Determining personal care consumers' preferences for a consumer-directed cash and counseling option: survey results from Arkansas, Florida, New Jersey, and New York elders and adults with physical disabilities

The Tasks and Characteristics of Supportive Support Brokers

In the United States, under the Cash and Counseling or budget authority model of self-directed personal assistance where the participant manages his or her own services and supports, the Support Broker role was established to assist and coach the participant. The support broker role grew out of a person-centered planning process where focus groups and surveys helped ascertain what potential participants wanted to help them establish a self-directed alternative. But, despite this role being described in policy guidance from the Center for Medicare and Medicaid, little research has been conducted examining the functions, activities and usefulness of this position. This study draws on 76 ethnographic case studies with early Cash and Counseling participants, examines what participants and their caregivers actually saw the support broker doing, and looks at what the participants found helpful and less than helpful. Participants and family caregivers saw support broker duties as falling into four areas: Coaching, Problem Solving, Advocacy and Monitoring. Equally important was how the support broker performed these duties. Key aspects of quality included: Familiarity, Supportive Relationship, Proactive Engagement, Responsiveness, Knowledge and Cultural Friendliness. These findings can provide the basis for establishing quality indicators for self-direction.

Stated preferences for long-term care: a literature review

Person-centred provision of long-term care (LTC) requires information on how individuals value respective LTC services. The literature on LTC preferences has not been comprehensively reviewed, existing summaries are contradictory. An explorative, scoping review was conducted to provide a thorough methodological description and results synthesis of studies that empirically investigated LTC preference outcomes based on respondents’ statements. A wide search strategy, with 18 key terms relating to ‘LTC’ and 31 to ‘preferences’, was developed. Database searches in PubMed, Ovid and ScienceDirect were conducted in February 2016. The 59 studies meeting the inclusion criteria were grouped and methodically described based on preference elicitation techniques and methods. Despite substantial methodological heterogeneity between studies, certain findings consistently emerged for the investigated LTC preference outcomes. The large majority of respondents preferred to receive LTC in their known physical and social environment when care needs were moderate, but residential care when care needs were extensive. Preferences were found to depend on a variety of personal, environmental, social and cultural aspects. Dependent individuals aspired to preserve their personal and social identity, self-image, independence, autonomy, control and dignity, which suggests that LTC preferences are a function of the perceived ability of a specific LTC arrangement to satisfy peoples’ basic physiological and mental/social needs. Research on LTC preferences would greatly profit from a standardisation of respective concepts and methods.

Developing Personal Care Programs: National Trends and Interstate Variation, 1992–2002

This paper examines the development of programs delivering personal care to the elderly and disabled. First, we report the latest national participant and expenditure trend data for the three main personal care programs: the Medicaid Personal Care Services (PCS) benefit, Medicaid 1915(c) waivers, and the Older Americans Act Title III. Second, to examine interstate variation revealed in the trend analysis, we present three time-series regression models of personal care development (expenditures, participants, and existence of PCS benefit) that control for state socioeconomic, political, policy, and provider characteristics. Positive predictors of personal care development include: percentages of population aged 85 and older, and nonwhite; per capita income; and liberal state politics. Negative predictors of personal care development include rates of Medicare home health users and hospital beds.

Consumer direction in long-term care policy: overcoming barriers to promoting older adults' opportunity for self-direction

There has been a growing trend in long-term care policy to offer individuals with disabilities the option of consumer direction (CD), where responsibility of managing care and support services is transferred from agencies to care recipients, thus supporting clients' self-determination. Although CD has been accepted as an option for non-elderly individuals with disabilities, barriers persist to promoting older adults' autonomy through CD. This article reviews the incorporation of CD in long-term care policy, addresses the current barriers to providing older adults the right to self-direct, and makes recommendations for overcoming these barriers through social work practice, policy, and research.

A pilot evaluation of the Family Caregiver Support Program

The purposes of this study were to evaluate a federal and state-funded Family Caregiver Support Program (FCSP) and explore what types of caregiver support service are associated with what caregiver outcomes. Information was obtained on a sample of 164 caregivers' use of eleven different types of support service. Descriptive and comparative analyses were used to detect the differences between users and nonusers of caregiver support services. Six measures included were caregiving appraisal scale, caregiving burden, caregiving mastery, caregiving satisfaction, hour of care, and service satisfaction. Using consulting and education services is associated with lessening of subjective burden; using financial support services is associated with more beneficial caregiver appraisal, such as better caregiver mastery. The findings are practical and helpful for future caregiver service and program development and evaluation and policy making for supporting caregivers. In addition, the evaluation method demonstrated in the study provided a simple and moderately effective method for service agencies which would like to evaluate their family caregiver support services.

