Determining the Right Level of In-Home Care

Who This Guide Is For

You know your loved one needs help at home but aren't sure what kind, how much, or who to hire. Maybe they just came home from the hospital. Maybe you've noticed a slow decline — missed medications, a fall, the house not as clean as it used to be. Whatever brought you here, this guide will help you think through the decision clearly.

Getting home care right means combining three things: the right type of care professional for your loved one's medical and daily needs, the right number of hours per week, and the right staffing model to keep it all sustainable. This guide walks you through each of those decisions. The goal is a care plan that's safe, appropriate, and cost-effective — not one that overpays for credentials you don't need, or underprepares for needs that put your loved one at risk.

Note: Scope of practice varies by state. Always verify your state's regulations before finalizing a care plan.

I. Assessing Care Needs

Three dimensions determine what kind of care professional your loved one needs and how much care they require:

• Medical complexity — determines whether you need skilled nursing or personal care

• Activities of daily living and daily tasks — determines the hours of care needed per day

• Cognitive status and safety — determines whether continuous supervision is needed vs. scheduled visits

Medical Complexity

There are two general factors that require nursing-level care rather than a personal caregiver:

Medication management is where most families get tripped up. The threshold is lower than you think. In most states, unlicensed caregivers can only provide verbal reminders ("It's time for your medication"). They cannot open pill bottles, hand pills, sort medications, apply prescription creams, give eye drops, or decide whether to give an "as needed" medication. Each of these constitutes medication administration, requiring a Licensed Vocational Nurse (LVN, also called Licensed Practical Nurse or LPN) at minimum. If your loved one can't independently get pills from bottle to mouth, you need an LVN. Using blister packs, pre-sorted medications or automatic medication dispensers can be good solutions in some cases to avoid or reduce the need for nursing level support.

Medical procedures requiring a licensed nurse (LVN minimum, sometimes a Registered Nurse or RN): wound care, catheter management, feeding tubes, tracheostomy care, oxygen management, blood sugar monitoring with clinical interpretation, and anything requiring sterile technique. Any caregiver can use automated devices (blood pressure cuff, thermometer, pulse oximeter) and record readings. A Certified Nursing Assistant (CNA) has formal training in vital sign technique. A nurse is needed when readings require clinical interpretation.

Activities of Daily Living and Daily Tasks

Activities of Daily Living (ADLs): bathing, dressing, toileting, eating, continence management, mobility, and transfers (bed to chair, in/out of vehicle).

Instrumental Activities of Daily Living (IADLs): meal preparation, grocery shopping, transportation to appointments, errands, light housekeeping, and laundry.

Unlicensed caregivers are able to support both ADLs and IADLs, and this is most often what they are hired to do. Key questions: How many tasks need help? What level — verbal cueing, hands-on, or complete care? How often throughout the day?

Cognitive Status and Safety

This determines whether your loved one needs continuous supervision vs. scheduled visits, and whether specialized dementia care is appropriate. Mild dementia (some memory loss, safe alone briefly) is very different from moderate (poor judgment, can't be left alone) or severe (24/7 supervision, behavioral challenges like aggression or wandering).

Care Credential Reference

Now match your loved one's needs to the right professional. Note that experienced home aides often have comparable practical skills to CNAs; the certification matters more in institutional settings.

Layering Professionals

The most effective care plans combine credential levels. For example, an RN visits weekly for assessment, an LVN handles daily medications and wound care, and aides cover the ADL/IADL hours. This matches the right skills to the right tasks and controls cost. Hiring an RN to provide ADL care is like hiring a surgeon to take your blood pressure.

Action Items: Determining Your Care Needs

• List all medications and how your loved one currently takes them. Can they independently open bottles, sort pills, and self-administer? If not, you need an LVN.

• Identify any medical procedures currently required (wound care, catheter, feeding tube, oxygen, injections). Any of these require an LVN at minimum.

• Walk through each ADL and IADL. For each one, note whether your loved one needs verbal cueing, hands-on help, or complete assistance.

• Talk to your loved one's physician about current medical needs and anticipated changes in the next 3–6 months.

