Attendant Management

Determining Attendant Care Need

From the book Yes, You Can! A Guide to Self-care for Persons with Spinal Cord Injury
published by Paralyzed Veterans of America (PVA), 1989
edited by Margaret C. Hammond, M.D., Robert L. Umlauf, Ph.D., Brenda Matteson and Sonya Perduta-Fulginiti, M.S.N.

...continued

INTERVIEWING

It has been the experience of many people with disabilities that half the people who make appointments for in-person interviews do not show up. Ask people to please call you if they change their minds.

Have a schedule and a contract ready for them to read. Have a notebook, to take down information like name, address, phone number, social security number, date of birth, ability to lift or transfer, drivers license number, social interests, and at least two work references. Other acceptable references are counselors, teachers, ministers, or probation officers.

Have someone else there to write this down if you are severely disabled. This person may also prove to be a good support person during the interview.

Discuss the job in greater detail. Let the applicant know what social behavior you allow, what unexpected events may arise, the things you like doing for recreation, and what areas of your life you want to be kept confidential.

Here is a short checklist you may want to use to help discuss background:

1. How many years of education have they completed?
2. Where were they born and raised?
3. Are they new to your state?
4. What kinds of work have they done and liked the best?
5. Have they had any experience of being around a person with a disability?
6. What are their attitudes toward disability?
7. How do they deal with boredom and stress?
8. Will they feel comfortable driving a large vehicle like a van?
9. Would they mind getting up in the night to turn you or help you go to the bathroom?
10. Do they understand that some physical lifting may be required?

Allow them to ask questions about your disability and lifestyle. They need to know in order to be able to do their job well. When you complete the interview, let the applicant know you will call them back with your decision. It is not a good idea to hire someone '`on the spot."

CHECKING REFERENCES

As any employer would, you should not hire anyone without checking references, even if it means writing or calling out of state. A foreigner must already have a work permit and social security number. Unless they do, you won't be able to hire them because of FICA, federal, and state unemployment tax requirements.

When calling on references, identify yourself, explain that you are disabled and are interested in hiring one of their past employees. Describe the nature of the work they will be doing and the need for having someone dependable and honest. Tell them you would like them to tell you some things about the person. Consider asking the following questions:

1. How long was the person employed?
2. Was the applicant dependable?
3. What about absenteeism?
4. Did this person deal with money on the job?
5. Do you consider this person to be honest?
6. How well did the person take supervision and criticism?
7. Can the person work independently?
8. How was this person's rapport with other employees and supervisors?
9. Please describe the ex-employee's personality.
10. What was this person's reaction to stress?
11. Why terminated?
12. Would you rehire?

MAKING A CHOICE

After you have checked the references, you want to pay particular attention to the answers on dependability, honesty, working and getting along with others, why they were terminated, and their rehire status.

Are your social lifestyles compatible? Do not hire someone thinking that person will change for you or that you have the right to control that person's life. What the attendant does on off-hours should not concern you as long as it does not affect the quality of work. If you need a lot of driving done, be sure he or she has a good driving record, because it will affect both your safety and insurance.

If for any reason you do not feel comfortable with the person, do not hire that person. (See the section in this chapter on "People Who Make Good Attendants.")

Find out how long the person will be able to stay. The longer, the better--but that should not keep you from hiring the person. Some employers will hire a qualified person for a short time if they are sure they will get good service. This can be helpful when you are waiting to be discharged from a hospital. You can look for a replacement once you are home. It also helps when you need to start school or go to work.

What sort of physical and emotional health does the person have? Emotional problems can be very difficult to deal with. If you suspect but are not sure the person has emotional problems or will not be able to handle the job, hire them on a two-week trial basis.

Let the applicant know your decision within a week or less.

Finally, do not hire out of desperation. Try to remain calm and clear headed. If you publicize as much as you can and have your schedule and contract in good order, it will increase your chances for success.