Linking the NIH strategic plan to the research agenda for social workers in health and aging

Although social work has a long and distinctive tradition of practice-relevant research aimed at enhancing the health and well-being of older adults, the profession has been underrepresented among the ranks of academic researchers and the National Institutes of Health's (NIH) scientific endeavors. In this article, the inherent capacities of social workers to generate and disseminate empirical health-related knowledge are discussed and recent developments in social work's geriatric research infrastructure are described. Emerging domains for advancing the profession's contribution to practice-relevant geriatric research on the federal level are identified and the next steps toward advancing the field's research agenda are posed.

Hiring relatives as caregivers in two states: developing an education and research agenda for policy makers

Meeting the long-term care needs of the growing aging population is a priority policy issue in the United States. Yet, hiring relatives as caregivers remains a controversial policy issue. This two-state case study reports findings about views from policy experts regarding a policy option to hire family caregivers in home- and community-based long-term care programs. Policy makers also discussed information needed by other states considering this option and effective approaches to disseminate findings about this option from the Cash and Counseling Demonstration Evaluation. Based on the study results, we present an education and research agenda to communicate these findings to policy makers.

Experiences of disability consumer-directed care users in Australia: results from a longitudinal qualitative study

The rapidly growing body of literature suggests that Consumer-directed Care (CDC) has the potential to empower consumers and improve the flexibility and quality of care. However, reports highlighting quality and risk concerns associated with CDC focusing on a longer time frame have been few. This paper presents the findings from a qualitative longitudinal evaluation of an Australian CDC programme. Focusing on the period between 2003 and 2008, it reports on the experiences of 12 families caring for a dependent family member. It is based on two external evaluations completed 6 and 36 months after enrollment, and one internal evaluation completed 48 months after enrollment. The findings were triangulated with internal memos, reports and minutes of meetings, as well as with the theoretical literature. The study demonstrates that CDC harbours considerable benefits for people with disabilities and their carers. However, the study also suggests that, over time, carers may experience an increased sense of isolation and lack of support as a result of their involvement in the CDC programme. The paper argues that the development of safeguards addressing these weaknesses is crucial for the sustainability of CDC programmes in contexts where risk cannot be simply transferred onto consumers.

The place of assisted living in long-term care and related service systems

PURPOSE

The purpose of this article is to describe how assisted living (AL) fits with other long-term-care services.

DESIGN AND METHODS

We analyzed the evolution of AL, including the populations served, the services offered, and federal and state policies that create various incentives or disincentives for using AL to replace other forms of care such as nursing home care or home care.

RESULTS

Provider models that have emerged include independent senior housing with services, freestanding AL, nursing home expansion, and continuing care retirement communities. Some integrated health systems have also built AL into their array of services. Federal and state policy rules for financing and programs also shape AL, and states vary in how deliberately they try to create an array of options with specific roles for AL. Among state policies reviewed are reimbursement and rate-setting policies, admission and discharge criteria, and nurse practice policies that permit or prohibit various nursing tasks to be delegated in AL settings. Recent initiatives to increase flexible home care, such as nursing home transition programs, cash and counseling, and money-follows-the-person initiatives may influence the way AL emerges in a particular state.

IMPLICATIONS

There is no single easy answer about the role of AL. To understand the current role and decide how to shape the future of AL, researchers need information systems that track the transitions individuals make during their long-term-care experiences along with information about the case-mix characteristics and service needs of the clientele.

Does disparity in the way disabled older adults are treated imply ageism?

Although the nearly one in seven Americans who have disabilities share many characteristics, the attitudes toward and the programs, care models, expenditures, and goals for people with disabilities differ substantially across age groups in ways that suggest ageism. Expenditures per recipient are substantially higher for younger individuals with disabilities, largely as a result of more effective advocacy. Programs that are rejected by younger people with disabilities are considered mainstream for older adults. As demographic, social, and economic circumstances change, preserving the programmatic separation will become more problematic. Increased competition for finite resources may motivate a closer examination of commonalities across disabilities in an effort to achieve greater equity.

