The world of caregiving for older Americans is undergoing seismic changes. As more and more people choose to age at home, demand for in-home care is rising – even as the workforce is contracting and the effects of the Covid-19 pandemic continue to be felt.
We surveyed dozens of providers in the City of Detroit and its suburbs to find costs of caregiving, as well as costs for delivering meals, adult day programs, respite care, transportation and alarm systems. This survey is part of a partnership with The Detroit News and the New York & Michigan Solutions Journalism Collaborative, a partnership of news organizations and universities dedicated to rigorous and compelling reporting about successful responses to social problems. The group is supported by the Solutions Journalism Network.
Among the things we learned in our February 2022 survey:
- The terms used for caregivers vary greatly from place to place. “Nursing” and “medical care” or “medical level care” might be interchangeable; “personal care” might include helping with a shower, and it is different from “companion care,” which might include sitting and watching TV with someone
- Many Michigan care providers are finding that there is a shortage of caregivers at the rates they are accustomed to paying. This is true to a certain degree right now in the U.S. labor market at large.
- A Michigan law enacting cost controls on medical care for car accident victims that took place in mid-2021 caused a lot of upheaval in the market, with the previously generous rates slashed. Those earlier generous rates came from Michigan’s no-fault insurance law, which let survivors of car accidents get full coverage for their home-care costs. The reform, passed in 2019, took effect in July 2021. Some agencies told us this meant they had more access to caregivers who had previously been paid very well via this program.
- Much of the caregiving marketplace is served by local providers with local staff.
- A few care providers with a national footprint have local offices in different parts of the country, while others serve as a sort of bulletin board where job-hunters can post their profile and salary requirements. Care.com and Sittercity.com operate on this model, and require you to sign up for an account.
In composing this guide, we learned about terminology and some things that are useful for understanding the marketplace in the Detroit area and in general. Here are some of the things you need to know.
What can you expect from different caregivers?
Hiring a caregiver can be a complicated process.
Providers may call their caregivers by different names; the categories might not be clear on an agency’s website and sometimes can’t be understood over the phone — and not every provider accepts private pay. We called providers and were able to get some private pricing over the phone, as well as a general gist of care categories.
- “Companion” or “homemaker” care means a caregiver will help the client with housekeeping, meal preparation or medication reminders, and can transport clients to appointments. Caregivers can also provide clients with companionship. In some cases, companion caregivers are not allowed to touch clients.
- “Nonmedical” care, which can also be called “personal” care, consists of helping clients with activities of daily living (often referred to as A.D.L.) such as bathing, getting dressed, traveling to appointments, incontinence care, and operation of a Hoyer lift to help a person get out of a bed or bath. In some cases, personal caregivers are not required to have licenses.
- “Medical” care is provided by certified nursing assistants (C.N.A.’s), licensed practical nurses (L.P.N.’s), and registered nurses (R.N.’s). Medical caregivers can help clients manage wounds or injuries, administer medication and intravenous infusions, take vital signs, and more, while also helping with A.D.L.’s. Medical care can also sometimes be called “private duty” care or “private duty nursing care.” This terminology seems to differ from provider to provider.
Marie Verheyen, the associate director for older adult services at the Oakland Livingston Human Service Agency (O.L.H.S.A.), spoke to caregiving best practices, although she didn’t classify herself as an expert. Verheyen says that legally, only C.N.A.’s and R.N.’s are authorized to give clients medication—but that’s not always what happens practically. According to the Michigan department of Labor and Economic Opportunity, employers have a right to schedule employees as needed. There are no minimum or maximum hours requirements. So while agencies should deploy more than one caregiver on a 24-hour shift, according to Verheyen, that’s not always what happens. Consumers need to vet the agency they’re working with.
We learned that some agencies require minimum shifts for personal or companion caregivers. Some agencies might stipulate that medical caregivers can visit only once per week. Some agencies will provide live-in or 24-hour care for clients. Whether a client needs live-in or 24-hour care depends on their care needs.
As a general rule, the higher a caregiver’s training, the higher the cost. Companion caregivers can cost less than $30/hour, while R.N.s can cost as much as $200/hour.