II. Hours and Intensity of Care

Estimating Hours

Five factors drive how many hours of professional care you need:

• Family availability. Consider what family can sustain over months, not just weeks. Be honest about evenings, weekends, and overnight.

• When help is needed. Is it just the morning routine? Through the day? All waking hours? Around the clock?

• Safety requirements. If your loved one can be alone between visits, scheduled care works. Wandering, fall risk, or cognitive impairment may require continuous presence.

• Degree of physical assistance. Standby cueing takes less time per task than full hands-on care, which affects total hours.

• Cognitive impairment. Dementia adds significant time to every task due to resistance, repeated explanations, and slower processing. Factor this into your schedule.

When You Need More Than One Caregiver

• Two-person transfers: If your loved one requires a mechanical lift or is too unstable for one person to transfer safely, two caregivers must be present. This typically means overlapping shifts during morning and bedtime routines.

• Medical + ADL overlap: If your loved one needs skilled nursing (wound care, medications) alongside continuous ADL support, you may need an LVN and an aide working during the same time block.

• Behavioral challenges: Severe dementia with aggression or resistance to care can require two people for safety during tasks like bathing or dressing.

• 24-hour care: One caregiver can't work all 24 hours — you'll rotate between different individuals in shifts. This doesn't mean two people at once, but it means hiring and coordinating multiple caregivers. Distinguish between live-in care (one caregiver sleeps on-site with breaks) and shift care (different people covering blocks of the day) — these have very different cost and labor law implications.

Action Items: Determining Hours and Intensity

Map your loved one's typical day hour by hour, noting where they need help, supervision, or cannot be alone.

• Identify which time blocks family can reliably cover and which need professional care.

• Determine whether any tasks require two caregivers (transfers, behavioral safety).

• Decide whether you need scheduled visits, continuous daytime presence, or 24-hour coverage.

• A care manager can help translate all of this into a specific weekly schedule and staffing plan.

III. How to Access Care

Three Employment Models

• Agency: The agency employs the caregiver and handles recruiting, vetting, scheduling, backup, payroll, and insurance. You have less control but zero employer obligations. Typically costs 50–80% more but includes full infrastructure.

• Private employment: You hire the caregiver directly and handle payroll taxes, workers' comp, scheduling, and backup. This gives you more control at lower cost, but you take on full employer responsibility — including covering call-outs and absences yourself.

• Blended: You privately employ caregivers for most hours, then maintain a relationship with an agency to cover time off, vacations, and unexpected call-offs. This combines the cost savings of private employment with reliable backup coverage, and is often the most sustainable model for higher-hour care plans.

Medicare Home Health

Medicare covers a home health aide when your loved one is receiving skilled services (nursing, PT, OT, speech therapy), is homebound, and has a physician order. There's no fixed time limit, but this benefit is for specific situations: short-term recovery or longer-term intermittent skilled needs. It does not cover ongoing daily ADL help. Once the skilled need ends, coverage ends. Long-term daily care requires private pay, long-term care insurance, or Medicaid.

Hospice

If your loved one has a terminal prognosis of six months or less, the Medicare hospice benefit covers nursing, aide services, medications related to the diagnosis, and equipment. Many families don't know about this benefit or delay enrolling. Ask the physician about eligibility.

IV. Common Mistakes

• Over-credentialing. Hiring an LVN when an aide would suffice means paying roughly double for credentials you're not using.

• Under-credentialing. Asking an aide to handle medications or wound care is illegal in most states and puts everyone at risk.

• Assuming "nurse" means daily hands-on care. Be specific about what you need: someone to give medications (LVN) or someone to help with bathing and errands (aide). RNs provide assessment and oversight, not 8-hour ADL shifts.

• Not reassessing. Needs change as conditions progress. Reassess every 3–6 months or after any hospitalization.

• Failing to layer credentials. Use an LVN for medication times and an aide for remaining hours. There's no reason to pay nursing rates for non-nursing tasks.

• Not planning for multi-caregiver needs. Two-person transfers and medical complexity require overlapping staff. Build this into your budget early.

• Confusing live-in with 24-hour care. These are legally and practically different arrangements. Getting this wrong creates labor law liability and care gaps.