If you decide to hire a home-care employee, you need to determine how much and what type of help your older relative needs. Following are descriptions of some of the types of home-care personnel:

Also in this article: General Eligibility Requirements for Home-Care Benefits Selecting an Agency Hiring a Home-Care Employee Interviewing Applicants Special Points to Consider References Job Expectations Needed Information Transportation Insurance and Payroll Ensuring Security Protecting Against, Identifying and Handling Abuse Supervising a Home-Care Worker

Housekeepers or chore workers may be supervised by the person hiring them and perform basic household tasks and light cleaning. Chore workers often do heavier types of cleaning such as washing widows and other heavy cleaning.

A homemaker may be supervised by an agency or you and provides meal preparation, household management, personal care and medication reminders.

A home-health aide, certified nurse assistant or nurse's aide, often referred to as home-health-care workers, is supervised by a home-care agency's registered nurse and provides personal care, help with bathing, transfers, walking and exercise; household services that are essential to health care; and assistance with medications. They report changes in the patient's condition to the RN or therapist, and complete appropriate records. Sometimes, home-care employees take on several of the roles described above.

Medicare may pay for home-health-care services through a certified home-health-care agency, if a physician orders these services. Home-health-care agencies focus on the medical aspects of care and provide trained health-care personnel, including nurses and physical therapists. For a patient to be eligible for services paid for under Medicare, she must need skilled nursing assistance, or physical, speech and/or occupational therapy. Home-health-care workers are a supplement to this care and usually help the older person for three hours a day, several days a week.

If your older family member or friend needs additional hours of care or requires custodial care, she may be eligible for services under Medicaid. The state where she resides determines whether her income and assets qualify her for Medicaid covered services. Otherwise, you or your older relative must cover the cost of having a home-care worker.

Home-care agencies, which can be nonprofit or for-profit, recruit, train and pay the worker; you pay the agency. Social Service agencies, in addition to home-care services, may provide an assessment of the client's needs by a nurse or social worker, and help with the coordination of the care plan. If services are being covered under Medicare, your doctor, care manager or discharge planner will probably make arrangements for a home-health-care agency.

If you select an agency, ask the following questions. Those questions starred with an asterisk should also be asked if you are hiring the home-care employee.

Unless your older friend or relative needs care for a limited number of hours each day, the rates charged by home-care agencies for homemaker, home-health-aide services and van services for transportation are often beyond the means of middle-income families. If this is the case, you may want to explore the option of hiring a home-care employee directly.

Avenues for hiring home-care aides include:

• asking other caregivers for referrals
• going to senior or other employment services
• contacting agencies that assist displaced homemakers and others entering the job market
• advertising in newspapers

Screen home-care employees carefully to ensure that they have the necessary qualifications, training and temperament.

Your interview with a prospective home-care employee should include a full discussion of the client's needs and limitations, with a written copy of the job description; the home-care worker's experience in caregiving and his or her expectations.

• If the older person needs to be transferred from a wheelchair, make sure that the aide knows how to do this safely. If the aide does not know how to bathe a person in bed or transfer, but is otherwise qualified, it may be possible to provide the necessary training, but make sure she can do it before hiring her.

• Do not try to hire someone on a seven-day-a-week basis. No employee can remain a good employee for long, if she does not have time for her personal needs and interests. Additionally, aides who live in or sleep over cannot be expected to be on call 24-hours a day. If your older relative needs frequent help or supervision during the night, you should hire a second home-care aide or have a family member fill in.

• If your older relative needs a considerable amount of help, live-in help may be available, which can be less expensive than hourly or per-day employees. However, keep in mind that you will be providing food and lodging and that it may be more difficult to dismiss live-in aides, especially if they do not have alternative housing available. It also is important to ensure that the aide has her own living quarters, and that she has some free time during the day, sufficient time to sleep and days off.

Have applicants fill out an employment form that includes their:

• full name
• address
• phone number
• date of birth
• Social Security number
• educational background
• work history
• references

Ask to see their licenses and certificates, if applicable, and personal identification including their Social Security card, driver's license or photo ID. Thoroughly check their references. Ask for the names, addresses, phone numbers and dates of employment for previous employers, and be certain to contact them. If there are substantial time gaps in their employer references, it could indicate that they have worked for people who were not satisfied with their performance. It is best to talk directly to former employers rather than accepting letters of recommendation. With the applicant's permission, it is also possible to conduct a criminal background check.

When hiring a home-care aide, it is important to list the job tasks and to ask applicants to check those they are willing to perform. You should also discuss:

• vacations
• holidays
• absences
• lateness
• benefits and wages

• the amount of notification time each of you should give if the employment is terminated

If you work and are heavily dependent on the home-care assistant, emphasize the importance of being informed as soon as possible if she is going to be late or absent so that you can make alternative arrangements. It is helpful to keep a list of home-care agencies, other home-care workers, neighbors, or family members who can provide respite care, if needed.

