As an older adult becomes more frail, either physically or mentally, the caregiver’s concern with the practicality of keeping a loved one at home increases. The dilemma over whether or not to stay at home with support or to move to a retirement community, assisted living facility, or nursing home becomes an issue. The thought of downsizing and moving to an unfamiliar new place can be daunting, as well as the fear of having less independence. Also, the impact of such a dramatic change in lifestyle can sometimes cause more harm than good. The following list of questions and knowledge of available resources may help your family in making a final decision. Long distance caregiving increases the dilemma, for the caregiver cannot “check in” as often.

Financial Considerations

Is a long-term care insurance policy in place? Does it cover in-home services? What is the waiting period? Is an evaluation of the older adult required? If so, have you contacted the primary care doctor to assist in the insurance company’s health evaluation? How many hours of care does it cover for hired caregivers? Does it cover special aids such as walkers or wheel chairs?

If long-term care insurance is not in place, have you researched the daily costs of staying at home—such as salaries and taxes for hired caregivers, utilities, home and yard maintenance and repairs, groceries, housekeeping, etc.?

Socialization Considerations

As an older adult loses mobility and can no longer drive, he/she can start to feel the effects of isolation. If the older adult chooses to stay at home, the following questions need to be addressed:

  • Is there an adult day services facility, church group, or senior center nearby that can provide stimulating programs for socialization (lectures, bridge, games, volunteer opportunities, etc.) or fitness activities?
  • If there is a live-in family caregiver? Is respite care available to provide several hours of personal time for the caregiver during the week? Caregiving agencies exist that provide respite services as well as 24 hour per day coverage for older adults and disabled individuals. Have a backup plan if the caregiver is out with sickness or a vacation. Some assisted living or nursing home facilities provide short term stays for just such situations.
  • Are there friends, family members, neighbors, or congregation members who can be encouraged to visit or to telephone (both to see if the older adult needs anything and just to chat) on a regular basis? Many faith-based communities have Stephen Ministers who are trained to visit homebound older adults—does your community have this resource?
  • Has the older adult taken advantage of the resources available through the public library that can lessen loneliness or boredom, such as free videos, books on tape, and large print books that can be ordered over the phone? Is there someone who can tape favorite shows to be watched at later times?
  • If the older adult is unable to read due to vision impairment or loss of ability to concentrate, is there someone who can read to him/her each day? The Library for the Blind has a free service for audio books. Check with your local public library.
  • Has he/she been encouraged to learn how to use the computer—a great way for keeping in touch with family and friends via e-mail, keeping current with the news, shopping, etc?
  • Is there a radio that can be set at a special channel for music or news?
  • Is there a phone beside the bed?
  • Have an emergency plan in place for power outages.

Meal Considerations

Another concern for older adults living at home is wheather they are receiving proper nutrition, along with the safety issues involved with cooking. As both appetite and physical/mental capabilities diminish, be sure to address the following issues:

  • If the older adult is on medication, is there a failsafe method to ensure that daily meds are taken at the appropriate time with or without food (as prescribed) and that they are stored in a container clearly marked in large print for each day: a.m. and p.m.?
  • Is there a fire extinguisher in the kitchen (as well as other rooms) that the older adult knows how to use and would be able to operate?
  • Is the older adult still able to read the instructions on food packages and turn the knobs on oven and burners? If not, has there been instruction on use of microwave? (A caregiver can prepare meals on plates in advance to be reheated later.)
  • Is a schedule in place so that he/she will eat breakfast, lunch, and dinner at regular hours?
  • Is the older adult aware of “Meals on Wheels” or “Mobile Meals,” programs where volunteers deliver one hot meal five days a week to the home? Not only does it ensure one good meal; it also means that there will be someone “checking in” on a daily basis.
  • Are fresh fruit and other easy-access foods kept available?
  • Is there someone to check the refrigerator once a week to see what is needed from the grocery store and to check expiration dates on perishables?\

Home Assessment for Mobility and Safety

When an older adult chooses to remain at home, there are adaptations that will make living alone easier and safer and give more peace of mind to them, the family, and caregivers. Insurance will sometimes pay for specific devices and/or modifications. Even small changes in the home can improve safety and enable older adults to remain there longer.

Exercise helps. Modest weight lifting and Tai-Chi, are known to improve balance and strength, while walking and gardening can keep one healthy and in good shape. Even a stroll down the street is beneficial.

