Using Live In Caregivers as an Alternative to Assisted Living

Introduction

The idea of live in caregivers is appealing to many families caring for elderly loved ones because they offer an alternative to assisted living or nursing homes by providing around-the-clock or overnight care in the home.  In this article, we explore how live in caregivers work, what they cost, Medicare and Medicaid benefits and other financial assistance and payment options. 

How Live-In Care Works

There are two types of live in caregiver situations; those in which the caregiver maintains another residence beside the home of their client and those caregivers who live strictly in the home of their client.  This difference impacts both the amount of, and type of care provided as well as the cost of care.  In either situation, there must be a room available in the home of the individual in need of care that they can assign to their caregivers. 

1) Live in caregivers who maintain another residence typically work in teams.  There will be two caregivers who switch off spending nights in the care recipient's home.  Usually they are with the care recipient during daytime hours as well.  They provide "round the clock" care.  This type of live in care is more appropriate for individuals who have higher care needs.  Caregivers will likely be providing assistance once, twice or more times throughout the night and will therefore experience significant disruptions to their sleep.  The fact that they live with the care recipient is thought of as a convenience to the care recipient not as a benefit to the caregiver.  They are not providing care in exchange for room and board.

2) Live in caregivers who do not maintain a separate residence usually are the sole night-time caregiver but the care recipient receives other assistance during daytime hours, be that home care, adult day care or spending time with family and friends.  The caregiver's presence in the home at night is thought of more as a safety valve, or as an "on call caregiver".  It is not expected their help will be required every night.  They are providing care, at least partially, in exchange for room and board.  Some live-in caregivers in this situation also work a second job during daytime hours.

 

Types of Care Provided by Live In Caregivers

Live in caregivers provide all the same types of care and have all the same duties as other home care or home health care workers.  They can provide personal care, assistance with the activities of daily living, companionship, and if trained, nursing services. Care is (or can be) on par with that provided in assisted living or nursing homes.  It is very common for live-in caregivers to also prepare meals, do the shopping and provide transportation assistance for recreational activities or medical appointments.   Live in caregivers are especially common when assisting persons with Alzheimer’s as they require supervision but necessarily constant care.  Persons with Parkinson’s related dementia also utilize live in care as they require assistance with mobility but not necessarily higher level nursing skills.  

 

Live In vs. Residential Care Comparison Table

Live In Care vs. Residential Care (Assisted Living or Nursing Homes)
Live In Care Residential Care
Offers one to one care Less than one to one care
Few social and recreational opportunities Frequent social and recreational opportunities
Control over timing and type of meals Scheduled meal times and limited options
No doctors or emergency care Immediate doctors and emergency care available
Maintain familiar living environment Move to unfamiliar living environment
Can keep pets Most residences prohibit pets

 

Costs and Compensation

Did You Know?  Seniors and disabled individuals can receive free assistance locating live-in caregivers.  Get help here.

Unlike other types of aging care, it is very difficult to estimate what live in caregivers cost.  Estimates range from as low as $1,000 / month to as high as $5,000 / month.  There are many reasons for the dramatic range, the most significant ones are the geographic area in which the care recipient resides, the amount of care required and whether or not the caregiver maintains a separate residence.  If one works as a live in caregiver in exchange for room and board, this will obviously offset the cost.  One should look to the cost of renting a single room in one's geographic area to get an idea of this portion of the compensation.  Other factors include if a caregiver will provide a vehicle or vice versa, if the care recipient provides the caregiver with access to a vehicle and if it can be used for personal use.  Finally, the expected frequency of sleep disruption during night-time hours is an area of great sensitivity to the caregiver and sometimes undervalued by the care recipient's family. 

Viewed another way, for persons requiring full-time care or supervision, the cost of a live-in caregiver is typically less expensive than full-time home care or nursing home care but financially similar when considered as an alternative to assisted living.   Of course, home ownership, mortgages, rents and other utilities play into the equation, so everyone's situation is different. 

 

Live In Caregiver Agreements / Checklist

It is very common and strongly advised that for both parties' benefit and protection, live in caregivers and their clients (the homeowners) make a Live In Care Agreement or Contract. This is especially important considering the lack of live in caregiver laws and regulations in most states.