• the employee's salary
• when he or she will be paid
• reimbursement for money the aide may spend out of pocket

When hiring a home-care assistant, it is helpful to spend a day with him or her, so that you can go through the daily routine together. At the very least you need to inform the home-care worker, both verbally and in writing, about the older person's:

• likes and dislikes
• special diets and restrictions
• problems with mobility
• illnesses and signs of an emergency
• possible behavior problems and how best to deal with them
• therapeutic exercises
• medications, when they are taken and how to reorder them
• dentures, eye glasses and any prosthesis

Also provide information, verbally and in writing, about:

• how you can be contacted
• contacts in case of an emergency
• security precautions and keys
• clothing
• medical supplies, where they are kept, and how they are used
• food, cooking utensils, and serving items
• washing and cleaning supplies and how they are used
• light bulbs, flash lights and the location of the fuse box
• the location and use of household appliances

If free or low-cost transportation is not available, try to hire someone who drives since this saves you substantial amounts of money in taxi or commercial van ride fares. If the home-care employee is going to drive your family car, you must inform your insurance company, and provide a copy of the aide's driver's license to your insurance agent. Your insurance company will check to see if the license has been revoked, suspended, or if the aide has an unsatisfactory driving history. If the home-care assistant has a car, discuss use of her car on the job and insurance coverage.

Check with your insurance company about coverage for a home-care employee, and contact the appropriate state and federal agencies concerning social security taxes, state and federal withholding taxes, unemployment insurance, and workman's compensation. If you do not want to deal with these somewhat complicated withholdings from the employee's salary, payroll preparation services can issue the employee's check with the necessary withholdings for a fee.

Some home-care aides work as contractors. Even in these cases, you must report their earnings to the Internal Revenue Service. Before employing an aide on a contract basis, consult your financial advisor or tax preparer to make certain that you are following the IRS rules that govern contract workers, since there can be a fine line between who is considered to be an employee versus a contractor.

Regardless of who cares for your elderly relative, protect your private papers and valuables by putting them in a locked file cabinet, safe deposit box, or safe.

• Make arrangements to have someone you trust pick up the mail, or have it sent to a post box where you can pick it up.

• Check the phone bill for unauthorized calls, and, if necessary, have a block placed on 900 numbers, collect calls, and long-distance calls. You can always use a prepaid calling card for long distance calls.

• Protect checkbooks and credit cards. Never make them available to anyone you do not thoroughly trust.

• Review bank, credit card statements, and other bills at least once a month, and periodically request credit reports from a credit report company. Your bank can provide you with the names and addresses of these companies.

• If you do leave valuable possessions in the house, it is best to put locks on cabinets and closets and to have an inventory with photographs.

Although abusive situations are not common, you must be alert to the possibility. They are one of the primary reasons why it is so important to check a home-care aide's references carefully.

You can help to prevent abuse situations by:

• Ensuring that the home-care assistant thoroughly understands what the position entails, your care receiver's medical problems and limitations, as well as behavior that could lead to stressful situations.
• Ensuring that the home-care aide is not overburdened.
• Keeping the lines of communication fully open so that you can deal with potential problems.

Following are possible signs of abuse or neglect:

• personality changes in your older relative or friend
• whimpering, crying, or refusing to talk
• unexplained or repeated bruises, fractures, burns, or pressure sores
• weight loss
• an unkempt appearance
• poor personal hygiene
• dirty or disorganized living quarters
• confusion, excessive sleeping, or other signs of inappropriate sedation

If you witness or are told by a reliable source about neglect; physical abuse; emotional abuse, including yelling, threatening, or overly controlling, possessive behavior, which often involves isolating the older person from others; seek help, if necessary, in replacing the home-care aide as quickly as possible. Ensure that your relative is safe before confronting or dismissing the worker, especially if you are concerned about possible retaliation.

Once you have hired a home-care worker, make sure that the lines of communication are fully open and that both you and the worker have a clear understanding of the job responsibilities to the older person and to each other. Explain what you want done and how you would like it done, keeping in mind that the home-care employee is there to care for the older person and not the rest of the family.

If the home-care worker lives in, try to ensure that he or she has living quarters which provide you, the older person and the assistant the maximum amount of privacy possible.

Once the home-care aide is on the job, periodic and/or ad hoc meetings can be held to discuss any problems the home-care assistant or the older person may have with the arrangement and to find ways to resolve them. It is important to be positive and open in your approach to resolving difficulties. In most cases, they can be corrected.

However, if, after repeated attempts, you find that major problems are not resolved satisfactorily it may be best to terminate the relationship, and seek another home-care employee. During this time, it may be necessary for your older relative to reside temporarily in a long-term care facility or for you to hire an aide through an agency. It is best to have reserve funds on hand should such an emergency arise.

While home-care may not be less expensive than nursing home-care or assisted living, it offers older people the opportunity to remain at home. What is more, it affords a degree of flexibility and choice for the at-risk elderly that few other living arrangements can provide.

This material is from the Administration on Aging's "Because We Care: A Guide for People Who Care." The Administration on Aging is an agency of the U.S. Department of Health and Human Services.