Sunday, January 30, 2011

Price versus Cost in Homecare

If you needed care for yourself, a spouse, or a parent, what would be your biggest concerns? Would it be price? How about reputation? What about expertise? Is safety your biggest concern?

We get calls to Visiting Angels on a regular basis in which the conversation starts "what do you charge?" Is it because family members are only focused on the price, or because they don't know what to ask? I think it's a combination of both, but rarely is cost alone the only consideration.

Individuals who are seeking care, for one reason or another, have a lot on their mind and on their plate. They often are seeking care blindly, knowing very little, or nothing about eldercare. Without education, information and guidance, those seeking care don't know all the questions to ask, and what to consider when choosing care.

Although the cost of care is a definite consideration for most people, it should never be the only consideration when seeking and choosing care. Safety is a great concern, as is reliability, but those also shouldn't be the only concerns either. Yes you want to know the staff providing care has had thorough background and criminal checks, and the agency or facility provides reliable care. Those things are necessary to know, and are not to be taken lightly when choosing the care provider, but there are many things to take into account which can make a huge difference in the care provided and the benefits to the care recipient and family.

What about expertise? Is it important to have people knowledgeable, and trained in geriatrics and eldercare? What about when a family member is affected by Alzheimer's or another dementia? Would any care provider do, or would you want someone who understands the disease, has been trained in communication techniques, and can provide the skills necessary when caring for people affected by dementia?

If you had cancer, would a family doctor be sufficient for you or would you want a specialist? Of course you would want someone who specializes in treating cancer patients. It should be no different when seeking care for an aging loved one. Specialty physicians may or may not charge more than your family physician but it isn't just about the price, is it? What would be the cost to your health if you chose a family doctor who hasn't the experience, training, and specialty in treating cancer? This is the difference in price versus cost. No one chooses a physician just based on price. You wouldn't want to go to your primary physician to treat cancer because he was cheaper, risking complications, and wasting time, only to end up going to a cancer specialist in the end, because the primary doctor couldn't provide what you needed.

Every single day families are choosing homecare providers based on price. Taking cost into consideration, and the value of what you're getting for that price, can end up saving you time, frustration, money, and even your loved one's health.

There is a huge differentiation in private duty homecare, from costs, to experience, to training and expertise. Private duty homecare also varies by State. Some states license private duty homecare agencies, and some do not. The states that license have regulations, and criteria in which agencies have to adhere to in that state. Some licensed states have a distinction between hands on, or personal care, and hands off, or companionship care. Agencies have to meet specific criteria to provide personal care, over and above companionship or custodial care. It takes a different level of training and experience to assist with bathing, transferring, and incontinence care, than it does to cook a meal, provide housekeeping, or companionship.

Having a caregiver experienced in transferring patients from bed to wheelchair, opposed to an inexperienced caregiver can mean a difference in trust, comfort, and preventing a fall. If an aging adult has experienced a fall in the past, and many in wheelchairs have, they need to be confident that the caregiver who is transferring them isn't going to let them fall. A nervous patient is more of a fall risk because they are stiff and guarding movement in an effort to keep from falling again.

As unbelievable as it is to me, it should be to you, that some states have no licensure or regulation over private duty homecare. Michigan, the state I live in and own a private duty homecare agency, in, is still an unlicensed state. Anyone in the State of Michigan can open a private duty Homecare agency for $20 or $30 and a business license. You don't need to have any formal education, experience or training. You can hire anyone to provide care, and not be required to train them or even background check them, because there are NO regulations. I have literally met and heard about some scary individuals who have opened Homecare agencies. One woman I met at a job fair was trying to hire caregivers. My opinion was she needed her own psychiatric care.

Even licensed states may not mandate the most thorough or up to date criminal background checks. If the requirement is a state check or a check through the state's police department, it is not adequate enough. Crimes are charged and convicted at the county level. It could take months to over a year for that information to be entered in the state system. Educating yourself on criminal background checks and asking the care provider what kind of checks they do, can give you adequate information as to their knowledge, and the safety of your loved one.

