In-Home Care Agencies Face Challenges Keeping Seniors at Home

By Pamela D. Wilson, MS, BS/BA, NCG, CSA 

In-home care agencies face challenges keeping seniors at home. Seniors desire to remain at home with care from in-home caregivers. Seniors and in-home care agencies have similar goals. How can differences of opinion about the quality of care and poor communication be managed? Do seniors expect too much? Are in-home care agencies desperate to hire any warm body to fill a shift  so much that they overlook caregiver skills and qualifications?

Tips for in-home care agencies to address the concerns of seniors are listed below. Concerns of in-home caregivers are also mentioned. Recommendations for care agencies and caregivers are offered to support the idea of keeping seniors at home. 

Caregivers who are in-home companions, personal attendants, home health aides, and certified nursing assistants provide a valuable service to seniors. Because the workplace for these individuals is in private homes, more support, training, and communication is necessary to increase senior client satisfaction and reduce caregiver agency turnover. This requires in-home care agency management to have specialized roles and to make a greater effort to coordinate information between caregivers and client families.

challenges keeping seniors at homeThe In-Home Care Agency Franchise Boom and Industry Challenges

The aging population is fueling the growth of franchise opportunities for in-home care agencies. (1) Many new in-home care agency owners find the idea of helping seniors attractive because of personal experience with a family caregiving situation. The challenge to client care is that many new owners lack healthcare and caregiving industry experience. Many lack experience in training and managing care staff.

The lure of senior population growth and financial gain are quickly balanced by the challenges of staffing and the many details of running an in-home care agency. At least initially, many owners are the “jack of all trades,” to the extent of filling shifts for caregivers who fail to show up for work and completing all other activities related to managing the business.

In-home caregivers offer significant benefits to support seniors to remain at home. The reality of low industry wages, lack of training, and staffing difficulties result in senior and family client dissatisfaction. Licensure and certification requirements have increased which is positive for the consumer but may be challenging for agency owners.

To survive as an in-home care agency owner and as a caregiver, individuals must truly have a servant’s heart and be devoted to the care of the senior population. The work is challenging and at times thankless. Self-satisfaction comes from making a positive contribution to the life individuals and family in need.

Concerns of Senior Clients and Family Members

When hiring an in-home care agency, senior clients and family members are naïve about the process and questions to ask. Belief exists that the management staff of the in-home care agency will take care of all of the details including training and managing the in-home caregivers. While this is a common belief, this is not the reality of the in-home care industry. Clients bear equal responsibility. 

Few discussions occur in advance by in-home care agency management about client responsibility for fear of not closing the sale. Assessment and sales staff present in-home agency care as a comprehensive solution to support seniors to remain at home. Knowing the limits of expertise is important so as not to make promises that are not deliverable. Agencies citing themselves as comprehensive solutions are rarely able to fulfill this promise.

After the completion of initiation paperwork, caregivers begin showing up at the home of the senior. The challenges of keeping seniors at home by the in-home care agency are readily evident:

  • A different caregiver shows up every day.
  • Caregivers are late to work and leave early.
  • The ringing of the caregiver’s personal cell phone is a constant work interruption.
  • Caregivers expect to eat the client’s food.
  • Lack of skill training results in caregivers being unable to cook simple meals or complete laundry requests.

After experiencing these surprises, seniors and family caregivers realize that they have the responsibility of not only managing but training a revolving door of caregivers coming into the home. Prior expectations about punctuality, having a trained caregiver who speaks English, and consistent attendance evaporate.

Five Recommendations for In-Home Care Agencies to Increase Client Satisfaction  

Below are five recommendations for in-home care agencies to increase client satisfaction. Improving service levels by having trained management staff able to train caregivers in key areas of concerns by seniors is an attainable goal.

1 Create Lead Caregiver Positions to Support Caregiving Consistency

As a guardian, power of attorney, and care manager for many in-home care client situations, one of my primary concerns was a consistent caregiving staff. When schedules extended over several days, the goal was to have a lead caregiver who was the trained expert on the client situation. The lead caregiver could then train other caregivers scheduled with the client and serve as the main contact for questions or requests.

Many of the in-home care agencies with whom I worked were unable to guarantee a consistent caregiver or a trained back-up for when a caregiver failed to show up for a shift. The honesty of these agencies was appreciated. I made a choice to seek care with other agencies more able to meet my expectations for client care. 

The inability to provide consistent caregivers results in inconsistent care for the client placing at risk the senior’s ability to remain at home. Having a revolving door of caregivers also makes it difficult to monitor who knows about the personal situation of the client, sometimes placing client safety at risk.

