at night, they are expected to assist their senior client only for quick chores, such as going to the restroom.

By contrast, in the 24 hour type of care, shift caregivers are expected to remain on full duty for the entire duration of their shift, with only one or more quick breaks in between. The most common type of 24 hour care involves three 8-hour shifts in which the caregivers are alert and in full functioning mode.

Benefits of Live-In Care

Care recipients that opt for live-in caregivers benefit from the presence of someone with them day and night. Having made the fundamental decision to remain in the sanctity and comfort of their own homes, such care recipients love the live-in schedule for several reasons:

• Lower Cost: A considerable amount of money can be saved by using single live-in caregivers instead of 24 hour care provided by way of two or three shift personnel.
• Easy Transitioning: The live-in program is ideal for convalescing from injury or illness as it avoids the nervous periods during which shift changes are occurring.
• Better Communication: The care recipients’ family members enjoy talking to a single caregiver when they call for updates in their loved one’s health
• Greater Reliability: Live-in relationships involve greater bonding between the care providers and their patients; they have in the past shown less turnover in caregivers than in live-out relationships.

The cost-savings incurred in live-in arrangements make in-home care a stronger, more reliable living option than assisted living facilities.

Comparing Live-In and 24 Hour Care

24 hour care providers work by the hour, whereas live-in caregivers usually work by the day. In addition, care recipients who require live-out care are typically individuals who require much more attention (usually day and night) than those who can make do with a live-in type of care. For example, patients who choose 24 Hour Care in a care facility may:

• Need turning in bed every two hours to avoid bed sores and other inactivity-related complications
• Be individuals with dementia who cannot be left unattended for even short periods of time, and have a disposition to wandering or different forms of agitated sleeplessness
• May be diabetics who need regular monitoring and dispensation of insulin
• Have a high fall risk, or someone on a strict medication regimen or Hospice

In contrast, the typical patient who benefits from live-in care is someone who needs minimal attention at night.

In terms of household accommodation, live-in staff are able to utilize the household’s availability of food and beverages (at their clients’ expense), whereas live-out staff are required to bring their own food.

Duties of a Live-In Caregiver

Live-in caregivers normally provide the same care regimen as those who work by the hour:

• Companionship and socialization
• Assistance with Activities of Daily Living (ADLs)
• Meal preparation, shopping, and transportation
• Medication reminders
• Liaising with family members and often the rest of the medical team

Live-in caregivers also provide a safety net for dementia patients who may not need continuous care as much as they need supervision.

Cost of Live-In Care

There are many misconceptions about live-in care, including what is legal in terms of working hours and payment. Many people still adhere to the myth that they can get a caregiver, perhaps a foreign student, who will work for free room and board. Others believe a live-in caregiver should be at their beck and call day and night. Such situations and caregiving scenarios are illegal and each state has different rules and regulations for live-in care.

The first thing to know is that if you hire a live-in caregiver privately, most of the legal regulations disappear. For the most part, regulations impact home care and referral agencies.

In some states, the time a caregiver spends resting and sleeping at night is allowed to be deducted from the overall cost. Several years ago, the state of California changed the rules in favor of caregivers being paid for their sleep time. This had a major impact on the cost of live-in care, bringing it close to the hourly cost. Texas, however, allows privately hired caregivers who work at least 5 consecutive days to be paid a flat daily rate.

Multiple caregivers can be employed to avoid paying overtime and reduce overall costs. This hiring practice, however, calls for the supervision of several people, increased scheduling, and can cause greater confusion in patients with dementia. Weighing the cost-benefit of live-in care and 24 hour care services is necessary for each individual based on their unique situation.

Where Can You Find a Caregiver?

Hiring Privately

A caregiver can be found in the classified sections of newspapers and magazines, on referral websites, through personal referrals, or in lists provided by public senior agencies. One can also independently find caregivers through personal advertisements, screening, and interviewing. Privately hired caregivers can conceivably work a live-in schedule for as little as $100 to $125 a day, bearing in mind that the family picks up the tab for food and beverages, rent, electricity, etc.

