How refreshing to read about an existing Visiting Nurse Association that still functions, free from affiliation with a profit-making group.

Along Chicago's North Shore both the VNA and early hospice programs were co-opted by hospitals once Medicare and Medicaid came into being. Home Health Care is no longer community based, but just one of a hospital's branches.

I cannot tell you how much a solid, middle-class retirement income has done to save the life of my DF-in-L. He has enough monthly income to pay for someone to be with him and assist him all day, so the family can take over on nights and weekends. My mom could never have done this at all, had she ever needed it. That is the difference between having only $2500 more to spend toward home health care each month.

Since I am in nursing homes as part of my job, I have to say that I don't think our smart, witty, fun, politically-engaged 92-year old would still be with us if he had gone to a nursing home when he suddenly went blind and needed 24-hour care at age 91. Not with everything that happened afterward! He has been home for all but about a month (excluding multiple hospital stays). He was in a nursing home Sub Acute Rehab for a month this autumn following a bout of pneumonia. (He came home with C. Dif. diarrhea, so is still getting skilled home nursing care a couple of days a week.)

Instead, he has the most caring, tireless, and perfectly-matched uncertified aide with him 40 hours a week, and a competent and certified aide (without the other attributes) another 10, and he pays cash for both. He also pays their Social Security. We use a certified agency for everything else, but not for his minute-to-minute helpers. His aides even stayed by his side at the nursing home and advocated that they be more gentle, that they listen to what he was telling them, that they stop gesturing and use spoken language to communicate with him. With all his challenges, we found that we needed to provide the very same shifts of aides and family members we have at home. The nursing home was needed to get him stronger in daily PT/OT and to provide two and three-person assist with his care until he got strong enough to come home, but we dared not leave him there alone except from 10 pm to 7:30 am, when we hoped that he would be asleep.

We did try the agency route for home health aides, but it did not look like it was ever going to settle down into regular staff who actually got to know him. He would have staff who knew him for a few days, then someone else. Their hurried "shower day" sessions were chaotic, with the second person who arrived to help for an hour never the same. It really does take practice to remember that the elder you are working with cannot see gestures or understand what you want when you say "grab here," wwithout placing his hands where you want them. Dad would have just put up with it, too. He is not a complainer. But we have Dad at our house, and were home at times and saw it. We saw the changing names on the agency log sheet, and we asked Dad questions about the care.

I read much of the last article that JKom linked to, then went and skimmed the other two. I found them to be an interesting bit of reporting that reads like a brochure promoting the services provided by the company Marki Flannery runs. It may be a worthy not-for-profit, but the question-and-answer format and the lack of other industry sources or other viewpoints makes me want to look for the little "advertisement" disclaimer at the top of the page, as it were. No slam against you, JKom, please understand. It is an interesting article and gives a good understanding of what an agency CeNA will do, from the point of view of one agency.

One of their points stuck out, for me: " If the patient had been with us from the beginning, the proper treatment would have been prescribed by the doctor and managed by the nurse in cooperation with the patients physician, and the aide would have received proper instruction about what needed to be done."

None of DadÂs professional caregivers  be they home care nurses, therapists, wound-care specialty nurses, PAs or doctors - have objected in the least to giving their patient-specific instructions to family members or to our hired home health aide. Why would they? They have never asked if an agency sent her to us or if she was hired privately. Is this different in New York (where the home care agency interviewed is located) or in other states? WonÂt the home care nurses show these things to privately hired aides? I would fire the home nursing agency if that were the case.

I guess my point is that our privately hired aides are trained how to take care of Dad. I donÂt need one trained to take care of Mrs. Smith, too. She does not live here. Our aides have four family members to call if they have a question. Sometimes they have a home health agency, too, if Dad needs skilled nursing care. I guess that if Mrs. Smith had no one to help her, some of the points that Marki Flannery makes would have more weight, but she talks as if every home health aide customer had the same needs, and they do not. For instance, I donÂt think that an agency wants their aides responsible for letting our dogs in and out. We needed someone who could feel comfortable doing this (and who our rescue with a horrific start in life could get used to). Dad moved in with us when Mom died so that our dogs could be a comfort to him, they are a big reason he lives here. We need that job of a familiar person to let them in and out covered.

We needed someone who could listen to hours and hours of political coverage (of a poplulist slant) and not go nuts. We found someone who not only did those things, but she engaged Dad in teaching her about politics, in how to read the racing page in the newspaper, and in understanding the fine points of baseball. We pay her very well and will do anything we can to further her employment when Dad passes on. She is priceless to our family. The other aide is good, too.

Please take your own situation into consideration when reading the article. I am disappointed in the NYT for such a strange article. If they wanted to help families understand issues related to home health aides for the elderly, an article that talked about the profession from other prospective would have been needed.

One big issue Dad thought he had taken care of was home health aide insurance coverage. Unfortunately, I do not think his extended care coverage he paid extra to buy has helped pay a dime. It is not a real Long Term Care policy. It was designed to kick in when someone needs help at home, but do not need a nursing home. Limitations on the coverage make it useless. It does not cover Nursing until he maxes out his Medicare home Nursing benefit, (which he has not done), and it cannot pay if you think you need more services than Medicare will provide each week. It will not pay for home care aides unless we submit him to being cared for by a licensed agency - with their changing staff - for home care aide services. With agency aides, he could get one hour a day with this policy. In exchange for this $15/day benefit, we would have had the work of teaching each new stranger who entered our home all about his exotic illnesses and how to cope with our three dogs. This was so unhelpful it has not been something we even considered trying to use. This policy was a waste of his money. When you have these insurance options to consider, look carefully at them before you enroll. This one was offered by his employer and seemed helpful on paper, but was not helpful at all.

>>I am disappointed in the NYT for such a strange article. If they wanted to help families understand issues related to home health aides for the elderly, an article that talked about the profession from other prospective would have been needed. Just so folks know, this is an ongoing blog, not a short-run series of articles. Author Jane Gross has devoted a number of columns to the LTC and home health aide issue, giving both her experiences as well as the readers' comments section, which adds a fuller picture of how these issues are affecting real-life people every day.

I reiterate, I did not post this article as the end-all/be-all of LTC care. I posted it because it is one of the very, very few articles I have ever seen that actually lists costs. When people are trying to forecast for a personal budget as they will age, it's important to at least have some sort of baseline on which to estimate healthcare costs. A semi-educated guess is degrees better than an uninformed guess.

Oh, no I never thought you were saying it was the whole story. I missed seeing that it was a blog. Sorry, my bad.

NP - I probably should have pointed out that in one of the boxes on the side, there's a listing of the previous columns. I find sometimes I miss reading the individual blog postings, so it's helpful to scan what the previous column titles were, then I catch up with ones I think might be interesting to read!

And thank your for posting your personal experiences - I think that really helps people to think about the many aspects of what is a very personal and complex life decision.