One of the most difficult challenges you face when caring for an aging parent or disabled child is finding a good quality home care company. Whether you need full time care, or just a little extra help to fill in the gaps when you can't be there, you are making a serious decision.

Unfortunately, many families don't know how to "shop" for home care. The only question they know how to ask is "What do you charge?"

Here are 10 questions to ask your home care company to help you get a better understanding of the company and the services they provide. Getting answers to these ten questions will help you make a more informed decision about caring for your loved one.

1.  What areas do you serve?

Make sure your home care company serves your town or community. Ask them if they currently have clients in your neighborhood. Some home care companies will say they serve an entire city or region but most specialize in a local area. Companies that serve your neighbors will be less likely to have problems providing back-up staff if your regular caregiver is unavailable.

2.  Are your caregivers employees or sub-contracted?

There are four types of home care companys; employers, registries, referral companies, and independent caregivers.

Employers – Home care companies hire and pay their employees directly. All employees are covered by the workers’ compensation and liability laws of your state. Employers are subject to federal tax, Social Security, and Medicare withholding and applicable state and local income taxes.  Many customers will eventually end up using a home care company such as Right at Home.  Hassles such as days off, theft and liability issues end up overwhelming clients and costing more in the long run.

Registries – Registries are companies that coordinate the scheduling of caregivers, but pay their caregivers as independent contractors. In these cases the caregivers are independent and responsible for their own taxes. The registry charges you, and then pays the individual caregivers without withholding taxes or insurance. In some cases, the registry will use a split fee model where you write two checks each week, one to the registry and another to the caregiver.

The registry typically provides scheduling services. This model is designed to reduce overall expenses by reducing liability, benefits, and workers’ compensation costs. While you may see savings, this also may increase your liability. You need to make sure that your caregivers have appropriate coverage if they are injured while working in your home.  In some cases, the caregiver could be considered your employee and you would be liable for withholding taxes, including social security and Medicare taxes.

Referral Services – Some home care companies only provide referrals and background screenings. These companies recruit and screen caregivers and place them in your home for a fee. The fee is typically a one time fee, then you become the legal employer. If the caregivers working in your home are being paid directly by you, you are obligated to acquire a federal employer identification number (EIN) and pay federal withholding, Medicare, state and local taxes as well as employer matches. In some states you will also be obligated to provide workers’ compensation insurance, family medical leave, and meet other state labor industry practices.  Referral Services can generate significant savings over the long term. However, many families feel the additional paperwork, tax and bookkeeping expenditures, and management time is a substantial burden. We strongly recommend that you consult an attorney and an accountant if you decide to become an employer.

Independent Caregiver – There are many individuals who sell their services as caregivers.  They place an ad in the local paper, and make individual arrangements with families to care for a loved one.  Although this may be the least expensive option, there are a number of potential liabilities that you face as the employer of an independent caregiver, including tax withholding, workers’ compensation, and unemployment compensation.

You’ve seen the “nanny-gate” cases in Washington, D.C. where high level government officials got into political difficulty because they hired independent caregivers to care for children or perform household services. They had not withheld taxes and had not paid for workers’ compensation or unemployment insurance. They ended up owing back taxes and losing favored political appointments because of their unlawful employment practices.

Understanding how your caregivers are paid can be critical to your safety and your potential liability.

3.  What is your dress code/uniform policy?

Ask the agency if they have a standard dress code or uniform policy. This is a matter of personal preference for your family. Some families prefer that their caregivers give the appearance of hired nursing assistants, while other families prefer a more casual dress.  Determine if the agency has requirements, and if they are willing to vary from those requirements at the family's request.

Typically caregivers are allowed to wear "whites" which consists of white pants, casual shoes, and a light colored top or polo shirt. Some agencies allow jeans or slacks, sweaters or T-shirts.

Generally speaking, agencies prefer, because of the nature of their work, that caregivers don't wear dresses, skirts, sandals, heels, or loose fitting clothing. Some agencies have policies against jewelry besides watches and small earrings.

If you requested an agency make an exception from their typical policy, make certain that the exception is warranted by their work. For example, you may request jeans if the caregiver is providing house cleaning, or you may request that a caregiver dress more formally if they will be accompanying you to church or temple.

Understanding the dress code and the agency's willingness to vary from that dress code will help you determine if the agency is a good fit.

4.  Will your caregivers transport your family member?

A big need for many families is to provide transportation for their loved one to doctors appointments, physical therapy sessions, church or temple, social events, entertainment and recreation. Some agencies will allow caregivers to drive their clients in the client’s vehicle. Some agencies will allow caregivers to transport their clients in the caregiver’s vehicle. Some agencies own vehicles and provide transportation services. Each of these methods carry a certain amount or risk, and different companies have different policies regarding client transportation.

To avoid liability, many agencies do not permit caregivers to transport clients. However, some agencies will allow you to sign a waiver of liability. Finally, when using your family’s vehicle, make sure to verify appropriate coverage with your auto insurance provider.