The recommendation for in-home care agencies is to look at senior clients from a care team approach. Assign a lead caregiver, at a higher wage,  who will accept greater responsibility and manage the caregiving team. Assigning a lead caregiver will increase client satisfaction and reduce the frustration of continually training new caregivers. Offering a lead caregiver position will provide a career path for caregivers seeking to advance. Employee turnover will decrease as the result of greater job satisfaction and feeling valued.

2 Match Caregiver Skills to Client Needs

Challenges in hiring and staffing by in-home care agencies result in mismatches between caregiver skills and senior care needs. As a care manager, I provided agencies with a list of tasks and desired qualities of caregivers to make a personality match. The care agency scheduled time for me to interview caregivers who I eliminated or confirmed to be a good match for the client.

The challenge for in-home care agencies in making good caregiver and client matches is that the agency staff member meeting the client is not usually the individual responsible for staffing the case. Better communication between the assessment staff and thestaff scheduling the caregivers in the senior’s home is required to make a good match.

Sometimes caregivers are assigned to a client based on proximity and driving distance instead of skill need and match. Driving distance is a known constraint for many caregivers who may have older vehicles that are less reliable.

The same matching constraint is relevant to assigning a caregiver with no dementia experience to the home of a senior client diagnosed with dementia. As a result of caregiver inexperience, the client experiences an increase in behaviors. The caregiver lacks the skills to interact and redirect client behaviors positively.

The caregiver becomes afraid and feels threatened by a senior client who is screaming and yelling. The caregiver quits after the shift. The client’s family is dissatisfied and decides to find another agency. Basing a match on proximity, and failing to verify skills, results in failed relationships.

One recommendation is for care agencies to consider discussing an additional mileage allowance with the client for a caregiver who is a good skill and client care need match. Training specific to diagnoses like memory loss, Parkinson’s disease, and other common chronic illnesses is important so that caregivers feel confident to provide care.

3 Care Plan Training – Tasks

After matching skills to client needs, the next step in the sequence is reviewing the plan of care with agency caregivers to confirm confidence in completing the requested tasks. Sending a caregiver to the home of a client with a care plan on a piece of paper is another situational disaster. Caregivers are high touch, high need employees who thrive with a high level of communication, support, and training to address skill gaps.

By presenting care plan training as positive, caregivers will be confident that they can learn through skill gaps. Highly trained caregivers are beneficial to in-home care agencies and result in satisfied clients. How nice would it be for in-home care agencies to receive compliments, rather than complaints, about caregivers serving clients!

In my experience, in-home care agency management rarely provides caregivers with sufficient background information about a client’s needs—even when I provided the information to in-home care agency management it was rarely passed along to the caregivers. This was a task I took upon myself in my effort to train the caregivers of my clients.

Some in-home care agencies are short staffed and overworked. As a test, I always asked the caregivers in the homes of my clients if the agency gave them a care plan. The response was usually no.

The issue of a lack of care plan training may be representative of not having a dedicated employee on the team whose sole focus is making certain that clients receive the care requested and the caregivers assigned are competent to fulfill their responsibilities. This communication gap between requests for skills and ability to complete tasks results in embarrassment for the caregiver who is asked to complete a task beyond their skill level. What happens when a caregiver untrained in bathing a client is asked to assist and the client falls and breaks a hip?

Simple client requests like sending a good cook who can make meatloaf, fry eggs, and bake cakes are easy to define. The caregiver can either complete the task or not. Agency management must be thorough in identifying and assessing caregiver skills.

Seniors who have complicated medical diagnoses benefit from certified nursing assistants or caregivers with a higher level of training who can identify changes in condition and monitor care. These are special skills that require training and experience.

The technical side of care relates to monitoring care and providing hands-on care. In my opinion, certified nursing assistants are better matches for clients with more complicated care needs. Monitoring vitals, fluid, and food intake, encouraging clients to exercise, and other similar tasks require skills and expertise. Being able to notice when a client is having a bad day just by looking at a client is another important observational skill as is client documentation.

Failing to train caregivers specific to the implementation of care plans results in a rocky start to the caregiving relationship. Caregivers become placed in uncomfortable situations. Seniors become frustrated with caregivers they view as incompetent.

Not creating and training caregivers on care plans for clients is poor customer service. As a result, caregivers become distrustful of management staff. They feel misled about having their skills matched to client situations. Clients become dissatisfied and lose confidence in agency management. Rather than achieving the common goal to keep seniors at home, everyone loses.

The recommendation is for the caregiver supervisor to have a background in training specific to care plans, task-related skills, and building relationships. Lack of training in all areas is a repeated concern of caregivers and the seniors to whom they provide care.

