Is Home Health Care an Option?

By Attorney Joseph L. Matthews, Nolo

The benefits of home health care are great, but it's not always practical.

In recent years, more and more elders are turning to home care to meet their personal and health care needs. This trend is particularly welcome in light of public health surveys indicating that up to half of all nursing facility residents could live independently if they had adequate and affordable home care services. And other studies have shown that the longer people remain independent from institutional care, the better their overall physical and emotional health.

Home care may be adequate and affordable for an elder who needs help with some physical movements around the home — bathing and getting meals, for example — or with exercise, physical therapy, or monitoring a chronic health condition.

Unfortunately, though, long-term home care is not always a practical solution. If the elder needs extensive medical treatment or close monitoring for many hours each day, the difficulty of arranging different types of care may make home care impractical — and the cost may become prohibitive. In most cases, long-term home care also requires family members to fill in gaps that the outside care services do not cover. For many people without such family assistance, long-term home care is simply not an option.

Home Care Defined

The term "home care" encompasses a multitude of medical and personal services provided at home to a partially or fully dependent elder. These services often make it possible for an older person to remain at home, or with a relative, rather than enter a residential facility for extended recovery or long-term care.

Depending on what is available in your community, home care and related supplemental services can include:

• health care — nursing, physical and other rehabilitative therapy, medicating, monitoring, and medical equipment
• personal care — assistance with personal hygiene, dressing, getting in and out of a bed or chair, bathing, and exercise
• nutrition — meal planning, cooking, meal delivery, or meals at outside meal sites
• homemaking — housekeeping, shopping, home repair service, and household paperwork, and
• social and safety needs — escort and transportation services, companions, telephone check, overall planning, and program coordination service.

Not everyone using home care will need all of the services available. And of course, not every community will offer every possible service. Even if they do, a single program or agency might not provide everything the elder will require. Additional needs may have to be filled by community agencies or organizations, adult daycare or senior centers, individuals hired through informal networks, and family and friends. Geriatric care managers can help establish a home care program for elders who require a mix of different types of care — different services from different providers.

The Independence Advantage

One of the great advantages of home care is that it permits an older person to maintain a feeling of independence and comfort in familiar surroundings. Also, you and your family may be better able to control the care received — and to avoid care that isn't necessary.

On the other hand, for home care to work well, you and your family must take the initiative to find services, coordinate different programs and personnel, monitor home care needs and performance, figure costs and budgets, and make changes when required. And you and your family will be making all these decisions without a professional institution to help. This decision-making responsibility can add an extra burden to the daily task of meeting the elder's needs for physical care.

For some people, remaining at home isolates them from social activity and limits mental stimulation. Although friends and family often intend to provide lots of companionship, too many elders wind up spending their days in bed asleep or watching television. An organized elder residence, on the other hand, offers both a community of people and a constant stream of activities.

The Possibility of Savings

In addition to the physical and emotional advantages of remaining at home, there can also be significant financial savings if the care required is not too complicated or frequent and family and friends help out. While residential care facilities average $30,000 to $100,000 a year, home care can average from 25% to 90% less, depending on what care is required. You save by not paying for unnecessary services or institutional overhead. The things you provide yourself at home — food, drugs, and supplies — come without any nursing facility mark-up.

However, home care often becomes more expensive over time. Home care needs may become more extensive or complicated, and family members may not be able to pick up the slack, which could require additional paid care and services. Sometimes, hidden expenses make the true cost of home care too high. Families often fail to calculate peripheral expenses: the continued or expanded cost of running a home (such as taxes, utilities, insurance, and maintenance); the cost to family members of transportation and missed work; and the costs of temporary workers to fill in when family members can't make it or when regular care falls through.

Assessing the Quality of Care

Though the comfort and financial advantages of home care sound attractive, you may have some doubts about whether the quality of home care compares to the qualify of care in a nursing facility or other elder residence.

Medical and nursing care. The American Medical Association, the American Hospital Association, the American Nurses' Association, and the U.S. Department of Health and Human Services all stand behind the quality of medical and nursing care delivered by home care agencies that are certified by both Medicare and your state's home care licensing agency. So, when medical or nursing care — as opposed to assistance with nonmedical activities of daily living — is a significant part of the home care you need, you should seek help from certified agencies rather than independent caregivers. Also, ask your doctor whether the medical or nursing care you require can be safely and adequately delivered at home.

Nonmedical care. Most of the care people need at home is not medical or nursing care, but help with what are called the activities of daily living (ADLs). These include bathing, using the toilet, dressing, eating, getting in and out of bed or a chair, and walking around. For people with Alzheimer's or other cognitive impairment, home care may consist primarily of making sure that the person does not become lost, disoriented, or injured.

For these kinds of nonmedical assistance, home care is often better than residential care. Home care is provided one-on-one, whereas residential facilities have staff-to-resident ratios of one-to-ten or more. And by choosing and monitoring a home care agency or individual home care providers, you may be better able to control the quality of care you receive. On the other hand, tracking the effectiveness of home care is primarily up to the family, whereas residential facilities have professional staff members who are supposed to check regularly on the quality of nonmedical care provided.

Home Care May Not Last Forever

Even if home care is a workable alternative, it may not remain so. Physical needs change over time; home care that now works well may later become impractical. For this reason, you may want to begin planning for the possibility of residential care at some later date — especially if you or your family member is facing Alzheimer's disease or some other form of dementia.

Your planning should take two forms. First, get to know the kinds of residential facilities in your area. At the same time, begin to consider how you might pay for residential care. If it appears that Medicaid may be an option, explore ways to protect some of your assets while still qualifying for Medicaid coverage.