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How to Hire (and When to Fire) a Caregiver

The right personality is more important than you might think, but when the quality of help suffers, you need to act

By Kristine Kevorkian, Ph.D

From time to time, when I worked as a social worker in a skilled nursing facility, visiting family members complained to me about certain staff members. Residents too often were worried that if they themselves griped to senior managers, there might be some form of retaliation.

That's understandable — and it's why we must advocate for our loved ones in long-term care residences. If there's a staff member who isn't doing his or her job properly, an administrator needs to know. And if the issue is a bad attitude, and not just a need for more specific training, perhaps it's time for that aide to find another job.

Addressing problems with an in-home caregiver can be more complicated. The person your family hired may turn out to be unqualified or have a negative attitude. But the patient may still like him or her, in spite of apparent flaws.

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Dr. William King, a primary care physician in Los Angeles, has helped patients deal with these issues and has hired in-home caregivers for family members. He's met aides who have been flummoxed by their responsibilities and those who have shirked them altogether. Sometimes family members have not explicitly conveyed the job's responsibilities. Sometimes caregivers know what's expected of them, but have different opinions about how best to proceed.

Soon after King's family hired a home health aide to help his ailing sister, he wanted to let the person go. He was concerned about her qualifications and feared she was more focused on filling the role of companion rather than caregiver. But his relatives disagreed because his sister felt so comfortable with her, and in the end, the aide proved herself as a caregiver. King now instructs his patients to consider compatibility as a factor when hiring, along with qualifications and ability.

What You Should Look For

If you're seeking a home health aide who will become your loved one's primary companion during the day, it's important to discuss cultural, age and gender differences with the care recipient and the rest of your family first, so you can find the right match. Even better, King suggests a trial period of a week or so "to see how everyone feels about the caregiver and how the caregiver feels about the patient and scope of work."

No matter how well an interview goes, he says, "Once the job begins, the patient and caregiver might not like each other." Or the aide may realize that the job's physical or psychological demands are too burdensome.

(MORE: Is Your Loved One's Caregiver Qualified?)

King regularly makes home visits to patients and has seen firsthand the difference that family support can make in the hiring and managing of caregivers. Many of us will find qualified help through word of mouth — recommendations from family, friends or within our faith-based communities. Others will post ads online or work with an agency. But however we search for an aide, it's important to check references and observe the worker on site.

A recent study of the hiring practices of 180 home health care agencies nationwide, financed by the National Institute on Aging, found that many were hiring random responders to Craigslist postings and sending them into the homes of seniors suffering from dementia. Still more agencies conducted no criminal background checks or drug tests, and routinely lied to clients about their staff members' experience and training.

King recommends that any applicant you consider should have certification in cardiopulmonary resuscitation and first aid. He also advises asking for proof of a tuberculosis screening within the past year, as well as a recent test for community-associated Methicillin-resistant Staphylococcus aureus (CA-MRSA), which can be transmitted by skin-to-skin contact and cause painful skin infections and boils.

You should also observe the prospective worker perform all medical tasks he or she will be expected to conduct, like providing medication, delivering injections or taking blood pressure. And it's important that the aide is able to read and understand medication labels and dosage instructions. (Learn more from Next Avenue about how to interview and screen home health aides.)

Keeping an Eye on Things


As we all know, even when interviews go well and an aide gets off to a great start, things can go wrong. The relationship can sour, follow-up visits may raise concerns about the quality of care or changes in the patient's needs may require a switch to someone with more skills. But as is the case in long-term care facilities, seniors may be reluctant to speak out for fear of angering a caregiver or burdening family members. That's why consistent visits and observations by physicians, visiting nurses and family members are so crucial.

However, when the primary family caregiver does not live near the patient and is unable to make regular visits, it can be difficult to keep tabs on home health aides. The most recent benchmark annual report from the Alzheimer's Association, 2013 Alzheimer's Disease Facts and Figures, explores the challenges such family members face as "coordinators of care," the lack of communication chief among them.

If you're a long-distance family caregiver, you can take steps to insure that your loved one's aide is being monitored by building a network of relatives, family friends, neighbors and even delivery people who are willing to check in regularly and contact you with status reports. If the patient lives in a community that is part of the Village Movement, which supports aging in place with a variety of services, there may be additional opportunities to arrange for other regular visitors who can advise you of any red flags. There may be technological options to help you keep an eye on things as well.

Doctors and nurses are especially valuable sources. When King makes a home visit and finds a caregiver not doing a good job, he speaks with the aide directly and reviews the patient's needs. He advises family members to do the same. If he notices that medications are disorganized or improperly stored, he goes over proper procedures. This issue is often complicated, he says, when patients receive medications and supplements by mail and require an aide to manage ordering and refills, organize bottles and prepare doses.

If a doctor has requested that a patient's vital signs be recorded daily, it's crucial that the caregiver does it each day, not once a week. If the patient has regularly scheduled checkups or if a doctor makes home visits, the caregiver's log must provide the data that highlight changes in blood pressure, blood sugar, weight, sleep patterns or other key indicators.

When Things Go Wrong

Above all, family members must remember that even when a caregiver bonds with a loved one, his or her most important role is as a member of the patient's medical team. The right aide can make a tremendous difference in a senior's quality of life. When he or she does not perform to your standards, when they spend more time watching television or texting than they do tending to their charge or maintaining a clean and safe household, early intervention is the best strategy, King says. (Financial fraud and elder abuse are also important concerns. Learn more from Next Avenue about identifying signs of fraud and taking action against abuse.)

MORE: Our Caregiver Took Advantage of My Father but I Still Wanted Her by His Side

If a clear review of job expectations does not lead to an improvement, King recommends that you find a new caregiver before firing the existing aide to ensure a quick transition. Poor performance by a caregiver can translate to poor health outcomes for your family member. We need to monitor the quality of care our loved ones receive, to make sure they're treated with the same dignity and respect we'd want if we were in their shoes or hospital gown. One day, most likely, we will be.

Kristine Kevorkian, Ph.D., M.S.W., has worked as a deputy coroner and a hospice medical social worker. She lectures and teaches frequently on aging, end-of-life care, death, bereavement and grief.

Kristine Kevorkian, Ph.D Read More
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