How to Hire In-Home Help

In-home care becomes necessary when circumstances such as illness, cognitive decline, frailty or injury make it difficult to remain safe and comfortable in one’s own home. There are two levels of in-home care available — skilled or medical, and non-skilled or non-medical. You may require services from both types, or services could be provided by one or the other depending on your level of care needed.

How do I get this?

Use the list below to identify regular tasks and determine what you can do by yourself, what your family and friends are able to help with, and what is not being done. Once you have identified what you need help with, use these tasks to write a job description for what your in-home worker will be paid to do. This list is also helpful if you hire an agency which will create a care plan based on these tasks.

Tasks

Bathing – standby or hands-on assistance with bathing in tub, shower, or bed
Personal (Non-Skilled/Non-Medical) Care – assistance with dressing, brushing teeth or denture care, shaving, hair care, foot care and grooming needs
Skilled (Medical) Care – care by a licensed nurse (or someone working under a licensed nurse) to manage medical needs including wound care, catheter changes and setting up medications
Medication Assist – reminding and/or assisting an individual to take medications correctly
Toileting – assistance with toileting or incontinence products
Ambulation – help walking, using a wheelchair, or other assistive device
Transfers – assistance movement from wheelchair, tub, bed, toilet, automobile, etc.
Positioning – turning or changing an individual’s position to avoid discomfort or injury
Range of Motion – providing assistance in movement of legs and arms as directed by a physician or physical therapist
Eating and/or Feeding – assisting with eating
Meal Preparation – preparing nutritious meals to eat immediately or reheat later
Errands/Appointments – transporting or escorting to shopping, appointments or errands
Housekeeping – maintaining a safe, sanitary environment with a special focus on kitchen, bathroom and laundry
Supervision – providing protective supervision for individuals who are not safe if left alone because of confusion or poor judgment

Frequently Used Terms

As you begin the search for an in-home worker, you may hear some terms which are unfamiliar to you. These terms can give you an idea of the level of care you may be looking for. Be aware that some are used by home care agencies to assign costs.

Activities of Daily Living (ADLs): These are specific activities that individuals must perform with or without assistance to live independently including bathing, dressing, eating, etc.
Companion – a companion provides social contact, going along on walks or errands.
Homemaker – housekeeping, grocery shopping, laundry/linen changing, and meal preparation (but no personal care).
Personal Care – dressing, bathing, hair care, ambulation, medication reminders and other non-skilled personal care needs.
Personal Care Assistant (PCA) – can help with personal care needs (like bathing and management of incontinence) but cannot provide services that a licensed nurse must perform.

Paying for In-Home Care and Finding In-Home Workers

There are several methods of paying for in-home help. Try to investigate all of the options below to determine if you qualify for financial assistance. If you need assistance exploring options, contact Aging & Disability Resources at 303-480-6700 to speak with an aging specialist.

1. Hiring Through an Agency: There are many agencies offering private paid in-home services. Using an agency will save time and the interviewing process because they have a pool of vetted workers to choose from. Agencies also handle wages, taxes, timesheets, insurance coverage and management of having someone in your home. In addition to your worker, a care coordinator from the agency will have contact with you regularly to update your plan of care.

Each agency conducts their background checks differently which you’re encouraged to ask about. Services are typically structured based on the level of care you require, and you may pay more per hour. Agencies may also have requirements for a minimum number of hours. Some may offer a sliding fee scale.

2. Direct Hiring: Directly hiring a privately paid in-home worker may save you money and be more flexible in choice of schedule and worker. However, it is more work to screen, interview, file taxes, insure and hire. You may not have a backup if your worker gets sick and you are responsible for all supervision and management.

If you decide to hire privately, you must follow state and Internal Revenue Service (IRS) laws and have obligations in record-keeping for your in-home worker. Also be aware that accidents can happen to your worker while working in your home and you are liable. Contact your homeowners insurance company to learn about liability coverage. Contact the IRS and state taxing authority to understand your responsibilities for hiring a private worker.

