In-Home Care vs. Nursing Homes: What’s the Difference?

Updated

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

Most people don’t expect or want to rely on care as they age. However, as people get older some families look for more support as they try to manage their loved one’s chronic medical conditions, injuries, safety, general decline, and dementia.

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The dreaded words “nursing home” might be avoided at all costs, but there are times when it is the only option. Avoiding nursing home care is more likely if you may be able to take advantage of home care options. 

Early financial planning and understanding your available choices are critical pieces when it comes to paying for care. You may be a family caregiver who needs support. Resources are available if you know how to use and pay for them. If you’re looking for a place to start, here are some suggestions to help walk you through the process.

By researching and investigating available options, you can help feel prepared and confident in making the right care decisions for your loved one.

In-Home Care vs. Nursing Homes: Overview

As you and your family prepare to make decisions about in-home care versus nursing home care, there is much to consider. Even this past year has revealed things about these two care options that you may not have known. 

The COVID-19 pandemic mandatory quarantines and unnecessary deaths in nursing homes have families and health care professionals rethinking their approach to care for older adults. The conventional thinking has been that nursing home care is the only option for very sick and disabled people.

For some, this will remain the case. But for others, the endemic problems with nursing homes and the numbers of people who have died from COVID, nursing home placement is not a choice they feel comfortable with.  Other families are taking their loved ones out of nursing homes and trying to manage care at home where they can control visitation and care. 

In some cases, your loved one may be too ill or disabled for acceptance into assisted living. In-home care has its share of challenges, too, and there is no perfect answer. The turnover rate in the in-home care industry is high, so companies compete for the best caregiving staff, and you can expect that caregivers will come and go. Comparing in-home and nursing home care will help you decide what is best for you and your loved one. 

Summary of In-Home Care

In-home care is private pay through agencies or online companies that pair caregivers with clients. There is a great deal of flexibility with hours and days of care with overnight and 24-hour availability. The decision to transition to nursing home care from in-home care might depend on what the caregivers can and can’t do for a client.

Summary of Nursing Home Care

Nursing home care is the highest level of medical care outside a hospital. In-home care costs can equal or exceed nursing home care costs, especially if private nursing is involved. But, for families that can afford it, they would rather keep their loved ones at home and will do everything to make that possible. For others, nursing home care provides a stable and safe environment for a loved one who is very sick.

                          Home Care                                                Nursing Home Care

Admissions

Admission is based on whether staff can legally and safely provide the care requested.  

It varies by state, but generally speaking, you can expect extensive admission paperwork. Included is a physician’s order for nursing home care, history and physical, orders for treatment and medications, and proof of vaccinations.  

Cost

According to the Genworth, the costs of care survey, the hourly median costs of in-home care was $23.50. This hourly rate will vary depending on the state, agency, and the number of hours care is needed. 

Genworth estimates the median monthly cost of care in a semi-private room in a nursing home to be $7,756. As with in-home care, these costs will vary depending on the state where you live and the specific nursing home.

Who Is It For 

Each state determines the tasks that in-home caregivers can perform. In some states, caregivers can provide more complex medical tasks. But, at the very least, anyone who needs help with bathing, dressing, cooking, transportation, and companionship can benefit from in-home care.  

Nursing home care is for people who require a high level of attention and medical intervention. For a person who is disabled and needs round-the-clock care, nursing home placement might be the only option.  

Pros and Cons of In-Home Care vs. Nursing Homes

As you compare the pros and cons of in-home and nursing home care, there may come a time when you have no choice. Factors such as cost, safety, and availability of family caregivers can push you one way or the other. 

Keep in mind that you might have to be flexible as the care needs of your loved one change. 

Pros and cons of in-home care

Pros

  • Your loved one is at home, where most people say they would rather be. The familiarity of personal items, the proximity of friends, places of business, and family offer comfort and peace of mind.
  • In-home care is flexible. Your loved one could have more extensive needs at one time and less at another. Depending on the company, you might contract for as little as 2-3 hours a day up to live-in 24-hour care.
  • If you are dissatisfied with a particular caregiver, you can request a change. In a nursing home, it is unlikely you will have any choice of caregivers.

Cons

  • If you find a caregiver you really like, they may leave due to the high turnover rate in the industry.
  • Costs can soar if your loved one needs a lot of care over multiple days per week.
  • You will most likely have several different caregivers coming into the home, not just the one you like.

Pros and cons of nursing homes

Pros

  • Due to the availability of 24-hour nursing and medical support, your loved one will get almost everything they need.
  • Nursing homes are equipped with nutritionists and dieticians who can address those needs if your loved one has special nutritional needs or swallowing problems.
  • Maximum assistance with transfers is available.

