Note: This post is part of an educational E-Series for Care Managers that outlines the Legal, Financial, and Practical sides of private-hire live-in care. Every other week, a new set of questions will be addressed. 

Let’s continue this e-series where we left off last week, and answer the next practical questions about live-in care.

1. Which live-in schedules are the most successful with caregiver retention?
2. Why you shouldn’t trust all of those glowing caregiver references.
3. Why clients with racism and/or xenophobia issues rarely are a good match for live-in care.

1. Which live-in schedules are the most successful with caregiver retention?

Why is this question so important? According to Home Care Pulses 2019 Benchmarking Study, caregiver turnover has increased to an unprecedented 82% (700+ agencies across the country were surveyed). Basically, this means that 4 out of 5 caregivers quit (or get fired) from their agency within the first year. Holy cow! The reported culprits are a low supply (of caregivers) and high demand (of clients), combined with inconsistent work schedules and low industry pay.

That trend begs the question, “How do clients retain a quality live-in on the private-hire market?” There are of course multiple ways to do this successfully and I will be more than glad to discuss them with you if you want to schedule a private call. For this series, I will focus on one of the major factors that affect turnover: weekly schedules.

On the private market, the weekly schedules, ranked in order, with the highest retention are:

1. 7 nights, 6.5 days each week (8-12 hours off each week)
2. 6 days (24 hours off each week)
3. 7 days most weeks, then a half week to a week off , each month.

The key here is that the more days they are scheduled, the lower the chance that your client will lose them to another family, given that the pay/workloads are relatively the same. The time off is covered by a family member or a local home-care agency.

For long term retention, families can choose to offer their live-in additional time off per year. Some favorites are:

• One weekend off a month
• One 3-day weekend off each quarterly
• One week off every 6 months

Private-hire live-in positions are almost impossible to make work without some kind of outside support.

What’s surprising to many clients is that professional live-ins rarely want more regular days off. As a matter of fact, live-in caregiver turnover seems to proportionally increase for each day less than 7 that the job requires. So, a 5-day position has a higher turnover than a 6-day; and a 4-day position has a higher turnover rate than a 5-day, etc.

I speak to dozens and dozens of live-ins each month about open positions. The reason that they tell me they prefer to work 7 days over 5 or fewer days, is that when they are at work, living in someone else’s home, they are rarely anywhere near their own home. They don’t know anyone local, are often without a vehicle, and their family may be across the state, country, or even the world. The thought process is, “as long as I am here, I might as well make the most of it and get paid for being here.”

If it’s a high needs case, you are best to keep the schedule at 5+ days and offering them some flex days off to take as needed, or some 2-3 hour breaks during the week, rather than try to cut down their regular days to less than five. If the care-recipient is up a lot at night, you are better off bringing in a local caregiver to cover the 11pm-7am shift, than cutting the live-in’s day schedule back. 

The live-in scenario is a whole different animal than hourly staffing. Hourly caregivers by default will be local and probably have friends and family nearby. Live-ins, except in major metro areas, are rarely local. Very, very few caregivers do live-in jobs. You have to have a real homebody disposition and be able to handle long stretches of monotony, day after day.  

Often I’ll get calls from CNAs who are shocked to discover that an advertised position requires them to stay at work 24 hours a day. “My husband would divorce me!” “Can’t I split it with someone and just do 12 hours?” “You couldn’t pay me enough to do that.” “Is that even legal?”

Professional live-ins, on the other hand, ask me, “How many days a week?” and if I say five or fewer, they often say “Call me when you have something full-time!” It’s a whole different mindset.

There is, of course, a second part to the schedule conversation. What about daily schedules? What are the norms? How often do they need breaks, and what about 3 am when they are sleeping and the care-recipient needs help? As I said earlier, feel free to schedule a call with me to learn more. Otherwise, I would be writing a book here instead of an e-series!

2. Why you shouldn’t trust all of those glowing caregiver references.

Clients and care managers always want to know, “How do you screen the live-in candidates?” I run down this list:

1. Screening interview
2. Verification of live-in care references
3. CNA/HHA verification (when required by long-term care insurance)
4. Secondary interview (case specific)
5. Nationwide criminal background check
6. Phone/video interview with the family/care manager
7. Face-to-face interview with the care recipient (when possible)
8. Social security trace (AKA search)
9. County criminal check (every county courthouse in every state that they have ever lived in)
10. Federal criminal background check
11. 10-panel drug test
12. Optional MVR or credit report

Then I tell them that most applicants never get past #2, verification of references. Why is that? I’ll tell you why. Many applicants on the private market use their co-workers, family, or friends as fake references.

First of all, there is nothing better than a real private-hire reference. The problem with most caregiver references that are from care facilities or agencies is that it’s rare that someone will tell you more than the person’s start/end dates of employment and job title. They could have been the best employee or the worst. You just don’t know and corporate policies prevent them from telling you one way or the other.

The great thing about a legitimate private hire reference is that they are not aware of or concerned with liabilities like a corporate company is. My favorites go something like this: “Martha was great with dad. So trustworthy and warm-hearted. She did everything for him in those last two years. We actually asked her to sing at his funeral. Did you know she sings? Dad loved having her there. BUT I will warn you that it’s best to keep her out of the kitchen as she is a horrible cook.”

So if private references are best, how should you go about checking them, knowing that they may be fake? And why do caregivers risk it?

I think that one of the reasons is that it is so easy to get away with. You are not calling a company; you are calling someone’s cell phone. The fake reference knows the dates, basics about the case “she took care of my mom, who had dementia,” and they have only good things to say about the applicant like, “she was amazing!” What they fall short on is detail, unless the fake reference is a co-worker, then they know enough about live-in work that they can sound very real.

