Home Care Vs. The Alternatives: How To Choose?
Many older Americans choose to move into some form of senior housing. But each year more and more choose to stay in their homes. It’s not a black-and-white choice, and whatever arrangement you choose, home care can dramatically expand your options.
For many these days, the ideal approach to aging involves aging in place—staying in your home and taking the steps necessary to remain independent for as long as possible. Many are still choosing the better-known options: retirement communities, assisted living facilities, and other institutions designed to care for older people. But an increasing number of seniors are choosing to stay at home and get whatever help they need to remain there.
Aging at home comes with all the same challenges: Health and mobility issues present threats to independence wherever you live. But home care agencies—which provide all the services that come with an assisted living facility, but do so in the client’s own home—can enable a senior to remain at home throughout the aging process, and at a cost comparable to other options.
Because many seniors choose to age in place because of their emotional attachment to a particular home or community, home care can also give loved ones the reassurance that their family members are being well cared for without forcing seniors into an unfamiliar, and possibly distressing, environment—and home care can, if needed, keep seniors at home all the way through the end of life. What’s more, home care can also expand the range of options available to any senior, allowing them to choose to stay at home—or seek care outside of it—as best suits their situation.
Kinds of Care
Before we talk about choosing between home care and out-of-home care, we should probably talk about the types of care available to people looking for help as they age. Roughly speaking, they fall into two main categories: the types of care you can receive in your home, and the types you can only receive by leaving home.
There are various kinds of help that someone can receive at home:
Strictly speaking, “home care” covers two main types of non-medical care delivered in the client’s home: help with activities of daily living (things like bathing, eating, keeping track of medications, and mobility) and instrumental activities of daily living (essential tasks that aren’t directly related to physical needs, like preparing meals, light housekeeping, and other household chores). Many home care companies will separate these two categories into personal care and companion care or housekeeping.
Home care is often thought of as something that’s provided for the long haul. Recovery care, on the other hand, involves all the same services as home care, but is provided on a temporary basis for someone dealing with an acute issue such as recovery from a surgery or an injury.
Another type of temporary care, respite care is home care provided when a client’s ordinary caregivers are unavailable.
Home Health Care
This type of care is also called skilled nursing care. Home health care is the provision in the home of the kinds of services usually provided in a nursing home or rehabilitation facility, such as regular changes of bandages or wound dressings, the actual administration of medication, intravenous treatment or nutrition, and other complex interventions requiring higher level nursing skills.
Hospice And Palliative Care
Hospice care involves specialized care for those approaching the end of life; palliative care involves caring for anyone suffering from an underlying disease that is regarded as untreatable. In both types of care, the aim is to keep the client comfortable: this will often require a combination of home care—to keep the client in good spirits and as healthy as possible—and home health care—to administer medication or perform any necessary medical interventions.
Care Outside Of The Home:
Senior living isn’t really a form of care, or even of institutionalization. In senior living, fully able older adults who just want to let go of the responsibilities of living alone will sometimes move into a retirement community or senior housing community. This type of housing is usually designed specifically to be used by seniors, and can take the form of apartments, condominiums, or even freestanding homes. Such living arrangements almost never include the types of services covered by home care, though the communities may, by design, make life easier in general for the aged.
Assisted living facilities provide room and board and some assistance with activities of daily living. But while “assisted living” is sometimes used as a catch-all for any senior housing that includes some kind of personal care, such facilities may not have medical professionals on staff in the way they would be at a nursing home.
Just as with home care, some assisted living facilities and nursing homes provide temporary care for a client whose main caregivers may not be available, or may need a temporary rest.
Some seniors in a senior living, assisted living, or nursing home situation may require more help than the staff may want to take on, or may want to hire a dedicated caregiver who will give them personalized care. In these cases, they will often access concierge care, in which a home care agency assists them in the facility where they reside.
Seniors with more serious health issues may need to enter a nursing home. These types of facilities are also known as skilled nursing facilities—and may also go by the name of long-term care facilities or rehabilitation facilities. Nursing homes provide more complex types of types of medical assistance and generally offer direct assistance to address patients’ health problems.
Hospice is a specialized facility for housing and offering care to those who are approaching the end of life: usually the care offered can only deal with the symptoms of any underlying illness, provided with the aim of making the patient as comfortable as possible.