3. Health First Colorado – Home and Community Based Services (HCBS): These are state-funded Medicaid programs offering in-home care to individuals needing personal care who meet income and resource guidelines. You must qualify financially as well as functionally based on your care needs. Apply through your county Human Services department for the financial application and through your county’s Single Entry Point for the functional assessment:

County Departments of Human Services

Adams (720) 523-2000
Arapahoe (303) 636-1130
Broomfield (720) 887-2200
Clear Creek (303) 679-2365
Denver (720) 944-4347
Douglas (303) 688-4825
Gilpin (303) 582-5444
Jefferson (303) 271-1388

Single Entry Point Offices

Rocky Mountain Human Services – 844-790-7647; SEPquestions@rmhumanservices.org (Adams, Arapahoe, Denver, Douglas)
Adult Care Management – (303) 439-7011 (Broomfield, Clear Creek, Gilpin)
Jefferson County Options for Long Term Care – (303) 271-4216

4. Private Insurance: Some long-term care insurance policies provide coverage for in-home care. If you have this type of insurance, talk to your company to determine eligibility.

5. Medicare-Covered Home Health Services: Medicare provides limited, intermittent coverage for skilled/medical in-home care as prescribed by a physician to people who are homebound. It does not pay for personal care or homemaker services such as help with toileting, cooking, housekeeping, etc. Bathing help may be included while skilled care is being provided. For more information, call 1-800-MEDICARE or talk with your primary care doctor about getting a referral.

Hiring an In-Home Worker:

The best way to find a worker or home health agency is to get a recommendation from a family member, friend, or a trusted resource. Your place of worship or an organization you belong to may also be helpful resources.

Begin by checking on the Colorado Department of Public Health & Environment’s website to be sure the home health agency you’re considering is licensed: www.colorado.gov/pacific/cdphe/home-care-agencies-consumer-resources

Also review the agency’s licensure record and any recorded deficiencies: click on “Inspection & Occurrence Findings”, select city or county, payment source and press “Start Search”. Click on the agency. Select “Occurrence Investigative Reports” and health surveys.

Setting up a Job Description and Contract

The purpose of a job description or contract is to clarify the duties and responsibilities of both the employer and the worker. You will want to know for yourself:

Hours needed
A brief description of duties
Preferences such as non-smoker or male/female
Hourly rate you would like to pay

Having a formalized agreement is essential if there is a dispute about salary, hours of work, tasks, etc. If you hire an in-home worker through an agency, they will create the contract. If you hire a private individual, you will need to create the contract and job description.

A contract/job description can always be revised or updated as needed. It is important to be as specific as you can in a contract to lessen the chances for confusion or disagreement. If the job involves special skills such as lifting into the bathtub or giving medications, the worker should be trained and experienced in those skills.

Arranging an Interview

When contacting possible agencies or workers, ask a few questions on the phone before setting up an interview. For example, ask about their work/business history and other experiences. Once you have decided which applicants or agency meet your qualifications, schedule the interview.

For your own safety, arrange for a friend or family member to be there for your first interview if you are hiring directly. Usually in-home agencies will send out a representative to assess your needs and create a contract before they assign a worker to you. You can ask the agency representative to be present the first time your worker comes to your home.

Have your sample contract or list of tasks ready to give to the applicant or agency representative. Write down the name, address and telephone number of the applicant or agency. Below are some suggested interview questions. Feel free to make up your own list for your particular needs.

For agency: What kind of insurance do you take? Medicaid? Medicare?
For agency: What kind of backup coverage do you have if my worker is sick or on holiday?
Where have you worked before? What kinds of things have you done?
Have you ever provided care for a person similar to what this job requires?
How do you feel about cooking and eating what someone else wants?
What is the minimum/maximum number of hours a day you can work?
How do you handle people who are angry or upset? How do you resolve conflict?
Why are you choosing to do this kind of work?
What makes you uncomfortable or angry?
What is your attitude about smoking, drinking, or using drugs?
Is there anything in the job description which you would not do?
What commitment to staying on this job are you willing to make?
What training/certifications do you have? (CPR, First Aid, CNA, Fundamentals of Caregiving, etc.)
Please give me three references: two work-related and one personal.

