5 Major Differences Between Working as an HHA and a CNA in Home Care Settings

Most individuals assume that a CNA (Certified Nursing Assistant) is the “better” position, and that HHA (Home Health Aide) is the default option. This is not necessarily true, particularly in regards to home care. The roles have overlapping responsibilities, certifying agencies define competencies differently, and the fastest way to the paycheck is not necessarily the role with the longer title.

While they appear similar on paper – assisting elderly and disabled individuals in the comfort of their own homes with showering, getting dressed and transfers, while traveling to clients’ homes – there are fundamental differences which are dictated by the training pipeline, the legal scope of practice, the level of supervision, and the manner in which the compensation should be evaluated to make the most advantageous choice for the next several months. Here are 5 major differences to consider.

Training pipeline and the time it takes to start working

A CNA program is an intensive 75-120 hour state-approved course of study, followed by a competency exam and being placed on the state nurse aide registry. This is a legitimate and difficult credential to obtain, which takes between 2-4 months to complete from enrollment to starting the first shift, depending on class and exam availability.

HHA training varies drastically from state to state, and a surprising number of agencies do not require HHAs to be certified at all. For those that do require certification, the HHA training course is generally around 75 hours, and sometimes fewer, of state-approved instruction. Many agencies offer an in-house employer-sponsored program rather than sending candidates to a third-party training facility. This means that one can enroll in the program, complete the required orientation, and be working in as few as several weeks rather than a few months. This is an enormous difference for someone who needs the income right now. Particularly in the case of an individual considering both positions, and wanting the shorter time investment to start working, there are openings this month for HHAs which do not require months of study before seeing the first paycheck.

This is not to devalue the CNA program – a longer and more comprehensive training pipeline is generally indicative of a higher standard of competency. It is, however, important to note that the CNA course covers a number of competencies that are not utilized in the home care aide space, and therefore may be seen as a longer time investment for little additional benefit.

The difference in the scope of practice defines the role in many ways

The CNA is the only position of the two which has the opportunity to perform any medical or clinical tasks, and is able to do so under the delegation of an RN. Each state’s Nurse Practice Act and the individual RN delegating tasks for the aide will determine the clinical tasks which fall within the CNA’s realm of responsibility, but the ability to perform them is an inherent characteristic of the position.

The HHA, by contrast, is strictly limited to non-medical tasks such as bathing, grooming, toileting, transfers, meal preparation, housekeeping and companionship. These represent the Activities of Daily Living (ADLs) which are the foundation of personal care, and are also frequently delegated to CNAs when the client’s plan of care does not include monitoring of clinical indicators.

The practical point is that a CNA working for a client whose care plan does not include the monitoring of vitals or glucose falls under the same duties as an HHA, but for a CNA wage. This is, at least in part, why the two positions have different pay scales – because the CNA has the opportunity to do more tasks, but is not always required to do so based on the individual needs of the client. It should also be noted that the legal scope of practice for CNAs is higher, but the day-to-day responsibilities are often dictated by the care plan rather than the title. The ability to perform more complex duties may be the determining factor in choosing between the two positions, but it is also important to understand the likelihood of performing them on a daily basis.

The manner in which supervision is performed and who is responsible for delegating tasks is different as well

CNAs working within the Medicare system generally fall under the supervision of an RN case manager, who is responsible for developing the care plan, including any orders for the aide to perform within the home, as well as assessing the aide during the 485 review and every 60 days during the course of treatment, as per federal guidelines. This creates a formalized chain of command for the CNA, as well as appropriate documentation and evaluation of the aide’s performance.

For applicants comparing HHA openings you can start this month, supervision is one of the practical details worth checking before taking a role. HHAs, particularly those working in the private duty or private pay space, may report to a lead scheduler or care coordinator, rather than a physician or RN, whose responsibilities are focused on maintaining the staff schedule and general client satisfaction, rather than developing a care plan or monitoring the aide’s performance with the same level of scrutiny. This is not always the case – it depends on the agency and the level of supervision which is built into the job description. Some individuals may find this lack of medical oversight to be a plus, while others may feel more motivated by the additional responsibility. It is important to ask specifically in an interview, if considering a position as an HHA, who the individual would be reporting to on a day-to-day basis, and how often they would be reviewed.