HAVE A BACKUP PLAN

At some time or other, you will not have an attendant when you really need one. This could be due to illness, or to an attendant's being fired, or quitting without notice. When you first get into the business of employing attendants, figure out your emergency plan. You may cut down what you require, such as the housecleaning, or you can eat with a friend, or have a potluck. Arrange with a family member or friend to know your personal care, so that you can call on them to help you in an emergency. You may want to make arrangements with a neighbor (who would like to earn a little extra money occasionally) to know your care so that you can use that person when you have a need.

Some communities have organizations that can supply attendants on an emergency basis. These may be a local visiting nurse service or an organization for individuals with disabilities. You may make an agreement with another individual who has an attendant to share an attendant in an emergency.

The most important part of handling the sudden loss of your attendant is planning for that emergency situation and having several contingency plans. Remember that relatives and friends are just that...relatives and friends. If you have not overused them in the past for attendant functions, they may come through for you in an emergency when you have no attendant.

WORKING WITH AND SUPERVISING AN ATTENDANT

Being a supervisor may be a new role for you. To be an effective supervisor, you need to understand the skills involved. Supervising does not mean being a boss. Supervising means working with your attendant and guiding him or her to make sure the job gets done.

This section reviews the basic skills of effective supervision. It stresses the need to work with your attendant to solve problems and to be firm when necessary. Because of the close contact between attendant and attendee, the employer/employee roles can get confused. It is important for you to use supervisory skills to stay in control, to solve problems, and to maintain a good relationship with your attendant.

Your attendant has formally agreed to be responsible to the needs you have discussed. In return, he or she can expect your respect. He or she is a fellow human with their own life, of which helping you is only one part. Your attendant is not bound to you for more than the hours stated on the contract. You have a perfect right to expect that services will be satisfactorily performed. At the same time, you do not have an open charge account on your attendant's time.

Do not be demanding. Use the same tact and warmth with your attendant as you would a friend. If you find you are repeatedly short- tempered toward your attendant, objectively step out of yourself for a few minutes and retrace the heated events as a third person in the room. Try to see who was really at fault or what proportions of fault were involved. Ask yourself before you confront, snap at, or argue with your attendant, "Is this a real fault of my attendant that hampers my needs, or is this a personal habit of his that just gets on my nerves." If you really find your attendant is at fault, or considerably at fault, ask him, when he's clearly in a receptive and unhurried mood, to "discuss something with you." Get your attendant's point of view. If, on the other hand, you find you are mostly at fault, stop yourself. You will find that thinking before you speak helps you to maintain control. (See the chapter on "Psychosocial Adjustment" for other suggestions on communication.)

Expect that even an experienced attendant will forget items of your daily routine at times. Try to be tactful with your reminders.

Finally, if you need help on a special project, try to give your attendant some advance notice if possible. If it is time to change the bald tires on your wheelchair, or to do a non-routine spring cleaning of your dorm or apartment, try to let your attendant know this well in advance. This allows your attendant the courtesy of scheduling the project at a convenient time. This will help prevent the friction of a rush demand and increases the likelihood of a thorough job.

In general, show the same gratitude and respect toward your attendant as you would any other friend. A few "please" and "thank you" comments are appreciated by everyone.

Remember: Your Attendant Is Only Human

Confidentiality
Before you hire a person, let them know what things you want kept confidential. Respect each other's needs for privacy when using the phone, having company, or handling financial, family, and social information. Have respect for each other's bedrooms and personal property. Remember that when you discuss personal problems with your attendant and ask for an opinion, he or she may not be able to give the best feedback or advice. You are not hiring a counselor. Many people find it uncomfortable to even listen to the problems of others, much less give advice. Do not assume that your attendant will do this. If your attendant is willing to listen to you, you should be willing to do the same when he or she needs someone to talk to.

