If you’re searching for a caregiver, chances are you will hear a few companies quote rates that are approximately five dollars per hour lower than their competition. In this post, I explain why some firms charge lower hourly rates and why cheaper is not always better.

There are five main factors that affect the hourly rate charged to a family: location, qualifications of the worker, number of hours, profitability of the firm, and the business model.

1. The hourly rate can increase if the family lives in an expensive part of the country or the caregiver lives far away from the family. All things equal, a firm that employs a caregiver that lives closer to the family will be able to charge a lower rate than a firm that employs a caregiver who lives farther away from the family.

2. The more qualifications the caregiver has, the higher the hourly rate a firm will charge. For example in Washington D.C., a registered nurse (“RN”) may cost $40 per hour while a certified nursing assistant (“CNA”) may cost $25 per hour.

3. In most cases, the hours per day and the hours per week that a family needs a caregiver will affect the hourly rate—the more hours that a family needs a caregiver, the cheaper the rate.

4. Firms may charge more money just to be more profitable—while some firms may pay their caregivers higher wages, and therefore can justify their higher rate, more likely than not most firms of the same business model with above average prices are attempting to run a more profitable business by charging more for the same services.

5. There are two types of business models in the home care industry, registry and agency. The registry model is generally cheaper than the agency model. The rest of this post defines the registry model and explains why it is generally cheaper than the agency model.

A firm that employs the registry model does not hire its caregivers. Instead, the caregivers are independent contractors referred by the firm. Generally, a family will pay a billing company, which then pays the caregiver and the firm. The firm charges a referral fee as a portion of the hourly rate charged to the family for the caregiver’s services. The caregiver gets paid for the number of hours the family uses his or her services. Caregivers who work under the registry model are cheaper than the caregivers who work under the agency model because they typically do not get health insurance, retirement options, and other common employee benefits that come with working for a firm full-time. For this reason, families should ask themselves if they are comfortable employing someone who does not receive these benefits yet may work over 36 hours per week.

Many firms that use the agency model will say that the registry model is bad because the caregivers are not CNAs, they are not reimbursable by long-term care insurance, the families are responsible for scheduling other caregivers if their main one is absent, the families are liable for anything that the caregivers steal, and the families are liable for any injury to the caregivers.

The truth is that these are generalizations and cannot be extrapolated to all registry firms. Some registry firms only contract with CNAs, charge fees that are reimbursable by long-term care insurance, will schedule another caregiver if the main one is absent, will reimburse the family for the value of stolen goods, and cover the liability of the caregiver if he or she is injured on the job. There are registry firms that operate this way in Maryland and Washington D.C.

Of the five main factors that affect a caregiver’s hourly rate, factors (1) and (4) families can control by shopping around to different firms, (2) and (3) will be determined by how much care their loved one needs, and (5) depends on the family’s feeling toward the ethics of hiring a contractor who may not receive employee benefits for doing the same work that an agency-caregiver would do and who receives employee benefits. From what I can tell through my research, (5) affects the hourly rate by approximately $5.50.

If you contact a senior advisor, he or she can refer a firm that employs the business model that you prefer, help you get the care that you need, confirm that you are protected, negotiate to lower your cost of care, and ensure that you are paying a reasonable rate. If you want to learn more, here is a link to contact us.


I was at a caregiver talk two weeks ago and the presenter said that in the situation when one spouse must care for the other, 20% of the time the caregiver dies first. One reason that percentage is high is because the caregiver burns out. In my following post I talk about the symptoms of caregiver stress and a few resources the caregiver can use when he or she is feeling overwhelmed.

Spouses and people with some form of dementia are typically the most difficult people to care for1. For spouses, the caregiver is emotionally invested in the situation, and he or she may be frustrated that things aren’t the way they use to be. People with dementia can be tough to care for too because they may become violent, have emotional moments when they become confused, or think of conspiracies involving others stealing from them. There is no doubt that caring for someone else is tough and that’s why professional caregivers deserve our respect.

Caregivers must learn to care for themselves as well as the person they are caring for. The first temper tantrum is manageable. It’s the second one in a day, after a bad night’s sleep, that wears on the soul. That happens and it’s why caregiver stress is real. Its symptoms often mimic those of depression: changing sleep patterns, gaining or losing weight, feeling tired, losing interest in other activities, and being irritated easily1. As a caregiver, it’s good to check-in with yourself and assess if any of these things are happening to you. If so, it may be time to consider the next part of this post.