This is one of the most telling clues as to what a job description is hinting at – in many cases, agencies seeking to bill through Medicare are bound by the Conditions of Participation, which include background checks, competency evaluations, and specific supervision requirements for aides. An aide working for a private duty agency may fall under much lighter oversight, mandated only by the state. Two job descriptions using the term “aide” may be referring to vastly different positions, depending on the level of supervision required by the client.

The populations served by CNAs and HHAs are not interchangeable

CNAs working within the home care sphere are generally assigned more acutely ill clients with a wide variety of needs, including post-surgery, chronic conditions, wound care and monitoring and other responsibilities which fall outside of the aide’s scope of practice. HHAs are generally assigned more custodial clients with a focus on the ADLs, with a large portion of them presenting with dementia or Alzheimer’s.

This is not always the case – it depends on the agency, the client base, and the availability of staff. Neither position is inherently “easier” than the other – the legal responsibility and documentation involved in monitoring clinical indicators is generally more involved, but the challenges posed by dementia frequently present their own difficulties. It is important to determine what the individual’s level of comfort with each population is, if it is a deciding factor in the choice between the two roles.

It is also important to note that the populations served will often dictate the agency’s assignment practices. A competent agency will not assign an HHA to a client with a chronic medical condition if there is a CNA available to take the call. In a similar manner, a competent agency will not assign a CNA to a low-acuity custodial client if they have an HHA who is free and better suited to the assignment. If the job description does not make it clear what sort of population the aide is being asked to serve, it is frequently an indicator that the agency is not handling their assignments with the degree of care that they should.

Wages, portability, the long-term value of the credential and short-term considerations

According to the Bureau of Labor Statistics, nursing assistants earn higher wages, on average, than home health aides. This does not take into consideration the difference in the time to paycheck – if an individual is committed to entering the home care space but needs the income as quickly as possible, the shorter time to start for an HHA may outweigh the hourly differences. It is also important to consider the long term prospects – a CNA may leverage the title to become an LPN or RN, if that is the individual’s goal.

The portability of the credential, or the ability to utilize it at multiple agencies, may also influence the decision. Whereas a CNA certification is considered a general credential which is transferrable between employers and often states, HHAs do not always have a portable certification, depending on the state. The CNA credential also offers more flexibility, in the long term, for those considering the LPN/RN route.

It should be noted that both positions are growing in demand – BLS projects a 21% increase in employment of home health and personal care aides from 2023 to 2033. The need for both is expected to increase, but it is important to focus on the individual circumstances.

How to apply this knowledge to a specific position

With the information at hand, the most useful application is to the job search. Considering the information provided, the differences between the two positions can be used as a set of criteria to evaluate a specific job posting. A good job description will outline whether the position is for private duty or Medicare-certified aides, since it will be the determining factor in most of the other components. The description should include the scope of duties rather than a generic “assisting with activities of daily living” statement, and should note who the aide is reporting to on a day-to-day basis. It should be forthcoming regarding the necessary training, particularly if an in-house program is required rather than a state-approved course that can be taken at a third-party organization. Most importantly, it should indicate, explicitly or implicitly, the population which the aide will be serving, if it falls outside of what was previously discussed.

Poorly-worded job descriptions, on the other hand, generally hint at a poor structure within the agency, and may lead to complications further down the road, including unsuitable shifts, inadequate compensation or poor training resources.

The choice between private duty and Medicare-certified aides comes down to the individual

CNA and HHA are both viable, legitimate options for individuals seeking to enter the healthcare aide space. They represent two different entry points to the same career, dictated by a mixture of state law, the needs of the agency, and the individual’s needs. A CNA offers a greater level of flexibility and potential opportunities for advancement. An HHA presents a shorter time-to-start and a different client base with more focus on the ADLs rather than medical monitoring, with less investment of both time and money. The choice ultimately comes down to the individual and their personal circumstances. A careful reading of the job description, along with questions asked in an interview, will help determine the best fit option based on those circumstances.