What’s 24-Hour Senior Care? Cost, Pros + Cons

Updated

Certified Care Manager, Aging Life Care Professional, and National Master Guardian Emeritus

Most older adults say they want to age in place. However, a dramatic shift toward more care may mean that 24-hour care is the only way for someone to stay at home safely. Multiple caregivers come to the home during 24-hour care to cover every hour of the day. Private duty companies tend to be most adept at arranging this particular type of care.

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Despite the additional cost and concern, 24-hour care can bring some peace of mind knowing that your loved one is being cared for at all hours. It also means managing and monitoring several caregivers.

If you are a family caregiver trying to decide if it’s time for 24-hour care, we have some suggestions on what to look for.

What is 24-Hour Care for Aging Adults?

24-hour care is known as around-the-clock care, and there are two main ways to obtain it. One is through an agency, and the other is if you hire privately. If hiring privately, you will have to consider payroll and liability insurance along with background checks.

When a caregiver quits or cannot fulfill a shift, you are responsible for replacing that person. Management of several private caregivers is a full-time job, and you can always expect periods of stability followed by disorganization.

If you are hiring through an agency, the company will take care of staffing, payroll, liability insurance, and background checks. There are a couple of drawbacks to an agency, the biggest one being the cost.

The hourly cost of care will likely be higher than whatever rate you negotiate with a private caregiver. The other disadvantage of an agency might be a limited pool of available caregivers and high turnover.

In either of these cases, your goal for your loved one is to keep them at home while ensuring safe care. Every state has different guidelines for what caregivers can and can’t do for clients. Some allow for complex medical interventions like catheter and diabetic care. Others will only permit caregivers to offer companion care, personal care, errands, cooking, and cleaning.

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What’s the Difference Between 24-Hour Care and Other Types of In-Home Care?

When you think about 24-hour care, you imagine someone at the home or residence of your loved one all hours of the day and night. These periods can be divided according to caregiver availability and need, consistent with agency policy regarding breaks. 

The other type of in-home care families consider is live-in, which we describe in more detail below. Since not every state permits live-in, you may not have a choice. People choose live-in if their loved one sleeps through most of the night and doesn’t require assistance or monitoring overnight. 

The other deciding factor is sleeping arrangements. Without space or a separate sleeping area for a caregiver, you won’t be able to have live-in care, therefore 24-hour is your best option. 

The other type of live-in care that most families use is caregiving that varies in hours from just a few times a week to all day every day until nighttime. Some agencies require a minimum number of hours a week. 

How Much Does 24-Hour Care Cost?

24-hour care costs can vary depending on the area of the country where you live and the agency or private caregiver you contract with. Typically, the more hours there are in a single shift, the lower the hourly rate. Some agencies will charge a daily rate and then a lower overnight rate if the tasks overnight don’t require much intervention. 

Regardless of how the agency charges, the costs can add up. According to Genworth, the median monthly cost of care in the U.S. is $23.50 an hour. Some areas and agencies will be more, and some will be less. Doing the math based on Genworth’s median cost, a caregiver who arrives at 8 a.m. and stays until 8 a.m. the following day will cost $164.50 a day. At seven days a week, that is $1,151.50 a week, and $4,606 a month. This amount may seem like a lot, but compare that to the median monthly cost of assisted living in the U.S., which is $4,300.

When we get to the benefits and drawbacks of 24-hour care, you can evaluate the pros and cons of continuing with in-home care or considering assisted living. Many families opt for assisted living due to the convenience, but costs of assisted living and especially memory care can climb each year depending on the complexity of needs. 

How Do You Typically Pay for 24-Hour Care?

Paying for 24-hour care for many families can be a challenge. Preplanning with an estate planning attorney well before needing this level of care is best. No one thinks they will need 24-hour care until it happens, and the last thing you want is to deplete you or your loved one’s estate to pay for care. Some ideas on how to pay for care:

Long term care insurance

If your loved one already has a policy, great. If not, it might be too expensive to consider depending on their age and medical condition. Most long-term care insurance policies have a 90-day elimination period, meaning you have to pay out of pocket until you reach the end of the 90 days. Also, make sure the policy covers in-home care and not just assisted living.

Savings, annuities, and retirement

Savings, annuities, and retirement funds are an option for many people. Your parent or grandparent may be reluctant to use these funds, but that is what they are for. Reassure them not to worry about what is left behind for you or your siblings.

Home equity line of credit or refinance

If you own your home, it can provide a source of capital for in-home care. But, be careful. Pulling money out of your home can be tricky. Consult with a financial advisor before making a decision. 

Medicaid

Medicaid is a federal and state program for people who have minimal finances. Generally, you can have no more than $2000 in assets and $2382 in monthly income. If your loved one qualifies for Medicaid, there are state programs for providing in-home care. 

What Are the Benefits and Drawbacks of 24-Hour Care?

