Self-Direction of Home and Community-Based Services in the Time of COVID-19

During the COVID-19 pandemic, nursing homes and assisted living facilities have accounted for over 20% of all infections, adult day care and other congregate sites have closed, and traditional home care agencies are facing staff shortages. In this environment, self-direction of home and community-based services, where the participant can hire their own staff and manage a budget that can be used for a broad range of goods and services including home modifications and assistive devices, is seen as a promising intervention. Using self-direction participants can minimize the number of people who enter their homes and pay close family and friends who were already providing many hours of informal care, and now may be unemployed. The Center for Medicare and Medicaid Services is encouraging this approach. This commentary presents information on how states have responded using the new CMS Toolkit by expanding who can be a paid caregiver, increasing budgets and broadening the kinds of items that can be purchased with budgets to include items like personal protective equipment and supports for telehealth. This Commentary concludes with policy and research questions regarding how the delivery of long-term services and supports (LTSS) may change as the world returns to"normal".

UNMET NEEDS IN SELF-DIRECTED HCBS PROGRAMS

Unmet Need for long-term services and supports has been linked to a variety of harmful health outcomes. One suggested strategy for ameliorating unmet need is to give participants control of the budget and let them construct individualized plans. The evaluation of the Cash and Counseling controlled experiment documented a marked reduction in unmet need when compared to traditional agency-based solutions, but it also showed significant unmet needs remained. This paper, drawing from 76 ethnographic case studies of Cash and Counseling participants, gives us an understanding of what those unmet needs are, who sees them, and what participants and their family caregivers see as possible remedies. Certain areas of unmet need identified in this study stand out. These included health-related problems, environmental issues, and the caregivers’ need for relied. The paper concludes with implications for care integration and the training of support brokers as warnings about reducing budgets.

PARTICIPANT VIEWS OF THE TASKS AND CHARACTERISTICS OF SUPPORTIVE SUPPORT BROKERS IN SELF-DIRECTION PROGRAMS

This qualitative study draws on 76 ethnographic case studies with Cash and Counseling participants, examines what participants and their caregivers saw the support broker doing, and looks at what the participants found helpful and less than helpful. Participants and their caregivers saw support broker duties as Coaching, Problem Solving, Advocacy and Monitoring. Equally important was how the support broker performed these roles. Six attributes that mattered to participants were: Familiarity, Supportive Relationship, Proactive Engagement, Responsiveness, Knowldge and Cultural Friendliness. These findings from the participant and caregiver perspective have great import for the training of present and future care managers and support broker, and have implications for regulatory and even licensure requirements. These results can be a first step in constructing a quality framework for self-directed supports and services.

The times they are a-changing: Self-directed long-term services and supports and gerontological social work

The Partnerships for Person-Centered (PC) and Participant-Directed (PD) Long-Term Services and Supports (LTSS) Project (Partnerships Project) was a three-year effort funded by the New York Community Trust to develop and implement social work curriculum that would better prepare students for the changing practice demands of the aging and disability services network for self-directed LTSS (SD-LTSS). This article first describes the growth of SD-LTSS and the need for trained social workers on this service delivery model. The paper then describes the Partnerships Project that involved schools of social work along and aging and disability network organization partners in nine states. This description includes the major activities of the project including the creation of SD-LTSS competencies for social work education, the infusion of these competencies in beginning and advanced social work classes, and student assessment of their attainment of these competencies. This article then discusses the challenges to institutionalizing such curricular changes within social work programs and the need for a national strategy to train social workers for the demands of SD-LTSS.

"I'm just trying to cope for both of us": Challenges and supports of family caregivers in participant-directed programs

Recently, national attention has focused on the needs of family caregivers providing complex chronic care, noting the necessity to better understand the scope of challenges they encounter. Although a robust body of literature exists about the scope of family caregiving, little is known specifically about the experiences and perspectives of family caregivers who support participant directed (PD) participants, particularly across the caregiving trajectory. Therefore, the aim of this qualitative descriptive study was to describe what family caregivers of individuals with developmental disabilities, physical disabilities, aging, or chronic health conditions identify as the challenges they experience as complex, and their perceptions of the effectiveness and gaps in family support resources in PD. Semi-structured interviews were audio-recorded with a purposive sample of caregivers. Transcribed interviews were analyzed using conventional content analysis. Fifty-four caregivers of individuals with a range of disabilities participated (age 34-78, M 59.9 ± 8.8; male 19%; spouse 17%, parent 61%). Six categories emerged from the analysis: contextualizing complexity, complexity in transitions, coping with complexity: advocacy & isolation, supportive support, unsupportive support, and systems challenges. Caregivers emphasized the interplay between unpredictability, transitions, and complexity and the interaction between the person receiving support, the caregiver's own situation, and the environment. Findings highlight the need, and provide a guide, for family assessment and for tailoring interventions matched to the profiles and self-identified challenges of families living with disability. Social workers can learn what families see as complex and what support broker behaviors families find helpful, and which not.

