The Three Ways to Bring a Caregiver Home

What actually separates agency, registry, and direct hire?

One question separates the three, and it is not price. It is who employs the caregiver. A home care agency employs her. A caregiver registry, in most arrangements, does not. A direct hire makes you the employer. Who withholds taxes, who carries workers' compensation, who supervises the work, and who finds a substitute at six in the morning all follow from that one answer.

So the useful comparison is not three hourly rates lined up side by side. It is one sentence, asked of each arrangement: if this caregiver is injured in my mother's kitchen, or does not arrive on Monday, or is later found to have moved money out of an account, whose problem is it? The three models give three genuinely different answers, and most of the price difference between them is the price of those answers.

The employer of record is whoever legally owes the wage, the payroll taxes, and the duties that come with employment. It is the hinge the whole choice turns on.

That designation is not settled by what an arrangement calls itself. It is settled against the IRS's own definition of a household employee, and Publication 926 is the document written to walk a family through that determination and the federal employment taxes that follow from it 1Ref 1Internal Revenue Service (2026).About Publication 926, Household Employer's Tax Guide.That Publication 926 is the IRS document a family uses to determine whether a privately hired caregiver is a household employee and whether federal employment taxes are owed on the wages paid..

How a home care agency works

An agency employs the caregiver, which means the agency runs payroll, withholds and pays the employment taxes, carries the workers' compensation and liability coverage, schedules the shifts, and owns the problem when a shift goes uncovered. You are buying a service from a company rather than hiring a person. Your contract is with the company, and the caregiver is its employee, not yours.

That is what the agency markup pays for. The rate a family is quoted is not the caregiver's wage. Sitting in the gap between the two are employer payroll taxes, insurance premiums, recruiting and screening, schedulers, supervisor time, unemployment insurance, and the cost of paying someone to cover a shift nobody planned for. None of those line items disappear when a household hires privately. They move onto your side of the table.

The word "agency" hides two different things. Federal law sets aide training and competency-evaluation requirements and requires registered-nurse supervision of home health aide services, but that Condition of Participation attaches to Medicare-certified home health agencies 2Ref 2Office of the Federal Register (Code of Federal Regulations) (2025).42 CFR 484.80 — Condition of participation: Home health aide services.That federal aide training, competency-evaluation, and registered-nurse supervision requirements attach to home health aide services at Medicare-certified home health agencies, in contrast to a caregiver a household hires privately.. A private-pay company you engage for help with bathing, meals, and company is a different creature, and the federal standard in that rule does not reach a caregiver you hire yourself either. Asking an agency what training its caregivers actually complete, and who supervises them, is a fair question with a real answer.

Where an agency is strongest is the ordinary week that goes wrong. Someone calls in sick. Someone quits. Your mother comes home from the hospital needing two more hours a day than she needed last month. An agency absorbs that inside its own staffing. A household hiring alone absorbs it personally.

What a caregiver registry really is

A caregiver registry is a matching service. It recruits and screens independent caregivers, keeps them on a roster, refers one to your household, and takes a placement fee or a per-hour cut for the introduction. What it generally does not do is employ the caregiver. That is the whole of the agency vs registry difference, and it is the part families tend to discover only when something has already gone wrong.

A registry refers a caregiver. In most arrangements it does not employ one, which leaves the household as the employer without anyone announcing it.

The model is genuinely appealing, and not only on price. You are not paying for an employer's overhead, and you skip the hardest part of finding a caregiver without an agency, which is the finding. Someone else has already done the recruiting, and there is a roster to go back to when a match does not work.

The exposure is that the responsibilities an agency would have carried do not evaporate. They land on you, quietly. So these are the questions to put to any registry, in writing, before a caregiver walks through the door:

• Who is the employer of record here, the registry or me?
• Who withholds and remits the payroll taxes on what I pay?
• Who carries workers' compensation for this caregiver, and may I see the certificate?
• What exactly does your screening include, and how recently was it run on this specific person?
• If this caregiver cannot come on Monday, do you send someone else, or do I find someone?
• What happens to my fee if the placement ends in a week?

The answers to those six questions, rather than the label on the website, tell you which of the three models you are actually standing in.

Direct hire: you become the employer

Hiring directly means finding, screening, paying, scheduling, training, supervising, and eventually letting go of the caregiver yourself. You set the rate. You keep all of the money that would otherwise have paid for overhead. And you take on the employer's side of the arrangement, which is not optional and cannot be agreed away between the two of you in a text message.

The tax piece is where ordinary families are most often blindsided. Pay a household employee cash wages at or above the annual threshold and federal employment taxes come into play, along with the year-end filing that goes with them. Publication 926 exists precisely because this reaches people who never once thought of themselves as employers 1Ref 1Internal Revenue Service (2026).About Publication 926, Household Employer's Tax Guide.That Publication 926 is the IRS document a family uses to determine whether a privately hired caregiver is a household employee and whether federal employment taxes are owed on the wages paid.. Paying in cash does not remove the obligation. It removes the record.

What the work buys you is the thing agencies find hardest to sell: one person, chosen by you, there every day, who knows how your father takes his coffee and which step on the back porch is loose. For a household caring for someone with dementia, that continuity is not a nice-to-have. It is most of the clinical value of the arrangement.

