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(From Caregiver.com) One of the greatest long-term needs of older adults and those with chronic illnesses is for in-home, custodial care services. These workers are often referred to as home health aides, certified nursing assistants and custodial care workers. These in-home workers make it possible for people with functional limitations to remain at home in a comfortable, familiar environment. Home health aides (as we will refer to this class of workers) provide a wide range of assistance with activities of daily living (ADLs), such as bathing, dressing, grooming, assisting with ambulation or transferring, toileting, feeding and providing medication reminders. In addition, home health aides help with what professionals call, instrumental activities of daily living (IADLs), such as shopping, meal preparation, making medical appointments, transportation, laundry and companionship. While it is true that most people would prefer to remain in their own homes, there are circumstances in which care in a residential or nursing facility is more appropriate and more cost-effective. For example, the individual who needs round the clock care because of treatments or behavioral issues will find a nursing facility or residential setting likely to be more affordable. The biggest proportion of people who utilize home health aide services are those who need several hours per day of assistance, as opposed to those who need full-time care. Due to the cost and the increasing shortage of home health aides, many families seeking to hire in-home staff turn to private individuals rather than working through an agency. While at first glance this seems reasonable, it can also cause numerous problems and create unexpected liabilities for the family, who becomes the employer. Tax Issues Case Example: Mr. L hired a home health aide for his mother on the basis of a recommendation from a neighbor who also employed this individual. Mrs. L needed help because of a minor stroke that left her unsteady on her feet. Initially, Mrs. L only needed four hours of help per day to assure that she had a bath, that two meals were prepared and that the weekly shopping was completed. Occasionally, the aide also accompanied Mrs. L to some of her many medical appointments. As time went on, Mrs. L continued to have minor strokes that left her increasingly debilitated. After 18 months, Mrs. L was quite incapacitated and had lost her ability to speak. At that point, the family decided to ask the aide to live in full-time and provide total care to Mrs. L. This relationship was very loving and lasted until Mrs. L passed away. Because the aide had given up all of her other clients to care for Mrs. L full-time, she had no other immediate employment when Mrs. L died. Since she needed income to support her family, the aide filed for unemployment benefits. It was at that point, that the IRS became aware of the employer and filed a lawsuit for back unemployment taxes, penalties and a fine. The family of Mrs. L did not understand their responsibility as an employer and found themselves in a legal action that took over two years and many thousands of dollars to resolve. Workers'
Compensation and Liability Issues Case Example:
Home health aide, Myra Jones had a history of back injuries after many
years of work in rehabilitation facilities. Her injuries always responded
well to treatment, and were kept at bay with back supports provided
by her employer. When Mrs. Jones had the opportunity to follow one of
her clients home from rehab as a private aide, she took advantage of
the offer and worked privately for Mr. S. Over time, Mr. S began to need increasing amounts of physical care, especially for transferring and dressing. Mrs. Jones found herself increasingly taxed by the care of Mr. S, but she had become so attached to him that she did not express her concerns to the family that had hired her. One day, as Mrs. Jones was dressing Mr. S, she bent down to help him with his shoes and her back froze in place. She was unable to straighten up. She managed to creep to the phone to call a friend for help, but she had to insist that Mr. S not move out of her sight for fear that he would wander off. Mrs. Jones
had found herself being treated in the rehabilitation facility in which
she used to work. The doctor told her that she would not be able to
work as an aide again. As she got stronger, Mrs. Jones filed for worker's
compensation and disability insurance. Abuse and
Exploitation Families don't fail to provide supervision out of malicious neglect. Supervision is often difficult because of geographic distance, lack of expertise, or the close emotional bonds that often get established between the aide and the person receiving the care. Furthermore, families often do not have the time or the resources to do criminal background checks, or to contact references, if they even think to ask for references. Sometimes families are so grateful for the care provided by an aide that they are also vulnerable to manipulation and exploitation. Agency
Supervision In situations in which there are personality issues because of cognitive changes or a history of challenging relationships, the agency supervisor is available to provide guidance and support to both staff and care recipient. This can be very fragile, especially if there is a lack of trust or behaviors that are strange to the home health aide. The support of a supervisor can help the aide understand that this is part of the disease process and cope with behaviors so that the aide and the client can have a successful relationship. Often, supportive supervision is the key to making a challenging situation work. Case Example: Mr. B lost his wife who had cared for him for over 60 years. He needed help with shopping, meal preparation, transportation and an appropriate selection of clothing. His family had hired many aides on his behalf. It seemed that Mr. B would fire every aide after only a few days, always stating that they didn't know how to do anything right. When Mr. B came to us, the home health supervising nurse spent time talking with him about his needs and expectations. She learned that Mr. B was unhappy because none of the aides did things the way his wife had done them and this made him feel uncomfortable in his own home. The nurse supervisor explained that everyone had different ways of keeping house. Mr. B was amazed because he thought that all women learned the same routines. Having realized this, the nurse spent more time with Mr. B to find out what was happening that was different from what his wife had done. Amazingly, small things like letting dishes air dry on the counter, versus drying them and putting them away, were distressing to him. By going through the daily routine and learning about Mr. B's expectations, the supervisor was able to provide clarification to the aide and the first one placed in the home was able to be successful and have a multi-year relationship with Mr. B. The employer, whether it is a private individual or an agency, has a great deal of responsibility in hiring and managing a home health aide. This includes responsibilities that are financial, legal and involve governmental regulations. When a family is ready to hire home health aide services, they need to make a basic decision about the source of such assistance. This decision needs to take into consideration the type of help needed, the financial and tax implications, the need for supervision and the relative vulnerability of the person receiving the care. If the family is unwilling or unable to assume the full range of responsibilities, they would be better off working through an agency. If the family chooses to hire privately, they need to consult a lawyer and an accountant to assure that they make proper arrangements for all of their obligations. In addition, they need to stay involved in the relationship to assure proper care and a mutually supportive relationship.
Rona S. Bartelstone, LCSW, BCD,CMC has taught the psychology of aging, healthy aging and other courses on coping with aging parents for many colleges and universities throughout South Florida. She is also involved in extensive training and consultation in the area of aging, caregiving and programming for chronic care needs. Rona has worked with the Florida Department of Elder Affairs on a Task Force to develop an Ethics Curriculum in long-term care. Rona has also been featured in many national media articles about geriatric care management, including The Wall Street Journal, The New York Times and many others. Copyright ©caregiver.com, Inc. 1995 - 2002
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