Hospice, home health aide, taxes questions

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curmudgeon
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Hospice, home health aide, taxes questions

Post by curmudgeon » Mon Jul 01, 2019 12:53 pm

I have a relative who will likely be discharged from the hospital soon and going onto hospice at home. Spouse is somewhat frail, and will likely need assistance to some degree in caring for him. Time prognosis is uncertain, but probably not more than a couple of months.

Medicare hospice will provide some degree of assistance, but not on a daily basis. They do have LTC insurance (federal employee program) which will kick in without a waiting period because of the hospice situation. This will provide reimbursement for up to ~$200/day for care/etc in the home. The question is how to use this benefit in a way that will provide the most help and the least complications. It seems like hourly rates for help through an agency are about double what paying someone directly would cost - not surprising given organization overheads and profit. I think agency rates will be $50+/hr (HCOL area). My impression is that if they hire someone directly, they will end up with all the employer tax filing headaches and responsibilities; is this the case? Would a payroll service be advisable?

I think my suggestion will be to use an agency for a couple of hours per day at the start to keep things simple, at least until it comes to a point where the hours bring the cost of agency help to exceed the daily benefit. Guidance from others who have more experience or knowledge would be appreciated. We aren't in the immediate area, but can be there to help on occasion and do some organization.

littlebird
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Re: Hospice, home health aide, taxes questions

Post by littlebird » Mon Jul 01, 2019 1:28 pm

I think your suggestion is sound, and unless there’s a direct hire person already known to the family or to a close trusted friend of the family, I would go with agency personnel. Ask around about agencies; they vary widely. I was paying $23/hour with a minimum of 3 hours per shift for agency help that I was extremely happy with. Everyone’s needs are unique and I would arrange for 2 or 3 well recommended agencies to evaluate the patient and the home situation. The hospice should be willing to offer suggestions also.

quantAndHold
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Re: Hospice, home health aide, taxes questions

Post by quantAndHold » Mon Jul 01, 2019 1:37 pm

It completely depends on what the person needs that hospice won’t pay for. There’s a fair bit of overlap between what hospice will pay for and what a home health aide does. You will want to make sure you’re getting the most care for your dollar by using hospice for whatever they will do, and only using the home health for things that don’t overlap.

One thing hospice does pay for is a social worker. Hospice social workers deal with this kind of situation regularly. I would get the person enrolled in hospice, then have a meeting with the nurse and social worker about what hospice will and won’t provide, what the person needs, and how to get it paid for by the LTC insurance.

The hospice will be able to help make recommendations about home health agencies, too.

Cranberry
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Re: Hospice, home health aide, taxes questions

Post by Cranberry » Mon Jul 01, 2019 2:23 pm

Based on my family's experience, if someone is a fall risk and needs help to reach the bathroom, he needs someone available around the clock. Otherwise, it's the unhappiness of a nursing home.
In my state, CNAs can't do everything....they can't give meds, for example.
You're right about the cost - it's the last big spend, but that's what it's there for.

HereToLearn
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Re: Hospice, home health aide, taxes questions

Post by HereToLearn » Mon Jul 01, 2019 5:03 pm

I am shocked at the $50/hour cost from the agency. My mother was in the NY metro area, and agencies charged $27/hour.

My mother's LTC plan allowed me to hire a licensed provider independently, but I had to function as the employer: I-9, W-4, withhold FICA, file quarterly taxes, comply with workers' comp & NYS disability requirements. It was a fair bit of work. I couldn't just pay someone 'off the books' or the LTC carrier would not reimburse.

I hired Home Pay by Care.com, a division of Breedlove. I cannot praise them enough. I was so impressed by the helpfulness, professionalism, and intelligence of each person who answered the phone. I was a bit skeptical after the initial 'sales' conversation, but they delivered everything they said they would.

Most aides, and I believe most agencies, require a four hour minimum.

As someone else posted, if the patient is a fall risk, that risk remains 24 hours/day.

Happy to answer any questions you may have.

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Re: Hospice, home health aide, taxes questions

Post by GreenGrowTheDollars » Mon Jul 01, 2019 5:08 pm

Agencies will generally provide a much easier route and much better coverage for vacations/sick days.

