The goal of home care services is to allow elders to remain at home with dignity and to maximize their ability to be independent without jeopardizing their safety in any way. The term "aging in place" has become a catch phrase for describing this complex goal, and there is increasing support among health care professionals and policy makers for keeping elders out of nursing homes and in their communities with appropriate services.

Elders are not a monolithic group in terms of their needs. Many elders need only a small number of services to function independently at home. However, with hospitals and rehab centers shortening the length of patient stays, more and more elders who are at home have significant health care challenges and need a fairly high level of services to be provided at home.

Home care services fall into four general categories, although some home care service agencies may have more than one service provided by the same person.

Homemaker Services provide home management assistance, such as shopping, meal preparation, light housekeeping, vacuuming, laundry, and changing beds.

Personal Care Services provide assistance with daily living tasks, such as bathing, dressing, grooming, eating, moving from one location to another, and going to the toilet.

Home Health Care Services assist people with health and medical conditions that can be treated at home. Home health aides assist with personal care and basic health care such as taking vital signs (temperature and pulse), changing simple bandages and dressings, and assisting with medications.

Skilled Health Care Services provide registered nurses, licensed practical nurses, and physical, occupational and speech therapists to give skilled nursing care and rehabilitative therapies at home. Medicare will pay for home care when skilled services and certain necessary home health aide services are needed, usually following a surgery or acute care stay in a hospital. (For more information on Medicare or MassHealth coverage for these services, see Health Care Insurance Coverage: Medicare, Medigap and MassHealth, later in this section.

Family caregivers themselves possess an enormous amount of knowledge about what their elderly relatives need, but sometimes making decision about services and coordinating them over time can be overwhelming. In this case, additional professional advice and expertise can be very helpful, especially when you are first time elder caregiver. You do not need to do this alone!

Geriatric Care Managers are nurses, social workers, counselors or gerontologists. They may be accessed through an ASAP/AAA, a hospital, a rehab center, a community service center, or a multi-service private home care agency.

They are experienced in working with families, evaluating needs and dealing with complicated family dynamics. they will make home visits and assist in determining eligibility for resources. Families can choose what they need help with. These professionals can:

Make an assessment about the need for home care services;

Develop a care plan about the specific services needed;

Coordinate home and medical care and hire home care workers, either through contracts with designated service providers or through workers of their own agency;

Monitor home care services, reassess them periodically and make needed adjustments;

Secure respite care for family caregivers, adult day programs, long-term care and senior housing;

Provide assistance to families in addressing legal and financial issues;

Assist in dealing with the complicated government benefits; and

Assist with medical service and equipment providers.

If you work with a geriatric care manager through a publicity subsidized program run by an ASAP, the services will be free of charge or provided on a sliding scale basis.

If you are paying for a geriatric care manager privately , you will receive the same services as those provided by the ASAPs, as well as help in arranging long-distance caregiver support and other specialized services. There is a national organization (and a New England chapter) of private geriatric care managers that provides the names and background information about care managers in Massachusetts and across the country.

Geriatric Care Managers of New England Website: Geriatric Care Managers of New England. Phone: 617-426-3533.

National Association of Geriatric Care Managers, Inc. Website: National Association of Geriatric Care Managers, Inc.. Find a Care Manager. Phone: 520-881-8008

One of the first things a caregiver is asked when inquiring about home care services — whether through an ASAP or a fee for service agency — is, "What is your mother's (spouse's, father's, relative's) ability to manage ADLs?" Another mysterious elder care acronym!

"ADL" stands for "Activities of Daily Living." These are the basic activities involved in personal care and household work.

Planning for care should begin by assessing an elder's ability to take care of himself or herself. See Checklist of Activities of Daily Living, to assist you in determining what assistance is needed.

The checklist can help you to answer questions about physical limitations and memory problems affecting ability to:

Do housework, laundry, shopping, and meal preparation;
Do personal care, such as bathing, dressing, toileting;
Manage personal health care, such as medical appointments and medications; and
Handle personal finances and legal issues.

If you have filled in the checklist before making a call to an ASAP or home care agency, you will be able to have a more useful conversation, and move ahead with making decisions about home care services.