Being a Supervisor
Being a supervisor can be difficult sometimes, and no one can tell you absolutely how to do the job. The following is one way to maintain the performance of your employee. As an employer and supervisor of your attendant, it is important to provide good, clear feedback about job performance directly to your employee. For many people, "performance checks" create negative feelings such as fear, tension, or distrust. It is up to you, as an employer and supervisor, to make performance checks a positive, motivating experience. Good performance that is recognized and praised will probably make both your job (as supervisor) and your employee's job (as an attendant) much easier.

The attendant should understand that using performance checks benefits and protects them as well as you. In this model, we provide attendants with ongoing performance feedback by scheduling performance checks. Performance checks consist of the same checklist that you developed in sorting out your specific attendant care needs.

Performance Checks
How often they should be done, depends on you and your attendant. There is no rigid rule. You are responsible for giving feedback any time a job is not performed to your satisfaction. Simply remember that with a new attendant, the more often performance is checked, the sooner small problems can be solved. As a general rule, daily duties should be checked twice monthly; weekly duties once monthly; and monthly duties every two or three months. This does not mean that you should give feedback only while doing performance checks. In addition, performance checks should not be the only time you give positive feedback when duties are performed well. When your attendant is working hard and doing a good job, a little praise goes a long way.

Deal with Conflict
Many problems arise out of making assumptions. Although a contract should help to clarify basic issues, rules and agreements can be broken nevertheless. Then what do you do? If there is a conflict over duties, pay, time off, social conduct, or use of property, remind the person of their responsibility. If they refuse to comply with your wishes, act promptly and firmly to have them replaced. When one is dependent on another person for survival, it is not easy to fire them on the spot and replace them with another person. Allowing them to have their way, though, will mean you will have to go without service, and your health may be jeopardized.

Do not let things pile up. Deal with each issue as it arises. You may want to have an advocate help you and the attendant to settle the disagreement.

Communication
When communicating, it is not so much what you say as how you say it. Do not try to hide your feelings by saying something nice in a negative tone of voice. When talking to a person face to face, look at him or her. Evasive eye contact may convey a message that you do not want to listen to the person or deal with the issue. Also, communicating your appreciation on a regular basis is important so that your attendant does not feel taken for granted.

If you think your attendant is not going to listen well, consider writing letters about your concerns, or put them on tape if you cannot write. Have an advocate (a friend to help settle problems or check to see if you are o.k.). They can also follow up on your progress. Do not let something wait, especially if it relates to your care. Being assertive is very important. (See the chapter on "Psychosocial Adjustment.") Assertiveness is a skill that can be practiced, and several good books have been written about how to ask for what you need without being rude, nasty, or obnoxious. (See assertiveness examples )

ASSERTIVENESS EXAMPLES

1. A man with a disability had planned in advance to attend a concert he had long wanted to see. The day before the concert, his attendant asked him to find another driver, because the attendant had just gotten a dinner invitation from a buddy. The disabled man let the attendant know that he appreciated and understood the attendant's desire to go to dinner with the friend. Then he reminded the attendant of the previous agreement to drive him to the concert. The man also pointed out that it was too late for him to make other arrangements, so the attendant would have to fulfil the commitment to drive him to the concert.

2. A woman with a disability had hired a man to be her attendant. At the time of the interview, she explicitly stated that she had no interest in combining work with romantic involvement. After a month of employment, the man started making passes and suggestive remarks to her. She reminded him of their conversation at the time of hiring. She said she was sorry about his feelings for her, but she did not feel the same way. She stated that she would appreciate his not bringing up the issue again. If he brought it up again, she would have to let him go. The man said that he was sorry, too and would respect her wishes. He said that he would like to give a two-week notice of termination and then leave, because he could not promise that his feelings would change.

SALARIES AND FRINGE BENEFITS

As an employer, you will be paying a salary to your employee. This money may come from different sources. (See "DSHS Program" section.) The amount of the salary will be determined by your financial resources and the community's going rate of pay. You may also be providing room and board and benefits in addition to salary. (See "Your Responsibilities as an Employer" section.)

