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At Home Care, The Ins and Outs
Jan L. Warner

Who Needs Home Care?

People should consider home care if.....

Upon leaving the hospital after an illness, injury or operation, they have difficulty functioning on your own.

They need kidney dialysis or other complicated assistance.

If they seem to become more frail or, after an illness, find that they can't do what they did before or if they lose their balance easily and need someone to fix means or help with bathing or shopping.

How Can You Find Home Care?

Home health care agencies can provide professional care through registered nurses, speech therapists, or physical therapists. Some also have available personal care or housekeeping aides. If you want Medicare to pay the bill, you must use a Medicare-certified agency; however, with an agency, you may not get the same worker every visit.

Or, if you like, you may want to seek registries of home care professionals, sort of like a nurses' registry. In some, like those for nurses, the person to who you are referred will be both experienced and certified or licensed by your state in his or her field. If you need help with cooking, cleaning, and chores more than you need medical care, you might consider trying to find an independent worker.

But remember: If you decide to hire someone without going through an agency, you will be required to pay that person's Social Security after you have paid them $50 or more in any three month period. And the ways things cost today, this amount can be spent in a few hours. In addition, you may be responsible if your helper is hurt on the job. And if you have a complaint about the way this person you've hired acts, it's your problem. If you use an agency, on the other hand, you need only call the agency which will take appropriate action.

Are There Concerns With A Stranger Coming Into An Elderly Person's Home?

Definitely. To many elderly people, this is very difficult, especially since elder abuse is becoming more and more of a problem. Some people complain that the help they hire does nothing and they are afraid to say anything. That's why elderly people should try to have a trustworthy family member, a neighbor, a friend to act as their advocate and protect them.

Is Home Care Expensive?

Using an agency, skilled services that require a nurse or therapist can cost $60 to $80 for a three-to-four-hour visit--sometimes more for high-tech services like kidney dialysis. Homemaker, aide or companion services are typically priced from $40 to $60 a visit. Hiring someone through a registry costs about 30 percent less than going through an agency. Chances are you could find an independent worker for $6 an hour. For someone who needs a long-term home care, four hours a day, five days a week, the bill is typically $8,000 to $14,000 a year. It's not unusual for some people to spend $30,000 or more a year for long-term home care.

Does Medicare pay any of the bill?

Medicare pays the whole bill but only for skilled home care needed in recovering from an acute illness or injury and only if four conditions are met: The person getting the care must be housebound, under the care of a physician with a care plan signed by the physician, in need of part-time or intermittent skilled nursing or therapy, and the services must be provided by a certified home-health-care agency. What this mumbo jumbo means is that if you've been discharged from the hospital and you need skilled care, chances are you will get some short-term assistance from Medicare. If you need long-term home-health care, it's much more difficult to have Medicare pay. But we believe that well-informed consumers can sometimes get Medicare to pay for care that would otherwise be denied.

How would they manage that?

The key is to get your doctor to work with the agency providing the care to write a justification that Medicare will accept. The way the system is set up, the home-health agency makes the determination whether or not a person's care qualifies for Medicare coverage. If the agency is right, it gets reimbursed; if it's wrong, it doesn't get reimbursed for its services, and the client isn't charged. The home-care agencies have an incentive to be very conservative because they're on the hook if Medicare says your care doesn't meet their criteria.

How do you find a good agency or registry?

One of the first places an older person should turn is to the local Area Agency on Aging. The Eldercare Locator, (800) 677-1116, a service of the National Association of Area Agencies on Aging, can direct seniors to a local agency and to other community resources. The National Association for Home Care, (202) 547-7424, can also help you find a home-care agency in your area. Federal law requires that every hospital have a discharge or social-services unit to help patients devise home-care plans. About a third of the hospitals in this country own a home-care agency to refer you to; another third are affiliated with one. But hospital ownership or affiliation doesn't imply high quality. And consumers do not have to use the services of an agency that's recommended by a hospital; they can choose another agency.

What if I want to find somebody on my own?

Ask everybody you know for recommendations. Often you can find an independent worker through a church, friend or doctor. Although such workers tend to be less skilled, they can be very caring and devoted. On the other hand, there are some real pitfalls when you take someone into your home who isn't backed by an agency or some licensed group. There are a lot of obvious dangers, such as hiring someone who has a drinking problem, steals or is generally unreliable. We recommend that you ask for three references and be sure to check them. If you have any doubts, in some states you can call the police and ask if the person has a criminal record.

Are there practical problems that the elderly encounter?

Since home care is delivered in blocks of three and four hours, and an elderly person is more likely to need short bursts of help over a longer period of time, sometimes the aide doesn't have enough to do. So one of the common frustrations is: Here I am paying for this person, and she's reading a book or watching television. Another problem is that some aides steal money, belongings or food. One solution is to put money in a cash box and say to the aide, "There must always be $50 here, or receipts that add up to $50. Again, an advocate or buddy can help monitor and solve such situations.

Often there isn't a clearly understood agreement as to what the aide expects and what the client expects. Sometimes when people are sick and vulnerable, they're particularly sensitive. For example, you might have a worker in the kitchen playing loud music who has no idea that it's really upsetting the older person in the next room. And the older person is stewing away at this but doesn't say anything. Clarifying mutual expectations up front would help. We suggest you have a written contract, like the sample in the book, that specifies the work to be performed as well as your preferences on things like not playing the radio too loudly or not liking ice in your soda.

What services won't Medicare cover?

Medicare will only pay for personal-care services like bathing or dressing if the client is also receiving skilled services such as nursing, physical therapy, speech therapy or occupational therapy--and both kinds of services must be stipulated in the doctor's plan of care.

Will private medigap policies that supplement Medicare pay for home care?

Older persons in some states can now choose from as many as 10 standardized types of medigap policies, labeled A through J. If a consumer purchases plans D,G, I, or J, coverage will include some payment for personal-care services that supplement Medicare"s home-care coverage. This adds $30 to $50 to the policy's annual cost. The catch is that the person has to first qualify for the Medicare benefit, which means that he or she needs skilled assistance. For every visit received from Medicare, there is eligibility for an additional visit paid by the medigap policy specifically for personal-care services. The benefit has limits of $40 per visit and $1,600 a year.

Should a person buy other private insurance, too?

More companies are selling private, long-term care insurance that includes a home-care benefit. Unfortunately, if a person lives alone with no friends or family to count on, no private long-term-care insurance policy will provide enough care to keep him or her at home. If a person has a fair amount of informal support--spouse, friends or a child who lives nearby--home-care coverage from a private plan could be a good supplement to the informal care.

Are there other ways to pay for home care?

Most older people desperately want to stay in their homes. One option is a home-sharing arrangement--trading room and board in the house for part of the cost of home care. In addition, there are 18 million elderly homeowners, with combined home equity of over $800 billion. It's now possible to establish a line-of-credit reverse mortgage that doesn't commit you to drawing down your equity but gives you the option of borrowing should you need the money. People also ought to consider downsizing--moving out of that large house, which they probably don't need, to a smaller house or an apartment. In either case, downsizing will give you extra cash that could be used to purchase home care.

© 2002, NextSteps®.

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