What you give up is the machinery. There is no scheduler, no supervisor, no bench of other caregivers. The agency vs private caregiver decision is usually settled right here, and it is settled less by the good days than by what you can absorb on the bad ones.

Who vetted this person, and who is watching the money?

Someone has to check this person out, and the models differ in who that is. An agency runs its own screening and stands behind the result. A registry runs some screening, and how deep it goes varies by registry. A direct hire is screened by you, or by nobody at all. The same asymmetry holds for oversight after the caregiver is inside the house.

Informal hiring is where the gray market lives, and it carries hazards pointing in both directions. The Federal Trade Commission publishes red flags for caregiving arrangements that turn out to be scams: no in-person interview, a check written for more than the amount owed with a request to wire back the difference, pressure to move money quickly 3Ref 3Federal Trade Commission (2024).Is it a caregiving job or a scam?.Red flags for caregiving arrangements that are actually scams, including no in-person interview, overpayment by check with a request to send money back, and pressure to move money — the hazard of informal online caregiver hiring.. An arrangement that never meets face to face and moves fast on payment is the pattern, whichever party it is aimed at.

The other exposure is slower and quieter. A caregiver is a person in a position of trust with access to a home, a medicine cabinet, a mail pile, and often a checkbook. The Consumer Financial Protection Bureau maintains resources on preventing fraud and financial exploitation of older adults, including exploitation by people in positions of trust, which is what an in-home caregiver is in the plain, neutral sense of the phrase 4Ref 4Consumer Financial Protection Bureau (2025).Protecting Older Adults from Fraud and Financial Exploitation.That federal consumer-protection resources address preventing fraud and financial exploitation of older adults, including exploitation by people in positions of trust — the basis for the money safeguards recommended around any in-home caregiver.. The overwhelming majority of caregivers are honest people doing hard work for little money. Safeguards are not an accusation. They are what lets a family stop wondering.

Safeguards that fit any of the three models. Keep the caregiver off the bank accounts and off the credit cards. Have statements delivered somewhere a second family member sees them. Write down what the caregiver is authorised to buy and how they get reimbursed, so a grocery receipt is never a judgement call. And ask an agency or registry what its screening actually covers, rather than accepting that someone is "fully vetted."

Why continuity is the hardest thing to buy

Every household wants the same caregiver every day, and the structural reason that is hard has almost nothing to do with which model you pick. It is the workforce itself. Home care is a very large, very low-paid occupation with heavy turnover, and turnover is what breaks continuity. The caregiver who was perfect leaves for a job that pays slightly more or offers predictable hours.

Direct care workers number roughly 5.4 million, about 3.2 million of them in home care, with median earnings near $26,000 a year and roughly half relying on some form of public assistance 5Ref 5PHI (Paraprofessional Healthcare Institute) (2025).Direct Care Workers in the United States: Key Facts 2025.Direct-care workforce size (~5.4 million workers, ~3.2 million in home care), median earnings near $26,000 a year, roughly half relying on public assistance, and high turnover — the structural reason caregiver continuity is difficult under any model..

That is the fact sitting underneath any honest look at no-show risk compared across the models. An agency does not have fewer absences because its caregivers are more reliable. It has a bench, so an absence becomes a substitute instead of a crisis. A private hire has no bench, so an absence becomes your Tuesday. The trade is stark: an agency converts a missing caregiver into a stranger, and a private arrangement converts a missing caregiver into you.

Households that hire privately and do it well tend to build a bench themselves. A second caregiver who works one day a week and knows the house. A neighbour who can cover two hours. A written plan for the morning nobody comes. Doing that on purpose, before it is needed, is most of the difference between a private arrangement that runs for two years and one that collapses in a month.

Where to start when you are not sure

Most families do not choose a model in the abstract. They choose under time pressure, usually within days of a fall or a hospital discharge, which is exactly when the expensive default looks like the only option. If that is where you are, the sequence that keeps the most doors open is to settle the hours and the tasks first, then decide who employs the caregiver, and only then compare prices.

Local help exists for precisely this. Area Agencies on Aging coordinate and provide local home-based services, including homemaker and personal care help, home-delivered meals, and caregiver support, and they can tell you what exists near you and what a household might qualify for without selling anything 6Ref 6Administration for Community Living (2025).Area Agencies on Aging.That Area Agencies on Aging coordinate and provide local home-based services — homemaker and personal care help, home-delivered meals, and caregiver support — that help older adults remain at home.. The Eldercare Locator, a free federal service, is the front door to finding yours. Starting there costs nothing and regularly surfaces subsidised options families did not know were on the table.

A reasonable default, held loosely: an agency when the situation is still unstable, the hours are few and awkward, or nobody in the family has the bandwidth to be a manager. A direct hire when the hours are long and steady, someone can genuinely supervise, and continuity matters more than backup. A registry when the middle is what you want, but only once the employer-of-record answer is in writing.

None of this is permanent. Plenty of households start with an agency to survive the first few weeks, then consider switching to private hire once the routine is known and a particular caregiver has proved herself. If that is the plan, read the agency contract before you get attached to the person, and look specifically for what it says about hiring its caregivers directly.