Falls, though, are a concern. One in three older adults over 65 will fall each year. Only 10% of those who get help within 12 hours will be able to return to an independent home. The traditional (and a good) solution in personal emergency response systems (PERS or medical alarm systems) is a panic button worn as a pendant or bracelet that can be pressed to bring assistance. However, data shows that many older adults will not wear the button, let alone be able to use it in an emergency. But, advances in
technology have progressed now to simple, mobile systems, which provide real-time, “intelligent,” in-home monitoring, via customized sensors, which can monitor both user AND their home for signs that an emergency or problem might have occurred and then send instant alerts, within the house, and to those designated (i.e. family members, caregivers, neighbors, 911 etc.), who can provide the most appropriate help for the situation.


Checklist for Preventing Falls in the Home

  Use carpet with short, dense pile.
  Apply double-sided tape to rugs that can slip.

Arrange furniture so you can walk easily around.


Make sure electrical and extension cords are not in the walking path.


Make sure you can turn lights on without having to walk through dark areas.

  Use nightleights extensively.
  Keep exits and hallways clear.
  Use sturdy chairs with armrests to help you get up.
  Provide bright, evenly distributed light.
  Use window shades that reduce glare.
  Have more than one phone in the house.
  make sure surfaces are safe and non-slip.
  Avoid scatter rugs or doormats that may be dangerous.
  Make sure that if there are floor level changes, that they are clearly marked.
  Put handrails on both side of the stairs.
  Make sure the steps are even.
  Use non-skid, contasting tape, rubber stair treads or coated skid-resistant material on non-carpeted steps. Allpy tape to clean, dry surfaces at one-inch intervals. Use three long strips of tape on each step.
  Make sure there are no electrial or extenstion cords in the walking path.

Check for loose carpeting along the stairs.


Repair or replace worn or loose carpet.


Select a carpet pattern that allows you to see the edges of the stairs clearly.


Do not place scatter or area rugs at the top or bottom of the stairs. All rugs should be firmly attached.


Use good lighting (at least 60 watt bulbs) in the stairway. Install on/off switches at the top and bottom of the steps.


Never leave objects on the stairs.


Watch out for a single step. People often trip when there is only a single step.


Take your time when going up or down the stairs.


Be especially careful when carrying large loads or when wearing shoes that are easy to slip in.


  Use sturdy stepstools with handrails.
  Throw away stepstools with broken parts.
  Clean skills immediately to avoild slipping.
  Use rubber bathmats or strips in the tubs and showers.
  Install at least two (2) grab bars in the tub and shower.
  Clean water from the floor.
  Use raised toilet seats and/or handrails, securely fastened, if the older adult is unsteady.
  Use a nightlight.
  Install handrails along any stairs.
  Spread sand on icy walkways.
  Keep the garage floor clear of any spills. Especially oil or grease on cement floors.
  Make sure windows and doors are easy to open and close.
  Make sure locks are sturdy and easy to use.
  Make sure the doorways are wide enough for walker/wheelchair.
  Check that door thresholds are not raised too high.
  Create space to maneuver while opening/closing doors.
  Create a view panel for the front door and ensure that is at a proper height for the resident.
  Outlets/switches should be easy to turn on and off.
  Outlets should be properly grounded to prevent electrical shocks.
  Extension cords should be in good condition. Are they needed?
  Smoke/carbon monoxide detectors should be placed in all necessary areas.
  Know how the alarm system works, if available.
  The telephone should be easily available for emergencies and equipped for hearing enhancement, if necessary.
  The doorbell should be audible throughout the home.
  Check heating pads for wear before each use.
  If the older adult requires an electrical life-sustaining device, notify the power company so that power can be restored promptly during an emergency.
  Place "No Smoking" placards on all entrances to your home. These placards are provided by the oxygen company.
  Do not use more than 50 feet of tubing between the oxygen source and the patient.
  Do not place oxygen tanks within 1 1/2 feet of windows/doors or other objects.
  Roll the tubing and carry it to avoid tripping and falling when walking. 
  Do not have open flames, such as pilot lights of gas stoves or water heaters within 12 feet of any oxygen equipment. This warning applies to the tubing too.
  Place the telephone number of the electric company on or at every telephone. Call in the event of a power outage.

Disposal of Hazardous Materials

A. Needles

  • Never recap needles.
  • Place needles and syringes inside a metal can with a lid or other apporved container.
  • Store needles and syringes out of reach of children and out of sight of visitors.
  • When the can is 3/4 full, place can without lid in the oven for one hour at 350 degrees to melt the syringes.

B. Drainage Waste

  • Place all used dressings in a plastic bag and place it inside of your household trash bag.
  • Wash hands thoroughly with soap and water before and after contact with waste.
  • Disinfect soiled clothing by washing separately in hot water with bleach.
  • Use disposable gloves whenever possible.