If the applicant is obviously unsuited, be non-committal about future contact. Remind a suitable applicant that you will need to check references before making a decision. Review the following checklist before ending the interview:

Was the person on time for the interview?
Was his/her appearance and grooming appropriate for the occasion?
Did the applicant and I agree on the terms and conditions of the contract?
Do I need to modify my contract before employing this person? How?
Did I get at least three references to call to verify his/her ability to perform needed services?
Did I say when I would notify the applicant of his/her acceptance or non-acceptance?
Do I have the name and number of the applicant/agency?
Did I feel comfortable or at ease with the person?
Did I note anything that made me uncomfortable? (dress, speech, behavior, etc.)
If the job involves special skills (such as lifting into the bathtub or cooking diabetic meals), will the worker require specialized training?

Checking References

Never hire someone without checking references! Before making a hiring decision, call at least three references to learn more about the applicant. Briefly describe why you are looking for a worker and ask the reference if the applicant would be a good match for your situation.

Questions to Ask References

How long have you known ______________? Dates? In what relationship?
Is ___________working for you now? Has ______ worked for you in the past? If no longer working for reference, ask: Why did ________ leave? Would you re-hire?
What was ______’s position with you? Can you tell me more about his/her responsibilities?
How did_______ get along with you and/or others?
What were your impressions of _____ as a worker?
Did _______ show initiative or wait to be told what to do?
Did you find _______ reliable, trustworthy and honest?
Was _______ punctual and dependable?
What were his/her strengths and weaknesses?
Were you aware of any problems with drugs or alcohol?
Any other problems that could interfere with ______’s performance?

Supervising In-Home Workers

Once an applicant is offered the job and accepts, the agreement should be signed before the worker starts. Then a start date is chosen. Each party should have a copy of the signed agreement.

Here are some tips for supervising your newly-hired worker:

Make a list of the steps for each task, including preferences for cleaning products and supplies to be used, the locations of these items, and reminders of parts of the task which could be overlooked, for example, “please separate the white wash” or “please sweep under the table”.
Avoid following the worker around the home. Instead, ask to be notified after each task is completed. Check off each step that has been finished correctly. Simply remind the worker if any step has been left out.
Be sure to acknowledge any extra effort or thoughtfulness, even if what has been done does not fit exactly with your specifications. It is important to focus on the person’s good will rather than small mistakes.
Correct major errors by giving information rather than criticism. Unless an error occurs repeatedly, assume the person needs more information about how something should be done.

Maintaining Open Communication with Your In-Home Worker

Open communication between you and your in-home worker can maintain a positive relationship. People appreciate being told when they are doing a good job. It is also important to tell people about factors that irritate you or unacceptable job performance. Small annoyances can often cause larger problems when not discussed.

Be sure your expectations are clear:

Give specific, written directions regarding duties to be performed and when breaks are appropriate.
Develop a checklist to be completed by yourself and the in-home worker by the end of each shift.
Demonstrate difficult tasks and have the worker practice for you.
Review privileges such as eating meals at your home and the use of your telephone.

Be fair, honest, and kind, and remember to respect your worker’s privacy.

Praise a job well done. People need to be appreciated. Describe what you like. For example:

“Thank you for putting non-skid strips in the bath. I feel much safer.”
“I really appreciate the extra care you take in cleaning under the furniture (around the sink, etc.). Having a clean home feels wonderful.”
“Thank you for making the effort to be on time.”

Get small irritations off your chest before they build up. In the event of irritations or problems, permit ample time to discuss and resolve.

Abuse Prevention and Ethical Considerations

County Adult Protective Services (APS): Unfortunately, elder abuse is all too common without proper advance planning, accountability and supervision. Abuse can take many forms from accepting gifts to theft of medical/personal items, physical abuse or emotional battering and neglect. Become knowledgable about different forms of abuse including physical and sexual abuse, neglect, self-neglect and financial exploitation.

An important ethical consideration for families and older adults is how to handle gifts. An in-home worker should not accept gifts of money or anything else. It violates the professional relationship that should be established between a worker and the person receiving care. This is a difficult concept for many people to accept. The relationship between an in-home worker and care receiver is, by its nature, one that has an imbalance of power. The in-home worker is usually more able-bodied, physically and sometimes mentally. For the in-home worker to receive gifts other than wages jeopardizes the balance of power and drifts into the area of elder abuse or exploitation.