For persons hiring a live in caregivers through a home care agency, it is almost certain the agency will provide the agreement. However, for those hiring private individuals as live in caregivers, not through an agency, they should make certain their agreements include the points from the following checklist in addition to the usual contractual information.

  • Estimated monthly hours of active care to be provided by the caregiver
  • Estimated number of hours the caregiver will be "on-call" during the month
  • Total payment due to the caregiver
  • Portion of payment due to the caregiver which is offset by room, board and other expenses.
  • Overtime expectations and compensation
  • Expected usage of caregiver's vehicle for work purposes and the form and amount of reimbursement for such usage
  • Areas and rooms of the home to which both the caregiver and the care recipient will have access and those which are deemed off limits
  • Contract termination rights of each party (to prevent forced, immediate move-outs or leaving the care recipient without assistance)
  • Other house rules and conditions of the agreement; for example, guest and pet policies

 

Payment Options for Live In Care

Payment for live in care, for the most part, comes out-of-pocket.  Providing room and board and possibly a vehicle is a smart way for an elderly person to maximize the underutilized assets at their disposal.  Offering these to caregivers at no cost offsets the dollar amount they would otherwise be required to pay.  When financial assistance is available, it is typically not designated specifically for live in help, rather for home care in general.  Read more on that subject here.

What follows are the benefits of programs commonly available to the elderly and if, and how, these programs might be used to pay for live in care.

Medicare

Does Medicare pay for live in caregivers?  Unfortunately, the answer is no. Medicare does not provide assistance for live in caregivers.  Medicare, in limited situations will cover the cost of home health care visits, but these are for care that is medical in nature (not personal care) and reserved for individuals who are physically unable to leave their places of residence.

Medicare does not consider live in care a covered benefit and therefore Medicare Supplemental Insurance policies also do not cover this service.  These policies only pay the deductibles and co-payments of services covered by Medicare, they do not broaden the range of services.

Medicaid

Medicaid is complicated and its benefits differ in every state.  Having said that, in many states there are Medicaid programs that provide financial assistance can be used to pay for a live-in caregiver.  Assistance is most likely to be provided through "consumer directed HCBS waivers".  HCBS Waivers are programs for persons requiring nursing home level care who elect to receive care at home instead in a residential care facility.  Consumer directed HCBS Waivers provide the care recipient with flexibility regarding choice of care provider and what care is necessary for their needs.  Given this flexibility Medicaid beneficiaries may be able to use their allocated care budget to retain a live in caregiver.  One can see a complete list of state Medicaid Waivers relevant to the elderly that offer a consumer directed option here.

Further, some Medicaid Waivers allow for adult foster care or adult family care. This benefit is usually intended to allow an elderly person to move in another person’s home. However, some allow for the reverse situation where a live in caregiver moves in with the care recipient. Learn more about Medicaid and adult foster care.

Veterans' Assistance

The VA has no formal live in caregiver program in which unrelated individuals care for elderly veterans by living in their homes.  However, the VA does offer two programs that provide veterans and their surviving spouses with financial assistance that can be used to pay for a live-in caregiver.  Extensive information on these programs is provided on this website.  Read more about Veterans-Directed Home and Community Based Services and Veterans' Pensions.

Reverse Mortgages

Reverse mortgages offer a way for aging homeowners to receive a portion of their home equity in cash on a monthly basis which can then be used to pay for care.  Reverse mortgages are particularly well suited to pay for live in caregivers, when considered as an alternative to assisted living or nursing home care.  One requirement reverse mortgages have is that the homeowner reside in their home.  Obviously in the case of assisted living or nursing homes, the homeowner does not live at home and therefore reverse mortgages cannot be used to pay for these types of care. 

Live in caregivers provide a nice workaround to this problem.  By hiring a live in caregiver, the elderly individual or couple can remain in their home.  As long as they remain in their home, they can receive a portion of their home equity in cash each month, which can then be used to pay for their live in caregiver.  Learn more about reverse mortgage pros and cons.