A professional live-in caregiver provides personal care and assistance to individuals, including those suffering from chronic illness, Alzheimer’s disease, and dementia, within the home setting. Typical duties of a live-in caregiver include meal planning and preparation, assistance with grooming, dressing and toileting, medication management, laundry and light housekeeping, and transportation/escorts to doctor’s appointments or social engagements. Professional live-in caregivers are often provided by an outside agency, which may also coordinate their services with the client’s preferred in-home health agency and other medical providers.

Caregiving in the home

A recent survey suggested that nearly 90% of Americans over the age of 65 would prefer to remain at home as they age.[1] As the population of the United States grows older, the demand for home health aides and professional live-in caregivers is expected to rise more than 40% by 2026.[2] Informal caregivers include any unpaid individual, such as a spouse, neighbor, or adult child, who provides personal assistance to an elderly, ill, or disabled person in the home.[3] Formal caregivers, including professional live-in caregivers, are paid for their services.[4] These individuals may have received certification as nurses aides, home health assistants, or personal care assistants; however, in many states, live-in caregivers are not required to have any specialized training or education.[5]

Services

Basic Principles of Caregiving: Like all forms of caregiving, professional live-in care is provided with respect for the dignity of the individual in need of care. Communication with the client, as well as their primary physician, other health care providers, and family members, is key to ensuring that the individual receiving care is able to participate, to the greatest extent possible, in decisions about their health and other matters affecting their daily life.[6]

Depending on the level of service being provided, a professional live-in caregiver may assist the client with personal hygiene, laundry, and light housekeeping. The live-caregiver can also help coordinate the client’s personal agenda, including scheduling, transportation, and escorts to medical appointments and social engagements.[6]

Client Monitoring: Because of the one-on-one nature of live-in care, the professional caregiver is in the best position to monitor the client for changes in breathing and inform their doctor of any potential warning signs.[7]

Live-in caregivers may monitor the client’s body temperature, blood pressure, and blood glucose, as recommended by their physician. They will also remain alert for changes in the client’s mental status, including signs of depression or dementia.[8]

Social and Companion Care: Professional live-in caregivers can also provide social and companion care for elderly people who live alone.

In doing so, they seek to improve their client’s quality of life by facilitating opportunities for social interaction, and helping them to maintain friendships, continue hobbies, and engage in physical exercise as recommended by their healthcare provider.[9]

Assistance with Meal Planning and Preparation: Live-in caregivers can ensure their clients maintain a healthy diet by assisting with meal planning and preparation, monitoring body weight, and arranging for pleasant mealtimes.[10]  In some situations, professional live-in caregivers will even provide assisted feeding to those who have difficulty swallowing or otherwise eating on their own due to certain medical conditions, such as a recent stroke or Parkinson’s disease.[11]

Medication Management: Elderly people and those coping with chronic illness often have complicated medication regimens, with many taking multiple prescription and over-the-counter drugs. Each medication will require a specific dose; some may need to be taken at certain times of the day or night, with or without food; and others may induce drowsiness or other side effects.

A live-in caregiver can ensure medications are taken correctly, refilled as needed, and monitor the client for signs of adverse reactions.  It is important that the client’s healthcare provider educate caregivers about their medication needs to optimize long-term management at home.[12]

Ensuring a Safe Home: It is the responsibility of live-in caregivers to ensure their client is safe at home. This includes inspecting the floor for trip and fall hazards and eliminating or mitigating any that do exist. The caregiver will also see that the thermostat is set to a comfortable and healthy temperature, and make sure that the bathroom is outfitted with fixtures and knobs the client can use, as well as grab bars and other aids that will ensure the client’s safety. The live-in caregiver should also periodically check all smoke and carbon monoxide detectors in the home, so they remain in good working order.[13]

Training and screening

Throughout the United States, any home health agency that accepts Medicare must employ certified home health aides who've undergone a minimum 75 hours of training, including 16 hours of on-the-job instruction. Individual states may also impose additional screening and training requirements on live-in care agencies that accept Medicare. Private live-in care agencies that do not accept Medicare are not subject to any federal or state screening requirements.[14] However, reputable agencies will implement their own screening programs, including requirements for criminal background checks and personality assessments.[15]

Live-in care vs assisted living

Assisted living facilities provide personal care assistance to people who need some daily help, but don't require the level of skilled care found in nursing homes.[16] These settings may serve as few as 25 residents, while others can house in excess of 120 people. Many assisted living facilities also offer varying levels of care, including dementia and Alzheimer’s care.[17]

Residents of assisted living are usually provided with an apartment or private room, and share common areas, such as dining rooms and rec rooms. While assisted living arrangements vary by state, most facilities offer meals, medication management, personal care assistance, and opportunities for social interaction. Some may even provide transportation to doctor’s appointments and opportunities for shopping and other off-site excursions.[17]