With the growth of aging adults and the anticipated growth as Baby Boomer's age many individuals are jumping into the eldercare industry focusing on the financial gain rather than providing the best in care. People are opening eldercare consulting businesses after caring for a parent, believing they have enough experience to guide others. Books and websites are popping up in the marketplace daily related to eldercare. As in any field there are good and bad, but the boom in unqualified care providers, and those appearing to be experienced consultants is making it very difficult for consumer's to distinguish the difference.

Individuals need to be more discerning than ever as to the laws in their state, the background, experience, training, and expertise of care providers they are considering. Although private duty homecare  is non-medical it definitely plays a huge role in the health and safety of the adults they serve. As a registered nurse and Geriatric Care Manager  I often wonder how nonprofessionals run and direct private duty agencies. I, and my clients take for granted the value we add to care because most don't know the difference. I approach assessments of new clients, care and the direction of my staff from a nursing background. I can't separate the nurse in me and think from a nonmedical perspective. I provide care management services for free that would cost families an average of $125.00 an hour. We include care plans from a nursing perspective to improve health, safety, and mobility outcomes, and reduce hospitalizations. We have an extensive training and testing program to increase the knowledge and skills of our staff, so our client's can rely on competently trained staff to meet their needs. As a Geriatric Care Manager, my assessment goes way beyond what other agencies owned and directed, by say a business major, can offer.

Would it be important for you to to know how to improve health, safety, and independence from a care provider, who also offers education, solutions, resources, and referrals, or do you want someone who doesn't have the education, experience and expertise to address anything outside of their services? Would you want care providers who either don't train their staff or who can't sufficiently train their staff, and offer solutions to the myriad of problems that can occur in the lives and homes of aging adults, because they lack the education, training, and experience themselves?

Most families that come to us for care are very tired. Many have just been through an exhaustive hospitalization, or rehab and really want to do everything possible to avoid further decline or future hospitalization if I had $1 for every senior who said, "I don't want to go back to the hospital", well.... You get the point. Another example of price versus cost is the ability to implement preventative actions in a care plan, and/or handle a perceived emergency. A business major can't tell you how to avoid future exasperation's of congestive heart failure, but a nurse can. A business major can't necessarily direct a perceived emergency in the home when the caregiver calls, but a nurse can. I have helped clients avoid going to the emergency room, and I have sent clients to the emergency room. I have personally attended to a health crisis in homes that not only helped clients avoid hospitalization, but have saved lives, and prevented surgeries, by applying nursing interventions that were appropriate and effective. Would a slightly higher price in care be worth the expertise that could keep your loved one from another hospitalization, or further decline of independence?

There is a cost involved in training, hiring and retaining staff, the time it takes to give individual attention to providing a plan of care specific to each clients needs. The time spent on thorough assessments, introducing caregivers to clients prior to service, phone calls and emails with family members offering education, solutions, resources and referrals, all should be considered in the cost of care. The time I, and my administrative staff spend on initiating, and providing individualized care, and the attention and time we spend on making sure our staff can meet and exceed our clients expectations is much more than agencies who only focus on their services from a non medical standpoint.

Clients and families don't consider what goes on behind the scenes when they are looking at costs. How much is it worth to you to have an expert working behind the scenes discussing your mom or dad's situation with their caregivers to improve outcomes, while another agency is spending that time banging on doors in the community trying to get more business? Don't get me wrong, all businesses need to market, advertise, and spend time and money to stay in business and grow, but it only stands to reason that a provider who has less to consider, and only focuses on their services, would have more time to market, and a provider who considers health, safety, and outcomes would have less.

If an owner/director has no medical training, experience, or medical license, there will be no time spent on addressing the medical aspects of care, because it isn't even taken into consideration. When it is considered there is a tremendous amount of time spent because the thought process is entirely different. Going back to a patient having cancer; a family doctor will take into consideration the things he or she knows, and make decisions based on that. The actions and time spent will stem from his or her knowledge base. A oncologist, or cancer specialist, has a whole extra block of knowledge, that took an additional 3-6 years of medical school,  to consider as he or she decides what tests to run, and what course of action to take. Wouldn't it make sense that the expert would spend more time than the non-expert, assessing, testing, planning treatment, and providing that treatment?  Time also includes ongoing education to keep up with the latest findings, treatments, and procedures.