Planning for care should also include an assessment of certain physical capabilities of the elder in question — most importantly, mobility, vision and hearing.

Mobility — The ability to safely move around one's own home, and one's neighborhood, is often compromised with advancing age. For a professional assessment, ask you Primary Care Physician (PCP) or get a referral to an occupational therapist. To make your own assessment, you can use a tool developed by the Society of Hospital Medicine.

Vision — Vision impairment is common among the elderly and often leads to reduced social interaction and quality of life, depression and injuries from falls. However, because the elderly often do not report their vision problems to their healthcare providers, vision screening is recommended. It is largely accepted that treatment for many vision problems common in older adults, such as cataracts and refractive errors, is available and can improve the quality of life for many elders.

Hearing — Hearing deficits are also common among older adults and can have adverse consequences for quality of life similar to vision impairments. Assistive technology such as hearing aids and cochlear implants can be used to augment basic hearing loss, while more serious conditions may require specialized medical attention.

The Massachusetts Eye and Ear Infirmary in Boston has resources to help caregivers secure the kind of screening tests their elders need and has the services to respond to eye disease and significant hearing loss. They can also help to make referrals to specialists in other parts of Massachusetts. See Massachusetts Eye and Ear Infirmary > MEEI for Patients, for a listing of their services and physicians. Or call 617-523-7900 (TDD 617-523-5498).

Planning for home care also involves consideration of health issues affecting both physical and mental health. Caregivers may want to consult with the elder's primary care physician or geriatric specialist to evaluate mobility issues, an elder's capacity to take medications on their own, and their ability to eat on their own.

Nutrition is a major issue for elders remaining at home. Caregivers need to answer several questions in order to determine if elders are:

Getting the right kinds and amount of food to meet daily health requirements;

Capable of shopping for the right foods and preparing them; and

Eating the food they prepare or that is prepared for them.

If the elder in your care is having difficulty managing proper nutrition, there are meal services available to help.

In Massachusetts, the Elderly Nutrition Program is a federal and state funded nutrition program, administered by the Executive Office of Elder Affairs, which allows local elderly agencies to provide nutritious meals to senior citizens. The Program helps to address a number of problems faced by many elders, including poor diets, poor health, food insecurity, and loneliness. Key nutrition services include nourishing meals, as well as nutrition screening, assessment, education and counseling, to ensure that older people achieve and maintain optimal nutrition.

The Elderly Nutrition Program offers two types of meal programs. The Congregate Meal Program provides at least one meal per day at senior centers, churches, schools and other locations. The congregate setting provides opportunities for socialization and companionship. It also offers programs related to nutrition education, exercise activities, health promotion and disease prevention. Some programs also offer meals on weekends. Transportation is often available for those who have trouble getting around on their own. Home delivered meals, or "Meals on Wheels" program provides nourishing food for elders who are not able to prepare their own food and are homebound.

People age 60 or older and their spouses are eligible to receive nutrition services. There is no income eligibility requirement. A voluntary donation of $1.50-$2.25 is requested. To find the nearest agency, call Elder Affairs: 800-882-2003, or you local Council on Aging (COA) or Aging Service Access Point (ASAP). This subsidized program can also be supplemented with meals purchased through private services, and your local COA or ASAP can help you locate these services.

Combining these four elements — ADLs, physical capacity, health and nutrition issues — can help caregivers make their own assessment of the need for home care services. A useful tool to aid this process can be found in the "Caregiver's Handbook: A Guide to Caring for the Ill, Elderly, Disabled...and Yourself," produced by Harvard Health Publications which includes a 4-page "Questionnaire to Determine Needs." Go to Harvard Health Association > Wellness and Prevention > Publications on Caregiving. The Handbook costs $16.00 and be ordered as a print book or downloaded in a PDF format.

Caregivers can arrange services either by contacting their local Aging Service Access Point (ASAP) or by going directly to a private home health care agency. Your local ASAP will provide an initial assessment free of charge and explain your eligibility for subsidized home care services.

