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How Does Cash and Counseling Affect the Growth of Participant-Directed Services
Abstract
This article shows how the innovations of the "cash and counseling" model and the widespread dissemination of positive findings from the scientifically rigorous Cash and Counseling Demonstration and Evaluation contributed to the proliferation of participant-directed services options in publicly funded home- and community-based services programs over the past decade. The cash and counseling model of participant-directed services has now diffused beyond Medicaid into Older Americans Act and Veterans Health Administration-funded programs. As the United States becomes increasingly diverse, the flexibility of participant-directed services to tailor services and supports to individual needs and preferences seems likely to stimulate further growth in participant-directed services.
... According to Nixon (2008), this program targets caregivers caring for an older adult who are 60 years old and above. In other parts of the United States and Canada, Foster et al (2003), San Antonio et al (2006) Keefe and Rajnovich, (2007) and Doty et al (2012) report on the Cash and Counseling program which is an expanded model of consumer-directed care in that it provides a flexible monthly allowance that elderly Medicaid beneficiaries, can use to hire their choice of workers, including relatives, and to purchase other services and goods as states permit. Cash and Counseling requires elderly persons to develop plans showing how they would use the allowance to meet their personal care needs and provides counseling and fiscal assistance to help them plan and manage their responsibilities. ...
... Rather, respondents reported that the payment allowed them to provide better care and to have an intense sense of responsibility (Mahoney et al, 2000). Doty et al (2012) are of the view that public program that allow financial incentives to be given to family members who care for elderly relatives give the elderly person opportunity to exercise choice and control over Research on Humanities and Social Sciences www.iiste.org ISSN 2222-1719(Paper) ISSN 2222-2863(Online) Vol.4, ...
Ageing has become a global phenomenon and indeed a critical policy issue receiving some recognition by governments of developed countries where it is reflected in the government's vital document of economic and social development strategy. Globally, the greatest increase in the number of older people is occurring in the developing and middle income countries and Nigeria is not an exception. All over the world, family caregivers continue to be the primary source of care-giving for elderly people, and their own care-related stress, financial strain and compromised health – is often overlooked. However, many developed countries have implemented a number of policies that directly or indirectly target family carers of elderly persons. This is based on the fact that they realise that care-giving is associated with a significant reduction in employment and hours of work, especially for individuals providing a high intensity of care. This paper therefore is an attempt to propose one way of supporting and maintaining the supply of family care in Nigeria so that this very important societal resource is harnessed. The paper present what is happening in other countries and based on that suggest what could be done in Nigeria to support care givers of elderly people.
... This movement has led to the establishment of state-and county-based services to meet the needs of this population. 13 As more individuals with IDDs are served in their homes and community settings across the United States, the importance of effective transition planning and access to community supports such as Developmental Disability Services is clear. 14 Previous research has found that many families and individuals experience better outcomes (fewer unmet needs, higher community involvement, and higher satisfaction) when they are enrolled in self-directed care. ...
Objective:
To explore the barriers faced by parents of individuals with intellectual and developmental disabilities when obtaining and using Developmental Disability Services (DDS) to support adolescent transition.
Methods:
The authors conducted a basic interpretive qualitative study using semistructured interviews. Interviews were manually coded by the team of university-based researchers using constant comparative analysis. The codes were grouped into themes. Thematic saturation occurred after 18 interviews with parents (n = 10) and service coordinators for DDS (n = 8).
Results:
Barriers to DDS enrollment included emotional and administrative burden, fear of invasion of privacy, lack of a qualifying diagnosis, difficulties in accessing information about services, and misinformation about services. Barriers to DDS use once enrolled were difficulty in finding/hiring direct support professionals, high turnover of direct support professionals, and lack of training and skill among direct support professionals. Participants also noted high turnover among service coordinators, further administrative burden from hiring direct support professionals, and required home visits by service coordinators as additional barriers to service use. Participants reported benefits of DDS including increased inclusion for clients in the community, the use of person-centered skill building, and access to respite care and system navigation support.