If you feel unsafe or uncomfortable with your in-home worker who is from an agency, contact their supervisor first. If your concerns are not being addressed or you have concerns about your own private in-home worker, contact Adult Protective Services in the county where you live.

Note: APS is not an emergency service. In the event of an emergency or if you feel your life is in danger, call 911. If you are 70 years or older in the state of Colorado, the county may send a police officer to complete a welfare check.

Adams 720-523-2057
Arapahoe 303-636-1750
Broomfield 720-887-2271
Clear Creek 303-679-2365
Denver 720-944-2994
Douglas 303-663-6270
Gilpin 303-582-5444
Jefferson 303-271-4673

Misuse of Time: Examples include using up time doing easier tasks first, taking frequent breaks, and excessive use of mobile devices or watching TV. Here are some tips to address misuse of time:

On your checklist, be sure the harder or more critical tasks are listed first.
Give criticism as soon as possible after the problem occurs.
Keep criticism brief and to the point.
Mention one incident at a time and make a suggestion for improvement.
Focus on the situation, issue or behavior, not the person.

TIP: Use supervisory skills and a written checklist to maintain a professional relationship.

Taking advantage of the person:

Worker wins trust and then takes advantage of sympathy and/or friendship by sharing personal and/or financial problems, resulting in you offering “loans” or gifts to the worker.
Persuades you to sign for hours not worked, allowing late arrival/early leaving, bringing children/partner/friends to work.
Offers to be listed on or help change legal documents (for example, offers to be an agent on Power of Attorney forms or will, or a beneficiary or co-signer on bank accounts/property)

When In-Home Help is Resisted

Even though in-home workers may be essential, the idea is sometimes resisted. It is important to respond to this issue with understanding. Some common concerns are:

Maintaining Sense of Independence: Many people view accepting a stranger’s help as an insult to their independence. What they may not realize is that they may have already accepted help in the form of neighborly assistance or family visits. It is important to involve the person needing care in the entire process of hiring and supervising the in-home worker.

Fear of Depleting Savings: It may be helpful to compute the cost of in-home care over a year so that the exact cost can be seen relative to the benefits received. Compare this to the cost of moving into an assisted living or retirement community.

Fear of Reduced Contact with Family Members and Friends: Assure the person receiving care that contact with family and friends will continue. Offer frequent phone calls and set dates for social contact. By stating clearly that the intention in hiring help is to prolong the ability to provide care, family and friends can sometimes show that hiring help is the very opposite of abandonment.

Fear of Victimization: A new in-home worker may represent a threat. After all, this is a stranger who is gaining access to the individual’s personal items. People who have hearing, vision or mobility deficits may feel very vulnerable. Ways of dealing with this issue may include:

Obtain Referrals from Friends: An employee of a trusted friend can be an excellent prospect.
Be a Physical Presence: It is sometimes wise for a family member or friend to be present during the first few sessions. Later, this person or others can make occasional, unplanned visits. Neighbors can also be helpful with this because of their proximity to the person.
Carefully check references and make sure a background check is completed.

Worry About Lack of Supervisory Skills: Older people may need to learn how to provide clear instructions and appropriate supervision to gain confidence in their in-home worker’s abilities.

Create a list of tasks you need help with before any interviews take place. This list is also helpful if you hire an agency which will create a care plan based on these tasks.
Whether you hire your own in-home worker or go through an agency, keep this list of agreed-upon tasks handy. This makes sure tasks are clearly stated and can be verified if not performed. It also structures the relationship on a professional foundation.

Discomfort Beginning the Process: Start slow. It may be wise to start with a small amount of hours of in-home help and gradually increase the hours as the recipient becomes more comfortable.

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This guide is brought to you by the Denver Coordinated Workgroup. The Denver Coordinated Workgroup is made up of experts from the field of aging who are committed to creating and sharing information in order to guide people to the services they need to thrive as they grow older. Western Care Partners is proud to serve with this group of talented professionals.