As with any kind of care, there are benefits and drawbacks of 24-hour care. There is no right way for everyone, and it is essential to honor your and your loved one’s priorities. For you, assisted living may be much more convenient, but your family member wants to stay at home. Over time the situation may sort itself out, and you will both arrive at an acceptable decision. 

Unfortunately, sometimes the urgency of the situation doesn’t give you much time to think about what is best, and you have to spring into action immediately. That’s ok, but if you can consider the following before and during 24-hour care. As things change, so will your choices and decisions. Flexibility and close oversight are vital to the success of 24-hour care. 

  • As you evaluate the feasibility of 24-hour care, first find out what caregivers can and can’t do in your state. If your loved one has needs that exceed what a caregiver can provide, you might have to look at other options.
  • Compare costs of 24-hour care and assisted living. If 24-hour care is going to exceed the cost of good assisted living, take that under consideration in making your decision.
  • Evaluate your loved one’s home as well. Most people underestimate the value of doing a complete accessibility assessment of the home. Look at safety features, fall risk hazards, stairways, lighting, and emergency response systems. 

Benefits

Though the cost can seem prohibitive for those just starting out on the caregiving journey, there are quite a few benefits to hiring 24-hour care. Some of those are the following:

  • Staying at home: Most people, when surveyed, prefer the comfort and familiarity of home.  Replicating a lifetime of memories is not easy anywhere else, and the proximity of neighbors, church, and friends is a valuable, irreplaceable support.
  • Control of caregiver environment: When you hire private caregivers, you and your loved one control the tasks and duties provided. 24-hour care is 24-hour attention that can be individual and tailored to the specific needs of your loved one. 
  • Peace of mind: In an assisted living facility, there is someone available 24 hours a day, but not in your family member’s room. With 24-hour care, there is always someone there to respond to needs and emergencies.
  • Eyes and ears: With 24-hour care, the caregiver can report on changes and problems. 
  • Flexibility: If you or your family member wants a change of caregiver, you can ask for it. When caregiving needs change, so can the assigned tasks. 
  • Pets: Most assisted living communities have a weight limit on pets. If your loved one has a large dog or several pets, being at home is a big advantage. 

Drawbacks

As mentioned above, the biggest detractor to 24-hour care and most care in general for loved ones is cost. But with 24-hour care, there may be a few other considerations to review before starting to look. Here are some of the potential drawbacks:

  • Cost: At some point, you may not be able to sustain the cost of 24-hour care. 
  • Medical needs: Care for your loved one may start well enough, but in time the complexity of their medical problems might exceed what the personal care agency can provide.
  • Caregiver management: Turnover in the caregiver industry is very high. On a practical level, this means that you might find a caregiver you really like, and then they leave the agency. There is also the problem of inconsistent care throughout the week due to multiple caregivers coming in. 

How to Tell if a Loved One Might Need 24-Hour Care

Deciding if you need 24-hour care can be challenging. You may already have a combination of family caregivers and private duty staff providing several hours of care per day. Caregiver burnout may also necessitate the need for professional help. This patchwork of care may end up being unsustainable due to safety concerns or the inability of the family to continue to provide care.

The cost of 24-hour care can be very expensive. For families who can afford it, keeping someone in their home may be the best option, because that is what the person receiving care wants.

If you’re looking for flexibility, you might be able to start with 24-hour care and make adjustments later if your loved one’s condition improves. Keep in mind, most private duty agencies do not have nursing services available. If you need nursing, you will have to arrange for that separately.

If you’re unsure of whether you need 24-hour care for your family member, here are some things to note.

1. Frequent falls

Falls can be devastating for older adults. They can lead to permanent disability, and recovery time from an injury can be long and arduous.

Older adults have falls for a variety of reasons: poor balance, muscle weakness, and dementia. Sometimes a cluttered and disorganized home with lots of stairs increases the risk of falls.

2. Confusion

Confusion can be caused by dementia, urinary tract infections, and other medical conditions. Some adults can confuse daytime and nighttime or are frequently awake in the middle of the night. Others have increased agitation at night, a condition known as “sundowning.” 

Confusion and memory problems can often occur together. Your family member may be quite frightened as they experience these symptoms, and you may also be concerned about their safety and wellbeing.

3. Illness or accident

This could be anything from a recent hospitalization to a stay in a rehabilitation facility following a hip fracture, stroke, heart attack, or another medical event. For someone to return home safely, they will likely need help with bathing, dressing, toileting, and fall prevention.  

4. Wandering

Wandering is a serious and potentially dangerous problem. People wander from their homes at all times of day or night and in all kinds of weather.

Others who are still driving can get lost and are unable to find their way home.

5. Difficulty eating or drinking

For people with dementia or neurological disorders, choking may be a concern. If you have a loved one with swallowing problems, they may be on a special diet that requires supervision throughout the meal. You may also have a loved one that needs help remembering to eat.