Would a lower price be worth the cost of untrained or poorly trained staff, no understanding of your Mom's condition or needs, no recognition of risk factors that lead to another hospitalization, no education or resources to reduce your stress or help you make informed and appropriate decisions, and cheap, inaccurate criminal background checks? Or is it more important to get the most value for the price?

Think about what you would need to help you best care for your Mom, reduce your stress, anxiety, and lead to better outcomes for your Mom and family. Do you have the time to seek educational resources, figure out how to keep your Mom as healthy and independent as possible? Do you have the time to take off work for repeated hospitalizations? Does your Mom or family have the financial resources to pay for more care because preventative measures haven't been put in place and she becomes more dependent? Do you want to employ your own criminal background check company because the lower cost agency doesn't do the most accurate and up to date criminal background checks, and your Mom may not be safe? Those are things that need to be considered in price versus cost.  Remember the old axiom... "Beware the cost of the lowest price."

Is there value in a slightly higher priced agency who can offer case management services, has a medical professional on staff to assess your Mom and the family situation, and directs the plan of care. Is it worth thoroughly screened and trained caregivers who have been with the agency for years? Is it worth preventing a future health crisis, and hospitalization. Is it worth your peace of mind knowing your Mom is in the hands of experienced, educated, professionals that specialize in geriatric care, and dementia? Is free and immediate education, information, resources and referrals to trusted provider's and companies specific to your Mom's condition and situation worth the additional cost?  Is having a nurse, or medical professional available as a resource worth the cost? Is a thorough hiring process that includes pre-screening, employment reference checks (more than dates of employment), thorough, and  up to date criminal background checks, name, social security, and residence checks, and orientation and training worth paying a little more for care?

When you "shop" around for homecare ask what is included in the cost. Find out about the owner's background, whether a nurse is on staff, how the caregiving staff is hired, checked and trained, whether a plan of care is initiated and followed, how they decide what caregiver(s) are placed with clients, how long they retain caregivers, how long they retain client's, whether they have and offer educational resources, whether they refer to trusted provider's and companies outside of their services, and can they recognize the need for additional services or products. Ask for references, and to speak to current or previous client's or families. Ask for the health professionals license number and check their standing with the state they are licensed in.  You can find that information on your state's website, as to whether the license is current, has any complaints or misconduct, or has any other notable incidences, such as suspensions or revocations. There are nurses out there who have had their license revoked or suspended, and individuals claiming to be nurses who are not.

Years ago I worked in the Alzheimer's unit of a long term care facility. The facility had several units for different patient needs. They had hired a woman who claimed to be a registered nurse, and apparently didn't check her license with the state, because after several months of her employment with them, they found out she was not a nurse at all. She was pulled to my unit when we were short staffed, and I had worked with her. I had no indication that this woman was faking being a nurse. Con artists can be very good at deception.

Interview agencies and take note of what they ask, what information they provide, and their knowledge of the condition that led the family to seek care. It usually isn't too hard to distinguish between experienced and knowledgeable agencies and professionals, and those who's only focus is to provide their services to you. Ask them how they differ from similiar agencies in the area. An agency in my area told a medical equipment supplier they would never refer to them because they don't deal with equipment. That was shocking to me! I can't count the number of referrals I've made for safety products such as shower chairs, or grab bars in the bathroom. If the agency isn't looking out for the safety of your loved one, immediately cross them off the list. If they can't recognize safety risks, they sure aren't going to train their staff in safety measures, which puts you and your loved one at risk for a crisis.

If you have any red flags with a provider during interviews or conversations, take those seriously. Dig deeper into what has alerted you and caused concern before you just brush it off and ignore it. Our intuition can protect you and your loved one, so listen to it.

I hope I have provided enough information so you will consider more than price, and understand that it's important to evaluate the costs and value of your chosen provider.

I am always open to questions should you come across something in the article you want to know more about, or are facing a situation that you have questions about. Feel free to post your question under comments, or email me directly at the email below.

Angil Tarach-Ritchey can be reached for questions or comments at, or

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