While some agencies volunteered information about how they verify employees — through background checks or other certification systems — most did not. Potential clients can check agency websites or call for more information on employee background checkings and bonding.
Case study: Kindred at Home
National caregiver agencies might also have different licensing requirements than mom-and-pop agencies. According to Tiffany, a representative at national home healthcare provider Kindred at Home, interested patients or family members must call the intake line at 1-866-227-3524 and go through the process to verify whether the specific Michigan provider they’re looking for accepts private pay. Tiffany said most only take Medicaid, Medicare, or private insurance.
Kindred at Home also has specific licensing requirements that might not apply to other providers. At K.A.H., “skilled” nurses include licensed R.N.’s, L.P.N.’s, occupational therapists, physical therapists, social workers and speech therapists. Patients must be referred by a doctor for these services and need to have seen their doctor within 90 days prior to referral or within 30 days after referral. The doctor’s visit notes need to document exactly why the patient needs whatever kind of skilled service they need. Insurance won’t cover the service without this documentation.
“Home health aides” are non-skilled trained assistants who are not C.N.A.’s — but the patient must also have a referral for this service and the same 90-day or 30-day rules apply for insurance reimbursement. Home health aides help with bathing and showers. At Kindred, they come once per week for one hour.
K.A.H. offers “personal care assistance” in some states, but not Michigan. Personal care assistants are not licensed and patients don’t need a referral. P.C.A.’s help with housework, meal prep, bathing, and transporting clients. They are flexible and come when the client needs, for a minimum of 3 hours each visit.
How is Michigan’s caregiving system funded?
Gov. Gretchen Whitmer recently reorganized the state’s caregiving agency structure; the Health and Aging Services Administration is now known as the Bureau on Aging, Community Living and Support, which operates under the Michigan Department of Health and Human Services.
Individual care providers receive Bureau on Aging money through Michigan’s 16 regional Area Agencies on Aging (A.A.A.’s), which contract with outside providers and provide direct services, to people both paying privately and through insurance. Not every provider will take private pay, according to Heather Hill at D.H.H.S.: If a client is on Medicaid, for example, Medicaid will pay for the entirety of the services they need.
For clients not on Medicaid, it is really up to each individual provider whether they’ll accept private pay. “If someone wanted to get a list of the companies that do accept private pay, they can reach out to their Area Agency on Aging,” Cindy Masterson, the director of the Bureau on Aging’s Operations & Aging Network Support Division, said.
Hill and Masterson also said that what a specific caregiver is called can depend on both the provider agency and the type of service provided. For Medicaid clients, caregiving categories and descriptions — home health and nursing care, for example — are defined by Medicaid, and providers must stick to those guidelines. Area Agencies on Aging and their contracted providers must comply with the Bureau of Aging’s operating requirements, which define what medical and personal care entail.
What you can do when hiring care
If you’re looking for a caregiver in Michigan, Masterson and Hill both recommend reaching out to your local A.A.A., which can provide guidance on finding the care that’s right for you. Masterson also recommends looking up agencies that accept private pay on the Better Business Bureau website.
The operating standards for A.A.A.’s in Michigan can be found here, and you can find your local Area Agency on Aging using this map.
Other states may have similar agencies on aging to help in finding caregivers.
Nationwide star ratings for home healthcare providers, nursing homes, hospitals, rehabilitation facilities and other care providers are calculated by the Centers for Medicare and Medicaid Services, under the name “Care Compare.” Find them here. Find explanations here and here.
Leslie Kernisan, a board-certified geriatrician, writes about caregiving for older adults at her blog at Better Health While Aging. Find it here.
The Eldercare Locator is a public service of the Administration on Aging (AoA), an agency of the U.S. Administration for Community Living. Find it here.
This story was produced through the New York & Michigan Solutions Journalism Collaborative, a partnership of news organizations and universities dedicated to rigorous and compelling reporting about successful responses to social problems. The group is supported by the Solutions Journalism Network. The collaborative’s first series, Invisible Army: Caregivers on the Front Lines, focuses on potential solutions to challenges facing caregivers of older adults.