Many seniors would rather downsize than continue to wrestle with the challenges of home maintenance
Choosing the Right Care For You
Talking about different types of care in the abstract, however, doesn’t make it any easier to figure out whether you should age in place or enter one of the various types of facilities that offer care. That’s because every person’s situation is unique, and every person has unique needs and motives as they choose the type of care they want.
For that reason, it may help to walk through some scenarios that families find themselves in, and use them to guide your decision-making as you choose your next step.
Scenario 1: What If It’s A Healthy Senior Living Fairly Independently?
One situation that often arises is a healthy senior who lives fairly independently who nevertheless feels that they need some help. This can range from organization or home maintenance to ordinary household chores, like cleaning or laundry, that the client wants to take a rest from after a lifetime of work.
Home care—in particular the lower-level type of care often referred to as companion care—is probably the best bet in this situation: if everything else is going well, why leave home for a facility? Home care can also offer some additional advantages, depending on the situation: for example, if the senior is far from loved ones, the caregiver can give the family updates on the client’s condition, and provide reassurance that might not otherwise be available.
Note, however, that even healthy seniors often choose to move to some sort of senior living arrangement. Many seniors would rather downsize than continue to wrestle with the challenges of home maintenance, and senior living and assisted living can be a great option if a senior must give up their home for some other reason—to move to closer to family, for example.
Scenario 2: What If It’s A Senior With Health Challenges Living Alone?
A healthy, independent senior has plenty of choices, naturally. Things get more complicated if you or your loved one is confronting significant physical challenges. In such a situation, assisted living could be the best choice, but it’s not automatically the right way to go: home care can expand the range of options—and may still be necessary before and after the move to assisted living.
One of the first questions to ask is whether health challenges are isolating the senior from their friends or loved ones. If no friends or family live nearby, then assisted living might well be worth a look. On the other hand, some seniors find the move to a facility isolating, too, as limits on space and privacy can make visits less attractive for friends and family. In this situation, it’s also important to remember that many home care companies provide transportation—to social events as well as medical appointments—and so home care can help with isolation as well.
One issue that sometimes arises as seniors lose their independence is that the family begins to be (understandably) concerned about the health and well being of their loved one. In such cases, many turn to assisted living as a means of gaining peace of mind about the patient’s health and safety. Such concerns are natural, but home care agencies can also help provide reassurance about seniors with health or mobility challenges who live at home. In addition to paying visits, home care companies will often supply their clients with medical alert systems that allow the user to summon help even when they can’t reach a phone; many agencies also offer special services that will advise about safety risks in the home and even take steps to make the home safer.
Ultimately whether the senior’s health warrants moving into a facility comes down to the senior’s own preferences. Certainly assisted living may be an option, but there are many reasons, including a simple desire to keep the house in the family, that can make home care a much more attractive option.
Scenario 3: What If The Senior Has A Spouse With Different Care Needs, But They Want To Stay Together?
Sometimes couples find themselves in a scenario where one of them needs a different level of care than the other. This can lead to a lot of distress, since it’s generally not possible, for example, for someone to take up residence in a nursing home who doesn’t need nursing care—even if their life partner does. And when one partner doesn’t need a facility at all, finances can be an issue: the proceeds from the sale of a home are one of the main ways seniors finance their stay in an assisted living facility, but if one member of a couple hopes to continue in the home, that source will be unavailable.
Home care can open up some new possibilities in this scenario. Having an onsite caregiver available for a few days a week can relieve a spouse of some of the most burdensome aspects of care, and even if one spouse needs more involved care or around-the-clock supervision, hiring a caregiver can allow both spouses to remain in familiar surroundings.
Many home care companies offer special services for those with Alzheimer’s
Scenario 4: What If The Client Has More Serious Health Problems?
Beyond these scenarios, you begin to enter situations where some sort of institutionalization may be necessary. But the choices are still not as cut-and-dried as they may appear at first. For example, Alzheimer’s and dementia can appear to significantly increase the need for an assisted living or specialized memory care facility. But especially in the early stages, home care can provide those with memory impairments the supervision they need when other caregivers aren’t available or need a break from their duties. Many home care companies offer special services for those with Alzheimer’s, too, and that type of attention, combined with the comfort of being in familiar surroundings, can make it easier for friends and family to connect with a loved one with memory impairments.