If caregivers are hired independently, someone needs to manage FLSA (overtime) rules compliance, get worker's comp coverage set up, as well as get set up as an employer with the state and feds. That is a LOT of work. (Admittedly, my experience was in California, which might just be the worst state ever for regulatory complexity, but it may not be hugely easier elsewhere.)

From a payment perspective, it was much easier for agencies to get paid by Long Term Care than for us to get reimbursed for individually-hired aides. We had to file a ton of paperwork with the LTC company for each aide. The agencies didn't have to do that.

Given the expected short nature of hospice, I'd go the agency route.

(PS: My advice to anyone bringing caregivers/hospice into the home: Get an inexpensive wall safe installed and lock up wallets, checkbooks, blank checks, spare keys and jewelry, or get those out of the house. Theft was a real issue. If the patient will be taking any controlled drugs, consider locking up all but a very minimal supply. One of my mom's aides stole her morphine. :mad: )

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Re: Hospice, home health aide, taxes questions

Post by RetiredAL » Mon Jul 01, 2019 5:19 pm

I was paying $27/hr to Home Instead for Health Aides in Stockton CA this spring. When it became apparent that 2 shifts were not adequate, I moved my Dad into an Assisted Living Facility. The Assisted Living cost is slightly more that what one shift of 'at home' costs.

His LTC Insurance covered the 'at home' immediately up to month the limit, the Assisted Living is subject to the waiting period. The month limit was 2/3'rds of what the 'in home' 2 shifts was costing.

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Re: Hospice, home health aide, taxes questions

Post by ChrisC » Mon Jul 01, 2019 6:06 pm

Just curious. What is the extent of Medicare coverage for hospice care?

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curmudgeon
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Re: Hospice, home health aide, taxes questions

Post by curmudgeon » Mon Jul 01, 2019 6:31 pm

Many thanks for the feedback. I haven't actually seen quotes for the hourly rates from health aide agencies yet, but the hospice co-ordinator mentioned $45-50/hr was pretty typical for agencies there, ~$25 for direct hire. This is in an expensive corner of coastal CA (not big city). On the positive side, the spouse can deal with a lot of basic things, just not heavier lifting.

quantAndHold
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Re: Hospice, home health aide, taxes questions

Post by quantAndHold » Mon Jul 01, 2019 6:44 pm

ChrisC wrote:
Mon Jul 01, 2019 6:06 pm
Just curious. What is the extent of Medicare coverage for hospice care?
https://www.medicare.gov/coverage/hospice-care

Basically, Medicare pays for hospice care at 100%. The hospice benefit pays 100% for a lot of stuff that isn't normally covered by Medicare, but not everything. The nursing care thing is a sticking point. Hospice pays for some things that are usually part of assisted living or nursing care, but not everything.

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Re: Hospice, home health aide, taxes questions

Post by littlebird » Mon Jul 01, 2019 8:16 pm

ChrisC wrote:
Mon Jul 01, 2019 6:06 pm
Just curious. What is the extent of Medicare coverage for hospice care?
Hospice supplies a visiting nurse as needed, an aide for bathing 2-3 times a week, all meds, tests, and supplies needed for the patients terminal condition. A doctor’s consult when needed. Durable things like a hospital bed, and expendable things like incontinence supplies. A social worker and a chaplain came with my dh’s hospice. Respite care would have been available had I needed it. Palliative care. Encouragement and positive feedback to me, the caregiver, was invaluable.I cannot say enough good things about hospice care. And no charge at all.