The state's service provider is its Home Care Program, run by the Executive Office of Elder Affairs and coordinated by Mass Home Care and Aging Service Access Points (ASAPs). Call 1-800-AGE-INFO (1-800-243-4636) during regular business hours Monday through Friday (Mass Home Care and Elder Affairs operate this toll-free number).

The ASAP case manager will come to the house and conduct a needs assessment to determine eligibility for the Home Care Program, and other relevant programs and services. Eligibility for the Home Care Program is based on age (60 or older), financial status (there is a sliding scale based on the elder's ability to pay), and the need for assistance with a number of activities of daily living (ADLs). If your situation qualifies for subsidized care, an individualized service plan is developed with the elder and his/her family. The ASAP coordinates and monitors the services provided and reassesses needs on an ongoing basis.

Homecare services are also provided for specific populations through subsidized health care programs. Basic contact information follows and more is listed in the Health Care section.

Program of All-inclusive Care for the Elderly (PACE) provides comprehensive care for low-income elders. For more information about PACE contact the MassHealth/Medicaid Customer Service Center: 800-841-2900 (TTY: 800-497-4648).

Senior Care Options Program (SCO) is a managed care program that is offered to eligible MassHealth members age 65 and over, at all levels of need, in both community and institutional settings in most areas of the state. Contact the MassHealth Customer Service Center: 800-841-2900 (TTY: 800-497-4648).

Veterans programs — Elders may be eligible for home care coverage through the Veteran's Administration (VA) CHAMPVA program. In many cases homecare services to manage daily living tasks are covered by the VA. Call 877-222-8387 to determine whether your eligibility covers these services. For more information about health insurance coverage for veterans, see Supplements to Medicare: Military Service Benefits, Section 3, Part 2.

Finding a private home care agency requires some research. Your local ASAP can help you identify appropriate home care agencies and, if you are interested, private geriatric care managers. Also, the primary care physician or geriatric specialist working with you can recommend agencies. Other resources to contact:

The statewide information service, 1-800-AGE-INFO (800-243-4636) can list home care agencies in your area. Or go to: 800AGEINFO.COM.

Home Care Alliance of Massachusetts, a non-profit trade association of home health providers, (formerly known as the Home and Health Care Association) provides a Resource Directory on its website: Think Home Care > Locate a Home Care Agency > Patients & Families Link direct to MA map under "Locate." Search by city, town, region, and/or type of home care to find listings. Call 800-332-3500 for a printed copy of the Resource Directory or more information.

Growing Older in Massachusetts: A Guide for the Family, 2007 edition, is a publication listing a wide variety of Massachusetts resources, including a comprehensive list of home care providers. Regional editions of the book can be purchased by calling 781-534-2669, or go to Growing Older in MA.

There are several important distinctions to be made among home care service providers that affect the possibility of having some portion of these services covered by Medicare and Medicaid, and affect your responsibilities as an employer/client.

Certified Home Care Agencies and Hospice Agencies provide both medical and non-medical services and have met strict federal requirement for patient care and management and therefore can in some cases provide home health services covered by Medicare and Medicaid. These agencies take care of all benefits and tax requirements for their employees.

Non-Certified Agencies also provide medical and non-medical home services but are not licensed. The same labor standards apply to employees of these agencies as to the employees of certified agencies.

Placement services provide medical and non-medical services and the providers are self-employed independent contractors, not employees.

Independent Workers are employees hired directly by the elder or family caregiver, who is then legally responsible to pay state payroll taxes and worker's compensation. There is no oversight or licensing of these services, and no source of coverage to pay for them.

For more information on the differences between these types of agencies, see the website of the Home Care Alliance of Massachusetts, Think Home Care.

For elders who are medically eligible and homebound, some of the costs for home care services are covered by Medicare, Medicaid (MassHealth), health maintenance organizations (HMOs), and some health and long-term care insurance plans.

For people who meet eligibility requirements for programs managed by the ASAP, services are subsidized on a no-fee or sliding scale basis. If you would like additional information about eligibility for state and federal subsidies see the National Council on Aging, "Benefits Check Up" website National Council on Aging-Benefits Check-Up. Also, contact the insurance providers to clarify what is covered by your elder’s plan.