Additional In-Home Support

As a result of the emotional and physical stresses associated with long-term caregiving for an elder at home, there is often a time when outside support becomes necessary. In-home care, also called “personal support services,” is defined as non-medical, personal support, custodial services. Service providers can offer anywhere from one to 24 hours of care, and no doctor’s order is required. However, long-term care insurance, depending on the policy, may or may not cover these services.

Services include but are not limited to: transportation (to and from doctor’s appointments and social activities), light housekeeping, meal preparation, medication reminders, bathing and grooming assistance, and companionship. Agencies that provide these services should be licensed with the state (a requirement in Tennessee).

Numerous agencies exist that provide trained helpers who range from nurses to sitters/professional caregivers. There are
also service providers that can help with all other day-to-day management of the older adult's life (i.e., bill pay services, management of petty cash, maintenance of home, shopping, etc.) Some of the best help can be found through word of mouth. The process of finding someone dependable and good; however, can be quite challenging. Below are a few tips to keep in mind while choosing an appropriate caregiver for your family:

  • Research the reputation of each agency thoroughly.
  • Iiterview prospective employees before they meet with the older adult. If they seem to meet with your requirements, be sure that the older adult is involved in the hiring process. It is important that he-she feels comfortable with this new person in his/her daily life.
  • Ask for references and follow through by calling them.
  • Make sure a thorough criminal background check in all states of residence for the last ten years has been conducted on anyone coming into your home. Because background checks can differ, if you use an agency, always address specific issues. If you prefer to hire an independent contractor, you should contact a professional company specializing in this kind of business. Check “Employment Screening Companies” in the yellow pages or on the internet. Also check the TN Department of
    Health Nurse Aide/Elder Abuse Registry at 1-800-778-4504.
  • Check to see if the applicant is a smoker. If so, set guidelines for smoking areas and time allotment.
  • Present a written list of expectation, as well as a contract stating salary, holiday pay (some request time and a half), withholding tax, etc.
  • Before signing a contract, it is essential to first have a "trian run" and a detailed list of duties prepared.
  • Keep in mind that fewer faces and consequently fewer changes and adjustments are ideal. Try to make a schedule that is consistent.
  • Ask hired caregivers to wear a nametag with large print.
  • Have the helper answer the phone by giving first the name of the resident followed by his/her own name. Always keep a notepad and pen handy to record messages even if the older adult is not asleep. It is helpful for both the older adult (who might suffer from short-term memory loss) and family members to know who has called. (When the older adult is taking a nap, have the phone “turned down” or off in that room to ensure a good rest).
  • Ask if the agency conducts pre-employment, random or scheduled drug screens of employees.

Some Qualities to Look for in a Professional Caregiver

A. A Professional Appearance

Appearance provides clues about a person’s attitude and professionalism. One should be clean, well-groomed, and dressed appropriately for the job. Try to look beyond generational norms—blue hair does not mean a person is a bad caregiver! Don’t be fooled by size: some large people move quickly and smoothly. By the same measure, a slight, slim person may be quite strong. The important factors are that one is well-trained and uses the proper equipment.

B. Good Observational Skills

A good caregiver is observant and sensitive to changes in the older adult's condition. In evaluating this, have the caregiver interact with them. Together you can judge whether the caregiver seems to have a “feel” for the person and the situation, as well as the skills to identify and deal with the older adult's physical and emotional needs. Trust your instincts.

C. Good Communication Skills

The ability to communicate with persons with perceptual problems may make caregivers seem rather odd at first! Accustomed to working with hearing-impaired or visually-impaired persons, they may speak more loudly and slowly than you are used to. Or they may ask questions not normally asked on an interview. However, good intuition can be much appreciated by someone who can’t verbalize his/her needs. Note if they look the older adult in the eye. Or use touch. Or give the older adult time to respond.

D. Quiet Self-Confidence

Arrogance and “an attitude” are not helpful; a sense of quiet self-confidence is. After all, part of the job is to give reassurance to you and your loved one. You need to feel you are both in good hands.

E. An Open Mind

Good caregivers must be tolerant and accepting of ideas and beliefs that may not be their own. Care receivers are often different from their caregivers in age, gender, ethnicity, and beliefs. They often take out feelings of frustration, anger, or other strong emotion, blurting out insults or even physically striking out at the caregiver. An experienced caregiver will not take this behavior personally but will try to assess the issue or circumstances and respond appropriately.

F. A Sense Of Humor And Creativity

For caregivers, who often face many challenges with clients who are dealing with a variety of issues, an even temperament and a sense of humor can avert many potential crises. Creative problem-solving in helping the older adult to maintain a sense of dignity, respect and even autonomy is an important quality for delivering care in a professional and nuturing manner.

