Avoiding Hidden Pitfalls of Home Care
By Sheila McMackin, MSW, LCSW
Social Work Today
Vol. 5 No. 3 P. 17

Hiring home care providers isn’t easy. Consider all the responsibilities. Agencies can help.

Older Americans and frail individuals have the right to safe and trustworthy care. Whether the care is provided by a family member, a residential institution, or an in-home caregiver, all patients deserve to have access to quality care on which they and their families can depend.

Unfortunately, the largely unregulated home care industry does not always make this possible for consumers who choose in-home care. Too many negative stories of people who hired home caregivers only to be taken advantage of have created skeptical attitudes toward the home care industry. However, with a little knowledge about the differences in home care providers and what they mean for the consumer, patients and their families can feel secure in their choice of hiring an in-home caregiver.

Social workers aim to help clients make decisions and choices they can afford without compromising their safety. When it comes to home care, social workers must educate themselves on how choices in caregivers affect clients beyond their pocketbooks.

Home Care: A Growing Trend
The aging of the U.S. population means that a greater number of people are seeking extra assistance with activities of daily living. Additionally, more Americans are dealing with chronic or debilitating health conditions and are creating an increasing consumer demand for long-term care. As people seek ways to avoid institutionalized care, the increase in home healthcare and nonmedical home care services is quickly taking the place of traditional care options such as nursing homes.

Thanks to government support of home care vs. institutional care and the growing popularity of long-term care insurance as a third-party payor, consumer use of private home care services is soaring. With more than 20,000 providers delivering home care services to some 7.6 million individuals, the demand for quality home care is high (Health Care Financing Administration, Office of the Actuary March 2001).

However, unlike nursing home and institutionalized care, the home care industry is largely unregulated and not all models of private home care offer the same protection for the patient. In response to the need for industry regulation and quality standards, the National Private Duty Association (NPDA) was formed to help create industry guidelines, as well as educate the public and health professionals about the complexities of private home care and the potential risks and liabilities involved with the different business models.

Understanding Private Duty
Private duty refers to nursing, homemaker, home care aide, and companion services that are provided to individuals within their homes. The services are paid directly by the patient and his or her family members through a variety of public and private sources. Most states do not require private duty companies to be licensed or meet regulatory requirements. Even something as simple and expected as caregiver background checks are not always guaranteed.

The risks involved in using private home care services are divided evenly between the provider and consumer. Patients and families, accustomed to a Medicare or Medicaid model of care, are often not aware of the differences in the types of private home care business models and the risks involved.

Most private duty providers fall into one of two categories, a registry or referral service or a private duty agency. Understanding the critical differences between registries and agencies and the responsibilities of each is critical when seeking private duty care.

Who’s Responsible? Registries vs. Agencies
A key difference between registries and agencies is the caregiver’s employer. Typically, registries or referral services do not employ their caregivers while agencies take full responsibility for employing their workers and everything that entails.

Registries act as matchmaker services, assigning independent contractors to clients and patients who need home care and placing the responsibilities for managing and supervising the worker directly on the patient or the patient’s family.

Because registries and companies who place private personnel do not actually employ their care providers, their in-home placements pose a greater risk to patients in a variety of areas. When a registry or privately placed care provider is in a private home, supervision, monitoring, government-mandated taxes, and workers’ compensation coverage falls on the consumer. Since the registry does not employ the caregivers, they cannot supervise them and often the workers are not trained. Unmonitored, unsupervised care poses undue risks to the patient, including financial risks and the possibility of emotional or physical abuse.

Private duty agencies, on the other hand, employ their workers and take full responsibility for the supervision and training of those workers. Caregivers are bonded, insured, and, if need be, licensed. The agency also does the accounting and bookwork, provides the supervision and discipline, carries the insurance, and ensures that shifts are covered.

Most private duty agencies who are a part of the NPDA comply with industry standards to protect patients and help prevent problems arising from unsupervised care providers. NPDA member agencies train their staff, monitor their work in private homes and facilities, complete criminal background and abuse checks on all staff, and are responsible for most potential liability issues. Consumers who use an NPDA member agency can feel confident that they are hiring quality caregivers who are committed to the safety and best interests of the patient.

Quality and Cost
Many consumers may be tempted to hire from a registry because of the lower costs when compared with the cost of an agency-employed caregiver. However, consumers need to be fully aware of the liabilities and responsibilities that accompany the registry caregiver, and often the additional financial responsibilities that a registry worker requires makes the initial lower cost deceiving.

Although registries are able to cut costs because they don’t have the same overhead as an agency that trains, supervises, and employs its workers, the long-term ramifications that can result from hiring an agency worker are often not worth the risk.

Additionally, while the skills of an untrained and unsupervised registry worker are often limited, agencies are able to offer a higher level of expertise and services so that when the patient’s health deteriorates or their needs change, the agency is better equipped to meet their needs. An agency’s ongoing training and commitment to employee education means a higher quality caregiver.

Making Strides in Home Care
As the trend toward home care continues to rise, more horror stories of patients being taken advantage of by home care providers are occurring. This negatively impacts the home care industry, but without regulation there is no way to assure consumers of the quality of care. Both the government and the home care industry are taking notice of this issue and advancements toward industry regulation are being made.

Formed in 2002 in response to the lack of standards in the growing private home care industry, the NPDA has been actively educating the public about the potential pitfalls of unregulated home care. With more than 650 member agencies in 45 states and Puerto Rico, the NPDA is a national voice for organizations that provide private duty home care services and an advocate for services that benefit home care consumers—elders, children, persons with disabilities, those with chronic health conditions—and people whose quality of life can be improved by having a care worker help in their home.

As part of a national public education campaign that emphasizes consumer safety and informed decision making in private home care, the NPDA published a position paper about the risks associated with registries as well as industry standards and codes of ethics for home care providers. Additionally, the NPDA Legislative Committee has been actively working to influence legislation that would protect consumers as well as home care employees and set standards for the private duty home care industry. Current legislation is underway in California and Illinois, and the NPDA is poised to work with other states as the movement spreads.

By supporting efforts to set standards and regulations for the home care industry and by educating your clients about the differences in home care providers, you can help create better quality of care for your clients and improve the image of home care as a whole.

— Sheila McMackin, MSW, LCSW, is the president of the National Private Duty Association and owner of Wellspring Personal Care, a Chicago-based private duty agency serving older adults and individuals with disabilities. She serves on the National Committee for the Prevention of Elder Abuse and is a member of the National Association of Social Workers.

Client Responsibilities Checklist When Using Independent Workers
When a client hires an independent home care provider, the client becomes the legal employer of the caregiver. With this role comes certain responsibilities and obligations, including the following:

• Payroll — As the employer, the consumer is responsible for maintaining a payroll system, including withholding state and federal payroll taxes, unemployment, Medicare, and Social Security. When the consumer fails to do this, the government may assign the individual, family, or estate for back taxes and penalties.

• Worker-Related Injuries — Most states require employers to provide workers’ compensation protection. Many consumers of home care who are aware of this incorrectly assume that their homeowners’ insurance will cover worker-related injuries when in fact, homeowners’ insurance usually specifically excludes employees in the home.

• Abuse and Exploitation — Without the security of an agency or company acting as the employee’s supervisor, consumers can set themselves up for abuse or other issues that result from improper screening and monitoring of the caregiver. It’s important to check references and conduct a criminal background check prior to hiring a caregiver.

Find a Quality Private Duty Provider
Visit www.privatedutyhomecare.org for a list of National Private Duty Association (NPDA) members in your area. NPDA members adhere to guidelines and standards to protect the consumer.