If you have some extra spending dollars each month, hire a caregiver. Caregivers are typically trained professionals who can help ease the load from your shoulders. He or she also may be able to teach you how to care for your loved one when the caregiver is not there. That’ll make you more effective at your job, which will help to mitigate anything from going wrong and causing you to get frustrated. Additionally, the caregiver will free your time so that you can focus on you. As a result, you may spend your time sleeping, getting chores out of the way so that you can get to bed on time, socializing with friends, or maybe traveling. Taking care of yourself is important, because when you’re well-rested, the next temper tantrum will be much easier to manage. A caregiver can free up your time to rest. Think about hiring one if you’re feeling overwhelmed.

What if you don’t have extra spending dollars each month for a caregiver? There’s great news: you have high-quality options! County governments all over the country are funding respite care programs. Respite care is short-term care. If you’re an unpaid, live-in, primary caregiver for a senior you may apply to receive free home care—check with your county on the programs and terms. In Montgomery County, Maryland, you may qualify for a maximum of 140 hours a year in free home care through The Arc Montgomery County, a local chapter of a larger not-for-profit2. Given there are 168 hours in a week, these respite care programs aren’t long-term solutions; however, they may allow you to catch up on sleep and then clear your mind. Once you’ve recovered, you should join a support group, take a couple classes on caring for your loved one or shadow a caregiver, get organized, and then develop a plan. By taking these steps, you will have given yourself a chance to be proactive towards managing your loved one’s situation.

If you take the latter approach and still find your stress levels creeping up, don’t be afraid to ask for help. Family members, adult day care, and caregiving agencies may have the resources to relieve you just long enough to get your mind centered again. Even if you spend a little money to relieve yourself, it’s okay. Do it. The caregiver must remember that he or she has to keep himself or herself in a good mindset; otherwise, he or she runs the risk of becoming an ineffective caregiver. If you don’t know who to call or what resources to turn to, contact a senior advisor. He or she may be able to lower your caregiver costs, put you in contact with a local respite care program that is funded by the government, or introduce you to other services that can help relieve your workload.




D.C.’s Board of Nursing’s mission statement reads:

The mission of the Board of Nursing is to safeguard the public’s health and well-being by assuring safe quality care in the District of Columbia. This is achieved through the regulation of nursing practice and education programs; and by the licensure, registration and continuing education of nursing personnel.”

In addition to other titles, D.C.’s Board of Nursing oversees certified nursing assistants (CNAs) and home health aides (HHAs). These are certifications to people that caregiving companies hire, and each certification corresponds to a different degree of responsibility. Within Washington D.C., CNAs are only allowed to provide personal care in senior living communities, while HHAs can provide personal care in communities and in the homes of their clients. Home care firms hire CNAs and HHAs depending on their business’s needs.

In D.C., caregiving firms were under the impression that they may apply for two types of licenses, a Nurse Staff Agency license and a Certificate of Need. The Nurse Staff Agency license is a license that a registry uses to refer caregivers to homecare agencies and facilities, such as assisted living and skilled nursing facilities. It’s useful for a company that staffs senior living communities with caregivers. There’s also the Certificate of Need, which is required for an agency who would like to provide care, including skilled services to patients in their home. D.C. takes precaution with administering these licenses due to the complexity of the services which may be provided. On average, it takes an agency two years to get approved for a Certificate of Need (CON). A homecare agency license or a homecare license in addition to a Certificate of Need is required to provide skilled services.

Approximately 12 years ago, D.C.’s Board of Nursing sent a ‘Cease and Desist’ letter to the homecare agencies that did not hold a healthcare license. The letter instructed agencies to apply for a homecare license or stop providing care.  As a result, homecare agencies were directed to apply for either a Nurse Staff Agency license or a Homecare License. However, D.C. was not issuing new CONs at that time.