Conclusion:
Although all participants reported benefits of acquiring services, there are significant barriers to acquiring and maintaining these services. Recommendations based on these barriers are provided for DDS, federal policy makers, and local support professionals along with a toolkit of potential strategies to support families.
... Some states limit enrollment in piloting programs, while others, like California, have been using CDS programs for decades. Across the country, over 800,000 people use CDS programs (Doty et al., 2012), with California accounting for 60% of enrollees. Most states, however, have fewer than 500 participants. ...
Consumer-directed services (CDS) are a type of support system designed to increase the quality of life and self-determination of clients, such as adults with developmental disabilities. Occupational therapists can play an important role in facilitating people's involvement in CDS supports. This paper describes CDS, evidence that supports their use, and ways that occupational therapists use their training in person-centered practice to enhance CDS supports and self-determination. A case study is used to illustrate the application.
... Participant-direction in long-term care and disability supports for adults has included finding, interviewing and hiring in-home or personal care staff, managing a budget, and working with a team of therapists, a fiscal intermediary, and a support broker or case manager (Gross et al. 2012;Mahoney et al. 2007). Participant-direction has become widespread in long-term care supports for adults (Doty et al. 2012). Less is known about participant-directed program models for children. ...
This study investigated families' experience of choice within a participant-directed Medicaid waiver program for young children with autism. Fourteen parents or grandparents participated in in-depth interviews about their experience of choosing personnel, directing in-home services, and managing the $25,000 annual allocation. Key findings included families' preference to hire providers with whom they have a prior relationship, parent empowerment and differences of opinion about parents as teachers. Professionals implementing participant directed service models could benefit from understanding the strong value parents' placed on the personalities and interpersonal skills of providers. Parents' descriptions of directing rather than merely accepting autism services revealed increased confidence in their ability to choose and manage the multiple components of their children's HCBS autism waiver program.
Publicly funded self‐directed budgets for purchasing community‐based long‐term services and supports for people with intellectual and/or developmental disabilities (IDD) have become a wide‐spread service model in the United States and internationally. The current study aims to understand parents' experiences in navigating self‐directed support programs with their adult child with IDD. We utilized qualitative content analysis of interviews with 26 parents of adult children with IDD enrolled in self‐directed budget programs in five U.S. states. Twenty‐four parents reported numerous programmatic barriers to person‐centered supports falling within three thematic areas: administrative issues, budgeting challenges, and inadequate supports. Parents of adult children with IDD value self‐directed supports, although programs cannot cover all possible independent living needs due to a number of factors, including unavailability of desired supports, program rules, or budget limitations. As practices vary by program, our research suggests approaches from different programs that families may find helpful.
Villages, which are community-based initiatives designed to help older adults age in place through a combination of services, participant engagement, and peer support, have expanded rapidly since their initial development in the early 2000s. Using a sample of Villages in the United States, we examined variations from characteristics of the Village model as portrayed by media and organizational leaders. Results indicate there is no uniform Village model that can be implemented and evaluated by policy makers, funders, service providers, and researchers. Based on the extent of member involvement, methods of service provision, and funding sources, we developed a conceptually and empirically informed typology of Villages that reflects the model's focus on consumer involvement. Descriptive analyses indicate potential differences in member, community, and organizational characteristics. This emerging typology has implications for understanding the implementation and sustainability of Villages, including whether specific Village types are best suited to certain community contexts.
© The Author(s) 2015.
Informal family assistance is often a key factor in determining whether a person with a disability can live in a community setting. However, the practice of paying relatives as caregivers remains controversial. This article reports findings from the Cash and Counseling Demonstration and Evaluation (CCDE) in Arkansas, in which consumers receive a cash allowance to purchase personal assistance services. In this comparison of consumers who hired family vs. non-family workers, consumers who hired relatives received more service and had equal or superior satisfaction and health outcomes, as compared to those who hired non-relatives. Findings are further clarified by drawing from worker focus group reports and program experience, and policy issues are specifically addressed.