Many believe hiring privately is the cheapest way to find a caregiver. Unfortunately, when one considers payroll, taxes, worker’s compensation, auto insurance, and a considerably decreased ability to thoroughly vet the individual, this may not be the safest, easiest or cheapest solution. Besides, the entire exercise would have to be repeated every time a caregiver leaves for another job, and you would have to fill-in personally or through other caregivers every time your primary caregiver is sick or otherwise needs time off.

Registries

Registries are also referred to as 1099 Agencies. The cost of a live-in caregiver hired through registries varies between $200 and $300 a day. Registries have ongoing issues with the IRS, and are often left to deal with many legal matters. The IRS deems that a 1099 Agencies’ claim of providing someone with a “Private Contractor” will not absolve them from violations.

Home Care and Referral Agencies

A home care agency handles all responsibilities:

• They continually hire new caregivers so that by the time you need one, they are able to provide you with a caregiver who is a good fit with your loved one’s needs.
• They thoroughly vet their caregivers, including criminal and reference background checks.
• They then fill-in with another care provider when their main caregiver needs time off.
• They supervise their caregivers on assignment on a regular basis.
• They pay the caregivers’ wages, benefits, and taxes, then bill you with all expenses paid.

The cost of getting a caregiver through a home care agency can run between $350 and $450 a day.

Referral Agencies

These agencies refer caregivers and enabling clients to hire them directly as employees. They thus provide a selection of qualified individuals to interview and hire with the assurance that they have been trained, screened and are legally authorized to work in the U.S.(e.g. Kindlycare.com). Through guidance and referrals, they can provide clients with necessities like payroll services, worker’s compensation, auto insurance, and information about local regulations. Clients are able to not only select their preferred caregiver, but are also provided with the necessary resources to maintain legal and tax compliance.

Referral agencies are the perfect compromise between being entirely on your own and paying the high cost of a home care agency. A live-in caregiver hired in this manner can run you between $250 and $350 a day, but varies by state.

Employee Classification

Many families choose to label their privately hired caregiver a 1099 “Independent Contractor”. As such, they can avoid paying taxes which is something frowned upon by the IRS. When you hire an individual to care for your loved one at home, the IRS considers you a “Household Employer”, and they consider the caregiver to be the family’s employee. Attempting to classify the caregiver as an “Independent Contractor” can be considered tax fraud.

IRS Rules for Employee Classification

The carer is considered someone’s employee when they are in the position to dictate not only what type of care is provided, but when and how it is done. If the caretaker is one’s employee, it does not matter whether the work is full-time or part-time, or how the caretaker is hired (i.e, classified ad, word of mouth, or agency) as long as they are paid on an hourly or daily basis. The employer thus maintains control over the relationship, and the care provider is considered to be their employee.
By contrast, if a home care or referral agency provides the caretaker and controls what work is done and how it is done, the IRS deems that worker to be the agency’s employee (not the family’s).

Protect Your Loved One: Vetting a Caregiver

Regardless of how a caregiver is hired, there are precautionary measures that must be taken in hiring a caregiver to protect your loved one and their property:

1. Criminal background check (Federal and county): If you are dealing with a home care or referral agency, find out if the prospective caregiver has been “Live Scanned.” This report requires fingerprinting and will report all arrests, court cases and dispositions, probation and sentences, and other post-conviction orders for relief. A Live Scan will also show civil matters such as restraining orders, involuntary mental health commitments, civil contempt findings and other miscellaneous law enforcement-related matters. References for a caregiver are unreliable. Thorough reference checks are necessary to ensure safety, reliability, and overall care success.
2. Valid Driver’s License:  Check for DUI’s, moving violations and/or suspensions.
3. Automobile Insurance: If the caregiver owns a car, you must make sure they are insured. It is a red flag if your caregiver drives to work and cannot produce auto insurance.
4. Worker’s Compensation Insurance: This insurance covers the caregiver if they get injured on the job. While some states automatically include Worker’s Compensation on Homeowner policies, the fine print usually states that this covers workers who are in the home less than 10 hours per week. Your homeowner’s insurance carrier should be contacted regarding a rider.
5. Non-Owned Auto Insurance: Call your agent and have your caregiver added to the automobile policy before they are allowed to drive your loved one around.
6. Liability Insurance: Protects your loved one in the event of negligence or when something of value in your loved one’s home is damaged. If your loved one is injured as a result of a caregiver’s neglect or malfeasance, Liability Insurance will compensate.
7. Fidelity Bond: Covers financial mismanagement, fraud, embezzlement and theft. Depending on the amount and the circumstances, the bonding company may provide compensation before the claim is actually adjudicated.

