Information for Determining Which Type of Home Care is Most Appropriate

home caregiver talking with clientThe following list of questions should encompass most care questions that need to be asked when seeking home care. It is meant as a guide to helping one find good, quality, dependable home care when appropriate.

Understand the type of care services needed.

  • Regular or Light Housekeeping (can be daily, weekly, bi-weekly or monthly)
    Those household chores that are done daily or weekly fall into this category; things like vacuuming, doing dishes, laundry, changing beds, dusting.
  • Heavy Housekeeping or Chores (usually seasonally, quarterly or monthly)
    This includes those household chores that are done seasonally like spring cleaning, washing windows, work that requires moving furniture or getting down on hands and knees to accomplish.
  • Companionship
    After the death of a spouse or friend, living alone can require some paid ongoing companionship. Also, someone who is confused or has memory loss may need some light supervision for safety. Meal preparation usually also accompanies the staffing of a companion.
  • Nighttime Care
    This includes when a person is unable to get out of bed to the toilet, or when a dementia causes “sundowning” and the confused person has nights and days mixed up; sometimes extra assistance is needed throughout the night for safety or to give a caregiver a break.
  • Personal Care (usually required daily or several times a week)
    When assistance is needed with bathing, toileting, eating, dressing, grooming, walking, getting out of bed or out of a chair, or being lifted, and making certain that medications are taken as prescribed, the requirements differ and usually are staffed with a more highly trained person.
  • Transportation Assistance
    When frailty occurs, the loss of transportation can be confining. A home bound person may need assistance with transportation to activities, shopping, medical appointments, etc. It is important to know if the care needed requires the use of a car, or if there is a car available for use, and also if there are any special transportation needs like a wheelchair accessible van.
  • Geriatric Care Management
    Household money management and paying bills are things that should always be separated from direct care. These activities, as well as ongoing household management that falls outside of the services of a direct care provider, oftentimes require the services of a care manager. Other services care managers provide fall into categories that bridge the gaps between direct care and ongoing care needs, which may include a move into another living arrangement and the closing up of a household.
  • Medical Care
    When there is an acute problem, nursing may be needed. Examples are care for a wound (dressing changes), injections, monitoring of health conditions like diabetes or blood pressure or heart disease, assistance with medical equipment like dialysis, assistance with an indwelling catheter, assistance with a naso-gastric (NG) tube feeding or a ventilator.
  • Rehabilitation
    Following a stroke or an accident, sometimes rehabilitation is needed to improve or retain function. Examples are exercises to improve the range of motion of arms and legs, physical therapy following an injury to improve functioning of the injured body part, speech therapy or help swallowing which might be due to a stroke, Parkinson’s disease or ALS, and respiratory therapy.
  • Care for a Terminal Illness
    Terminally-ill individuals have choices for care in the process of dying. Hospice is one choice which entails a range of services from nurses and mental health professionals to spiritual advisors. Their main role is to provide comfort to the dying person and the family and to assist with pain control should that be necessary.

Understand the types of agencies that provide care.

Private Duty/Private Pay Agencies

Unlike Medicare certified home health agencies, many states do not require private duty agencies to be licensed or meet regulatory requirements. Due to this fact, there are several different levels or models of home care within the private duty/private pay spectrum. There are two types of private duty business models:

  1. The full service agency employs caregivers, monitors and supervises care, and provides W-2s to their employees
  2. The nursing registry or healthcare registry simply matches client and caregiver and does not employ, train, monitor or supervise workers sent into private homes

Full Service Agencies

    • A full service agency usually offers the basic homemaker services and support through assistance with daily living, but also may offer a higher level of care to address some medical needs a patient may have. This is based on state licensure, if there is licensure.
    • Supervision within agencies is usually performed by a nurse or other medical professional.
    • Caregivers are employed by the agency and are bonded, insured and, if need be, licensed.
    • The agency also does the accounting and bookwork, provides the supervision and discipline, carries the insurance, and ensures shifts are covered.

Nursing Registries/Healthcare Registries

    • Nursing registries provide services from basic homemaker services to skilled nursing care.
    • These types of nurse registries and employment registry agencies act as “matchmaker” services, assigning workers to clients and patients who need home care and place the responsibilities of managing and supervising the worker on the patient, a family member, or a family advisor or care manager.
    • Because registries and companies who place private personnel do not actually employ their care providers, their in-home placements could pose a greater risk to patients in a variety of areas.
    • When a registry or privately placed care provider is in a private home, supervision, monitoring, government-mandated taxes, and worker’s compensation coverage usually fall on the consumer.
    • Since the registry does not employ the caregivers, the registry personnel cannot supervise the in-home workers, and oftentimes the workers are not trained.