Consumer-directed long-term care service programs give participants the flexibility they want, while reducing unmet need for home and community-based services and supports. States' efforts to expand such programs under Medicaid, including those supported by federal Cash and Counseling demonstration and evaluation grants, are often hindered by challenges related to costs, staffing and organizational issues, new infrastructure requirements, and resistance from stakeholders. Yet states have developed a number of successful strategies for overcoming these challenges, even in financially trying times. Their experiences offer valuable insights, guidance, and encouragement to other states contemplating consumer-directed service expansions.
ASPE develops or reviews issues from the viewpoint of the Secretary, providing a perspective that is broader in scope than the specific focus of the various operating agencies. ASPE also works closely with the HHS operating divisions. It assists these agencies in developing policies, and planning policy research, evaluation and data collection within broad HHS and administration initiatives. ASPE often serves a coordinating role for crosscutting policy and administrative activities. ASPE plans and conducts evaluations and research--both in-house and through support of projects by external researchers--of current and proposed programs and topics of particular interest to the Secretary, the Administration and the Congress.
Medicaid service use and expenditure and quality of care outcomes in California's personal care program known as In-Home Supportive Service (IHSS) are described. Analyses investigated Medicaid expenditures, hospital use, and nursing home stays, comparing recipients who have paid spouse caregivers with those having other relatives or unrelated individuals as their caregivers.
Medicaid claims and IHSS assessment data for calendar year 2005 were linked for IHSS recipients aged 18 years or older (n = 386,447)
The rates of ambulatory care-sensitive hospital admissions and Medicaid-covered nursing home placements were at least comparable among IHSS recipients' with spouse, parent, other relative, or nonrelative caregivers. Statistically significant differences reflected more desirable outcomes for those with relatives as paid caregivers. In no comparisons did those with spouse providers have worse outcomes than those with nonrelative providers. Average monthly Medicaid expenditures for all services were also lower for IHSS recipients with family provider.
There were no financial disadvantages and some advantages to Medicaid in terms of lower average Medicaid expenditures and fewer nursing home admissions when using spouses, parents, and other relatives as paid IHSS providers. This argues in favor of honoring the recipient's and family's preference for such providers.
"Consumer-directed" models of financing and services delivery are compared with models that emphasize professional control and accountability within the context of Medicaid-financed personal care services (PCS). The Medicaid PCS benefit finances aide or attendant services for low-income persons with functional disabilities to assist them with daily living tasks. Consumer-directed modes of service provision permit service recipients themselves to have greater choice and control over all aspects of service provision. Client surveys in three states found that clients were most satisfied with the program elements of Medicaid PCS services that gave them more choice and control. Case studies of how Medicaid PCS programs in particular states are administered indicate that the use of aides who are independent providers, unattached to a home health or home care agency, is a critical aspect of consumer direction. By itself, however, this factor does not guarantee consumer direction because other Medicaid PCS rules and regulations may restrict client choice and control.
To examine the service experiences and outcomes of low-income Medicaid beneficiaries with disabilities under two different models for organizing home-based personal assistance services: agency-directed and consumer-directed.
A survey of a random sample of 1,095 clients, age 18 and over, who receive services in California's In-Home Supportive Services (IHSS) program funded primarily by Medicaid. Other data were obtained from the California Management and Payrolling System (CMIPS).
The sample was stratified by service model (agency-directed or consumer-directed), client age (over or under age 65), and severity. Data were collected on client demographics, condition/functional status, and supportive service experience. Outcome measures were developed in three areas: safety, unmet need, and service satisfaction. Factor analysis was used to reduce multiple outcome measures to nine dimensions. Multiple regression analysis was used to assess the effect of service model on each outcome dimension, taking into account the client-provider relationship, client demographics, and case mix.
Recipients of IHSS services as of mid-1996 were interviewed by telephone. The survey was conducted in late 1996 and early 1997.