"It's Changed Everything": Voices of Veterans in the Veteran-Directed Home and Community Based Services Program

The purpose of this study was to understand the value and impact of the Veteran-Directed Home and Community Based Services program (VD-HCBS) on Veterans' lives in their own voices. Focus groups and individual interviews by telephone were conducted to elicit participant perspectives on what was most meaningful, and what difference VD-HCBS made in their lives. Transcripts were analyzed using content analysis. The sample included 21 Veterans, with a mean age of 66±14, enrolled in VD-HCBS an average of 20.8 months. All were at risk of institutional placement based on their level of disability. Five major categories captured the information provided by participants: What a Difference Choice Makes; I'm a Person!; It's a Home-Saver; Coming Back to Life; and Keeping Me Healthy & Safe. Participants described the program as life changing. This study is the first time that Veterans themselves have identified the ways in which VD-HCBS impacted their lives, uncovering the mechanisms underlying positive outcomes. These categories revealed new ways of understanding VD-HCBS as an innovative approach to meeting the person-centered needs of Veterans wishing to remain at home, while experiencing quality care and leading meaningful lives, areas identified as priorities for improving long term services and supports.

Unmet needs in self-directed HCBS programs

Unmet need for long-term services and supports has been linked to a variety of harmful health outcomes. One suggested strategy for ameliorating unmet need is to give participants control of a budget and let them construct individualized plans. The evaluation of the Cash and Counseling controlled experiment (CCDE) documented a marked reduction in unmet need when compared to traditional agency-based solutions, but it also showed significant unmet needs remained. This paper reanalyzes 76 case studies from the CCDE to, for the first time gain an understanding of what those unmet needs are, who sees them, and what participants, caregivers and support brokers think might reduce this problem. Using a collective or multiple case study approach to understand this phenomenon, unmet needs were sorted into five categories using real life experiences of respondents. Unmet needs for assistance in managing the employer and budget tasks of self-direction were also captured.This paper discusses situations where the clinician researchers documented needs that were not expressed by the care recipients and provides a picture of where and why unmet needs remain.The paper concludes with strategies for reducing unmet needs and training future social workers.

Preparedness of representatives for people with dementia in a self-directed program

Representatives enact their role as decision-making partners across the intersection of participant direction (PD) and dementia care. Self-rated preparedness for key dimensions of the role endorsed by a panel of experts in PD and dementia was assessed by telephone survey of 30 representatives of persons with dementia in a PD program. The sample (daughters 60%; Black 50%; rural 70%) was diverse in length of time in the role and additional responsibilities. They represented participants with moderate to advanced dementia and ≥ two additional chronic illnesses. Overall preparedness scores were in the pretty well to very well prepared range, with variation across dimensions and between individuals. Preparedness varied according to what has to be done day-to-day in dynamic or unpredictable situations, gauging decisional capacity, anticipating changing needs, ensuring safety, supporting a dementia-capable care team and negotiation. Stress was related to having a safety net of capable back-up supports and dementia care literacy. Areas of strength, individual variation and particular challenges along the trajectory of representing can guide development of support counselor interventions to provide representatives with tailored training and resources as they enable the benefits of PD for persons with dementia.

Housing and Employment Outcomes for Mental Health Self-Direction Participants

OBJECTIVE

In self-direction, participants control individual budgets, allocating service dollars according to needs and preferences within program parameters to meet self-defined recovery goals. Mental health self-direction is associated with enhanced wellness and recovery outcomes at lower or similar cost than traditional service arrangements. This study compared outcomes of housing independence and employment between individuals who participated in self-direction and those who did not.

METHODS

This quasi-experimental study involved administrative data from 271 self-directing participants. Using coarsened exact matching with observed demographic, diagnostic, and other characteristics, the authors constructed a comparison group of non-self-directing individuals (N=1,099). The likelihood of achieving positive outcomes between first and last assessments during the approximately four-year study period was compared for self-directing and non-self-directing individuals.

RESULTS

Self-directing participants were more likely than nonparticipants to increase days worked for pay or maintain days worked at 20 or more days in the past 30 days (number needed to treat [NNT]=18; small effect size) and maintain or attain independent housing (NNT=16; small effect size), when analyses controlled, to the extent possible, for observed individual characteristics.

CONCLUSIONS

Based on data from the nation's largest and longest-standing program of its kind, results suggest that mental health self-direction is associated with modest improvements or maintenance of positive outcomes in employment and housing independence. This research adds to the literature examining self-direction in the context of mental health and begins to fill the need for a greater understanding of self-direction's relationship to outcomes of interest to service users and families, providers, and system administrators.