Living-in caregivers can provide all of the services found in assisted living, but in the client’s own home, eliminating the need for a potentially traumatizing move.[18] Live-In care also allows for constant one-one-one interaction between client and caregiver, as the patient is the only individual receiving care. By comparison, the average assisted living staff provides only about 2 hours and 19 minutes of total direct care and 14 minutes of licensed nursing care per resident per day.[19]

Live-in caregivers can provide other benefits like in-home cooked meals, medication monitoring, transportation, social interaction, and other valuable benefits.[20]

Assisted living can also be fairly expensive. Depending on the state, base rates, which cover at least two meals per day, housekeeping, some personal care assistance, and either a one-bedroom apartment or private room with private bath, averaged nearly $3,500 per month.[21] Among all long-term care options, assisted living has seen the greatest cost increases, rising an average of 6.7% between 2017 and 2018.[22]

Live-in caregivers vs family caregivers

It's estimated that 4.2 million Americans have provided unpaid care to an adult age 50 or older in the last 12 months. The value of services provided by informal caregivers has steadily increased over the last decade, with an estimated economic value of $470 billion in 2013, up from $450 billion in 2009 and $375 billion in 2007. Family caregivers spend an average of 24.4 hours per week providing care, while nearly 1 in 4 caregivers spends 41 hours or more per week providing care.[3]

Caregiving can present significant financial burdens for families. For example, more than 60% of family caregivers recently reported that they had cut back on work hours, taken a leave of absence, or made other career changes because of their responsibilities.[22] Half were late to work or had to leave early, and 1 in 5 reported that caregiving had resulted in financial strain.[23] Family caregivers are also more likely to suffer from depression and anxiety, use psychoactive medications, have worse self-reported physical health, experience compromised immune function, and die prematurely.[23]

The extreme stress experienced by many family caregivers is also considered one of the leading risk factors for elder abuse.[24]

In addition to daily care, professional live-in caregivers can be engaged for a few hours a day, or for several days a week, so family members may work part-time, run errands, attend to their own personal needs, or simply relax. Live-in care can also be arranged whenever family caregivers take a vacation or otherwise need to be away from home overnight.

Benefits of live-in care

Professional live-in caregivers allow their clients to avoid moving to a nursing home, assisted living, or other long-term care facility. This benefits the client by:

  • Freeing them from strict schedules and regimens imposed by many long-term care facilities.
  • Allowing the client to retain as much independence as possible.
  • Ensuring family and friends may visit whenever they like.
  • Enabling the client to find comfort in familiar surroundings and happy memories.
  • Ensuring they can retain cherished possessions, pets, or hobbies.
  • Allowing the client to continue personal habits and favorite routines.
  • Providing a healthier environment, with less risk of exposure to contagious illnesses that are often present in a clinical setting.

[25] In general, elderly people who are able to remain at home exhibit improved levels of cognition, better daily functioning, decreased levels of depression, and lower rates of incontinence compared to nursing home patients.[26]

Canada: Live-In Caregiver Program

The Live-In Caregiver Program (LCP) was offered and administered by the government of Canada and was the primary means by which foreign caregivers could come to Canada as eldercare, special needs, and childcare providers. The program ended on November 30, 2014, and a regular work permit has been needed since then.[27]

While such services were offered by Canadian citizens or foreign immigrants with permanent residence (PR) status, government provisions for a room and board deduction as well as a basic rate of pay that frequently total provincial minimum wage standard allowed for the program to be more affordable for many families. Caregivers who came to Canada through the program are eligible to apply for PR status after working a minimum of two years within four years of their arrival (plus 3 months). For many who would not otherwise qualify for PR status under any other category, this was one of the motivations for participation.

Standard qualifications were regulated federally, though conditions of employment were determined at a provincial level. Requirements included a minimum of 6 months of training or 1 year of compatible employment within the last 3 years—though various exceptions and additional stipulations do apply.[28] Such regulations and complicating bureaucratic procedures are the driving force behind the creation of Live-In Caregiver (or Nanny) placement agencies, who act as a mediator between families, caregivers, and the government—providing support for documentation and advice on the program.[29]

In 2014, the Government of Canada conducted a Gender-based Analysis Plus (GBA+) report on the Live-in Caregiver program. This analysis led the government to identify issues in the program relating to the requirement that caregivers needed to maintain residency at the same address where they were employed.[30] The 2020 Annual Report to Parliament by the Minister of Immigration, Refugees and Citizenship indicates that employees were subject to exploitation, abuse and isolation from their families as a result of this residency requirement.[30]

