How to Choose a Home Care Agency in Houston: 14 Questions

Most Houston families are choosing a home care agency for the first time, under pressure, during a discharge or right after a diagnosis. There is no time to become an expert on the industry, and the marketing on every agency's website looks roughly the same.

The good news is that a small number of questions, asked directly and pressed for a specific answer, will tell you almost everything you need to know. Below are the fourteen we would ask if we were the family sitting on the other side of the phone. Use them on us. Use them on every Houston agency you interview.

Why this list exists

Home care in Texas has two very different operating models sitting inside one industry. On one side, agencies employ caregivers as W-2 employees, run a real training program, put a registered nurse over every case, and bill long-term care insurance directly. On the other side, registries and 1099 shops act more like matchmakers, sending contractors to the home with minimal oversight and pushing the risk and paperwork onto the family.

A polished website will not tell you which model an agency runs. These questions will.

For a printable version of this list to bring on tours or use on the phone, our office keeps one at [the 14 questions to ask any Houston home care agency](/resources/14-questions/).

Question 1: Are your caregivers W-2 employees or 1099 contractors?

Why it matters. A W-2 employer withholds payroll taxes, pays into unemployment and workers' compensation, and is legally responsible for the caregiver's actions on the job. A 1099 contractor is technically the family's problem when something goes wrong. If a caregiver is injured in the home and the agency uses 1099 contractors, the homeowner's insurance may end up on the hook.

What to listen for. A straight yes, we employ our caregivers as W-2 with payroll taxes, workers' compensation, and unemployment. Not "our caregivers are like employees" or "we handle the paperwork."

Our own answer: W-2, always, no exceptions.

Question 2: Do you run background checks and a drug screen before hire?

Why it matters. Texas HHSC requires criminal background checks. It does not require drug screens or the level of vetting a serious agency runs.

What to listen for. Multi-state criminal background check, sex offender registry check, motor vehicle records check for anyone driving a client, a pre-employment drug screen, and reference verification with previous employers. Ask specifically about the drug screen. Many agencies do not run one.

Question 3: Is a registered nurse in charge of my case?

Why it matters. Houston has plenty of agencies where a scheduler is your only point of contact, and no clinician ever looks at the case. When there is a change in condition, a new medication, a fall, or a hospital transfer, a scheduler is not equipped to handle it.

What to listen for. An RN completes the initial assessment, writes the plan of care, and reviews the case on a set cadence (monthly for stable cases, more often for complex ones). The RN is reachable by phone. Not "we have a nurse on staff who consults when needed." Actual clinical oversight, named.

Our own answer: I do it. Every case at our agency has an RN plan of care and RN review.

Question 4: What is the caregiver-to-supervisor ratio?

Why it matters. A supervisor with 80 caregivers cannot know any of them well. A supervisor with 20 can.

What to listen for. A specific number. We keep it under 25 caregivers per supervisor at our agency, most Houston agencies we respect are similar. Some large chains run 50+ per supervisor and it shows up in the quality of the visits.

Question 5: How much dementia-specific training does a caregiver receive before working with my mother?

Why it matters. Texas HHSC minimums are low. A caregiver who has not been trained specifically in Alzheimer's and other dementias will handle sundowning, wandering, and refusal-of-care by escalating instead of redirecting. That is when families call and want to change caregivers.

What to listen for. Dedicated dementia training that goes beyond the state minimum, ideally with a named curriculum, ongoing case-by-case coaching from an RN, and simulation or role-play rather than a video-only course. Our own [Neuro-Aware Dementia Care](/programs/neuro-aware-dementia-care/) program is built around this exact gap.

Question 6: What is your minimum shift and weekly minimum?

Why it matters. A cheaper-looking hourly rate often hides a shift minimum that makes it impossible to book two hours in the morning and two hours at dinner. A weekly minimum means the agency will not staff a case that is smaller than a set number of hours.

What to listen for. A specific answer. Our own answer: 4-hour visit minimum, 20-hour weekly minimum. That is the honest floor for a W-2 employed model. Agencies that quote lower minimums are often using 1099 contractors or filling the schedule with different caregivers each shift.

