How to Decide: Agency Care or Self-Directed Care

If you are in a Medicaid waiver or a Home and Community Based Care program, the state will provide you with a caregiver. But you have a big choice to make!

🎀 If you want, you can select an agency and that agency will send a caregiver to your house.

🎀 Or if you want, you can sign up for self-directed care. With self-directed care, you get to choose and hire your own caregiver, and the state pays the salary.

Big decision! Here’s some pros and cons each way:

Agency Care

🎀 Advantage: Less paperwork

🎀 Advantage: Less bureaucratic confusions and complications

🎀 Disadvantage: In some states you will get less caregiver hours if you go through an agency. You may only get half the hours.

🎀 Disadvantage: The agency does not guarantee to cover all your shifts. Sometimes they can’t find someone to work and so you won’t get a caregiver until they find one, or you may have days when no caregiver arrives.

🎀 Disadvantage: Agency may have rules that do not allow the caregiver to use their car or to drive you places.

🎀 Disadvantage: Some agencies will not allow the caregiver to handle your money. This means they cannot shop unless you are with them.

🎀 Disadvantage: This is a bad combination. If they cannot drive you places and they cannot shop without you there, shopping may be impossible.

🎀 Exception: In some states, your home aide program will provide a certain number of free trips each month. Some states provide only medical transportation, but other states will take you anywhere you want to go door-to-door. You can bring your aide with you. In this case, it is less of a big deal if your aide cannot drive you.

🎀 Disadvantage: If you have special needs, such as not wearing perfume, it may be harder to get the agency to these arrangements and the caregiver may not agree.

🎀 Disadvantage: You can’t control who they send. You can’t pick someone you like.

🎀 Disadvantage: Some agencies only pay their workers $7-$8 per hour and it is hard to find anyone who is good or willing to keep a job at this pay rate. Self-directed care may pay higher.

🎀 Disadvantage: In some areas people report that there is a shortage of aides available from agencies. Many people experience high turn over (constantly being sent new aide and having to keep training new people) or getting very limited help because no aides are available – particularly in rural areas.

Self Directed Care

🎀 Advantage: Pick your own attendant. Choose whoever you want. (exception: In many states it cannot be your spouse).

🎀 Advantage: You may find someone more you feel more comfortable with if it is someone you already know and trust. Here’s some tips for How To Ask A Friend To Be Your Home Aide (So they actually say yes!)

🎀 Advantage: You are not limited to the aides who work at the agency. You can hire (almost) anyone in the world: Where to Find Home Aides

🎀 Advantage: You may have better luck finding someone who meets your needs. For example, if you need someone who owns a car, you can be sure to only hire someone who owns a car. If you want someone who can shop for you, you can be sure to only hire someone that you trust to give your grocery money to.

🎀 Advantage: In some states, your caregiver will get a higher salary and/or you will get more care hours.

🎀 Advantage/Disadvantage: You supervise the person and you are the “boss.” Maybe you like this, maybe you don’t.

🎀 Advantage: If you choose your own caregiver, you have the option to arrange a live-in caregiver if you want to. This can give you more care, if you need it. There are a lot of additional advantages as well. For example, your aide may not have to pay taxes, or you may get extra help with your utility bills: How to Get Extra Help if You Have a Live-In Caregiver

🎀 Advantage: In some forms of affordable housing, you may be able to get an extra bedroom or larger voucher to accommodate your live-in aide. Your aide’s salary and income will not affect rent calculations. This means you can offer an aide salary, plus a free place to live. How to Request a Live-In Aide in HUD Housing

🎀 Possible Advantage: Not true in all states, but in some states, as soon as you are approved, you can begin getting assistance right away. You do not have to wait for an agency to place someone. For example, if the date of your Medicaid eligibility is in January, but the paperwork is not all processed and in place til March, you may be able to start tracking caregiver hours in January, and then submit three months of timesheets at once.

🎀 Advantage: In most states, a caseworker will visit your house on a regular basis to answer questions, help guide you through paperwork and check in if you are having any other issues.

🎀 Advantage? Disadvantage? Some readers report their caseworkers are helpful. Others do not find them helpful.

🎀 Disadvantage: Takes time and energy to screen and select attendants

🎀 Disadvantage: You will need to take responsibility for the paperwork and timesheets, or to find a friend or family member who is willing to take on this role. Many readers report that there is a learning curve at the beginning. Once they figure out the system for timesheets, it gets easier and does not take much effort.

🎀 Disadvantage: It can be work to find a caregiver. If your caregiver quits or does not show up for work, you can be left without help.

🎀 Advantage/Disadvantage: The caregiver you chose must pass a background check for felonies or abuse crimes. (Other types of convictions may not be a problem). Maybe you think this is an advantage, maybe you don’t.

🎀 Disadvantage: It takes time to complete the paperwork to hire a new caregiver. The first paycheck may not come for several weeks or longer.

🎀 Advantage/Disadvantage: In some states is fairly easy to sign anyone up to be your caregiver just by filling out some paperwork. In other states, caregivers must be fingerprinted and go to an orientation and this takes time and commitment. It can make it harder to find someone and it can be a month or two to get the position in place.

🎀 Disadvantage: It is common for people to run into problems with timesheets and payment, especially at the beginning. You have to learn to fill out the timesheets exactly right, and may have to work directly with the payroll company to work everything out and resolve problems so your caregivers get paid. This can be a headache.

🎀 Advantage: Since you can choose your own person, you can try to find someone who is helpful with paperwork and will be able to assist you with filling out timesheets and forms, tracking deadlines, reading mail, faxing things, making phone calls, scheduling appointments, etc. This can help for navigating your home care and for any other services you may be on.

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Learn More

🎀 What are other people doing? What works and what doesn’t? Great stories and great advice: Do You Hire Your Own Home Aides? Or Use an Agency?

🎀 There are a bunch of other little things it might help you to know if you are in this program: How to Get Extra Help if You Are in a Medicaid Waiver Program

🎀 If you are not in a home care program and would like to apply: How to Get a Caregiver or Home Attendant