Not All Aides Are the Same: A Family Caregiver’s Guide to Who Does What
Note:
I’m not a nurse, a lawyer, or a certified anything. I’m just a long-haul family caregiver sharing what I’ve learned the hard way — through lived experience. This isn’t medical advice, legal advice, or professional guidance. It’s a map drawn from the trenches, for anyone else trying to find their way through.
🧭 Understanding the Roles: Who’s Who in Home Care
Not all “aides” are created equal — and not all services mean what you think they mean. Here’s a breakdown of the most common roles you’ll encounter in home care.
🧑🦽 Personal Care Aide (PCA)
Training: Minimal; often on-the-job or agency-provided
Scope: Non-medical assistance with daily living
Tasks May Include:
Bathing, dressing, grooming
Light housekeeping
Meal prep
Companionship
Medication reminders (not administration)
Limitations: Cannot perform medical procedures or administer medications
🩺 Home Health Aide (HHA)
Training: Formal certification (varies by state)
Scope: Similar to PCA, with some basic health-related tasks
Tasks May Include:
All PCA tasks
Checking vital signs
Basic wound care (under nurse supervision)
Assisting with medical equipment
Limitations: Still not licensed to perform invasive procedures or administer injections
🧑⚕️ Certified Nursing Assistant (CNA)
Training: State-certified with clinical hours
Scope: More medically focused; often works in facilities
Tasks May Include:
All HHA tasks
More advanced hygiene and mobility support
Monitoring and reporting health changes
Limitations: Still works under supervision of a nurse or physician
🧠 “Alzheimer’s & Dementia Care”: What It Really Means
Many agencies advertise “Alzheimer’s & Dementia Care” as a service — but what does that actually mean?
“The VA pays for our Senior Helpers. One of their services is Alzheimer’s & Dementia Care. I thought in the beginning that was going to be our plan. But that is not actually a singular plan. It is on top of other plans, and it is really more about assessment and planning. The actual home aides, most are not trained in Alzheimer’s & Dementia Care. They are help aides, not specialists.”
In most cases:
A care plan is created by someone with dementia training
The day-to-day care is delivered by general aides (PCAs or HHAs)
The aides themselves may have little or no dementia-specific training
Unless explicitly stated, “dementia care” often means planning, not specialized execution.
📋 The Checklist Illusion: What Gets Checked vs. What Gets Done
Agency aides are typically given a checklist of duties to complete during each shift. These may include:
“Walk with patient”
“Assist with hygiene”
“Prepare light meal”
Before clocking out, they check off each task — often on a phone screen you’re asked to sign without seeing the details.
But here’s the catch:
“Walk with patient” might mean a full lap to you — but to the aide, it might mean following them from the bedroom to the recliner.
“Assist with hygiene” might mean a full sponge bath in your mind — but to them, it’s handing over a washcloth.
Technically, they’re not lying. But practically? They’re not doing what you or the agency likely intended.
🧾 One-Time Aides, Different Rules
If your regular aide is out and a replacement shows up, they may not have the same:
Training
Experience
Comfort level with your care routine
Scope of duties
And yet, you’re rarely told this. You’re expected to treat them as interchangeable — but they’re not.
Every aide who enters your home — even for one shift — should come with a clear explanation of:
Their role (PCA, HHA, CNA, etc.)
Their scope of duties
Any limitations or restrictions
What they are not allowed or trained to do
Without that, you’re left guessing — and that’s not just frustrating. It’s dangerous.
💊 Medication: The Most Blurred Line in Home Care
What’s the Difference Between a Reminder and Administration?
Medication Reminder:
Involves prompting the care recipient to take their medication
Examples: “It’s time for your pills,” pointing to a pill minder
Can be done by PCAs or HHAs (depending on state and agency policy)
Considered low risk if the aide is not physically handling the medication
Medication Administration:
Involves physically giving or applying the medication
Examples: Handing over pills, applying medicated creams or ointments, giving injections
Typically requires additional training or licensure (HHA with certification, CNA, LPN, or RN)
Carries higher legal and medical risk if done improperly
In practice, many aides do apply creams, hand over pills, or assist with inhalers — especially when they’ve been with a client for a long time. But that doesn’t mean they’re trained or authorized to do so.
Why It Matters
If something goes wrong, the aide could be held responsible for acting outside their scope.
Families may assume aides are trained to do more than they are.
Aides may feel pressured to “just do it” — even if they’re unsure or uncomfortable.
🕰️ When You’re Not There: The Hidden Risks of Respite
Many family caregivers aren’t present during the aide’s shift. They’re working, running errands, or simply trying to rest. During that time, the aide becomes the sole caregiver — and the decisions they make carry real consequences.
If an aide:
Misinterprets a medication schedule
Applies a cream incorrectly
Misses a dose or gives the wrong one
Doesn’t recognize a reaction or symptom
…the family caregiver may not find out until hours later — or until something goes wrong.
What You Can Do
Have a written care plan: Include medication times, dosages, and what the aide is (and isn’t) expected to do.
Use labeled pill minders: Pre-filled and easy to follow.
Leave notes or voice memos: Especially if something changes that day.
Ask for a shift summary: Even a quick verbal recap can reveal what was missed or misunderstood.
Advocate for consistency: The more familiar the aide is with your loved one’s routine, the safer and smoother the care.