Cons

  • Nursing homes across the country have had problems with infection control even before the pandemic. 
  • Staff turnover and understaffing are problems at nursing homes. These issues contribute to inadequate care and higher infection rates. You will need to be very involved in the care and oversight of your loved one to ensure proper and safe care. 
  • The cost of nursing home care is high, and your loved one will likely share a room with another resident. If there is a private room available, the price will be even higher. 

In-Home Care vs. Nursing Homes: Type of Care Received

In-home care encompasses two types of care: home health care and what is referred to as private duty home care. These two types however, are very different. You can use one or the other or both at the same time.

Home health care

Home health care is medical care ordered by a physician. Generally speaking, for a person to be eligible for home health care they have to have a nursing need and be “homebound.” Being homebound means they are not driving independently in the community. Home health provides intermittent care, not 24-hour care. Home health care consists of the following:

  • Physical therapy: usually two to three times a week.
  • Occupational therapy: two to three times a week. Occupational therapists also do home safety/accessibility evaluations and make home modification recommendations.
  • Speech therapy: as needed.
  • Respiratory therapy: as needed.
  • Nursing care: checking vital signs, doing wound care, injections, diabetic care, IV antibiotics, etc.
  • Aides: to assist with transfers, bathing, and hygiene.

Note that Medicare aides are not permitted under Medicare regulations to do things like shop, provide transportation, cook, or clean.

Home care: private duty

This is where things get interesting. You might be dismayed or overjoyed to find out that where you live determines what an aide can and can’t do. If you are hiring through a certified agency, they must comply with state regulations.

The best place to look for information on your state’s requirements, other information related to nursing homes, support for family caregivers, and much more is AARP’s Long Term Services and Supports Scorecard

Here is an example of the differences between states and what their aides can do. These tasks may be delegated by a nurse. An aide in Alaska can perform a wide array of tasks including administering oral medications, drawing up insulin, administering eye and ear drops, performing intermittent catheterization, doing injections, and more. Contrast this with Alabama where there is one task that an aide can do: administer a glucometer test.

For states that restrict aides, that leaves the following tasks to perform:

  • Assist with bathing, dressing, and hygiene
  • Shop for food and cook meals
  • Provide transportation
  • Light housekeeping
  • Medication reminders

This is not to say that these tasks are not valuable, because they are. But, if your loved one has more complex medical needs, home care may not be enough. Many families augment home care with home health care for as long as they can.

Nursing home care

Nursing homes provide all of the medical care a person needs. It is considered the highest level of care outside a hospital. With 24-hour nursing, aide service, and therapy services, nursing homes take care of people who have complex medical and/or behavioral needs. According to the Centers for Disease Control and Prevention, it is estimated that almost 50 percent of nursing home residents have some form of dementia. In some states, dementia cannot be the only reason for admission. There have to be nursing needs as well.

Nursing homes also assist with transfers, bathing, dressing, toileting, and hygiene. Physical, occupational, and speech therapy are also available for residents who qualify. 

In-Home Care vs. Nursing Homes: Cost of Care

The costs of care between in-home care and a nursing home can depend on several factors. Different parts of the country will have variable rates for both in-home and nursing home care. Unless you have long-term care insurance or VA benefits, the cost of care in both will be private pay.

In-home care costs

We have discussed the median cost of in-home care in the U.S., but that hourly rate doesn’t consider other variables. For example, if your loved one requires 24-hour care, the cost could be comparable to nursing home care. Some families opt for live-in care where two or more caregivers live in separate quarters to care for the client. 

Most companies offer some kind of discount for overnight or multiple hours of care. That said, over time, in-home care costs can soar. 

Nursing home care costs

Nursing home care costs are generally all-inclusive, meaning everything a resident requires is provided under a flat daily or monthly rate. Incidentals like personal care items are the responsibility of the resident. The majority of nursing home care is paid for by Medicaid when someone deletes their assets and can qualify. 

The high cost of care in a nursing home reflects the high level of medical support necessary to meet the needs of very ill and disabled individuals.

In-Home Care vs. Nursing Homes: Admissions Process

The admissions process for in-home care and nursing homes is very different. Much of this is due to who is paying for the service and what their requirements are.

Home health care

A referring physician coordinates your loved one’s admission for home health care. Once the order is written, a nurse schedules a home visit to do an assessment and arrange for physical, occupational, and aide service to begin.

Home care, private duty

The consumer arranges home care. No doctor’s order or insurance authorization is required. Once you have decided on the home care company you want to use, you arrange for the days and hours needed and sign a contract.