Consumer enrollment and experiences in the Cash and Counseling program

STUDY CONTEXT

Consumer direction of Medicaid supportive services raises concerns about who should be permitted to self-direct, whether consumers should be allowed to pay family members, whether a self-directed option increases demand for services, and how to ensure quality. The Cash and Counseling programs contained features designed to address these concerns. DEMONSTRATION ENROLLMENT: Many consumers used representatives to manage the allowance on their behalf and others chose to disenroll, suggesting that beneficiaries were capable of deciding for themselves whether the programs were suitable for them. Participation among eligible beneficiaries during the demonstration was modest, suggesting that consumer direction did not itself substantially increase the demand for services. CONSUMER EXPERIENCES: Most consumers were able to assume the role of employer without difficulty, many hiring relatives or acquaintances as workers. In each state, more than 85 percent reported they would recommend the program to others seeking more control over their care, and more than half said the program had "improved their lives a great deal."

Designing the Cash and Counseling Demonstration and Evaluation

OBJECTIVE

The Cash and Counseling Demonstration and Evaluation (CCDE) was designed as an experiment in shifting the paradigm in home and community-based long-term care from a professional/bureaucratic model of service delivery to one emphasizing consumer choice and control. The experimental intervention was an individualized budget offered in lieu of traditional Medicaid-covered services, such as agency-delivered aide services or a plan of care developed and coordinated by a professional case-manager, which typically involves authorization for several different providers to deliver a range of services. Within the spending limits established by their budgets, program participants were largely free to choose the types and amounts of paid services and supports they judged best able to meet their disability-related personal assistance needs.

STUDY POPULATION

Medicaid beneficiaries in selected states who volunteered to participate. In all of the participating state Medicaid programs, beneficiaries eligible to participate included elders and younger adults with chronic disabilities and, in one state, adults and children with mental retardation/developmental disabilities could also participate. Minor children and adults with cognitive impairment could participate via representatives (family or friends who agreed to assist them in managing their services or to act as their surrogate decision-makers).

DATA SOURCES

Members of the CCDE management team describe the rationale for and implications of key design decisions.

STUDY DESIGN

Key design decisions included the choice of research methodology (random assignment of CCDE participants in each state to treatment and control groups), selection of the state sites (AR, FL, NJ, NY), and the need for the CCDE to comply with federal waiver requirements for Medicaid research and demonstration projects. Principle Findings. The CCDE design was successfully implemented in three of the four state Medicaid programs selected for participation.

CONCLUSIONS

The successful implementation of the CCDE (results from the evaluation are reported elsewhere) led to replication efforts in other states. The CCDE also inspired changes in Medicaid law and policy, including the 2002 "Independence Plus" Initiative by the Centers for Medicare and Medicaid and sections of the Deficit Reduction Act of 2005 intended to promote consumer-direction in Medicaid.

Cash and Counseling: A Promising Option for Consumer Direction of Home- and CommunityBased Services and Supports

The Cash and Counseling Demonstration began as a 3-state social experiment to test the claims of members of the disability community that, if they had more control over their services, their lives would improve and costs would be no higher. The 2004 expansion to 12 states brings us closer to the tipping point when this option will be broadly available. The original demonstration was a controlled experiment with randomized assignment, supplemented by an ethnographic study and a process evaluation. Consumers managing flexible, individualized budgets were much more satisfied, had fewer unmet needs, and had comparable health outcomes. Access to service and supports was greatly improved. Consumer direction is increasingly accepted as a desirable option in home and community services.

The Cash and Counseling Demonstration and Evaluation: Focus Groups Inform Design of a Consumer-Directed Cash Option

The purposes of the study were to explore consumer preferences for a cash option, to inform the ongoing CCDE survey and program design, and to identify the messages that the CCDE and other states should include when informing consumers about a cash option. The preference study consisted of 3 parts: 11 presurvey focus groups, a telephone survey in each of the 4 participating states, and 16 post-survey focus groups. This article highlights unique results from pre- and post-survey focus groups. Focus group discussions were audiotaped and videotaped and transcribed. Transcripts were manually coded and text was clustered according to the moderator’s guide questions and some new and recurrent themes that emerged. Overall, focus group participants, including elders, expressed positive feelings about the CCDE, especially about having a role in hiring workers and determining the workers’ schedules and responsibilities. Focus groups provided important lessons about features to highlight when presenting program information to potential consumers and their families. Program planners must also bear in mind consumer concerns, especially considering that less than 10% of eligible Medicaid consumers volunteered for the cash option. These findings will be useful in guiding other states as they develop new cash and counseling programs, especially those in the current Cash and Counseling replication project.