5.  What types of personal care are allowed?

There are three levels of care provided by home care companies; companion care, personal care, and skilled care.

Companion care includes meal preparation, light housekeeping, assistance with daily activities such as letter writing, reading, and entertainment. This level of care is designed to provide peace of mind for the client and the family. At the companion level of care the caregiver generally does not touch the client.

Personal Care includes the basic Activities of Daily Living (ADLs) – bathing, dressing, toileting, transferring, and feeding. This level involves hands-on care and requires a higher level of training than companion care.  Many states have specific licensure laws and regulations that govern personal care.

Skilled Care is provided by a licensed professional such as a nurse, licensed practical nurse, physical therapist, or occupational therapist. While these skilled services are often covered by third party payers such as Medicare, Medicaid, and private insurance, these services may also offered on a private pay basis.

6.  What funding is available to help pay for personal care?

Generally speaking, personal care or companion services are not covered by insurance or Medicare. A few states have Medicaid programs for people with disabilities. Some local communities have government programs or charitable programs that subsidize home care. Many of these programs are affected by the income of the recipient, but not all. Your home care agency may be able to direct you to some of these funding sources.

If you have purchased long-term care insurance it may cover a portion of your costs for in-home care. Additionally, some insurance programs or government programs are reimbursement based. You'll need to determine if the responsibility is yours to request a reimbursement, and how much you'll need to pay out-of-pocket prior to reimbursement.

The fastest growing segment of home care is private pay home care, where clients and families choose to use their personal financial resources to provide the peace of mind, quality of life, and independence that comes with staying at home rather than moving to a facility.

7.  What is your cancellation policy?

Occasionally you'll have to cancel services with your home care company.  When this happens, you need to determine their cancellation policy. Try to look for an agency that treats its customers fairly. Most clients will cancel a caregiver from time to time.

8.  What happens if I have an issue of concern after business hours?

The rule of thumb in home care is that the worst situations only occur nights, weekends, or on holidays. Home care is a 24/7/365 business. You want your agency to have a very clear process for managing problems outside of regular business hours.

Some agencies use answering services, others use pager systems, and a few larger agencies will staff their office 24 hours a day. With today's technology there is absolutely no reason that you should expect to not be able to reach someone at your home care agency within a few minutes.  You need to know how to contact them after business hours and how they will respond.

9.  What are your rates?

Some agencies charge an hourly rate, while other agencies have packages of service. You'll want to find an agency whose services and packages fit your needs and your budget. The more home care you buy, the better your hourly rate should be. Most of the expenses incurred by the agency are for the first hour of service.

When you compare hourly rates to the pay rate of your caregivers, it's not unusual to see a 100% difference. Providing quality home care is expensive and high-quality agencies will charge you accordingly. When asking about rates be sure to evaluate total value, not lowest price.  Make sure you're getting what you need and you are only paying for what you get.

You’ll also want to have a clear understanding of the home care company’s billing procedures, and payment due dates. Many companies bill weekly or bi-weekly and expect to be paid before the next billing cycle. These are small companies who must pay their caregivers and make tax deposits. They need to receive regular payments in order to meet their payroll.  Many companies have a defined policy of how long they will continue to provide service after the due date of the bill.  Often, the company will discontinue services if they are not paid on a timely basis.

10.  How do you handle customer complaints or caregiver conflicts?

Almost everyone who receives care will have problems from time to time. A caregiver becomes unreliable, or the client and caregiver's personalities may clash. Many families find it difficult to report these problems because they don't know how the agency will handle the complaint. They don't want to make problems worse by having an agency discipline a caregiver. Conversely, sometimes companies will refuse to discipline a caregiver and simply move them to a new client.

Be up front with your agency. If you acknowledge that possible conflicts may arise you will find that your agency will be more likely to manage your complaint effectively. Have an open discussion about "what if" scenarios and see how the agency reacts. Ideally your agency will take complaints very seriously and act as a liaison to resolve conflict quickly and effectively.

Identify your personal champion.

I have learned that every home care company has good quality people, and many of them also have people who are just punching the clock. Have a few conversations with the agency and try to identify the people in the company who are passionate about their work. Befriend them and make sure that they personally handle issues, particularly scheduling and customer service issues.
Someday you'll need someone to make something happen quickly. You'll have a problem with a funding source, a conflict with a caregiver, or an issue with health or safety. When that happens you want to know specifically who to call for assistance.

Final word of advice...

Shop around. You'll find prices will vary. Services companies offer will vary. You will feel different levels of comfort with the staff of these companies. The actual care you receive from any agency will be very similar to other agencies, however, the service you get and the price you pay from agency to agency can be very different. Look for best value rather than best price. Try to determine what your family needs, and which agency will best support you.

Inviting people into your home to provide care can be a great experience for you, your family, and the caregiver.  You will become an inter-dependent group of people who each have a role.  Identify quality home care companies to support that relationship.