If an agency will not name a minimum, that itself is the answer.

Question 7: What are your holiday and overtime rates?

Why it matters. Six federal holidays a year plus caregiver overtime past 40 hours per week is a real line item. Over a year of 24-hour rotating care it can add $3,000 to $8,000 that families did not budget for.

What to listen for. A named policy in writing. Some agencies charge 1.5x on major holidays. Some pass the cost of overtime hours through at 1.5x. Neither is unusual, but both should be disclosed before you sign.

Question 8: Do you charge a re-engagement, restart, or reassessment fee?

Why it matters. A common pattern with cheaper agencies is that if care pauses and restarts (mom does well for a few weeks, then falls again), the agency charges a $50 to $200 restart fee and sometimes a new assessment fee. Adds up if care is intermittent.

What to listen for. No re-engagement fee, or if there is one, it is named upfront. Our own answer: none.

Question 9: Do you bill long-term care insurance directly?

Why it matters. LTCI reimbursement is the difference between a family paying full price out of pocket and the carrier writing the check. Not every agency has the accounting infrastructure to bill carriers directly (Assignment of Benefits) rather than making the family pay first and file for reimbursement.

What to listen for. Yes, we bill your carrier direct. Ask which carriers. Our own answer: 15+ carriers including Genworth, John Hancock, MetLife, Northwestern Mutual, Mutual of Omaha, TransAmerica, and others. If a family has a policy but does not know what it says, we do a free policy review.

Question 10: Can you show me your Texas HHSC license?

Why it matters. Every legitimate Texas home care agency has a license number issued by the Texas Health and Human Services Commission. It should be on the website, on the door, on paperwork.

What to listen for. A number, quickly. Our own answer: HHSC license #023721. You can look up any Texas agency's license and complaint history on the HHSC public website in about two minutes.

Question 11: What is your complaint history with HHSC?

Why it matters. HHSC publishes substantiated complaints against every licensed agency. A clean history over five or more years is meaningful. A history with multiple substantiated complaints is a warning.

What to listen for. An honest answer. Our own answer: zero substantiated complaints since we opened in 2017.

Question 12: What is your caregiver turnover rate?

Why it matters. Caregiver turnover is one of the most reliable proxies for how an agency treats its people. High turnover means new faces in the house every few weeks, more training gaps, more medication errors, and more distress for a person with dementia who needs continuity.

What to listen for. A number, honestly stated. National caregiver turnover in home care per Activated Insights industry data runs around 65 percent. Well-run agencies are meaningfully below that. If an agency will not name a number, it is likely above the industry average.

Question 13: Will the same caregivers come to my mother's house, or will the schedule rotate?

Why it matters. Continuity of care matters clinically and emotionally, especially in dementia. A rotating cast of caregivers means every shift starts with an orientation. Medications get missed. Small changes in condition go unnoticed. The person in your care feels like they are meeting a stranger every day.

What to listen for. A named primary caregiver, with one or two consistent backups for time off. Not "we will always have someone there," which is code for whoever is available that day.

Question 14: Who picks up the phone at 2 a.m. on a Sunday?

Why it matters. Home care emergencies do not respect business hours. When a caregiver calls out sick at 5 a.m., when a family calls after a fall on Christmas morning, when a client is refusing to let the overnight caregiver in the door, someone real has to answer the phone.

What to listen for. A human, on the first ring, at any hour. Not an answering service that pages a scheduler. Our own answer: our office team covers 24/7 including nights, weekends, and holidays. That is when most home care actually happens.

Question 15 (bonus): How do you handle a caregiver call-out at 5 a.m.?

Why it matters. Not a question we labeled at the top because most families do not think to ask it, but it separates real operations from marketing better than almost anything else on the list. Caregivers get sick. Kids get sick. Cars break down. A well-run agency has a backup plan and executes it without waking the family up.

What to listen for. A specific process. Ours: the on-call coordinator is paged the moment a call-out comes in. First priority is a caregiver already familiar with the client. Second is a caregiver in the neighborhood who has been briefed on the plan of care. If both fail, the coordinator or an RN goes to the house. The family gets a call, not a scramble, and the shift is covered.