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Re: Hospice, home health aide, taxes questions

Post by ChrisC » Mon Jul 01, 2019 9:15 pm

littlebird wrote:
Mon Jul 01, 2019 8:16 pm
ChrisC wrote:
Mon Jul 01, 2019 6:06 pm
Just curious. What is the extent of Medicare coverage for hospice care?
Hospice supplies a visiting nurse as needed, an aide for bathing 2-3 times a week, all meds, tests, and supplies needed for the patients terminal condition. A doctor’s consult when needed. Durable things like a hospital bed, and expendable things like incontinence supplies. A social worker and a chaplain came with my dh’s hospice. Respite care would have been available had I needed it. Palliative care. Encouragement and positive feedback to me, the caregiver, was invaluable.I cannot say enough good things about hospice care. And no charge at all.
So, I thought, as you appear to confirm, that Medicare covers a lot of hospice care. I'm sort of at loss to figure out the exact shortfall that the OP has to deal with given the comprehensive coverage of Medicare for hospice. There might be gaps in care that are not covered by Medicare but the OP says his relative has Federal LTCi with a DBA of $200. If my wife and I ever needed hospice care, we thought we would be completely covered as far as costs goes with Medicare and our Federal LTCi policies with a current, inflation adjusted DBA of $293. Perhaps, I'm missing something here.

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Re: Hospice, home health aide, taxes questions

Post by Sandtrap » Mon Jul 01, 2019 9:22 pm

MIL is 94, dementia, 24/7 home care.
Medicare pays for some items, IE: doctor prescribed RN visits, some supplies, but not 24/7 home care.
Runs close to 10k/month.

Not hospice, but may help get an idea of the costs of 24/7 home care.

j
Last edited by Sandtrap on Mon Jul 01, 2019 9:55 pm, edited 1 time in total.
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Re: Hospice, home health aide, taxes questions

Post by ChrisC » Mon Jul 01, 2019 9:27 pm

Sandtrap wrote:
Mon Jul 01, 2019 9:22 pm
MIL is 94, dementia, 24/7 home care.
Medicare pays for some items, IE: doctor prescribed RN visits, some supplies, but not 24/7 home care.
Runs close to 10k/month.

j
But that’s not hospice care, right? Is MIL terminally ill? My mom had dementia, was in a SNF for 24/7 care and we were belatedly approved for hospice care when she became terminal; yet it was too late for her to benefit from hospice care.

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Re: Hospice, home health aide, taxes questions

Post by Sandtrap » Mon Jul 01, 2019 9:53 pm

ChrisC wrote:
Mon Jul 01, 2019 9:27 pm
Sandtrap wrote:
Mon Jul 01, 2019 9:22 pm
MIL is 94, dementia, 24/7 home care.
Medicare pays for some items, IE: doctor prescribed RN visits, some supplies, but not 24/7 home care.
Runs close to 10k/month.

j
But that’s not hospice care, right? Is MIL terminally ill? My mom had dementia, was in a SNF for 24/7 care and we were belatedly approved for hospice care when she became terminal; yet it was too late for her to benefit from hospice care.
Correct.
Info added to help get an idea of the costs of home care as well.
j
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Re: Hospice, home health aide, taxes questions

Post by bsteiner » Mon Jul 01, 2019 10:07 pm

HereToLearn wrote:
Mon Jul 01, 2019 5:03 pm
... My mother was in the NY metro area, and agencies charged $27/hour. ,,,
That sounds about right. However, the caregiver only gets about half of that. Based on the experience of someone I know, the better caregivers prefer to work without agencies, for a price somewhere in between what the agencies charge and what the agencies pay their caregivers. As others have pointed out, it's more work to hire caregivers directly, but in addition to saving money you're more likely to get better ones.

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Re: Hospice, home health aide, taxes questions

Post by HereToLearn » Mon Jul 01, 2019 10:21 pm

bsteiner wrote:
Mon Jul 01, 2019 10:07 pm
HereToLearn wrote:
Mon Jul 01, 2019 5:03 pm
... My mother was in the NY metro area, and agencies charged $27/hour. ,,,
That sounds about right. However, the caregiver only gets about half of that. Based on the experience of someone I know, the better caregivers prefer to work without agencies, for a price somewhere in between what the agencies charge and what the agencies pay their caregivers. As others have pointed out, it's more work to hire caregivers directly, but in addition to saving money you're more likely to get better ones.
Yes, I agree with all you wrote above. I can understand why the agency has to retain that much of the pay. There is a great deal of work involved in vetting, scheduling, paying for insurance, overhead, the nurse who comes to the home to perform an evaluation, etc.