A few years later, D.C. stated that NSAs should not be providing care to patients in the home, but should only be functioning as a staffing agency for homecare agencies and facilities. Trade associations and other long term care groups met with D.C. and requested that they work together with D.C to create a strategy for appropriate licensure. The concern was for the patients being served and the caregivers as their clients, mostly seniors, would lose their caregivers. In addition, many businesses may end up in bankruptcy, which may cause a spike in unemployment. However, nothing happened for years.

About three months ago an alert went up on the D.C. Department of Health’s website that reignited the issue. The alert said that caregiving agencies who held an NSA license but were providing care in the home were operating in violation of the law. Agencies were advised they must obtain a homecare license and Certificate of Need if they want to continue to operate by providing care in the home. Once again the trade associations and their members gathered to discuss the impact with the Board. This time, it appears the Board is working with the caregiving agencies to smooth the transition. As a result of these discussions, emergency legislation was passed by DC and a new Home Support Services licensure has been created. This allows for personal care services only, to be provided by DC HHAs.

However, it’s going to be tougher for the agencies to continue to do business in DC as they had once done. In addition to licensing requirements, the Board is placing more mandates on D.C. caregiving agencies, which may reduce the number of firms that conduct homecare in D.C. One notable proposed change is that agencies must have office space within D.C. that is staffed 40 hours per week. How firms have been reacting to this proposal shows that the Board is serious about its policy changes this go-around. Already, homecare agencies have been partnering with senior living communities to secure office space in their buildings, in addition to leasing spaces of their own. Some agencies may drop out of the DC market as rental rates and additional staff push their costs too high to justify operating in D.C. Fewer firms in D.C. may mean fewer available caregivers to care for seniors at their homes.

Another requirement is that the Home Support Agencies can only use DC HHAs to provide care. Currently, many agencies are using DC CNAs, these aides must transition to DC HHAs if they are to continue working in client homes.  There is normally 32 hours of education followed by an exam in order to make that transition. The association is currently working with DC DOH to see if there is any way to expedite the process so that clients continue to be served.

​Stay tuned for updates.


Adjusting to life in a retirement home can be tough – it involves big changes, like leaving behind a home and all the memories it contains, as well as the feeling of losing a measure of freedom. Psychologists say that even positive changes can be as hard to adapt to as negative ones are, but you can help your loved one make a smooth transition.

Preparing Your Loved One – and Yourself – for a Move to a Retirement Home

Before your parent, family member or friend moves into a retirement home or assisted-living community, everyone involved needs to know what to expect. Sharing the timetable with your loved one can take some of the uncertainty away, so make sure that everyone involved knows when to start packing, when the move will occur, and when you’ll come to your loved one’s new home to help with the transition.

Also, keep in mind:

  • This type of move can involve significant downsizing that requires you to put your organizational skills to the test.
  • Your loved one may have mixed feelings about the move, and he or she may be reluctant to make such a big change.
  • Your attitude about the process, and the way you handle the situation, can have a big impact on how easy (or how difficult) it is on your loved one.

Set Firm Dates

Photo by Pixabay

Create a calendar to share with your loved one and others involved in the move. Pick dates for:

  • Downsizing and packing
  • Charity pick-ups, agarage or estate sale, or trash pick-up
  • Booking a moving truck or asking friends and family come to help
  • Moving day
  • Unpacking boxes and setting up the new place

Decluttering and Downsizing

Packing is stressful no matter how you look at it. Take it slowly (and start early, if that’s what it takes) to make things easier on your parent, friend or family member. Remember that your loved one’s participation can help him or her feel in control, which can minimize anxiety and quell nervousness about the big move – but also remember that this is a big job, and too much at once can be overwhelming. Try to keep packing, sorting and organizing confined to less than a couple of hours per day, and make it a sociable experience. If your loved one wants to stop and reminisce, join in; it’s not going to hurt anything.

If the person who’s moving has a lot of stuff (furniture, keepsakes, and other things that can’t come along), there’s a big decision on the horizon. He or she will have to decide whether to put everything in storage, hold a yard sale, or divide items between family members. This should definitely be your loved one’s decision – we’re talking about his or her belongings, not yours (think about how you’d feel if someone suddenly took the reins and dictated what was going to happen to your stuff).

Together, you can categorize each item and decide what your family member, parent or friend will take, store, donate or sell. Storage may be the best option, at least psychologically speaking, for your loved one. He or she still owns the furniture, mementos and other items, which can make adjusting to the retirement home that much easier.

