Cindy Johnson says she can empathize with elderly adults who need a helping hand. Before she opened Visiting Angels Home Assistance Services, an in-home care franchise business in Spokane Valley, she endured nine major surgeries in four years.

"It really slows you down. You've got to be willing to ask for help. That was a hard thing for me," she says.

Now, she's devoting her time to providing nonmedical help for elderly clients in Spokane County. Her in-home caregivers are available 24 hours a day, seven days a week, to provide assistance ranging from several hours of respite care for family caregivers to round-the-clock companionship. They assist clients with personal hygiene, meal preparation, light housekeeping, errands and shopping, transportation, or simple companionship.

Johnson says most of the people who engage the services of Visiting Angels are in their 50s or 60s. She says "baby boomers" often have parents who need help, but are wrapped up in the demands of their own businesses or jobs and can't devote the time necessary to care for them.

When someone calls, Johnson says her assistant director, Cherie Knight, will visit the family and the potential client, taking time to understand the types of help needed, the family dynamics, and the personality of the client. Then Knight and Johnson will discuss her findings and choose a caregiver most suited to the family's needs. The caregiver employed by Visiting Angels will have an initial meeting with the client. If everyone feels comfortable that it's a good match, the caregiver will get the assignment.

The company has 15 part-time temporary caregivers who work for an hourly wage. Visiting Angels also has one part-time employee who does bookkeeping. Families are charged $19 to $25 dollars an hour for home care services. The more hours a caregiver is scheduled, the lower the hourly charge.

Johnson says Visiting Angels often gets clients because they are nervous about getting in the bathtub or shower without someone present to help if they need it. Others, typically family members, contact the service because they're concerned that seniors aren't eating as well as they should. She says her caregivers are available to help from the early stages of needing assistance until the client requires a nursing home or hospice care. Because they often have become close friends, the caregiver might help a client adjust to a nursing home and continue to visit them there. Or they may stay at a client's home bedside for days at a time as they are dying.

Johnson says she is continually amazed by the compassion and dedication of the people she hires. "They make me want to be a better person," she says.

For family members who dedicate themselves to staying home with an ailing parent, the demands of caregiving can become overwhelming after awhile if they aren't getting any outside help.

"One of the things I like to stress to families is, don't wait until you're so burned out before you call an agency," Johnson says. "Take a three-day weekend to rest, and let us take care of Mom and Dad."

The Visiting Angels service here, part of a national franchise, began operating at 9207 E. Mission in 2007, when two Seattle-area dentists decided to launch the outlet and took on Johnson as a partner. With a graduate degree in recreation management and 15 years of experience in administering programs for the developmentally disabled, she says, "It just felt right."

Johnson says her silent partners "finance it all, and I do all the sweat equity."

In order to keep costs down for her clients, Johnson says she runs a bare-bones operation. She furnished the agency's 430-square-foot leased space on Mission with garage-sale finds, and she did the necessary remodeling with help from family members. After three years, the agency is just beginning to turn a profit, she says, but declines to disclose its annual revenue.

Visiting Angels' franchiser, Living Assistance Services Inc., of Havertown, Pa., has 400 franchise outlets across the U.S. Johnson says the in-home care industry is growing rapidly, because people are living longer and are healthier. An AARP Public Policy Institute study found that 53 percent of people needing long-term care chose to receive it at home.

"There's a huge population of seniors, and it's only going to grow because baby boomers are aging," Johnson says.

Some of Visiting Angels' clients are subscribers to long-term care insurance, and some are private pay. For those with long-term care insurance, the service submits a bill every week. The insurance companies "pay us in a very timely fashion. The family doesn't even have to see a bill," Johnson says.

For those without such insurance, Visiting Angels will help the family work out a budget among the siblings and help set up a schedule for family members to be involved with caregiving, to cut down on expenses.

Because the service doesn't have nurses on staff, state regulations prohibit it from taking on clients who receive public assistance for in-home care, Knight says.

In November 2008, nearly 73 percent of voters in the state passed Initiative 1029. That measure requires nonfamily long-term caregivers to be certified by the state, to increase their hours of training, and to undergo national as well as state criminal background checks.

The caregivers hired by Visiting Angels all have a minimum of 28 hours of training through a state-approved class called Fundamentals of Caregiving and will have passed a background check. In the future, the number of training hours required by the state will increase to 70 or more, and applicants who pass a test and pay for it will become certified, says a state Department of Social and Health Services Web site.

"It's going to be very expensive," Johnson says. "We don't know how it's going to work. Caregivers don't make that kind of money. The costs are going to have to go back on seniors."

Knight says the initiative isn't being implemented yet, because the large number and many types of in-home caregivers across the state complicate the setup of a system to do so.

"When I first started out, there were a lot of in-home care agencies here," Johnson says. "Some went under, and some were bought out by bigger companies. Little agencies are starting up all the time."

She doesn't worry about competition in the industry, saying there are plenty of seniors who need help.

"We just have to make sure we find them and help them out," she says.