Some families expect that home caregivers can do more than they are legally able to per state regulations. At the point of contact or during the care plan development, the company will clarify what tasks their caregivers can do.

Nursing homes

The states regulate nursing homes. Admission criteria to a nursing home will vary depending upon where you live. If Medicaid will be paying for a nursing home stay, the process can be lengthy and complicated, especially if you are “Medicaid pending.” Some states allow admission of “Medicaid pending” residents, while others require that Medicaid be approved before your loved one can enter a nursing home. 

Some facilities have both Medicare-funded rehabilitation beds and a few Medicaid beds. Finding availability might be a challenge.

In-Home Care vs. Nursing Homes: Paying for Care

How care is paid for is another difference between in-home care and nursing homes, depending on the type of care needed and insurance policy.

Home health care

Home health care is covered by original Medicare, Medicare Advantage plans, and private insurance. The most important fact about home health care is that it will be time-limited except in very rare cases. Insurance will stop paying if the patient doesn’t improve, for example. Or if the patient has reached their goals or refuses care.

If you are on Medicaid, the home health benefit may be more flexible, but the states make that determination. 

If home health is unable to help the patient recover sufficiently to function independently, nursing home care might be recommended. 

In-home care

In-home care is privately paid unless you have a long-term care policy that covers in-home care. Since most people don’t have long-term care policies, they typically have to pay an hourly rate. That rate varies depending on where you live and the number of hours you contract for. You can expect to pay anywhere between $20 to $35 an hour or more. 

If you decide to go outside an agency and hire on your own, you could pay considerably less. However, there are risks and responsibilities that go along with making that decision. A certified home care company will pay for background checks and assume liability insurance. If you hire outside an agency, you will have to arrange and pay for those protections. 

Through the Department of Veterans Affairs, the Aid and Attendance program provides a cash benefit to qualified veterans or their spouses. The veteran can use this money to pay for in-home care through approved companies.

Nursing home care

Nursing home care is almost always paid for through Medicaid. Qualifying for Medicaid means depleting your assets to a level determined by the states. It also means that your income cannot exceed a certain level. 

If you have a long-term care policy, that can help pay for nursing home care. Each policy is different and therefore will pay a defined amount per day towards your nursing home costs. You would be responsible for any costs that your policy does not cover. 

It is possible to pay privately for nursing home care, but it is expensive. Nursing homes can cost up to $9000 a month. By contrast, $9000 a month may pay for a lot of care at home or in assisted living, but it still may not cover all of the nursing and other medical needs that you or a loved one might have. 

The unfortunate fact is, many families have to deplete their estates to qualify for Medicaid so that nursing home costs are covered. You may consider meeting with an attorney who specializes in asset protection for Medicaid.

In-Home Care vs. Nursing Homes: Who Are They For?

Home health care, home care, and nursing home care differ in who they care for — here are the differences between each.

Home health care

Home health care is for short-term rehabilitation and nursing at home or in assisted living. It is for people who need some support and assistance to regain independent function. Home health care is intended to be a short-term solution—not ongoing support. 

Home care

Home care is a valuable resource to help people remain in their homes for as long as possible. Many people don’t have significant medical problems but may need assistance with shopping, cooking, transportation, medication reminders, bathing, dressing, and companionship.

People with dementia in particular can benefit from in-home caregivers. They may be medically stable but due to memory problems, they may need assistance during the day.

Nursing home care

Nursing home care is for people who need a very high level of care. They can’t afford to pay privately for the level of nursing that they require, or they aren’t safe regardless of how much care they are getting.

In-Home Care vs. Nursing Home Care

 As a family looking for care, consider all of your options in light of cost, safety, and accessibility. The goal should always be as much recovery as possible using as many paid resources as you can to preserve assets. With a little creative effort, you can find ways to support your loved one with the dignity that they deserve.


Sources

  1. Abelson, Reed. “COVID Forces Families to Rethink Nursing Home Care.” AARP, 8 May 2021, nytimes.com.
  2. Paulin, Emily. “Nursing Homes Cited Before Pandemic for Infection Control Issues.” AARP, 20 May 2020, aarp.org.
  3. Reinhard, Susan. “The Long-Term Services and Supports State Scorecard, One Year In: Keep ‘Picking Up the Pace.” AARP, 28 June 2018, blog.aarp.org.
  4. “Alzheimer’s Disease.” Fast Stats, Centers for Disease Control and Prevention, 11 March 2016, cdc.gov.
  5. “Cost of Care Survey.” Genworth, genworth.com.
  6. “VA Aid and Attendance Benefits and Household Allowance.” Aid and Attendance benefits and Housebound allowance, U.S. Department of Veterans Affairs, 1 June 2020, va.gov.
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