You can usually get rid of old and useless items, like old bills and paperwork that’s no longer necessary, but be on the lookout for important documents that you and your loved one must keep, such as:

  • Birth certificates
  • Deeds
  • Diplomas and degrees
  • Financial documents
  • Medical records
  • Military records
  • Passports
  • Powers of attorney
  • Wills

Keep all the important documents in a central location, and let other family members know where it is so nobody gets the wrong idea or feels left out of the process. Try to put it all somewhere neutral, like a safe deposit box.
If your loved one is okay with it, have adult children claim their own (but only their own!) keepsakes during the process. Old sports trophies, high school yearbooks and other items can go home with their owners to make things easier for everyone.

Pro tip: Sort before you start packing. Go through each room with colored tags to mark items for their final destinations. Remember that seniors can – and should – bring mementos and keepsakes to his or her new place so it feels like home.

If your loved one has pets, you may want to find a community that accepts them. By doing so, you’ll make the transition for your loved one smoother. Atul Gwande, author of “Being Mortal”, cites that pets can enhance a person’s will to live, which is associated with experiencing life with greater meaning, pleasure, and satisfaction. If your loved one cannot take his or her pets to the community, then he or she should decide where they’ll go.

Pro tip: It’s important that your loved one has purpose in his or her life. Purpose can be as simple as caring for a pet, visiting a grandchild regularly, or having a daily walk with friends. Choose a senior living community that supports your loved one’s purpose. If you need help, a senior advisor can speed up your search at no cost to you.

​What if You Can’t Get Your Loved One to Part With Items?

Many people don’t want to let go of things they feel are important. If it’s absolutely necessary (like when storage isn’t an option), you can try:

  • Talking to an antique dealer to find out how much items are worth.    Sometimes a dollar figure can make a big difference in a person’s decision-making process.
  • Hiring a professional organizer. If you’re too close to the situation and your help becomes frustrating for your loved one, it might be best to bring in an impartial third party who’s used to helping people let go.
  • Letting your loved one know where the items will go and that they’ll be treasured. This is especially important with things tied to the family legacy, like old documents and photos.

Handle the Paperwork

Photo by Pixabay

You may need to change your loved one’s address, transfer utilities to someone else’s name, or finalize registration at your friend or family member’s retirement home or assisted living community. Make sure you tackle each of these issues early so you’re not scrambling later. Don’t forget to update the address for your loved one’s:

  • Bank accounts
  • Credit card accounts
  • Driver’s license and vehicle registration
  • Insurance policies
  • Investment and retirement accounts
  • Medicare and Social Security
  • Newspaper and magazine registrations
  • Voter registration

After the Move

​Adjusting to a new environment, particularly if it’s a lot different than the old one, can take weeks or months. Your loved one needs plenty of time to settle in, get to know people (including caregivers) and start to feel at home, so don’t try to rush the process. Everyone reacts differently; where one person may feel relief at not having to maintain a big house alone, another might feel a little lost and miss their home, friends and belongings.

Here’s how you can help.

Understand That the Move Represents a Loss

​As an adult child, friend or family member, it’s easy to look at your loved one’s move as a “fresh start.” He or she will have cooked meals, nothing to clean and friends living right next door.

Your loved one might see that, too, but he or she is also mourning the loss of a home, belongings and community – and at the same time, the realization that old age or health issues has necessitated the move is sinking in. Avoid trying to force your family member or friend into the new social scene, too. Making new friends and getting comfortable takes time.

Be kind, patient and understanding with your loved one. Remember that you, too, will one day be in a similar situation.

Make Memories and Continuity a Priority 

Photo by Pixabay

​Find a shelf, cabinet or drawer where your loved one can easily access photo albums and other mementos. Hang his or her favorite pieces of art on the walls, and try to set up the space so it’s comfortable and homey. If your loved one has a favorite recliner, a family heirloom or other important items, make room for them.

If your loved one wants new items, like a flat-screen TV or something that will make the space more enjoyable, go for it – sometimes having something shiny and new makes the transition easier.

Show Support and Visit Often 

​Familiar faces can make living in a new place a lot easier, so visit as often as you can (or as often as your loved one wants you to). If you can’t visit, see if someone can help your loved one Skype or FaceTime you, or make regular phone calls to check up on him or her.