It was very challenging to hire more aides as the care need ramped up very quickly. An agency would have been useful, but I felt the aides I hired personally were committed. They were all lovely ladies who took wonderful care of my mother.

quantAndHold
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Re: Hospice, home health aide, taxes questions

Post by quantAndHold » Mon Jul 01, 2019 10:22 pm

ChrisC wrote:
Mon Jul 01, 2019 9:15 pm
littlebird wrote:
Mon Jul 01, 2019 8:16 pm
ChrisC wrote:
Mon Jul 01, 2019 6:06 pm
Just curious. What is the extent of Medicare coverage for hospice care?
Hospice supplies a visiting nurse as needed, an aide for bathing 2-3 times a week, all meds, tests, and supplies needed for the patients terminal condition. A doctor’s consult when needed. Durable things like a hospital bed, and expendable things like incontinence supplies. A social worker and a chaplain came with my dh’s hospice. Respite care would have been available had I needed it. Palliative care. Encouragement and positive feedback to me, the caregiver, was invaluable.I cannot say enough good things about hospice care. And no charge at all.
So, I thought, as you appear to confirm, that Medicare covers a lot of hospice care. I'm sort of at loss to figure out the exact shortfall that the OP has to deal with given the comprehensive coverage of Medicare for hospice. There might be gaps in care that are not covered by Medicare but the OP says his relative has Federal LTCi with a DBA of $200. If my wife and I ever needed hospice care, we thought we would be completely covered as far as costs goes with Medicare and our Federal LTCi policies with a current, inflation adjusted DBA of $293. Perhaps, I'm missing something here.
Hospice doesn’t cover the long term care component. It covers bathing and such, but not 24 hour care. That’s what the LTCI is for.

OP’s LTC insurance apparently covers $200/day in home care, which is helpful, but isn’t enough for 24 hour care at home. We don’t know what their LTC insurance would cover if the person were in a facility. I know my dad’s care, in the facility we chose, was about $350/day. In our case, an in-home aide was about $35/hour. We tried having an aide come in for 8 hours per day, but after a few days, it wasn’t working, and we moved him into a facility to give him 24 hour care.

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curmudgeon
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Re: Hospice, home health aide, taxes questions

Post by curmudgeon » Mon Jul 01, 2019 10:50 pm

ChrisC wrote:
Mon Jul 01, 2019 9:15 pm
littlebird wrote:
Mon Jul 01, 2019 8:16 pm
ChrisC wrote:
Mon Jul 01, 2019 6:06 pm
Just curious. What is the extent of Medicare coverage for hospice care?
Hospice supplies a visiting nurse as needed, an aide for bathing 2-3 times a week, all meds, tests, and supplies needed for the patients terminal condition. A doctor’s consult when needed. Durable things like a hospital bed, and expendable things like incontinence supplies. A social worker and a chaplain came with my dh’s hospice. Respite care would have been available had I needed it. Palliative care. Encouragement and positive feedback to me, the caregiver, was invaluable.I cannot say enough good things about hospice care. And no charge at all.
So, I thought, as you appear to confirm, that Medicare covers a lot of hospice care. I'm sort of at loss to figure out the exact shortfall that the OP has to deal with given the comprehensive coverage of Medicare for hospice. There might be gaps in care that are not covered by Medicare but the OP says his relative has Federal LTCi with a DBA of $200. If my wife and I ever needed hospice care, we thought we would be completely covered as far as costs goes with Medicare and our Federal LTCi policies with a current, inflation adjusted DBA of $293. Perhaps, I'm missing something here.
Having a CNA come to do bathing twice a week is a definite help, but if you get to a stage where you can't get out of bed (or you think you can make it to the bathroom and you fall and can't get up), life can be pretty challenging on the other days, especially if the spouse trying to help them is disabled to a degree as well. The path of hospice care needs are not always predictable.