6. Meal preparation

Your family member may get to the point that they can’t shop or prepare food. This usually occurs with people who have dementia.

They can’t sequence the steps necessary for meal preparation and can’t do so safely. A caregiver needs to shop and prepare every meal and snack.

7. Mobility issues

It is not unusual these days for someone to be discharged home from the hospital with significant mobility issues. This might mean they are on crutches or in a wheelchair. Caregivers have to help them transfer to the toilet, get in and out of bed, and take a shower. 

8. Nighttime supervision

24-hour care is most often started because nighttime supervision is needed. This could include help getting to the toilet, calming their agitation, and trying to stop wandering. 

9. Companionship

Companionship is often an underrated and underutilized aspect of caregiving.

Although caregiver focus is usually on activities of daily living, companionship offers much-needed socialization and mental stimulation. It can help alleviate loneliness and improve mood. A good caregiver can handle periods of agitation by using distraction and redirection techniques

How to Find the Best 24-Hour Care

Before jumping into finding care, it may be important to define what 24-hour care is and isn’t. Some people may confuse 24-hour care with live-in care, which are not the same.

Here are the requirements for live-in care according to the U.S. Department of Labor:

  • A caregiver must have a place to sleep for 8 hours during a 24 hour period. They are not considered to be a resident of the home.
  • The same caregiver can only be booked for four to five days in one period. Then another caregiver would need to take the other two shifts.
  • A four-hour break must be given to the caregiver during that 24 hour period. That being the case, someone needs to be available to cover the four hours when the caregiver is on break.
  • Private sleeping quarters in a homelike environment must be provided.

Some states don’t allow live-in caregivers, and in those states, people rely on 24-hour care. With 24-hour care in these states, it can be more flexible.

Some things that differ are the following:

  • Since the shifts are 12 hours or less, no breaks are required. This eliminates the need to fill in that extra four hours of care.
  • Sleeping quarters do not have to be provided. That doesn’t mean the caregiver doesn’t sleep on duty at night, but it is not a necessity.
  • There is lots of flexibility on how and when you want to schedule caregivers. As a family member of your loved one, you can decide how to best structure shifts.
  • With no sleep requirement, this allows a caregiver to actively monitor someone at night. This can be especially helpful for people who tend to sundown and are more agitated during night hours.

If you’re looking to start 24-hour care for your loved one, here are some tips for finding a good agency and managing caregivers.

Get recommendations

Talk to friends, family, and healthcare providers to get recommendations of licensed, bonded, and insured companies.

Even though you may not be hiring a geriatric care manager, you could try calling one in hopes of receiving recommendations of trusted companies they have worked with.

Interview companies

After you have selected your top three picks, interview the owner or manager. Let them know that you are considering 24-hour care and ask if they have the staffing to meet that need.

Ask for references and make sure they are licensed, bonded, and insured. Find out the cost of 24-hour care. Are there any options to help defray costs if that is an issue? If your family member has long term care insurance, will the company help you apply for that?

Scheduling

The more caregivers coming in during a 24-hour period, the harder it can be to manage a consistent schedule.

Multiple caregivers might also be upsetting for your loved one. Ask about the possibility of two or three caregivers to cover the 24-hours and how likely is it that you can expect the same caregivers each week? If you or your family member is unhappy with a caregiver, what is the process of having that person replaced?

Training

If you are considering 24-hour care, you may also be looking for trained caregivers to help with multiple, complex tasks. In a 24-hour period, your family member might need help going to the bathroom, assistance with meal prep and cooking, and management of agitation.

Once the agency has a care team in place, ask about their current and ongoing training. Your family member might have care needs that require a Certified Nursing Assistant (CNA). What is the ratio of non-licensed staff to licensed staff? What are the agency requirements for ongoing training?  

Staffing

Due to the high turnover of caregivers in the in-home care industry, staffing can change from week to week.

Ask about staffing levels and the availability of people to fill in during someone’s absence. How quickly can you expect a replacement if someone is unable to make their shift?

Communication

One of the most important questions you might want to consider asking is who is the person to communicate with regarding complaints or changes. Having one point of contact will simplify things. 

Some agencies have a physical book in the client’s home where caregivers can leave daily notes about what they did and any problems that have come up. Others have an online version of this same thing and family members have access to a portal. Ask about what method the company uses for caregiver documentation and how often you can view notes.

24-Hour Care Can Be a Lifeline

If your loved one wants to stay at home, 24-hour care can help make that possible. As you go through the steps of determining care and selecting an agency, approaching the situation with an attitude of flexibility will help things go more smoothly.

In-home care can feel like an unstable situation, but it is in response to evolving needs and managing the change of caregivers. 


Sources:
  1. “Fact Sheet #79-B: Live-in Domestic Service Workers Under the Fair Labor Standards Act (FLSA).’ U.S. Department of Labor. dol.gov
  2. “Cost of Care Survey.” Genworth. genworth.com
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