Everything You Need to Know About 24 Hour or Live-In Home Care
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As a concerned family member of an aging parent or grandparent, the idea of hiring an in-home care agency can be confusing. You may already have home care for a loved one, or a crisis has resulted in an urgent decision around needing care to support your elder at home around-the-clock. It’s common for older adults to need home care services after a fall or serious illness that landed him or her in the hospital. The need may be temporary, or long-term. We are here to help you understand the difference between live-in and 24 hour care and which option would be best for your loved on based on his or her situation.

When is it Time for 24 Hour or Live-in Care?

There are many reasons one may need 24 hour or live-in care:

  1. Wandering and agitation. For those who have dementia, managing sundowning can be a serious problem. “Sundowning” is typified by late day confusion and periodic agitation; all are common symptoms of dementia. Having someone available to monitor and manage this on a daily basis can be invaluable.
  2. Personal care and transfers. Sometimes assistance is needed with bathing, dressing and transferring. This could be due to dementia or a physical problem related to an injury or chronic medical problem. Someone may need assistance with toileting and/or dressing. Bathing safely can be a big issue for many people. It can be a huge relief to family members to have a caregiver either standing by for safety reasons or assisting with bathing.
  3. Fall prevention. A caregiver can help prevent falls. Falls are more likely to occur at night on the way to the bathroom. A 24 hour or live-in caregiver can accompany someone to the bathroom at night. During the day, a caregiver can monitor a person’s movements and encourage safe activity to strengthen muscles.
  4. Assistance with cooking and eating. Neurological conditions and dementia can impact someone’s ability to cook and eat safely. A 24 hour or live-in caregiver can cook, help with safe eating and provide hydration reminders. They can shop and plan specialty meals for any dietary restrictions.
  5. Pet care. People often need help with caring for their pet. This can include feeding, grooming, kitty litter duty and vet visits. Pet walking has been found to be a significant trip hazard for seniors. A caregiver can accompany your loved one while he or she walks the dog, for example, to help maintain safety.
  6. Companionship and stimulation. In many cases there is a combination of factors that necessitate 24 hour or live-in care. Companionship and stimulation can have a significant positive impact on someone’s mood and wellbeing. A caregiver can help keep someone with dementia busy, safe and stimulated with activities.
  7. Medication reminders. Many states do not allow caregivers to administer medications. However, caregivers can give reminders which helps to maintain consistency. A caregiver can also report any medication compliance issues.

What is Live-in Care?

Live-in care is where at least two caregivers live 24 hours a day at someone’s home. Here are the federal U.S. Department of Labor requirements for live-in care:

  • A caregiver must have a place to sleep for 8 hours during a 24 hour period. They are not considered to be a resident of the home.
  • The same caregiver can only be booked for 4-5 days in one period. Another caregiver would need to take the other 2 shifts.
  • A four-hour break must be given to the caregiver during that 24 hour period. That being the case, someone needs to be available to cover the 4 hours when the caregiver is on break.
  • Private sleeping quarters in a homelike environment must be provided.
  • If a caregiver is interrupted during the 8 hour sleep period, they must be paid for that time.
  • Live-in hours would put a caregiver into overtime hours due to the fact that live-in would be over 40 hours per week.

Some states, California for example, do not allow live-in caregivers so you will need to check with your state requirements to see if it is even permitted. In those cases where your state does not allow live-in, you should consider 24 hour care.

What is 24 Hour Care?

If your state does not allow live-in care, or you do not want or have accommodations for live-in, consider 24 hour care. With 24 hour care, two caregivers are booked daily and work 12 hours each, or three or more caregivers work for eight hours or less.

One caregiver can work a maximum of four 12 hour shifts per week, thereby eliminating the need for sleep breaks. However, you can allow the overnight caregiver to sleep if you choose.

24 hour care is billed at an hourly rate. The overnight visit is sometimes billed at a flat rate if it is a sleeping visit and an hourly rate if it is a non-sleeping visit. Please refer to the U.S. Department of Labor for wage rules on home care.

Advantages of 24 Hour Care

  1. Since the shifts are 12 hours or less, no breaks are required. This eliminates the need to fill in that extra 4 hours of care.
  2. Sleeping quarters do not need to be provided. That doesn’t mean the caregiver doesn’t sleep on duty at night, but it is not required.
  3. There is a lot of flexibility on how and when you want to schedule caregivers. As the family member of your loved one, you can decide how to best structure shifts.
  4. No sleep requirement allows a caregiver to actively monitor someone at night. This can be especially helpful for people who tend to sundown and are more agitated during night hours.

Agency vs. Private Hire

The temptation to hire privately and not through an agency can be strong. Why? There are several reasons why family members consider privately hired caregivers:

  • Typically, hiring privately means you will pay less and the caregiver will make more
  • The perception that you will have more control as the consumer
  • You may have strong recommendations from friends or family members on a reliable caregiver
  • You get to hire and fire

Let’s take a closer look at what is required if you decide to hire privately and not through an agency. Most people fail to account for the work, rules and responsibilities of hiring caregivers privately. Not to mention the liability associated with private hiring. An agency will alleviate the following issues and problems associated with hiring privately:

  1. Federal rules regarding wages and overtime must be followed. As the employer, you need to consider whether you will be paying payroll taxes. All other federal rules that we discussed above must be followed. If you do not follow state and federal guidelines when hiring a caregiver, you could be sued. An agency must comply with all federal and state rules and have processes in place to make sure this happens.
  2. State requirements for caregiver tasks. Do you want your care provider to administer medications or do blood sugar tests? Your state may prohibit caregivers from performing those duties. Home care agencies adhere to state regulations on what tasks a caregiver can perform. When you are considering care for your family member through an agency you will know up front what the care provider can and can’t do.
  3. Background checks. A good agency will do all background and drug testing. With a private hire, you are responsible for this.
  4. Liability. This is a huge issue that many people don’t think about. What happens if your family member accuses the caregiver of stealing or being abusive? What happens if the caregiver accuses the care recipient of assault or harassment? Licensed, bonded agencies handle these matters. If you don’t have special liability insurance, you could be taken to the cleaners if this happens.
  5. Shift coverage. What happens when the caregiver you have hired calls in sick at the last minute or doesn’t show? An agency is responsible for filling that shift, even if it is at the last minute. For private hires, you alone are responsible. Are you willing to leave your family member without care or have to miss a day of work because you can’t find a replacement?
  6. Incompatibility. Sometimes the care recipient and caregiver don’t hit it off. Some situations call for a trial of multiple care providers. Are you prepared to make those changes? Hiring privately, you may be tempted to keep the status quo rather than make the effort to change caregivers. A good agency makes sure you can interview several caregivers beforehand to make sure you get the right fit. If a new caregiver is needed, they have a full roster to pull from.

Surveys show time and time again that as people age, they want to remain in their own homes. The need for care can happen incrementally or all at once. Knowing your options and being prepared can help you make the best choice for your loved one. If at all possible, don’t wait for a crisis to occur! Then when the time comes, you will make the best and safest choice for your family member.

Resources

Fact Sheet # 79D: Hours Worked Applicable to Domestic Service Employment Under the Fair Labor Standards Act (FLSA)

Domestic Service Final Rule Frequently Asked Questions (FAQs)

About the Author(s)

Amanda Lambert is the owner and president of Lambert Care Management, LLC which provides care management for older and disabled adults. She is the co-author of, Aging with Care: Your Guide to Hiring and Managing Caregivers at Home (Rowman and Littlefield, 2018). She has worked for over 20 years in the senior-related industry including mental health, marketing and guardianship. She has a passion for topics related to health, wellness and resilience as we age.

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