By Paula Peaden, Esq. 
In-home services are often the key to keeping individuals with disabilities of all ages living in the mainstream community. But hiring and working with aides in the family home can be an emotion-fraught experience. Here are some tips.
Think Through Needs
Carefully consider exactly what services your loved one requires. These could include:
- companionship and meaningful occupations
- assistance with “activities of daily living,” such as eating, dressing, bathing and toileting
- medical care
- household chores
Especially for older individuals, it may be important to consider cultural background and their preference for a male or female aide.
In most cases, it’s necessary to sign up for a minimum number of hours or days per week. If full-time care is required, you may need to hire at least two aides, although some are willing to live on premises. For older persons needing significant care, assisted living facilities, where they can retain much of their independence, may be less costly than in-home assistance.
To ensure that everyone’s on the same page, write a detailed job description. If housekeeping is to be included, be specific. If cooking is needed, specify your loved one’s dietary needs and preferences. If you expect the aide to run errands, be sure they have a driver’s license and be clear about whose car gets used.
Unfortunately, the expense of home care must often be borne by the family—but there are exceptions:
- Medicaid – If income and asset requirements are met, and there are relevant waiver programs, Medicaid may cover the cost of in-home care. If the individual is a minor, the family’s financial situation is assessed, but if the person is an adult, it’s their personal economic need that’s evaluated.
- Medicare – This program covers in-home care when medical services are required. Individuals must be at least 65, have been receiving SSDI (Social Security Disability Insurance) for over 24 months, or have been diagnosed with ALS.
- Aid and Attendance – If the individual is a wartime veteran with disabilities who has limited financial means and they are receiving a VA pension, cash payments are available for home care.
- Long-Term Care Insurance – If the individual has a long-term care policy, it may cover home care. Policies differ and it’s important to read the fine print.If a doctor provides documentation indicating that an individual requires assistance with at least two activities of daily living for at least 90 days, expenses can be claimed as a tax deduction.
It’s always best to get suggestions and referrals from trusted friends who have personally worked with local home care aides. Your church, synagogue or mosque may also be able to direct you and—for a fee—geriatric care managers, who work with individuals of all ages, can reduce the stress of your search. Some of my clients have run ads, as well.
Home Care Agencies
There are a growing number of businesses devoted to vetting and managing home care aides, and they can certainly simplify the process. While they tend to be more expensive than hiring an aide directly, they deal with a lot of the complicated paperwork, such withholding for tax and Social Security. Agencies also assume the liability for on-job injuries and ensure that the aides they provide are bonded. If an employee is ill, they’ll provide a substitute, which avoids disruptions.
While you can certainly reject an aide who isn’t working out, you seldom have an opportunity to interview them ahead of time. Since an agency doesn’t always send the same person, your loved one may become confused.
Privately Hired Aides
You can—and should—interview a privately hired aide ahead of time, which gives you more control than working with an agency. While such individuals usually charge less than agency rates, managing the paperwork can get complicated . Their services may not be covered by Medicaid or private insurance, and if they become ill, you won’t have a ready replacement.
In some cases, it may be practical to pay a family member to help out with your loved one. While this isn’t appropriate for parents caring for a minor child, there are other instances where compensating a relative for their time and effort can benefit everyone. But there can also be complications, and it can change family dynamics, because the caregiver becomes an employee.
If the family member will be paid out of a special needs trust (SNT), the beneficiary’s eligibility for public benefits could be affected if the caregiver lives on premises or their salary exceeds the market rate. If the caregiver is also the SNT trustee, they could be breaching their fiduciary duty.
Interviews and Contract
If you’re not using an agency, you can begin by screening candidates over the phone, but you should then meet promising individuals face-to face. When possible, the person to be cared for should be included in the interview process. Observe carefully how prospective hires interact with your loved one.
In addition to questions about work experience and schedule, ask how they would handle behavioral issues—angry outbursts, stubbornness, anxiety or memory problems. Will they be able to lift your family member, if necessary? Then ask for references.
An agency will always provide you with a contract, but a formal agreement is just as necessary with a privately hired aide or family member. List all duties, hours of work, wages and tax withholding, timing of pay and benefits. The more explicit you are, the less likelihood of future misunderstandings.
Staying on Track
Regardless of the aide’s qualifications, a family member should be responsible for supervising them. The aide should report significant incidents at the end of each shift, and time should be scheduled to discuss concerns and any needed adjustments to the routine.
Sometimes personalities prove incompatible and changes must be made. But even in the best of situations, some turnover is likely, which can be distressing for the individual being cared for. Finding and keeping the right services is an ongoing process that may have its ups and downs, but it can play a crucial role in keeping a loved at home where they’re happiest.