A Senior’s Care Plan

Providing a detailed care plan for all caregivers to follow helps avoid misunderstandings and paves the way for long-term relationships that are less prone to insufficiencies in aspects of care. The plan of care provides insight and preferences, and establishes a routine for your loved one. It will also provide written documentation regarding rules and expectations. A home care agency’s care manager or supervising nurse will craft the care plan. Some have their own format that includes the agency’s policies and regulations for their caregivers.

What to Include in a Written Care Plan

• A brief history of the client: age, profession, spouse, and other family, hobbies, religion.
• Medical condition(s) and special requirements: Include medical conditions and accommodations, such as a diabetes diagnoses and how insulin should be administered. Also included is level of cognitive function or impairment.
• Personal appliances: e.g. eye glasses or contacts, hearing aids, dentures, prosthetics, cane, walker.
• Medication(s): Med name, Rx number, Doctor, instructions, dosage and use.
• Nutrition: Dietary restrictions, allergies, diabetes, gluten free, vegetarian, etc.; list of preferences, such as “hates fish” or “doesn’t want breakfast until after he has had coffee and read the paper.”
• Personal Assistance: How much and what type of help does the Senior need? (grooming, bathing, transfer, incontinence, and other personal care services.
• Physical Transfers: Has the caregiver successfully demonstrated safe and comfortable transfers from bed to wheelchair, etc.?
• Schedule and preferences: For example, “only bathes in evening” or “likes early a.m. walks before breakfast, naps in afternoon”.
• Pet Care: If pet care is required and provide specifics.
• Home Schedule: Trash pick up, lawn service, housekeeper, etc.
• Home safety: Alarm instructions, code, keys, etc. Is client allowed out alone or with other individuals, i.e. without the caregiver. Can client be safely left alone while caregiver runs errands?
• Activities: Are visitors allowed? Any restrictions? Favorite games, TV programs, music. Are meals out allowed and in what frequency and budget? Is there a regular exercise routine to be followed? Are certain activities frowned upon, e.g. a casino?
• Money: How is money handled and documented? Gift cards for grocery shopping, petty cash, checks written by client with caregiver present? (Caregivers should not be writing checks on their own).
• Housekeeping: The plan would have a whole listing of all the daily or weekly tasks that caregivers should perform.
• Expectations: rules for behavior, housekeeping, personal belongings in caregiver quarters. The clearer the rules, the less headaches to be encountered. This is particularly important if the client has any cognitive issues. Things to cover might include:

Are uniforms required? Are caregivers allowed to do their personal laundry in client’s machines?

What are the work hours? What are the instructions regarding caregiver absenteeism?

Are caregivers allowed to have personal visitors inside the client’s home?

Are bed linens to be changed before end of shift or is bedding merely to be removed and put in washing machine?

Do caregivers have permission to use client auto for personal errands? What errands are expected?

Which primary family member does the caregiver communicate with? How often and under what circumstances? Who can the caregiver provide information to?

• Emergency phone numbers and addresses: Doctors, “family responsible parties”, neighbors, Instructions re who to call after 911 has been summoned.
• Service providers with addresses and telephone numbers: Vet, dry cleaner, dentist, gardener, barber, auto service etc.)
• Things to know: Water shut off, fuse box, quirky appliances, garage door code, lawn irrigation schedule, etc.

Final Thoughts

Over time, changes will occur in your loved one’s mental and physical condition that will require increased care. It is necessary that you remember that your employee has rights and expectations. While an illness that keeps a caregiver up more than usual for one or two days might be acceptable, continued loss of sleep is not only detrimental to the caregiver, but it can also impact the quality of care that he or she can provide. While various scenarios are possible, if your loved one requires continuous night time supervision or care, it is time to switch to 24-hour care.

Finally, it is important to remember that the last thing you want is a high turnover in the number of people caring who for your loved one, particularly when the main caregiver has proven to be an optimal fit for their requirements. Treat your caregivers with the respect and empathy that they deserve and value their needs as if they are your own.