Home Care Agencies vs. Registries: What's the Difference?

When families hire from a reputable home care agency, they avoid the legal responsibilities of being the caregiver's employer.

Mom has fallen several times. She sometimes forgets to take her medications, the house is obviously not being kept up, and Dad, who has his own health problems, isn't strong enough to help her out of bed or to the bathroom. Family members help out at first, but busy as they are with jobs and other responsibilities, they are quickly overwhelmed by the caregiving and home maintenance tasks. The family realizes that it's time to hire an in-home caregiver.

But hiring a home care worker can be a daunting task. Where do you begin the search? Maybe you ask your doctor, or maybe a friend knows someone? Or do you take a chance with the Yellow Pages, want ads or craigslist? You worry about the news stories you’ve read where unscrupulous caregivers take advantage of vulnerable clients. It quickly becomes apparent that to hire a trustworthy, reliable caregiver, you need the expertise and support of a home care company.

But be aware that not all of these companies are actually home care agencies. Some are instead registry services. At a superficial glance, the two types of businesses seem similar: They both connect families with home care workers. But that's where the similarities end, and it's important to understand the differences:

Professional in-home care agencies provide a variety of health and custodial services in the home. These agencies are licensed and regulated by their states. They recruit, screen, hire, train and supervise their workers. The caregivers who come to your home are employees of the agency and are bonded and insured. You pay the agency, and the agency handles all payroll taxes and other human resources tasks.

A registry (sometimes called a private duty registry, independent contractor agency or staffing service) is an employment service for home care workers. Registries refer, but do not hire, home care workers. They serve as a middleman, providing families with a list of possible candidates for the job. They charge a finder's fee; once the worker is hired, the relationship usually ends.

This is the key difference: When you hire from a registry, you may become the caregiver's employer, and you might have to assume certain responsibilities, risks and liabilities.

Here are 10 tasks to anticipate as you consider whether you would want to take on that role:

1. Hiring. If you work with a registry, you receive a list of potential caregivers to interview. It is up to you to perform background checks, check references, and discuss duties, expectations, salary and experience—and then, to choose the caregiver whom you hope will meet your loved one's needs and preferences. If you work with a professional home care agency, the agency will take care of all these steps and more. They will send a bonded, licensed caregiver who is matched to your family's needs, selected from their own employees with whom they have a relationship.

2. Training. If you hire from a registry list, the caregiver may or may not have experience in providing care for a person with your loved one's needs. There could be a steep learning curve, requiring much of your time—and you may not feel qualified to provide that training. A professional home care agency will send a worker who has received professionally developed training and understands your loved one's needs, whether that be physical limitations or Alzheimer's disease. If you have questions, you can always call the agency.

3. Supervision. Once you have hired a caregiver, how do you know that the services you hired the person to perform are being done, and correctly? When you hire through a registry, it's up to you to monitor the situation. Families experience greater peace of mind when a professional home care agency is supervising and evaluating caregiver employees on an ongoing basis. The agency will also ascertain that the caregiver shows up for their shift and performs assigned tasks—an especially valuable plus when families live at a distance.

4. Payroll taxes. Professional home care agencies take care of payroll, including federal and state taxes, Social Security, Medicare and unemployment. If you hire through a registry, you are responsible for understanding and complying with this often-confusing array of withholding taxes. And you might face civil fines and even criminal penalties if you are caught paying "under the table" without complying with tax laws.

5. Work-related injuries. Eldercare workers are at risk of injury, such as sprains and strains from lifting clients, automobile injuries and falls. What if a caregiver you've hired through a registry is injured while in your home? As the employer, you could be responsible for the caregiver's medical bills and disability. Would your homeowner's insurance cover this type of claim? In most cases, no:  Homeowner's policies usually exclude coverage for employees in the home. It's much safer to work with a professional home care agency that carries liability insurance and worker's compensation for their employees.

6. Backup. Even the most conscientious caregiver will miss a shift from time to time, due to illness or a personal emergency. What if your caregiver quits on short notice? And what about those times when the caregiver is on vacation? Families may find themselves scrambling to cover their loved one's care upon those occasions. Professional agencies are equipped to provide a backup caregiver if your regular caregiver can't make it—even at the last minute.

7. Discipline. What if the caregiver isn't performing up to your expectations? What if he or she arrives late, misses shifts, or isn't caring for your loved one as requested? If you hired from a registry, you are on your own—you have to have the talk and set penalties for not improving, which is unpleasant and uncomfortable for most people. But if your caregiver is an employee of a professional agency, you can report problems to the manager so they can be handled in a less personal way. Agencies have a disciplinary system in place for helping the caregiver improve or, if it's your preference, they will send a different worker.

8. Ensuring your loved one's safety. It's a subject families would rather not think about, but it's important to know that every year unscrupulous, dishonest people abuse their position of trust to take advantage of vulnerable elders by stealing from, exploiting or even physically abusing them. Few registries perform background checks on the caregivers they place, and they are not allowed by law to supervise them—so if a caregiver you hire steals from your loved one, makes unauthorized charges with your loved one's credit card or worse, you are on your own in dealing with law enforcement. This is a dicey situation when you've hired under the table! Professional home care agencies perform criminal background checks and contact previous employers before hiring a caregiver; in the rare case that a caregiver does commit an illegal act, the agency will take responsibility and deal with law enforcement.

9. Termination. What if the caregiver isn't meeting your expectations, or your loved one does not like the caregiver, or if it just doesn't work out? Firing an employee is seldom pleasant. And there may be unemployment claims to deal with. But if your caregiver is employed by a professional home care agency, the agency will be able to provide you with a different caregiver.

10. Cost. When you're first comparing prices, it might seem cheaper to hire from a registry. But don't forget the hidden costs—and potential costs—of serving as your caregiver’s employer. You may need to pay an accountant, elder law attorney or geriatric care manager to help with payroll and other human resources tasks. You may lose income when you must take time off from work to fill in when a caregiver doesn’t show up, or to deal with problems with the caregiver. And then there's the possibility of hefty tax evasion penalties or even a personal injury lawsuit! Remember: You are paying a professional in-home care provider not only for the services of the caregiver, but also for an array of legal and human resources support tasks and protections.

For information on topics related to home care and healthcare, visit our Home Care and Healthcare Advocacy group on LinkedIn.  

Right at Home, Inc. is a national organization dedicated to improving the quality of life for those we serve. We fulfill that mission through a dedicated network of locally owned providers of in home care services.