Red flags on the tour and on the phone

Beyond the questions themselves, a few patterns are worth naming.

Pressure to sign the same day. Home care is a months-to-years relationship. If an agency is pushing a same-day contract with a discount that expires if you leave the office, that is a sales operation before it is a care operation.

No RN on the intake call. If the person taking the initial call cannot answer a clinical question and cannot get an RN on the line within a business day, the clinical infrastructure probably is not there.

Vague answers on complaint history. HHSC publishes substantiated complaints. Any Texas agency knows their own record. "We do not really have that number" means the number is bad or the agency does not track it.

A quoted rate meaningfully below the Houston range. Companion care in Houston in 2026 is $30 to $40 per hour, personal care $35 to $45 per hour, dementia care $38 to $48 per hour. A meaningfully lower rate almost always means a hidden minimum, a 1099 contractor model, or thin insurance coverage.

The three answers that should end a conversation

Any of the following, in isolation, is enough reason to keep interviewing.

"Our caregivers are independent contractors, but we vet them." Translation: 1099 model. The liability and paperwork belong to the family.

"Our nurse consults as needed." Translation: there is no nurse actually running your case. A scheduler is your only real contact.

"We do not have minimums." Translation: either the answer is not honest, or the model is 1099. A W-2 employed model has minimums because caregivers need enough hours to earn a living.

What the good agencies do next

After the 14 questions, the two next steps that separate a professional agency from a marketing operation.

A free in-home assessment by an RN, not a salesperson. A nurse comes to the house, meets the person needing care, meets the family, walks the home for fall hazards, reviews medications, and writes a plan of care. That visit is the actual work of matching a caregiver. If the first person in your house is a "care advisor" selling a package, you are with the wrong agency.

A written care plan and a written service agreement with the four line items visible. Hourly rate, minimums, holiday and overtime policy, cancellation terms. All on one page. Read before you sign.

Frequently Asked Questions

What license does a home care agency in Texas need?

A Home and Community Support Services Agency license from the Texas HHSC. Our number is #023721. You can verify any Texas agency's license and complaint history on the HHSC public website.

What is the difference between a home care agency and a registry?

A home care agency employs caregivers, supervises them clinically, runs training, and is responsible for the care. A registry is closer to a matchmaking service that connects families to independent contractors. Most Houston families are looking for an agency, not a registry, even if they do not know the distinction going in.

Do all Houston home care agencies bill long-term care insurance?

No. Only a subset have the accounting and claims infrastructure to bill carriers directly through Assignment of Benefits. Many will invoice the family and let the family file for reimbursement, which is where most LTCI benefits get left on the table. We bill 15+ carriers direct.

Is a lower hourly rate always a worse deal?

Not always, but often. When the rate is meaningfully below the Houston range ($30 to $48 per hour depending on level of care in 2026), one or more of the following is usually true: 1099 contractor model, no RN oversight, a hidden minimum shift, a re-engagement fee, or aggressive holiday and overtime billing on the back end.

Should I hire a caregiver privately instead of using an agency?

Some families do, and it can work for a short window. The tradeoffs are real: no backup caregiver when yours calls out sick, no payroll taxes or workers' compensation withheld, no supervision, no substitute for the family's judgment on training, and personal liability if the caregiver is injured in the home. For anything longer than a few weeks, most Houston families we work with find an agency is worth the higher hourly rate.

How fast can care start in Houston?

Same day is possible for straightforward cases if we already have a caregiver available in the right neighborhood. Most cases start within 24 to 72 hours after an in-home RN assessment. Complex dementia and 24-hour cases sometimes take a week to staff correctly, because we would rather wait for the right caregiver than send the wrong one.

If you are interviewing agencies this week

Bring this list to every call. Ask us the same fourteen questions you ask everyone else. A Care Manager, one of our nurses or a Care Coordinator, will answer each one with a specific number, not a slogan.

Call 713-766-0908 or download our printable version at [the 14 questions to ask any Houston home care agency](/resources/14-questions/).