The Live-in Caregiver program stopped accepting applications in 2014 due to a significant processing backlog of 27,000 applications.[30] The government subsequently launched two pilot programs: Caring for Children Class and Caring for People with High Medical Needs. These programs ended the accommodation requirement, a major critique of the previous program. Following additional consultations, the government relaunched these programs in 2019, under the titles of Home Child Care Provider Pilot and the Home Support Worker Pilot.[31] These pilots will run for five years. The relaunch of these programs brought a few important changes from the previous pilots launched in 2014. Firstly, they aim to provide a clearer pathway from temporary resident status to permanent resident status. Additionally, these new programs provide open-work permits for spouses and study permits for dependent children. Lastly, the caregiving work permits are now occupation-specific rather than employer-specific, allowing employees to quickly transition to a different employer if necessary.[30][31]

Criticisms of Canada's Live-in Caregiver Program

Contractual violations

A 2008 study by the Filipino Women's Organization PINAY Quebec and the McGill University School of Social Work found that only 22.1% of employers always respected the contract, and that 25% signed no contract at all.[32] Further contractual violations included: 34% of participants reporting denial of fair pay for unpaid childcare wages; 43% reporting having provided unpaid overtime; and 30% reporting having made purchases for the job with personal finances.[32] Participants also reported that they did not receive pay increases in adherence with minimum wage increases, and 75% reported not being paid on time.[32]

Labour violations

Critics have highlighted that the requirement that caregivers live with their employers leaves more opportunities for misconduct, as caregivers are constantly accessible and able to work long hours without a break. Additionally, caregivers are often not afforded privacy within their employers homes, often being denied independent living spaces. This lack of privacy leads to isolation from the broader community and isolation from the caregiver’s family.[32] Due to the lack of regulatory oversight, violations by employers often have gone without recourse. Additionally, caregivers often lack the English language skills or legal knowledge to articulate and report these violations.[32]

Educational criticisms

Another issue has been the deskilling of caregivers, who are required to have a grade 12 education (or acceptable equivalent) and domestic service training. Often, these workers have a university education or training as registered nurses, making them overqualified for the jobs they are performing. Furthermore, caregiver responsibilities under the program often do not encourage the development of additional skills that could provide upward mobility within the national workforce. As such, the labour potential of caregivers is largely under-utilized.[32]

Racial and gender-based inequities

Scholars have criticized the program for perpetuating a racist devaluation of the women who immigrate to Canada to work in the caregiving industry. According to this argument, migrant women come to participate in the workforce under the pretence of economic opportunity, but are not granted citizenship rights until they have been working for at least two years.[33] Scholars have characterized the program as exploitative based on its recruitment of migrant women to perform difficult jobs, while not putting adequate oversight and accountability measures in place.[33] Other critics argue that the program furthers existing racial stereotypes against Filipina women as being nurturing and loving, yet simultaneously “uncivilized” and lesser than.[34]

Critics contended that as a means of boosting immigration to Canada, the program failed to attract caregivers from a diverse pool of countries. For example, the Philippine nanny is often improperly stereotyped as the program's main market for applicants. While there may be a large and functional industry in the Philippines to produce qualified applicants, individuals from nearly every nation can qualify. Some caregiver placement agencies are substantially broader through their international advertising and the use of immigration legal services.