On various outcomes, recipients in the consumer-directed model report more positive outcomes than those in the agency model, or they report no difference. Statistically significant differences emerge on recipient safety, unmet needs, and service satisfaction. A family member present as a paid provider is also associated with more positive reported outcomes within the consumer-directed model, but model differences persist even when this is taken into account. Although both models have strengths and weaknesses, from a recipient perspective the consumer-directed model is associated with more positive outcomes.
Although health professionals have expressed concerns about the capacity of consumer direction to assure quality, particularly with respect to safety, meeting unmet needs, and technical quality, our findings suggest that the consumer-directed service model is a viable alternative to the agency model. Because public programs are under growing pressure to address the long-term care needs of low-income people of all ages with disabilities, the Medicaid personal assistance benefit needs to be reassessed in light of these findings. Consumer-directed models may offer a less elaborate and possibly less costly option for organizing supportive services at home. Study limitations may limit the generalizability of these findings. This was a natural experiment, in which only some counties offered both service models and counties assigned recipients to a service model. The use of a telephone survey excluded important recipient subsets, notably people with severe cognitive impairments. A more definitive study would include direct observations as well as survey approaches.
To assess Medicaid consumers' interest in a consumer-directed cash option for personal care and other services, in lieu of agency-delivered services.
Telephone survey data were collected from four states from April to November 1997. Postsurvey focus groups were conducted in four states in 1998. Early implementation experiences are drawn from three states from 1999 to 2002.
Participants (N=2,140) were selected for a structured telephone survey interview from a probability-sampling frame of current Medicaid consumers in Arkansas, Florida, New Jersey, and New York. Key variables include interest in the cash option, demographic and background characteristics of consumers, as well as previous experience and training needed. Postsurvey focus groups were also conducted with current Medicaid consumers.
Interviewers read the telephone survey from computer screens and entered responses directly into the database of the Macintosh Computer Assisted Telephone Interview software. Data were analyzed using SPSS 10.0 (http://www.spss.com) for Windows.
Cash option interest was positively associated with experience hiring and supervising workers, more severe levels of disability, having a live-in caregiver, living in Florida, and minority status. Age of the client was also a significant factor.
There is significant interest in the cash option, although interest varies among subgroups of consumers. Future research should continue to evaluate interest in the cash option among different groups of consumers, as well as actual experience with the option when the Cash and Counseling Demonstration and Evaluation (CCDE) evaluation findings are completed.
Personal care services (PCS) are intended to enable beneficiaries with physical or cognitive impairments to live safely at home rather than in nursing facilities. The quality and flexibility of these services, typically provided by home care agencies, may not be sufficient to allow some beneficiaries to continue living at home.
We sought to test whether consumer direction of PCS under Arkansas's Cash and Counseling demonstration reduces nursing facility use and expenditures, compared with traditional Medicaid PCS, and how it affects total Medicaid cost.
Interested adult Medicaid beneficiaries in Arkansas who were eligible to receive Medicaid PCS were randomly assigned (1) to have the option to receive an allowance instead of PCS (the treatment group) or (2) to receive traditional PCS through an agency (the control group). Between December 1998 and April 2001, 2008 beneficiaries enrolled.
: Nursing facility use and costs, PCS costs, and total Medicaid costs (according to Medicaid claims data).
Nursing facility use was 18% lower for the treatment group than for the control group during the 3-year follow-up period. Among those who had received PCS before the demonstration, nursing facility savings, together with savings in other long-term care costs, fully offset the higher PCS costs. These savings did not offset the higher PCS costs of new PCS applicants, since the increase in the proportion receiving paid care was so large for this subgroup.
Consumer-directed PCS in Arkansas reduces nursing facility use and costs more effectively than providing services in the traditional manner. This favorable reduction in nursing facility costs was much more pronounced in Arkansas than in the other 2 states (New Jersey and Florida) where the Cash and Counseling demonstration was carried out.