Paying Your Attendant
There are many programs in existence that may pay for, attendant care. Each program has different eligibility criteria, application processes, and employer expectations. It is important to consider using one or more of these programs for cash wages for the attendant. It is also possible to provide noncash wages, room and board, and other benefits as the sole payment or in combination with a cash wage. Your social worker and other team members are available to explore the various options. Review the material below and then discuss your attendant plan with your social worker or others. Remember that you are the employer and will be responsible for recruiting, hiring, firing, paying wages, and reporting cash and noncash wages for tax purposes.

DEPARTMENT OF SOCIAL AND HEALTH SERVICES (DSHS) PROGRAMS

1. Request application for Chore/Attendant Services from local DSHS office.
2. Caseworker will interview you in hospital or home to determine financial eligibility and medical need.
3. Provide verification on income, assets, and expenses. Provide a doctor's statement of medical condition and your need for an attendant.
4. You will be advised of eligibility in a matter of weeks, depending on your DSHS office.
5. Request an explanation of your responsibilities for attendant management (reporting hours, payment of Social Security Tax, etc.) if you are eligible for the program.

If denied for the program:

1. Look again at your own needs.
2. If you still feel you should get this help, call a caseworker and file an Exception To Policy (ETP) statement. List all care needs and expenses. Ask about exceptions to policy or a fair hearing to review your case. Each state has specific policy for reviewing applications.

Find out what deadlines there are for an appeal or review of your case.

DEPARTMENT OF VOCATIONAL REHABILITATION (DVR) - (IF YOU ARE A CLIENT)

1. Request application for DVR services for vocational counseling and training.
2. Counselor will interview you to determine financial eligibility and medical eligibility.
3. If eligible and enrolled in the appropriate program, you may receive some money to pay for some attendant services.

Obtain instruction in payment of attendant under DVR program and your responsibilities as an employer.

DEPARTMENT OF LABOR AND INDUSTRY (L & I) - (IF YOU ARE A CLIENT OR RECEIVE WORKER'S COMPENSATION)

1. Request that your doctor write a letter to L & I documenting the need for attendant care for an injured worker (you).
2. L & I will determine eligibility and advise you.
3. L & I sets fee and pays attendant directly.
4. You must pay Social Security and other employer taxes.

DEPARTMENT OF VETERANS AFFAIRS (VA) - (IF YOU ARE A VETERAN)

1. Apply for Aid and Attendant Housebound benefits and nonservice-connected pension or service-connected compensation.
2. Request that your doctor complete the VA form. Your doctor must document your medical condition on the form. Provide DD214 discharge papers.
3. Submit the form to the VA regional office.
4. Expect a one-to-two month period for processing of your request.
5. If eligible for the program, you must pay Social Security and other employer taxes.

PRIVATE INSURANCE

1. Contact your insurance agent. If a certain company is dealing with the medical affairs related to your injury, contact that company directly.
2. Provide medical documentation of your condition and need for attendant care.
3. The insurance company will determine eligibility.
4. If you are eligible, you must pay Social Security and other employer taxes.

HOME HEALTH CARE

1. Medicare, Medicaid, and some private insurance may pay for home visits by a registered nurse for skilled care needs.
2. All visits must be ordered by a physician.
3. The number and frequency of visits are limited, and home health-care personnel should not be used as regular attendants for an extended period of time.

Your Responsibilities as an Employer When Providing Cash Wages
If you are receiving funds with which to pay your attendant, follow the instructions from that funding source regarding:

• What payment records you must keep,
• In what way and how often you will be receiving this aid, and
• What procedure they suggest you use in paying your attendant(s).

The source may insist on obtaining the names and social security numbers of each attendant to enable their direct payment. Try to persuade your funding source away from this plan. You may find that the process of a check coming "automatically" to an attendant takes away some of your natural, employer's right to bargain with an attendant. Also, whenever you change attendants, the paperwork and delay in the payroll process can result in an unearned paycheck sent to your former attendant or a considerable delay in the first paycheck being sent to the new attendant.