Apart from Alzheimer’s, there are other ailments that can require more involved care, and can make staying at home untenable. But it should be noted that for many of these ailments, the appropriate facility is probably going to be one that provides nursing care, which is a more expensive proposition than assisted living. If the person needs skilled nursing care, then that need should form the basis of comparison if expense is a factor.
Finally, someone will often find themselves needing to enter a facility for an acute crisis like an injury. At that time, they and their family may feel that their only option is to go from the hospital (or rehabilitation facility) into a nursing home or assisted living community. Here again, though, home care can open up more choices: many home care agencies offer services designed specifically to facilitate recovery, and for someone desiring to return to the fully independent life they lived before a setback, these types of home care may make institutionalization unnecessary.
Scenario 5: What About The End Of Life?
No one likes to think about death, and making arrangements around the end of life can be an unpleasant experience. That’s why it’s easy to respond in crisis mode and turn to an institution—most likely a skilled nursing or hospice facility—when a loved one is approaching death. But if a senior is already at home, or could be released from an institution, hospice care at home could be the better choice. It allows the client and their loved ones to avoid the antiseptic environment of a facility and allows everyone involved to treasure those last days in familiar surroundings.
It’s important to be guided by medical professionals as one makes this decision: depending on the underlying condition, the end of life can present enormous challenges to family and caregivers, and it’s possible that the senior’s comfort will be best served in a facility. At the same time, the senior may be more comfortable at home, and if those overseeing their care don’t object, then the family should explore receiving end-of-life care at home. Such care can require a combination of home care and home health care, but it also means that a senior who loves their home and a family who loves to return there can maintain that connection all the way to the end.
Some of these home care agencies are starting to offer a private pay, non-medical line of services as the need to outsource care increases.
Should Cost Be A Factor?
We’ve touched on the issue of costs, but how much of a factor should they be in your choice of care? Before addressing this question, it’s important to note that the choice between home care and some sort of facility is sometimes presented as black and white, but care needs can evolve, can grow, and can sometimes even decrease, and this means that those two choices—between leaving home and aging in place—aren’t always mutually exclusive.
As we mentioned above, sometimes the move to a facility only needs to be temporary, as in the case of rehabilitation. Sometimes, too, a temporary move to a facility is necessitated by life circumstances, as when a family caregiver needs a rest, or is called out of the home for work or some other cause. In this case, aging in place includes time spent away from the home.
In addition, many people move into senior living or assisted living and find that they need more assistance than the facility provides, or would like assistance that focuses on them exclusively. In that case, many people turn to home care agencies to provide them with personal care (and companionship) while in a facility. Finally, moving from the home to a facility doesn’t happen all at once, and if care is needed in the transition, a home care agency may be able to help. So as you measure the cost of home care against the cost of leaving home, you should keep in mind that it’s frequently not a simple choice between one or the other.
Still, while assisted living and other forms of out-of-the-home care sometimes allow a senior to socialize more freely, some seniors find it to be an isolating experience to be removed from the places and people they know best. Moreover, while the choice isn’t always black or white, it can be the case that once you go outside the home for care, there’s no going back. The family may have to sell the house to finance the move to assisted living, and even if it they don’t, the hassle of maintaining the house may become one burden too many for the senior’s family and loved ones. Home care can provide continuity and community throughout the aging process, so as you weigh the costs of in-home care against the costs of care outside of the home, it’s vital to keep the patient’s preferences in mind.
What Cost Can You Expect?
That said, expense will always be a major factor in care decisions. But as you weigh the costs of home care against the costs of care outside the home, you should be aware of some potential hidden costs to each.
First, let’s look at some average top-line costs for each type of living arrangement, using the national median costs as provided by the Genworth cost of care study.
Senior living—$1000-$4000 per month
Assisted living community/facility—$3,750 per month
Nursing home/skilled nursing facility—$6800 per month
Memory care (for those with Alzheimer’s or dementia)—An extra $1200-$1500 per month on top of other costs.