The easiest way to weed out the fake references is to have already asked the applicant about the details of the case, the family, and the care. Then when checking the reference, instead of confirming what the applicant told you, you switch up some of the details and see if the reference corrects you. It’s an old recruiter’s trick. There is, of course, a whole toolkit that recruiters use to weed out fake references, but this is probably the easiest to teach.

For example: The applicant told you she did 7-day live-in from Oct 2017-July 2019, with a man from Littletown, who had a stroke and was wheelchair-bound. She has listed the daughter as the reference to call.

So now you call and ask them open-ended questions about the caregiver. They will probably hit most of the same data points that were on the application. Now ask them to confirm a specific detail that you changed or made up. For example: the care recipient’s first name, age, or hometown. It doesn’t really matter what it is. If it’s a real reference, they will immediately correct the misinformation. “No, my father’s name was John, not George” or  “no, he was 94 when he passed, not 85.” 

Some common red flags to look out for:

• Reference is listed as the grandchild of the care recipient. This is a common one used by younger CNAs, and it is often a co-worker.
• Reference has the same foreign accent as the applicant.
• After you announce yourself and tell them why you are calling, they say: “I can’t talk right now, let me call you right back.”

3. Why clients with racism and/or xenophobia issues rarely are a good match for live-in care.

As some of you know, I owned a private-duty home care agency in NJ for a couple of years. It’s where Grandma Joan was first started, as a service, before it outgrew my agency and became its own company.

When I first started the agency, I decided to enroll in the state’s nursing board home-health aide certification class, to learn what the caregivers that I would be hiring should know. Basically, I sat and took the 3-week class with “real” caregivers. I was impressed that there were a few paragraphs in the course about being a minority and encountering racism. (I think it was in the section on working with dementia patients). What I had no idea about was that the section should have been a lot longer.

Back then, it was just me, my mom (who some of you met at the ALCA National Conference in AZ this past April), and a half dozen part-time employees. I would take calls from potential clients, tell them about the service, and how we could help.

Occasionally, I would get a caller asking me, “Where are your caregivers from?” I learned over time that most people asking that question were really looking to find out if the caregivers were white. Some would be embarrassed, “I don’t know how to say this…but…are your caregivers white? Mom is from a different era….” I remember one woman telling me, “There is no way that dad is going to let a black person stay in his house.”

Once Grandma Joan’s Live-in Placements was born and spread from state to state, I quickly came across not only that same issue, but a whole new one–Xenophobia, or “dislike of or prejudice against people from other countries.” It’s very important for you as a care manager to know:

Almost all live-ins are foreign-born Americans of color.

While I am writing this (Tuesday), I take a call from our 888 line. Wonderful women, dad needs a live-in in PA. He had a stroke and has a PEG tube and the local agencies won’t touch it. She is so happy to hear of our option, “you’ve given me hope” and she then asks me the dreaded question “where are your live-ins from?” I explain that we don’t have any employees like an agency, we are like executive recruiters who specialize in private-hire live-in caregiver positions. Then I answer her question “Most are foreign-born Americans from Africa or the West Indies”. She pauses then says “I’m not sure if dad will be okay with that. I honestly don’t know.”

I grew up in our nation’s biggest melting pot, having lived in or right outside of NYC my entire life. I was not accustomed to xenophobia, and nobody in my social circle was openly xenophobic either. My family was on the other end of the spectrum. When I was 13 years old, I volunteered with a church group (Teen Missions International) to spend my summer living in a village in Haiti, while helping the group build a health clinic for the impoverished locals. We lived in tents outside of a mud hut village for six weeks, doing construction work for eight hours a day. We went through many challenges (no running water, electricity, refrigeration, bathrooms, etc…) but it was one of the greatest experiences of my life. Some of these villagers were literally dying from malnutrition and malaria but were so happy that we were there to help.  It made me eternally grateful for all that we have as Americans.

I also understand that there is a legitimate reason that some families don’t want a foreigner helping mom or dad. It’s that they are hard of hearing, and most immigrants have accents that can make the care recipient frustrated when they can’t understand them. We get it. It’s one of the reasons that we require the candidates to interview with the actual care-recipient before the family decides on hiring them.

There are some American born live-ins, but because of their rarity, they tend to be in high demand on the private market. Some families pay them more than market rate to attract and retain them (supply and demand), and what drives me nuts, is that many of them are less experienced at caregiving than other available candidates, “but Mom wants someone who she can understand and knows how to cook American meals”.  What they are doing is paying more per day for someone less qualified, so that Mom will accept the help in her home. I feel sorry for the adult children that have to navigate this with their parents, who are otherwise refusing any help. It’s not easy. Throw in dementia and it even gets messier.

We answered three very important questions today. Hopefully, you learned a little more than you already knew about how live-in care works on the private market. I understand that live-in care is not the solution for most families, but it is the perfect solution for some.

Feel free to call me with any questions or to discuss any of these points in more detail.

Next Thursday we will start the second part of this e-series, answering the Financial Questions, including:

1. What are the costs involved (including hidden costs)?
2. How payroll and workers comp are managed on the private market.
3. Does LTC insurance or VA Aid and Attendance reimburse your clients for a private-hire live-in?
4. Can the family reduce the caregiver’s pay for “room and board” expenses?
5. Is the family required to provide the live-in with health insurance or other benefits?

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Talk to you then!

David Petroski

888-250-2631 x 700

[email protected]