Training is a significant area that offers the greatest opportunity to make caregivers feel like they matter. Providing recognition for training and offering a career path to become a lead caregiver can balance the negative reality of low wages and a lack of benefits. Caregivers who feel supported and trained stay at companies instead of leaving.

4 Interpersonal Skill Training – Relationships

There is a significant difference in care situations that are social and relationship-based instead of specific to monitoring care around particular medical concerns. A combination of different skills is required for each type of situation including individuals diagnosed with memory loss.

Caregivers who are controlling and dictatorial are less successful than caregivers who speak in a calm voice and give seniors choices about how care is offered. Caregivers who are relationship focused and who learn client preferences and routines are more successful. Empathy, patience, and emotional stability are other important qualities. Caregiving situations can be stressful. A calm demeanor by the caregiver is beneficial.

The recommendation for in-home care agencies is to give caregivers the tools and training to improve relationships with senior clients. Many seniors are viewed as “tasks” instead of a person needing assistance with tasks. By the caregiver taking a more personal interest in client background, history, and preferences, the senior client becomes more comfortable and allows the caregiver to provide greater levels of support. This is a win-win situation.

This does not mean that relationships become unprofessional (refer to the next section on personal boundaries). Role-playing appropriate discussions with caregivers is helpful to allow the caregivers to visualize the difference between initiating a caring relationship conversation and crossing professional boundaries.

Team participation in role-playing training is one secret to retaining caregivers. Humor can be used to take situations to extremes for training purposes. When training is offered in this manner, caregivers are more likely to admit to improper behaviors and to learn appropriate ways to interact with senior clients. Caregivers will also be more willing to approach supervisors with situations that may be questionable.

5 Maintaining Professional Boundaries

Maintaining professional boundaries is a constant challenge. Senior clients and family members cross professional boundaries and train caregivers that doing so is acceptable.

Habits of caregivers who arrive late or leave early are “covered” by senior clients with in-home care agency management because of an awareness that the caregiver has to drop off and pick up children from school. One caregiver may not see that consistently arriving 15 minutes late for work is poor customer service when the client does not outwardly complain.  Inappropriate actions that are obvious to one caregiver may not be obvious to another.

When personal problems or concerns are brought into the workplace by caregivers, clients are unnecessarily burdened. The goal of in-home care is to relieve client burden—not add the burdens of the caregiver to the worries of the client. Personal disclosure of negative information to senior clients is inappropriate and must be discouraged

Maintaining professional boundaries is an important discussion to have with caregivers who may feel that the caregiver is part of the client’s family. Again a situation likely supported by the senior client and family.  I have had situations where caregivers acted as if the client was their personal possession and the client’s family was the enemy.

These caregivers battled with family caregivers, powers of attorney, and court-appointed guardians about the care of the client. The appropriate action is to train caregivers to bring concerns to the attention of a company supervisor for counseling rather than initiating relationship conflict with others that may be viewed as interfering or abusive.

The recommendation for in-home care agency staff is to discuss professional boundaries using real-life experiences on a regular basis. Explanations of why a behavior is good or inappropriate are necessary. Discussions about company boundaries must also occur with senior clients and family members to avoid surprise if a caregiver is disciplined for an inappropriate action.

I have experienced situations where families have become so attached to caregivers that boundary issues are constant. In these situations, I removed the caregiver from the case at risk of upset to client and family. Explanations were made to the senior client and family reinforce boundaries and why the caregiver was removed from the care situation

While clients and family members were upset, there was an understanding that agency policies existed. It is better to have early upset than allow caregivers to test boundaries that negatively affect the agency in the future.

In-home care agencies who are responsive to the concerns of clients and caregiver employees providing daily care will be more successful. Having management staff focused on the important efforts of client care plans and satisfaction and employee training increases client and employee satisfaction. As a result, in-home care agencies will face fewer challenges in keeping seniors at home.

Sources:

(1) Bailey, Renee. Home and Senior Care Franchise Report 2018. April 9, 2018. https://www.franchisedirect.com/information/home-and-senior-care-franchise-report-2018

Pamela D. Wilson, MS, BS/BA, CG, CSA is a national caregiving expert, advocate, and speaker who solves caregiving problems. Since 1999, she has been a direct service provider as a court-appointed guardian, power of attorney, and care manager. In response to the need for accessible, accurate, reliable, and trustworthy information Pamela offers online caregiving support and programming to solve caregiving problems, advance healthcare literacy, and promote self-advocacy. She collaborates with professionals in the areas of estate planning, elder law, and probate, financial planning, and healthcare to raise awareness of and sensitivity to family caregiving and healthcare issues. 

© 2019 Pamela D. Wilson, All Rights Reserved.

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