Using Live In Caregivers as an Alternative to Assisted Living

Page Reviewed / Updated - Jul. 2019

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 must be provided a space (and bed) to sleep and those that do not require that a caregiver be given a bed and a sleep break. This difference impacts both the amount of, and type of care provided, as well as the cost of care. In either situation, the care recipient must be available to provide care even during nighttime hours. Commonly, persons use the terms “live-in” and “24-hour” care to mean the same thing. However, while both types of care essentially are live-in caregiver situations, there are distinct differences between the two types of care, which will be covered below. In addition to “live in” and “24-hour” care, a third option of live in caregiving is available and is “overnight” / “daytime” care.

  •  “Live-in” Caregiving

With “live in” caregiving, there is generally a main caregiver who works between 4 and 5 days each week, providing 24-hour care during this time. The caregiver is given an 8-hour period to sleep at night (with this type of care a bed must be provided), although his / her sleep may be disrupted to provide care throughout the night. In addition, the caregiver is given a 4-hour break during daytime hours. During this break, another caregiver may or may not cover for the primary caregiver, depending on the care recipient, his / her needs, and the decision of the family. An alternative caregiver works the days the primary caregiver is off.

  • “24-hour” Caregiving

With “24-hour” caregiving, there will be two or three caregivers who work 8-12 hour shifts in the care recipient's home, providing "round the clock" care. This type of live in care is more appropriate for individuals who have higher care needs. With this type of care, sleeping breaks are not provided, unless a family chooses to allow the caregiver to sleep.

  • Overnight / Daytime Caregiving

With overnight caregiving, the caregiver generally provides care a couple of hours prior to the care recipient going to bed, during the night (if needed), and a couple of hours in the morning when the care recipient wakes up. In most cases, the caregiver is able to sleep during the night, as long as the needs of the care recipient allow it. In some cases, the caregiver may live in the home with the care recipient. Alternately, a caregiver may provide daytime assistance, live in the home, and provide nighttime assistance on an “as needed” basis. In this case, the caregiver's presence in the home at night is thought of more as a safety measure, or as an "on call caregiver".  It is not expected their help will be required every night.

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. In addition to supervision, 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 light housecleaning, give medication reminders, 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 not 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 / care recipients) 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 caregiver 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 limit
  • 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 visits are for care that is medical in nature (not personal care) and are 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 that 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 of 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 to 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.

Long Term Care Insurance

For persons who have long term care insurance, coverage may be provided to help pay for live-in caregivers. Unfortunately, this type of insurance is costly, and for persons who have an immediate need for care, this is not a viable option.