Ask your funding source and local tax people whether your particular plan of funding requires any attendant you employ to declare the income on federal, state, and/or city taxes. As a matter of courtesy, inform your attendant of any taxes they must pay at the time you employ him or her.

Your Responsibilities as an Employer When Providing Noncash Wages There is another way that allows you to deduct the "salary paid" from your income taxes. Quite simply, you reimburse the attendant by noncash means. As one quickly sees from the "Summary Chart" section to follow, both the paperwork and tax costs to employee and employer are considerably less for noncash than cash wages. However, more background homework is necessary. The IRS has specific criteria regarding when and how meals and lodging can be medically deducted. (See section on "Tax Laws of Special Interest.") One of the simplest ways to accomplish this is to offer your attendant(s) room at your home in return for their services.

Example: You have decided that it is best for your particular needs to hire two attendants. You rent a two-bedroom apartment, take one bedroom for yourself, give the other to your two attendants and have the attendants split the duties. In return, you offer your attendants noncash wages in any of various combinations of room, board, electric power, and so forth.

Before deciding what item(s) to offer, you may want to explore how much of each item is currently considered medically deductible for your particular living situation. As you will see from the "Tax Laws" section of this guidebook, a current Revenue Ruling implies that the cost of any commodity that is offered to the attendant, beyond that which you and/or your nonattendant family would need ordinarily, might be medically deductible. In short, if you would normally need a one-bedroom apartment, but you have to rent a two-bedroom apartment for the attendant(s), then the cost difference between the one-bedroom and two-bedroom apartments might be deductible. Similarly, the cost of additional food, electric power, etc. incurred only because of the existence of the attendant(s) is possibly deductible. You may well want to limit your noncash wages to deductible items. Choose, in priority, those noncash items that you can most easily prove you paid by means of receipts or other records. Clearly divide these expenses objectively by the number of people in the living situation. For example, lodging and power are easier to substantiate and divide objectively than food costs. To determine how large to make this noncash package, figure the amount of cash salary normally to be paid and equal that in noncash benefits. Whatever is NOT being offered in the noncash wage package must be understood from the beginning to be the financial responsibility of each occupant, such as food, clothing, utilities, and shaving articles. This goes for anyone who routinely shares a dwelling.

See the "Summary Chart of Tax Forms" to determine which reporting forms are still necessary. This means that you are telling the IRS who has received what amount of "income" from you. No FICA payments are required. Again, call your nearest IRS office for these forms, which will be self-explanatory.

To safeguard your own interests in case of IRS audit, see the notes at the end of the table l9.A for suggestions on your personal recordkeeping.

A SUMMARY CHART OF TAX FORMS

Certain filing requirements may be different from information supplied below due to such factors as personal situation of taxpayer or changing IRS policies and rulings. Use the data below as a guideline and check your particular situation and wage method with latest policy of your nearest IRS office. (See table 19.A)

KEEPING TRACK OF ALL THIS

It is really helpful to have a file on attendants you have interviewed (acceptable and unacceptable) and also the ones you hire.

You will need to keep information for tax reporting and W-2 forms. You may also want to refer to it in an emergency.

A file box is good for keeping verification forms, your copies of tax reports, and copies of cancelled checks for future reference.