Unmonitored, unsupervised care means a greater chance that care providers can exert undue influence on a frail person for personal financial gain, or the possibility of emotional or physical abuse.

For Medical and Rehabilitation Needs:

Certified Home Health Agency – An agency that has been surveyed and certified by a state agency to assure all Medicare Conditions of Participation have been met. These include clinical services, operational, financial, billing, and other organizational issues.

Certified agencies can also be accredited by the Joint Commission for Healthcare Organizations (Joint Commission), the Community Health Accreditation Program (CHAP), or the Accreditation Commission for Health Care (ACHC)—any of the three have “deeming authority”—if an agency meets the criteria for accreditation, it also covers the Medicare certification.

Understand reimbursement mechanisms.

Private Duty/Private Pay Agencies
  • Private Duty/Private Pay services are usually paid directly by the patient and his or her family members.
  • Long-term care insurance, worker’s compensation and some armed services funding may cover private duty/private pay services, if the agency qualifies for reimbursement under the policies.
Medicare Home Health Benefit Coverage Criteria

Medicare covers some home health care if one meets all the criteria below:

  1. The patient’s doctor decides medical care is needed in the patient’s home, and makes a plan for that care at home, and
  2. The patient needs at least one of the following: intermittent (and not full time) skilled nursing care, or physical therapy or speech language pathology services, or a continued need for occupational therapy, and
  3. The patient is homebound—normally unable to leave home and leaving home is a major effort. When the patient does leave home, it must be infrequent, for a short time. The patient may attend religious services. The patient may leave the house to get medical treatment, including therapeutic or psychosocial care. The patient can also get care in an adult day-care program licensed or certified by a state or accredited to furnish adult day care services.
    NOTE: If patients are too tired when they get to a facility for treatment (rehab) or testing (blood tests) or education (diabetic teaching class) to do the work then home health care is covered to bring treatment to them. It is important to remember that the reason for the patient to be homebound (arthritis, paralysis, etc.) may not be the main focus of care (wound care, monitoring medications after hospitalization for cardiac problems, and the most popular — treatment for Congestive Heart Failure).
  4. The care must be medically reasonable and necessary. It must be related to the problems encountered and the care plan must address realistic outcomes. The plan and care needed shows potential for an improvement in the patient’s health/activities of daily living.
  5. The home health agency caring for the patient must be approved by the Medicare program.

Medicaid Home Care

Medicaid is a Federal/State partnership funded by both entities to cover all types of healthcare for the poor. Coverage criteria and covered services are determined by each state and recipients do not need to be homebound or ill to receive the services, like home care. If the patient is mutually eligible, both Medicare and Medicaid can be payment sources with Medicare usually the primary payer and Medicaid secondary. Medicaid payments for home care are divided into three main categories: 1) the mandatory traditional home health benefit, and two optional programs, 2) the personal care option and 3) home and community-based waivers.


  • Hospice is a special concept of care designed to provide comfort and support to patients and their families when a life-limiting illness no longer responds to cure-oriented treatments.
  • Most hospices accept patients who have a life expectancy of six months or less and who are referred by their personal physician.
  • Hospice care neither prolongs life nor hastens death. Hospice staff and volunteers offer a specialized knowledge of medical care, including pain management.
  • The goal of hospice care is to improve the quality of a patient’s last days by offering comfort and dignity.
  • Hospice care is provided by a team-oriented group of specially trained professionals, volunteers, and family members.
  • Hospice addresses all symptoms of a disease, with a special emphasis on controlling a patient’s pain and discomfort.
  • Hospice deals with the emotional, social, and spiritual impact of the disease on the patient and the patient’s family and friends.
  • Hospice offers a variety of bereavement and counseling services to families before and after a patient’s death.
  • Hospice coverage is widely available—offered by most private insurance providers and through Medicare nationwide, as an optional Medicaid service covered by 47 states (excludes Connecticut, New Hampshire and Oklahoma).
  • Hospice sometimes has grants allocated to supplement Hospice Medicare provisions which cover some private duty services. These services are funded by public funds, are not considered private duty, and are geographically specific. Querying each hospice location is needed to determine if these services are available.
  • Most hospices will provide for anyone who cannot pay using money raised from the community or from memorial or foundation gifts.

Hospice Foundation of America and

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