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Re: Hospice, home health aide, taxes questions

Post by ChrisC » Mon Jul 01, 2019 11:46 pm

quantAndHold wrote:
Mon Jul 01, 2019 10:22 pm
ChrisC wrote:
Mon Jul 01, 2019 9:15 pm
littlebird wrote:
Mon Jul 01, 2019 8:16 pm
ChrisC wrote:
Mon Jul 01, 2019 6:06 pm
Just curious. What is the extent of Medicare coverage for hospice care?
Hospice supplies a visiting nurse as needed, an aide for bathing 2-3 times a week, all meds, tests, and supplies needed for the patients terminal condition. A doctor’s consult when needed. Durable things like a hospital bed, and expendable things like incontinence supplies. A social worker and a chaplain came with my dh’s hospice. Respite care would have been available had I needed it. Palliative care. Encouragement and positive feedback to me, the caregiver, was invaluable.I cannot say enough good things about hospice care. And no charge at all.
So, I thought, as you appear to confirm, that Medicare covers a lot of hospice care. I'm sort of at loss to figure out the exact shortfall that the OP has to deal with given the comprehensive coverage of Medicare for hospice. There might be gaps in care that are not covered by Medicare but the OP says his relative has Federal LTCi with a DBA of $200. If my wife and I ever needed hospice care, we thought we would be completely covered as far as costs goes with Medicare and our Federal LTCi policies with a current, inflation adjusted DBA of $293. Perhaps, I'm missing something here.
Hospice doesn’t cover the long term care component. It covers bathing and such, but not 24 hour care. That’s what the LTCI is for.

OP’s LTC insurance apparently covers $200/day in home care, which is helpful, but isn’t enough for 24 hour care at home. We don’t know what their LTC insurance would cover if the person were in a facility. I know my dad’s care, in the facility we chose, was about $350/day. In our case, an in-home aide was about $35/hour. We tried having an aide come in for 8 hours per day, but after a few days, it wasn’t working, and we moved him into a facility to give him 24 hour care.
I know, personally and painfully, the difference between long term care and hospice care. If someone is terminal, needs hospice care and is suffering from a debilitating illness that requires 24/7 care, then in most cases, the long term care will be short term and hospice care is really paramount to the well-being of the patient. My mother spent 11 years in a skilled nursing facility at $11K to $15K per month, and the last few months of her life, when she really should have been on hospice care for comfort, the cost of hospice care would have been borne entirely by Medicare.

In the OP's case, the initial post suggests this is a terminal situation -- thus hospice care would cover those palliative, comfort case costs; the rest it would seem, even for 24-7 home care, can be met by the LTCi or private resources, and if those resources are inadequate because the terminal situation becomes a very long goodbye, then it would seem one would venture off into a skilled nursing facility using whatever resources are available and then Medicaid as a backstop.

My major point was that if the OP's relative was truly going into hospice, then one is not really looking at long, long term care expenses.

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Re: Hospice, home health aide, taxes questions

Post by littlebird » Mon Jul 01, 2019 11:50 pm

ChrisC wrote:
Mon Jul 01, 2019 9:15 pm
littlebird wrote:
Mon Jul 01, 2019 8:16 pm
ChrisC wrote:
Mon Jul 01, 2019 6:06 pm
Just curious. What is the extent of Medicare coverage for hospice care?
Hospice supplies a visiting nurse as needed, an aide for bathing 2-3 times a week, all meds, tests, and supplies needed for the patients terminal condition. A doctor’s consult when needed. Durable things like a hospital bed, and expendable things like incontinence supplies. A social worker and a chaplain came with my dh’s hospice. Respite care would have been available had I needed it. Palliative care. Encouragement and positive feedback to me, the caregiver, was invaluable.I cannot say enough good things about hospice care. And no charge at all.
So, I thought, as you appear to confirm, that Medicare covers a lot of hospice care. I'm sort of at loss to figure out the exact shortfall that the OP has to deal with given the comprehensive coverage of Medicare for hospice. There might be gaps in care that are not covered by Medicare but the OP says his relative has Federal LTCi with a DBA of $200. If my wife and I ever needed hospice care, we thought we would be completely covered as far as costs goes with Medicare and our Federal LTCi policies with a current, inflation adjusted DBA of $293. Perhaps, I'm missing something here.
Hospice care is not a substitute for home health aides or a nursing home. They just visit; they don’t stay. They don’t prepare meals, take patient to bathroom, or empty catheter, give meds, wash and dress in the morning and undress every night, brush teeth and clean dentures. For these tasks, I had a three hour home health aide shift every morning and the same every night to care for my spouse in the last months of his life. In addition to hospice care. The care that hospice does provide, however, is fully covered by Medicare. You don’t get a bill.