You could use a card file or a notebook for information on attendant applicants. The data should include:

1. Name
2. Address
3. Phone number (message number also)
4. Date of birth
5. Social Security number
6. Driver's license number
7. Date you hired them
8. Date they were terminated
9. Reason for termination

GRACEFULLY PARTING WAYS WITH AN ATTENDANT

Even though you have taken much care in screening and choosing an attendant, the one you hire may prove to be unsatisfactory. In that case, you will have to make your dissatisfaction plain and be firm in your right to expect better service. If improvement does not occur, you should move quickly to find a satisfactory replacement. An unreliable attendant is not healthy for either mind or body. You must keep control over how your own basic needs are to be met in order to meet your goal of independent living. Try to leave on the best possible terms, because you may want to call on them in an emergency. Also, consider developing a checklist for what needs to be completed before an attendant leaves. Some things to consider are:

1. Make sure they have filled out a verification form (if you are receiving Chore services) before paying them.
2. Make sure all basic duties are completed so the new attendant can enter a clean and orderly household.
3. Get their key to the apartment/house.
4. Get a forwarding address or permanent phone number if possible. (Keep this information for your files.)

PREPARING FOR THE RECURRING CYCLE

The termination of an attendant will mean either a smooth transition into the employment of someone else or a frantic scramble for a replacement. It depends on whether you have done your homework.

With the best planning and preparation of the new attendant, even the most experienced employer may feel insecure in the transition from old to new. Anxiety is a natural feeling for anyone moving from an established, familiar situation into one which is new or uncertain. For certain people with disabilities, this twinge of insecurity will be a little more intense due to a little more architectural--or personal care --dependency.

Studying and analyzing as many aspects of the situation as possible and then preparing for them, has proven the best way to minimize that transition twinge. We hope that helpful hints of this text will best enable you to do so, for yourself.

Table 19.A -- A Summary Chart of Tax Forms Household or Domestic Help - Employer Concerns
(Each state has different rates. Find out your own state regulations to determine how much and how often to pay these taxes. In some states nothing is due if wages are under 1,000 dollar per quarter.)

CASH WAGES

IRS Form	Used Primarily to Report	When Due
W-4	Employee-desired amount of income tax to be withheld from cash wages (for "household employment" tax may be withheld only if both employer and employee voluntarily agree)	At beginning of employment and each time employee wishes to change withholding status
SS-4	To obtain employer's identification number (EIN)	One number for employer's lifetime for use when filing various IRS forms
942	a) Cash wages of $50 or more paid to each employee in any calendar quarter b) Income tax withheld during the quarter c) FICA (social security) taxes [about 6% of each employee gross pay amountl withheld from the cash wages of any employee meeting criterion lal, to be matched in amount from employer [attach check for combined tax amount to FICA-942 form)	4 times a year; within 30 days of the end of each IRS- defined calendar quarter (3- month period)
940 & 580 Federal Unemployment Tax	FUTA (unemployment) taxes (3.4% of first $6,000 paid to each employee) to be paid by employer; to household employers, those who paid cash wages of $1,000 or more during any calendar quarter	1/31 for wages paid in preceding year; file 940 with form 580
W-2	a) Cash income to employee b) FICA taxes withheld from employee c) Income taxes withheld (see note for W-4 form, regarding household employment). Workeris responsible to pay for withholding	1/31 for wages paid in preceding year, or within 30 days of employee termination if before end of year;
W-3	To be filed with Copy A of W-2 and sent to Social Security Administration	1 /31, with W-2

NONCASH WAGES

IRS Form	Used Primarily to Report	When Due
SS-4	(see "Cash Wages" section)	(See "Cash wages" section)
W-2 or	Value of noncash wages paid; check with nearest IRS office regarding which form should be used for your particular situation	(See "Cash wages" section)

Notes

1. Instructions for each IRS form are usually included on the particular form, "Circular C: Employer's Tax Guide," is a must for employer-taxpayers; all are readily available, free of charge, from your nearest IRS office.

2. Your employee must have a social security number; if not, have him/her file an SS-5 form with the IRS to receive one.

3. For noncash wage employers: be sure to save all bills, rent leases, payment checks, and receipts applicable to items of the noncash reimbursement; do not attach to tax forms, but save for at least four years in case of an IRS audit.

4. For noncash wage employers: an index card statement, containing information supplied in the informal example above, has been found very helpful to the personal record keeping of such taxpayers.