Begin with a two-week trail with an evaluation by all parties midway through. Comfort with the caregiver is important, but competence is essential!


Home Health Care

In the formal definition of home healthcare, the basic components are nursing care, social work, therapies (speech therapy, physical therapy, occupational therapy), and limited health aide services. These are ordered
by a physician and are short-term.

Most home healthcare is reimbursed through the Medicare and Medicaid systems. Generally, these two programs focus on illness care and have strict eligibility criteria. Home health covers skilled care services on an intermittent basis that are ordered by the physician to assist patients and families through a bout of illness. The patient must be home-bound and require medically necessary care. Home health agencies are regulated through state licensure and Medicare/Medicaid certification. For individuals who require in-home care but are not eligible for Medicare or Medicaid, there are benefits available through commercial insurance,
private pay, long-term care insurance and special waiver programs managed through state, local, and other federal funding. In addition to intermittent care, some in-home agencies can offer extended private duty care in the home that may in some instances be covered by the patient’s insurance program. Again, check first to determine that the agency providing care meets licensure and credentialing standards.

Medication Management

When an older adult is unable to manage medications independently and the family or professional caregiver becomes responsible, there are several systems that can be put in place. New technology is available that reminds the older adult at the appropriate time to take a pre-loaded dose of his/her medication. Some systems also have the capability of reminding the m of various other important health-related items (i.e., blood sugar checks, food thirty minutes before medications, etc.).

These systems assist in continuity of the medication regimen, which in turn allows the older adult to remain independent longer. Nurses and care managers can help in locating and managing these systems.

Avoiding Scams

Everyone, but especially seniors living alone, are susceptible to the ways scam artists operate. Discuss with the older adult the following advice:

  • Never respond to phone solicitations for products or winning sweepstake numbers.Key words that should arouse suspicion: cash only, get rich quick, something for nothing, contests, haste, today only.
  • Never release personal information to anyone who contacts you.
  • Do not give your credit card or Social Security information over the phone UNLESS YOU HAVE INITIATED THE CALL.
  • Beware of someone contacting you with information about lost relatives.
  • When approached for a donation, find out what charity or business is involved. If you have not heard of this charity, ask for written information. They will send it if they are a legitimate organization. If not, it is most likely a scam.
  • Check out any contractor coming to do work on your home. Ask for the contractor’s state license number. Call the TN Board of Licensing Contractors at 1-800-544-7693 to confirm that the contractor has an active license and has posted the required bond.
  • Check the standing of the business or service with the Better Business Bureau.
  • Beware of unsolicited door-to-door sales; under the law, you may cancel a door-to-door sale within three business days of the sale by notifying the seller in writing.

Financial Exploitation

Older consumers lose millions of dollars each year because of financial exploitation. This may be the result of an unknown con artist’s scam or financial abuse by someone the victim knows well. Financial exploitation is defined as the “illegal or improper use of an adult’s resources or property.” The National Center for Elder Abuse in Washington, D. C. indicates that financial exploitation accounts for about 12 percent of all reported elder abuse cases. This most likely is only a portion of actual cases, however, because victims often are too ashamed or embarrassed to report this type of crime. Everyone wants to help one’s family and friends, and it may be hard, for example, to refuse a favorite grandchild’s request to co-sign a car loan. However, keep in mind that the co-signer will be liable for the loan if the family member is unable to pay.

If you think someone is being swindled or taken advantage of by a person who tries to gain trust with a friendly and honest face or pleasant authoritative voice, ask these questions:

  • Has someone told you that you need home repairs and demanded an immediate cash payment? Has anyone offered to accompany you to the bank for a quick withdrawal? Has anyone asked you to withdraw your money for any reason?
  • Has a stranger asked you to put up "good faith" money so you can share in unexpectedly found valuables or cash?
  • Has a stranger offered to "bless your money", remove a curse from it or performed a ritual that will cause it to increase in value?
  • Have you received a telephone call or a visit from an alleged employee of a regulatory agency or bank examiner who claims to need your help in trapping a teller who may have been withdrawing money from your account?

Protections From Financial Exploitation

  • Consider having utility, phone, newspaper and other regular bills automatically paid by electronic transfer from checking or savings accounts.
  • Arrange for direct deposit for benefit and pension checks to reduce the opportunity for theft.
  • Stay in regular contact with a number of friends and family members.
  • Be watchful of a caregiver that tries to isolate the older adult.
  • Talk with the bank. Financial institutions are in a unique position to have early knowledge of on-going financial exploitation of older consumers. However, they will not give information to anyone who is not an owner of the account.
  • Remember oral promises are not binding, especially if a written contract exists and does not agree with the oral promise.
  • Don’t leave a hidden key outside.