Tuesday, January 30, 2018

A review of cottage industry around ‘elder care’ in India

During the past year, I have taken on the responsibility for caregiving for my elderly father and mother. My 80-year-old dad was diagnosed with Prostate Cancer and Parkinsons, and needs help with his basic needs including care and feed. My mother, senior in age herself, was unable to manage the affairs at home. Therefore, my wife and I decided to move back to India to live with them.

I decided to hire a caregiver to assist with my father’s day-to-day needs. For about six months, we hired an elderly lady to help at night with dad’s diaper change and bath and breakfast next morning. For about a year, he was a bit mobile and was able to walk around with assistance. Towards the end of last year, his condition took a nosedive and he was bedridden. We decided to engage a full-time caregiver at home.

My experience in hiring and managing caregivers has given me some insight into the highly fragmented cottage industry around senior-care. The vast majority of elderly-caregiving in India, is still managed by family members. However, nuclear families like mine are realizing that they are ill-equipped to take on the complex chores involved in supporting aging parents while also managing their own lives and families.

These are my observations on my year-long journey of vetting, hiring and managing caregivers for an elderly gentleman in India.

Hiring a caregiver for an elderly? Define your requirements

Elders at home who need a caregiver are obviously going to be infirm and helpless. They may find it hard to acknowledge that they need help with caregiving. The senior citizen will generally not be in a position to define all their requirements.

In a reversal of roles, the younger members of the family take on the responsibility of vetting and hiring caregivers and supervising them.

Caregiving for the elderly requires a person with empathy who can manage - and sometimes challenge - the whimsical needs of frail elders. They also need the physical and emotional resilience to manage highly stressful situations; and sometimes pushback doting family members who might have their own demands.

If you happen to be responsible for caregiving, you should begin with a simple checklist based on your specific needs and commitments that may include
  • Help with basic care and feeding of the senior citizen
  • Help with bathing or sponge bath and a change of clothing and general hygiene (e.g to prevent bedsores if the person is bedridden)
  • Change of diapers and cleanup, and fixing a catheter and urine bag as required
  • Administering medication and assistance with basic medical needs like a nebulizer or inhaler 
  • Generally keeping the environment clean and sterile to prevent infections
A checklist like this can be handy while vetting and hiring a caregiver since you will have to guide her/him with your specific needs during the initial days after they join your family.

A good caregiver can certainly help with basic needs, including feeding, bathing, toilet and other requirements of the elder. However, I realized that even engaging a full-time caregiver does not let a family abdicate its responsibilities that can include managing the logistics. For instance, I still have to manage the procurement and administration of medicines, medical supplies and other sundry needs.

My wife and mother manage the domestic chores at home, that now include care and feed for my father and also the needs of the caregiver. After all, a full-time caregiver becomes an extended member of the family, and will have their needs.

The cottage industry around caregiving for elders

The caregiving needs of home-care in India is unique since the middle-class families are increasingly fragmented and nuclear, and elders try to live and manage on their own till they are unable to. The concept of old-age-homes and senior living is still at a very nascent stage and is generally not tailored for the infirm and bedridden elders. Elders generally fallback on family at their hour of need.

Given the unique needs of the Indian middle class, an entire cottage industry has sprung up in this sector. Most caregivers are either individuals or small ‘agencies’ employing a few people who get clients via word-of-mouth referrals.  Unlike other menial services – like hiring servants or cleaners - caregiving for the elderly and infirm is a highly personalized affair. The needs can range from simple care-and-feed to more unique care depending on medical and other health-related conditions.

Caricature of Dad's caregiver - by our son Vijay

Caregivers in India are generally independent contractors who work for small-time agents. A few elder-care ‘chains’ like Portea are also trying to grow in this market by hiring and training caregivers and might include other ‘packages’ like service of nurses and doctor home visits.

There are some vocations like nursing and caregiving that require people with a certain even temperament who can step up and care for the needy and helpless. Caregiving is a service job that requires minimal training. As there are no requirements for training or education, the barriers to entry are low.

For a manual-job, with minimal medical skills, caregiving pays reasonably well. The current rate for a live-in caregiver in large cities like Bangalore ranges from 20-25,000 rupees a month; and about 14-16,000 for a day or night-shift. The ‘agency’ keeps a percentage of this amount as a fee and pays the caregivers about 10-12,000 rupees a month. Of course, the price I am quoting (circa 2018) is a ballpark and is generally open to negotiation based on one’s specific requirements and location where you live.

Hiring Caregivers: Lessons and tips: You can’t abdicate your responsibilities  

If you are hiring a live-in caregiver, you will also have to plan for other basic logistics like a living area for the caregiver and the elderly so that it doesn’t intrude into the day-to-day activities for the rest of the family. We are fortunate to be living in a house with a spare room with an attached bathroom that we have dedicated for my bedridden father and the caregiver, Andy. I arranged for a TV and some bedding for Andy and he was all-set.

By hiring a caregiver, you are essentially ‘outsourcing’ your day-to-day responsibilities. And like any outsourcing contract, you may delegate, but will have to retain administrative control. A caregiver can be expected to help with the basic needs of the senior-citizen, but will also require some active monitoring. You should also be willing to step in when required. For example, a senior’s health may not follow a steady trajectory and one must be around to understand the day-to-day changes and step-in and seek medical help when required.

Andy, the caregiver, we had hired for a small-agency, was from Manipur and had decided to travel back to his hometown for Christmas. His reasoning was simple: he had spent the past four years in Bangalore working for the agency and needed a break. He and I knew that he was probably not going to come back, but my mother had become very dependent on Andy. The agency promised a replacement a month in advance, but the transition to the new caregiver, Wyisng, wasn’t seamless.

The agent said he had identified Wyisng, who was coming out of another contract, but couldn’t ‘hold’ and house him till Andy was relieved; would we be okay to have two people living with us till Andy left on his vacation? My mother was distraught and confused that she would have to depend on yet another person to help with caregiving for my father.  I weighed my options and said we couldn’t accommodate two more people at home. I asked the agent to house the new guy till Andy was ready to leave. This is just a small example of a ‘firefighting’ I couldn’t have done if I had delegated the caregiving remotely.

The lesson here is simple: Vetting and hiring a good caregiver can certainly help with the basic needs of the elderly, but others in the family need to continually chip-in. A caregiver also needs to be continually monitored.

Dad's caregiver Wysing

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