Comparing these costs to home care can be difficult, since home care is usually charged by the hour. But a standard schedule for a client with relatively limited needs might run to 10-12 hours a week—roughly $800-$1000 per month at the national average rate of $21 an hour. Someone with more intensive needs, however, could easily need twice as much time, and according to the Genworth cost of care study, full time homemaker services can reach $4000 a month.
Physical therapy and exercises prescribed by a licensed doctor may be carried out by a non-certified home health aide, and in that case, Medicare would most likely cover the costs.
Whether you choose to move out or stay at home and hire a home caregiver, there are some hidden costs to be aware of. Here are some things to look out for as you look into pricing:
Of course, the hourly rate and the amount of care needed aren’t the only expenses to consider when it comes to home care: you or your loved one will continue to have to pay rent, or a mortgage, or property taxes, for example, and other costs related to housing. They will also have to continue to pay for food.
In addition, despite being paid for by the hour, hiring a caregiver doesn’t offer complete, unfettered flexibility. For one thing, many home care agencies will require a minimum visit length—a sensible request, given that there’s always a baseline amount of effort involved in getting a caregiver into the home in terms of overhead, travel time, and transportation costs. Offices that don’t require a minimum length may increase their hourly rate if the client is seeking less than a certain number of hours of care a week. Many companies will also require clients to pay a deposit or to pre-pay for a set number of hours before providing services.
Finally, even the hourly rate for home care is likely to vary depending on geography and on the type of care the client needs, so it’s important to get an estimate from one or more home care agencies in your area before you begin to compare home care costs with the alternatives.
If you’re just moving out of your home into a senior living community, your hidden costs will likely be relatively minor compared to the finances of selling your home and either paying rent or buying a new unit. At the same time, you should consider these potential expenses:
Will you need home care in the place you’re moving, or have additional expenses for transportation? This is a definite possibility, particularly if you’re going to be out of range of your ordinary support networks.Moving can be an expensive process in itself: if you’re downsizing, are you certain that moving into a smaller space will save you enough in the short or medium term to compensate for the cost of a move?If you’ve got more belongings than space, will you be selling them or giving them away? Or will you hope to keep them accessible by putting them into storage? This could be a significant additional expense to be aware of.
If you’re moving into a facility that will provide you with assistance with some of your activities of daily living, there can often be hidden costs here, too. Here are some to look out for:
Many assisted living facilities quote a monthly rate based on the resident taking advantage of a reasonable number of assistance services. But some adopt an à la carte approach, giving a top line number based on the cost of occupying a room, with services like dressing or bathing assistance listed as extra and coming at an additional cost. Before entering assisted living, try to make a list of the services that you’re likely to need, and then make sure either that those services are included in your flat rate for your living space or come at a reasonable additional cost.The same sometimes holds true for meals: if you’re expecting to eat in the dining room, make sure that you fully understand all the costs involved, and that those costs fit into your budget. As is true for senior living, moving and storage come with its own expenses, and these costs should be included when you’re making the decision to seek care outside of the home.
Skilled nursing facilities tend to vary much less in terms of the services offered, and you can expect for most of your expenses to be included in the top line number. There are still costs associated with giving up a home, however, and you should be aware of these. And keep in mind: residence in a skilled nursing facility is very expensive. Medicare only provides coverage for a limited time, and Medicaid only provides assistance after a patient has significantly reduced the assets they have available.
In the end, of course, choosing the care that’s best for you or your loved one involves many more considerations than just the cost. But as you make your decision, it’s important to realize that the cost of care itself involves a lot of variables, and both in the short term and the long term, bringing care into the home—even full time home care—can be a highly competitive option for those who want to age in place.
Whatever choice you make—and even if you approach aging with the belief that leaving home is inevitable—there’s a good chance that you’ll need to age in place for some length of time. What’s more, there are a number of situations where aging in place with the help of home care actually makes more sense than the alternatives. Particularly when you calculate the emotional toll of leaving a home of many years, or of leaving a much-loved community, choosing an institution can come with some hidden costs that make home care the better bet.
If you’re choosing between home care and assisted living arrangements, understand that neither is a perfect fit for all situations, and you may end up using some combination for some length of time. If you do have to choose, choose carefully to get the care that best fits your needs.