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It’s easy once you have the staffing
Clients reportedly love live-in caregiver services, but they can be the bane of private duty companies’ existence. Finding and keeping caregivers willing to live in a client’s home for several days or even weeks at a time can drain resources and frustrate customers and staff alike. After many years of operation, however, one provider finds live-in services an important and successful product line.
"Once you get the staffing in place, it’s actually the easiest to do," says Ann Short, RN, director of extended care for Preferred Health Care, a private duty company in St. Louis.
The company’s live-in workers, all employees, are mostly home health aides, including certified nursing assistants (CNAs) and companions. They perform personal care, light housekeeping, and errands for up to 16 hours a day and sleep in the client’s home the remaining eight.
Finding them is the difficult part, Short says. Although the company advertises, it recruits most live-ins through word-of-mouth referrals from other caregivers and clients. Preferred’s caregivers are predominantly middle-aged women with grown children and no day-to-day family commitments.
"We’ve had a little more success with those who live in rural areas. They’re OK to come in the city if they’re there for several days and don’t have to worry about driving in and out. Some of our existing caregivers also tried it and found they liked it," she says.
Preferred’s companions are exempt from Federal Fair Labor Standards wage-and-hour restrictions. The typical caregiver earns about $76 per day and receives overtime only on holidays. The rates are based on minimum wage for 12 hours. "If you don’t use companions and have to pay overtime, you can’t afford the service," Short explains. (See related story on companion services, p. 19.)
Clients, though still independent, need assistance with activities of daily living and no longer feel safe staying at home without support. They usually live alone, although some also have a spouse, Short says.
The company charges a $150 daily rate, prorated in 2-hour increments beginning at 9 a.m. Most clients directly pay for their care, although some have long term care insurance that usually reimburses up to $50 per day, according to Short.
Clients usually refer themselves to the service. Preferred runs a Yellow Pages ad under nursing services, and other business comes through word-of-mouth referrals. Some referrals also come from hospitals.
"We’re known as a live-in provider. There’s not that many, so we do get calls from hospitals. We can’t compete with a lot of hospital-based services, but this is one where we can," Short explains.
The company’s intake staff is trained to work with potential clients when they call about the service. "There’s usually a little exploration during intake. People know they need 24-hour care, but may not be aware of the options available," Short says. Staff emphasize the service’s advantages over shift care, including its cost effectiveness and more consistent and fewer caregivers. They also discuss the downside: Clients are responsible for themselves at night.
In addition to an initial exploration over the telephone, Preferred offers a free assessment, conducted by a supervising RN or LPN, to all potential clients. "They have to be OK at night. For example, they must get to the bathroom or commode by themselves at night. If they need help once in a while, we can do it, and if a client fell we would respond. But if they go the bathroom every two hours at night and need help to do it, they probably need some other service," Short explains.
Other considerations include whether the client requires an extreme amount of care every day, and the amount of physical work involved, for example, with obese clients. The service does work with Alzheimer’s disease patients as long as they do not wander at night.
Live-in employees must have prior caregiving experience, in either formal or informal care settings. Preferred also requires two previous work references, conducts criminal background checks, verifies driver’s license and car insurance, and certification of CNA caregivers. The company’s office-based orientation covers policies, procedures, reviews transfer techniques, infection control, and observation skills. Caregivers also receive an in-home orientation conducted by the field supervisor.
Caregivers spending so much time in clients homes may raise the specter of theft or out-of-bounds relationships, but Short reports that Preferred has not experienced such problems. The company bonds caregivers, but it also counsels clients to secure valuables. And it prohibits caregivers from handling any financial transactions without prior approval. Supervisors conduct patient evaluations every 60 days and the staffing coordinator is in constant phone contact just to check that everything is OK, Short explains.
In most homes, Preferred also limits each caregiver’s schedule. This not only helps them maintain therapeutic relationships with clients, but also helps with overall case coverage, according to Short. "We try to have at least two caregivers per client. Most work four or five days with two or three off, although some work three weeks on, one week off. We prefer this to avoid problems of becoming too involved, [caregiver] burnout, and resentment that they can’t see their own family," she explains.
Short also clearly outlines caregivers’ responsibilities upon hire and when assigning them to a case. This is especially important in keeping open communications about any changes in work load or problems in the home.
"We tell them, If you’re tired during the day and not getting sleep, you need to let us know,’" she explains.
Preferred does not guarantee coverage, but "we always find a way to staff cases, even if we have to eat the cost of hourly care in the meantime," she says. Companies offering live-in services can run into problems by taking on too many cases without sufficient staffing. "You can’t just call and get another caregiver everyday. You can’t contract with other agencies like other home care services," Short says.
Although operating a live-in service can be challenging, "patients love it because it allows them to continue living at home and it’s a great cost effective way to provide care," says Short.
• Ann Short, RN, director of extended care, Preferred Health Care, 15 Centre Pointe Drive, Suite 290, St. Charles, MO 63304. Telephone: (314) 997-4663.
• John Gilliland, attorney, 2670 Chancellor Drive, Suite 290, Crestview Hills, KY 41017. Telephone: (606) 344-8515.