Most families are not able to get the home care services they need covered by a third party, and home care can become a major expense. this is often a key issue to consider in doing long-term financial planning, See Financial Planning and Management, Section 2, Part 1.

The issue of paying family caregivers to provide home-based care is a topic of on-going debate among elder care practitioners and public policy makers. There is currently no federal policy in place, but there are state-level demonstration projects designed to test the costs and benefits of such an approach.

In Massachusetts there is such an experiment underway; it is called the Enhanced Adult Family Care Program. The overall goal is to keep elders in their homes and communities and out of long-term institutional care by extending the definition of caregiver to include qualified family and unrelated caregivers. It is being run by the Executive Office of Elder Affairs and the Office of Medicaid.

Caregivers receive $1,500 a month to provide 24-hour care for an elder at home. There are eligibility criteria both for the elder and the caregiver. The elder must be 60 or older, MassHealth/Medicaid eligible, and need help with at least three activities of daily living on a 24/7 basis. The caregiver can be a family member (excluding a spouse or legally responsible relative), or an unrelated adult 16 or older, who has completed a training course in home care and meets other criteria set by the state.

A pilot project called the "Caring Homes" program was launched in 2005-06. This "Enhanced Adult Family Care" program is based on experience from the pilot, and is now being run as an expansion of the MassHealth Adult Foster Care Program (for more about the AFC program, see Assisted Living, Section 5, Part 1.

Contact your local ASAP to learn whether you and the elder in your care qualify for this program.

Once you have determined what home care services are needed, how to pay for them and where to find them, then you are ready to compare the quality and cost of the services offered by different agencies.

1. How will the agency assess need? Although you may have performed a needs assessment for the elder in your care prior to contacting the agency, you should ask the agency how it determines the appropriate level of services you need. Your elder's needs may increase or decrease over time and the agency should have a process to assess any change in the services needed.

2. What is the training and experience of the caregivers? Ask what training the agency provides to its caregivers, and if the home care aides are certified by the agency. Does the agency require that its caregivers participate in a continuing education program? Ask if the caregivers are trained to identify and report changes in service needs and health condition.

3. Ask about the specific caregivers who will be assigned to your care. Do the caregivers have experience or receive special training in the type of care which is needed, such as Alzheimer's care? Or training with a particular type of assistive technology, such as a hoyer lift? How long have they been working in the home care field?

4. How does the agency develop the client's care plan, and supervise the caregiver? Does a medical professional or experienced supervisor evaluate and supervise the caregiver in the client's home and get input from the client? How much control and personal independence does an agency provide to its clients? How does an agency involve clients and family members in the process of assigning and supervising caregivers? Does the agency seek input from the client on his/her care plans?

5. How does the agency assure continuity of care? There are clear benefits to limiting the number of caregivers involved with a client. Can the agency reasonable assure that the same caregiver(s) will provide the home care services each week? How long do caregivers stay with the agency? What is the turnover rate? If a substitute caregiver is going to be sent, when does the agency provide notice to the client? Ask how the agency assures that the substitute caregiver will be familiar with the care plan and individual needs of the client and the family.

6. Compare the special or support services provided by different agencies to accurately compare costs. Does the agency provide a twenty-four emergency phone line? Ask if there are additional costs, such as fees or deposits, not included in the price quoted. Will you have to pay extra for holidays and weekends? If the client needs special equipment, will it be covered by insurance?

7. How can the agency be paid? If you will be paying for service, compare the billing process and any payment plans offered by different agencies. Compare how often you will be billed and whether you will be required to pay in advance.

8. Compare how much the caregiver will get paid. Does the caregiver earn enough to be dependable? Paying a decent wage, although costly for the family, will minimize turnover.

9. If you are paying for services directly, pay by check or get receipts for all cash payments.

These evaluation guidelines were adapted from the Massachusetts Attorney General's "Guide to Choosing a Home Care Agency: Important Questions You Should Ask," co-sponsored by the Home and Health Care Association of Massachusetts. A free PDF is available at Attorney General's Office > Elders > Elder Publications. If you do not have the ability of print from the website, call the Publications Line at 617-727-2200, ext. 2674 and request a copy.