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curmudgeon
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Re: Hospice, home health aide, taxes questions

Post by curmudgeon » Tue Jul 02, 2019 1:13 am

ChrisC wrote:
Mon Jul 01, 2019 11:46 pm

In the OP's case, the initial post suggests this is a terminal situation -- thus hospice care would cover those palliative, comfort case costs; the rest it would seem, even for 24-7 home care, can be met by the LTCi or private resources, and if those resources are inadequate because the terminal situation becomes a very long goodbye, then it would seem one would venture off into a skilled nursing facility using whatever resources are available and then Medicaid as a backstop.

My major point was that if the OP's relative was truly going into hospice, then one is not really looking at long, long term care expenses.
As you note, this is not expected to be a long-term issue (though the course of hospice can vary a lot in other scenarios). The OP was not about a shortage of resources, but rather what are the best and most effective ways to use what is available.

If a morning and evening caregiver shift is needed, and they are 3-hour minimums, then at the referenced potential local agency rates the costs may be beyond what the LTCi covers. Maybe we can find some lower cost agency options, but that can be its own challenge. Assuming the timeframe of need is only a month or two, I think the path in this case will be to cover the extra out of pocket and use an agency. If the potential need was for many months, or even years, then the effort of directly hiring caregivers and setting up a payroll service for them might become important.

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curmudgeon
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Re: Hospice, home health aide, taxes questions

Post by curmudgeon » Fri Jul 05, 2019 5:52 pm

Just a followup as things are coming into place. The costs for agency provided health aides wasn't as high as had been originally described to us (maybe they were thinking of RNs, but that is not the need here). It looks like $27/hr for an aide. Slight nuisance in that it is 4-hour minimum shift (a morning and evening 3-hour might have been more convenient to fit within the LTC cost coverage of $198/day for home care). There have been some challenges in the first couple of days at home, so I think the aide (starting next week) will be a significant help (hospice helped deal with the issues, but they aren't there on a daily basis). Paying though the agency makes claiming on the LTC much more straightforward, as well as easing the tax/employment headaches (CA can be a challenge).

I appreciate the comments, particularly the reminder about having a safe/lockbox for meds and wallets. As various things come up, there are a lot of different folks coming in and out of the house between visitors, hospice services, and aides, so it could be easy for stuff to walk off.

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Re: Hospice, home health aide, taxes questions

Post by Broken Man 1999 » Fri Jul 05, 2019 6:54 pm

I have aides for 2 hours a day, $20/hour. My M-F aide gets $12/hour. My Sat/Sun aide gets less.

Early on I used aides not through an agency, but there are drawbacks. If one of my agency aides can't come, or takes vacation, the agency can send another one without missing a beat. Not so if they are not from an agency.

I have had some aides stay with me over 10 years. My last two who left were in their 70ties, they were like members of my family. If they could have stayed they would have, but with hip and knee replacements, they just couldn't continue.

My current longest tenured aide has been with me 7 years.

I do try my best to treat them with utmost respect, and I give generously at Christmas time. And, a gift card here and there during the year. Their pay sucks, but that is the reality of these type jobs.

I have really been blessed with the quality of my aides, caring, and efficient.

Broken Man 1999
“If I cannot drink Bourbon and smoke cigars in Heaven than I shall not go. " -Mark Twain

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Re: Hospice, home health aide, taxes questions

Post by retiredjg » Fri Jul 05, 2019 7:03 pm

Broken Man 1999 wrote:
Fri Jul 05, 2019 6:54 pm
I have really been blessed with the quality of my aides, caring, and efficient.
Thanks for posting. Quite an insight. :happy

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