References

  1. ↑ Farber, Nicholas, Douglas Shinkle, Jana Lynott, Wendy Fox-Grage, and Rodney Harrell. December 2011. "Aging in Place: A State Survey of Livability Policies and Practices." In Brief 190. Washington, DC: AARP Public Policy Institute and National Conference of State Legislatures.
  2. ↑ "Home Health Aides and Personal Care Aides." Occupational Outlook Handbook. Bureau of Labor Statistics. 2019.
  3. 1 2 "Family Caregiver Alliance". www.caregiver.org.
  4. ↑ "Family Caregiver Alliance." Caregiver.org. 2019.
  5. ↑ "Home health care: Research behind the high-demand, low-pay occupation." Journalist's Resource. 2019. Accessed 28 Aug. 2019.
  6. 1 2 Dorling Kindersley (2013). Caregiver's handbook (1st American ed.). New York: Dorling Kindersley. ISBN 9781465402165. p. 144
  7. ↑ Dorling Kindersley (2013). Caregiver's handbook (1st American ed.). New York: Dorling Kindersley. ISBN 9781465402165. p. 148
  8. ↑ Dorling Kindersley (2013). Caregiver's handbook (1st American ed.). New York: Dorling Kindersley. ISBN 9781465402165. p. 153
  9. ↑ Dorling Kindersley (2013). Caregiver's handbook (1st American ed.). New York: Dorling Kindersley. ISBN 9781465402165. p. 66
  10. ↑ Dorling Kindersley (2013). Caregiver's handbook (1st American ed.). New York: Dorling Kindersley. ISBN 9781465402165. p. 43
  11. ↑ Dorling Kindersley (2013). Caregiver's handbook (1st American ed.). New York: Dorling Kindersley. ISBN 9781465402165. p. 56
  12. ↑ Ferguson et al, (2015). The caregiver role in thromboprophylaxis management in atrial fibrillation: A literature review. European Journal of Cardiovascular Nursing, 14, (2), 98-107. DOI: 10.1177/1474515114547647
  13. ↑ Dorling Kindersley (2013). Caregiver's handbook (1st American ed.). New York: Dorling Kindersley. ISBN 9781465402165. p. 30-31
  14. ↑ Gallagher, Mehgan (February 15, 2018). "The Truth Behind Home Health Aide Certification Requirements | O'Neill Institute". oneill.law.georgetown.edu.
  15. ↑ "Caregiver Screening". 10 May 2019.
  16. ↑ "Assisted Living vs. Skilled Nursing". July 3, 2019.
  17. 1 2 "Residential Facilities, Assisted Living, and Nursing Homes". National Institute on Aging.
  18. ↑ Walker, Charles; Curry, Linda Cox; Hogstel, Mildred O. (1 January 2007). "Relocation Stress Syndrome in Older Adults Transitioning from Home to a Long-Term Care Facility: Myth or Reality?". Journal of Psychosocial Nursing and Mental Health Services. 45 (1): 38–45. doi:10.3928/02793695-20070101-09. PMID 17304985.
  19. ↑ CDC.gov. (2010). Residential Care Communities and their Residents in 2010: A National Portrait. https://www.cdc.gov/nchs/data/nsrcf/nsrcf_chartbook.pdf
  20. ↑ "Cost". 9 August 2019.
  21. ↑ "AARP.org. (2011). Market Survey of Long-Term Care Costs" (PDF).
  22. 1 2 "Genworth's 15th Annual Cost of Care Survey Shows Continuing Rise in Long Term Care Costs". Genworth Financial, Inc. Newsroom.
  23. 1 2 "AARP.org. (2011) Understanding the Impact of Family Caregiving on Work" (PDF).
  24. ↑ Kohn, Robert; Verhoek-Oftedahl, Wendy (2011). "Caregiving and Elder Abuse". Medicine and Health, Rhode Island. 94 (2): 47–49. PMC 4961478. PMID 21456376.
  25. ↑ Strausbaugh et al, (2003) Infectious Disease Outbreaks in Nursing Homes: An Unappreciated Hazard for Frail Elderly Persons. Clinical Infectious Diseases, Volume 36, Issue 7, 1 April 2003
  26. ↑ Marek, Karen Dorman; Popejoy, Lori; Petroski, Greg; Mehr, David; Rantz, Marilyn; Lin, Wen-Chieh (May 2005). "Clinical Outcomes of Aging in Place". Nursing Research. 54 (3): 202–211. doi:10.1097/00006199-200505000-00008. PMID 15897796. S2CID 23566950.
  27. ↑ Immigration, Refugees and Citizenship Canada (March 31, 2007). "Live-in Caregiver Program". aem.
  28. ↑ Immigration, Refugees and Citizenship Canada (March 31, 2007). "Find out if you can change your employer - Live-in Caregiver program". aem.
  29. ↑ "Archived copy" (PDF). Archived from the original (PDF) on 2012-09-07. Retrieved 2022-07-12.{{cite web}}: CS1 maint: archived copy as title (link)
  30. 1 2 3 4 Immigration, Refugees and Citizenship Canada (2020-10-30). "2020 Annual Report to Parliament on Immigration". aem. Retrieved 2021-02-04.
  31. 1 2 Immigration, Refugees and Citizenship Canada (2020-09-18). "CIMM - Caregivers". aem. Retrieved 2021-02-04.
  32. 1 2 3 4 5 6 Brickner, Rachel K.; Straehle, Christine (November 2010). "The missing link: Gender, immigration policy and the Live-in Caregiver Program in Canada". Policy and Society. 29 (4): 309–320. doi:10.1016/j.polsoc.2010.09.004. ISSN 1449-4035.
  33. 1 2 Lee, Eunjung; Johnstone, Marjorie (November 2013). "Global Inequities: A Gender-Based Analysis of the Live-in Caregiver Program and the Kirogi Phenomenon in Canada". Affilia. 28 (4): 401–414. doi:10.1177/0886109913504152. ISSN 0886-1099. S2CID 147697867.
  34. ↑ Carlos, Jessica Krystle; Wilson, Kathi (July 2018). "Migration among temporary foreign workers: Examining health and access to health care among Filipina live-in caregivers". Social Science & Medicine. 209: 117–124. doi:10.1016/j.socscimed.2018.05.045. PMID 29859389. S2CID 44154583.
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