Refer to the new place as “home,” not “the home” or anything else. The way you talk about the assisted living facility will impact the way your parent, family member or friend feels about it, and it’s important that you don’t forget how powerful that can be.

Originally published on Redfin


Medicaid is a complex program, and when it comes to senior care, there are a few terms that people commonly mix up. In this blog post, we attempt to clarify any confusion between Medicaid, Medicaid Long-Term Care, and the Medicaid Waiver Program.


Medicaid is a social program that provides health insurance to millions of Americans including people with low income, children, pregnant women, elderly adults, and people with disabilities. It is administered by the state, according to federal requirements, but it is funded jointly by the state and the federal governments. It does not provide full coverage, meaning not all things medical are covered under Medicaid. Federal law requires that states provide certain mandatory benefits including: inpatient hospital services, outpatient hospital services, clinic visits, doctors’ office visits, and transportation to medical care. While it is common for folks to say that Medicaid does pay for a stay at a nursing home; just because someone has Medicaid doesn’t mean Medicaid will pay for his or her permanent stay at a nursing home.

Medicaid Long-Term Care

To have Medicaid pay for a permanent stay at a nursing home, a person must meet the law’s income and medical criteria, even if he or she is already covered under general Medicaid. If approved, the person is said to be covered under Medicaid Long-Term Care.

To be medically eligible for Medicaid Long-Term Care, a person must need routine skilled services or help with his or her activities of daily living (“ADLs”). Examples of skilled services include:

  • Medication management
  • Immunizations
  • IV care
  • Podiatry
  • Wound care (level 3 and 4)
  • Tube feeding
  • Assistance with breathing
  • Help with catheters

Nursing homes also provide aides that will help a patient with his or her ADLs. Transferring, walking, using the bathroom, showering, dressing, and eating are the six ADLs. The rules are vague as to how many ADLs one needs help with to qualify for Medicaid Long-Term Care, but at Senior Advisors Plus, we’ve generally seen that people who need help with three or more on their worst day would qualify for Medicaid Long-Term Care.

To financially qualify for Medicaid Long-Term Care, a person must meet two criteria, assets and income. Each state differs on its income and asset restrictions but generally the laws work like this:

  • A person can’t have more than $2,000 in countable assets to qualify.
  • A person can’t have monthly income that exceeds the average cost of a nursing home in the state.

A person who makes less than the income limit but has too many countable assets may need to spend down his or her savings to qualify for Medicaid Long-Term Care. In this situation, he or she may also benefit from talking to an elder law attorney. After spending down assets, the person should qualify for Medicaid Long-Term Care. Medicaid will then pay the difference between the person’s income and the cost of the nursing home.

Medicaid Waiver Program

A hospital is the most expensive setting of care, while nursing homes are not far behind. After a patient stabilizes following a procedure done in a hospital, he or she may be discharged to a nursing home or skilled nursing facility to recover and build strength. A skilled nursing facility’s goal is to help the patient transition back to the community. Commonly, people are forced to stay in nursing homes because they can’t afford to hire help at home. The Medicaid Waiver Program was designed to help these people transition back to the community, despite their financial constraints. The Medicaid Waiver Program may pay for home care services, assisted living, and other services that may prevent someone from returning to a nursing home. While people under the Medicaid Waiver Program do need assistance, the cost of the assistance that they need is far less than the cost that the Medicaid fund would incur if they remained in a nursing home. To be medically eligible for the Medicaid Waiver Program, a person may need help with the activities of daily living but not routine skilled services. Here’s the tricky part: it’s harder to qualify for the Medicaid Waiver Program than it is Medicaid Long-Term Care. The asset restriction is the same—$2,000—but the income limit is generally lower. We’ve generally seen the income limit to be around $2,300 per month; however, the income limit depends on the state. If a person makes over the income limit, then he or she is required to pay for assistance themselves. If a person makes less than the income limit, needs at-most intermittent skilled services, and needs help with some of their activities of daily living, then he or she may qualify for the Medicaid Waiver Program.

If you’re confused or worried about your current situation or the future, it may help to talk to someone. We offer free advice; just contact us.