🧾 A Note on Private Hires: When You’re the Employer
Some caregivers explore hiring help privately — outside of an agency — to gain more control, consistency, or affordability. It can work well for some families, but it comes with its own set of risks and responsibilities.
"I don’t have experience with private hires myself — because I can’t afford them. If the VA didn’t pay for our home help, I wouldn’t have any help at all. And I know I’m not alone in that."
Still, based on what I’ve read from other caregivers and what seems logical, here’s what I’ve learned:
Potential Benefits
You choose who you hire and when they work
Often more consistent care, fewer rotating staff
May be more affordable without agency overhead
Potential Risks
No background checks or training unless you arrange it
No liability coverage or formal oversight
You become the employer — responsible for taxes, scheduling, and conflict resolution
No backup if they cancel or quit
If You Go This Route
Get everything in writing: duties, pay, hours, expectations
Clarify what they can and can’t do — especially around medications or medical tasks
Consider liability insurance or a payroll service
Always have a backup plan
Private hires can work — but they’re not a magic fix. And for many of us, they’re simply not an option. That’s why understanding the agency system — and how to navigate its gaps — is so essential.
🧹 “I’m Not a Maid”: When Aides Misunderstand Their Own Role
Sometimes the confusion isn’t just on the family’s side — it’s on the aide’s side too.
You might ask an aide to mop the kitchen floor or wipe down the bathroom sink, and hear something like:
“I’m not a maid.”
“That’s not my job.”
“I’m a CNA — I don’t do housekeeping.”
And here’s the thing: they might believe that. They might have training as a CNA or HHA and think that makes them “above” certain tasks. But if they were hired through an agency to provide in-home support, and the contract includes light housekeeping, then yes — that is part of the job.
This kind of misunderstanding usually happens because:
The agency wasn’t clear with the aide about the expectations
The agency wasn’t clear with you about the aide’s scope
The aide is relying on their certification title, not the job description they were hired under
You didn’t hire a hospital CNA. You hired a home aide. And in the home, that often includes laundry, dishes, and yes — mopping the floor.
This isn’t about demeaning the aide’s skills. It’s about aligning expectations. If the agency says “light housekeeping” is part of the role, then the aide should know that. And so should you.
What You Can Do
Ask for a written duty list: What exactly is included in “light housekeeping”?
Clarify the aide’s role at the start: Especially if they’re new or a replacement
Loop in the agency if needed: If the aide refuses a task that’s in their scope, the agency needs to address it
Stay respectful, but firm: You’re not asking for a favor — you’re asking for the job to be done as agreed
When everyone understands the role — and respects it — the work gets done, and the dignity stays intact.
🛋️ When Familiarity Becomes Fatigue: The Risk of Getting Too Comfortable
Over time, a good aide can start to feel like part of the family — and that’s often a gift. Familiarity brings ease, rhythm, and trust. But it can also bring something else: complacency.
When an aide has been with your loved one for a long time, they may:
Start cutting corners on tasks they used to do thoroughly
Get too casual with hygiene, mobility, or safety routines
Spend more time on their phone or chatting than actually engaging
Assume they know what’s best — without checking in
And here’s the hard part: as family caregivers, we do this too.
We have slack-off periods — not out of laziness, but out of necessity. We let our loved one sleep longer so we can sleep longer. We skip a bath day to catch up on bills. We let things slide because we’re running on fumes and need to regroup.
But there’s a difference:
We’re not being paid. They are.
And if we are being paid, it’s not enough.
Not for 24 hours a day. Not for the emotional labor. Not for the constant vigilance that never really ends.
"I’ve seen this happen firsthand. An aide who had been with us for a while started showing up later and later, sitting more than helping, and checking her phone constantly. She was comfortable — too comfortable. And I get it. This work is hard. But when comfort turns into coasting, it’s the care recipient who pays the price. And the family caregiver who has to quietly pick up the slack."
When an aide starts treating the job like background noise — showing up but not really showing up — it’s time to reset expectations. That doesn’t mean confrontation. It means clarity.
What You Can Do
Revisit the care plan: Ask the agency for a fresh copy and review it together.
Have a check-in conversation: “I’ve noticed a few things slipping — can we talk about how to get back on track?”
Document changes: If routines shift (like letting your loved one sleep in), make sure it’s intentional — not just inertia.
Trust your gut: If something feels off, it probably is. You’re the one who knows the baseline.
Familiarity should never mean fading effort. And professionalism doesn’t have to mean coldness. The best aides strike a balance — and when they don’t, it’s okay to speak up.
🧭 Final Thoughts: The Manual That Never Came
Family caregivers are expected to manage a rotating cast of aides, navigate unclear job roles, interpret vague checklists, and ensure their loved one’s safety — all while juggling their own lives.
They’re expected to know:
What each aide is trained to do
What they’re allowed to do
What they might do anyway
And how to fix it when something goes wrong
And often, they’re expected to do all this from a distance — while working, resting, or simply trying to survive.
This is the reality of home care.
Not the brochure version. Not the agency pitch.
The real version — where the lines are blurry, the stakes are high, and the caregiver is the only one holding the whole thing together.
Caregiving is a system held together by people who were never given a manual.
But maybe, just maybe, we can start writing one — together.