Where are they now? Cash and Counseling successes and challenges over time

The positive results of the Cash & Counseling Demonstration and Evaluation (CCDE) led to the funding of a replication project that included 12 more states in 2008. Since then, the political and economic environments have changed. The authors sought to investigate how well the three original and 12 replication CCDE programs are coping with current challenges, and how their experiences may inform the growth and sustainability of emerging participant-directed programs. Semistructured telephone interviews were conducted with the 15 Cash & Counseling state program administrators. Key topics addressed included: successful aspects of state programs, biggest challenges for each program, and information program administrators would like to learn from state colleagues. Themes related to budget issues (e.g., staff shortages and program funding cuts) and non-budget related issues (e.g., understanding of program operations) emerged from the interviews. State program administrators also discussed program successes. To promote the sustainability and growth of participant-directed programs, existing participant-directed programs should be tied to national policy trends as well as review whether or not the programs address participant-directed principles. The development of new participant-directed programs should be based on other states' experiences as discussed in this paper.

Preferences for a Cash Option Versus Traditional Services for Florida Children and Adolescents with Developmental Disabilities

Traditional personal assistance programs often lack a significant consumer-direction focus that allows or encourages consumers to be in charge of their services. Independent evaluations of the Cash and Counseling Demonstration and Evaluation (CCDE) project are comparing costs of, quality of, and satisfaction with traditional personal care services versus consumer-directed cash benefit and information services. Because the disability community is composed of diverse subgroups, each group having with its own needs and concerns, the interests of each of these various populations should be assessed. This article presents the results of a telephone survey conducted in Florida as background research for the CCDE project to assess the interest in a cash option among families of children and adolescents with developmental disabilities. The findings indicate overall high levels of interest in the cash option, especially among individuals who were willing to pay a worker directly, persons who desired more involvement with services, and consumers dissatisfied with the current services. The authors of this article also include suggestions regarding how to communicate with families when informing them of such an option.

Intraoperative Simulated Weightbearing Lateral Foot Imaging: The Clinical Utility and Ability to Predict Sagittal Plane Position of the First Ray in Lapidus Fusion

The sagittal plane relationship of the first to second ray is a primary determinant of proper alignment in Lapidus midfoot fusion as assessed both clinically and on postoperative weightbearing lateral radiographs. The traditional approach to intraoperative fluoroscopic imaging allows for accurate assessment of fixation placement and intermetatarsal angle correction but only a crude evaluation of final sagittal plane alignment. Surgeons have used various methods in an attempt to load the foot during lateral imaging. This had led to inconsistent results and the potential for poor outcome. Skepticism exists regarding the ability of simulated weightbearing fluoroscopy to predict the final outcome, and evidence is lacking to support this practice. A prospective investigation was performed to assess the correlation of the first to second ray sagittal plane alignment as demonstrated on intraoperative simulated weightbearing lateral foot imaging studies and the 10-week postoperative lateral weightbearing radiograph. A consistent simulated weightbearing technique was used prospectively with 50 consecutive cases of Lapidus midfoot fusion with the goal of achieving parallel sagittal plane alignment of the first and second metatarsals with no divergence. Although 47 cases had no divergence and 3 had divergence with mild first ray elevatus, all 50 cases demonstrated a direct correlation between the intraoperative simulated and postoperative full weightbearing images. In conclusion, we believe the findings from our intraoperative imaging technique are a reliable predictor of first ray sagittal plane alignment in Lapidus midfoot fusion.

An Inventory of Publicly Funded Participant-Directed Long-Term Services and Supports Programs in the United States

After a decade of changes in federal law, regulation, and policy designed to promote the growth of publicly funded participant-directed long-term services and supports (PD-LTSS) programs, the number of these programs has grown considerably. The National Resource Center for Participant-Directed Services (NRCPDS) at Boston College started developing an inventory of these programs in 2010-2011 to determine the number and characteristics of publicly funded PD- LTSS programs in the United States. The 2010-2011 NRCPDS inventory provides baseline data for future research efforts in gauging the growth and expansion of this service delivery model. This article details the process for developing this data resource, some of the major characteristics of PD-LTSS programs in the United States, and discusses possible implications and areas for future research.

Incidence and Clinical Significance of Heterotopic Ossification After Partial Ray Resection

Heterotopic bone growth is a common finding after partial foot amputation that can predispose to recurrent wounds, osteomyelitis, and reamputation. Heterotopic ossification is the formation of excessive mature lamellar bone in the soft tissues adjacent to bone that is exacerbated by trauma or surgical intervention. The relevance of heterotopic ossification is dependent on its anatomic location. Its occurrence as a sequela of partial foot amputation can lead to prominence on the plantar aspect of the foot that can predispose the patient to recurrent neuropathic ulceration or preclude appropriate wound healing. Reulceration puts the high-risk patient who has already undergone local amputation at greater risk of recurrent infection and further amputation. The present study aimed to assess the incidence and risk factors for heterotopic ossification to further evaluate its role in partial foot amputation. A retrospective analysis of 72 consecutive patients who had undergone partial metatarsal resection was performed, with 90% of the cohort having peripheral neuropathy and 88% diabetes mellitus. Our findings revealed a heterotopic ossification incidence of 75% diagnosed radiographically. The initial onset of heterotopic ossification was not appreciated >10 weeks postoperatively. Ten patients (18.5%) exhibited heterotopic ossification-associated ulceration. The incidence of heterotopic ossification was 30% less in patients with peripheral vascular disease. These results indicate that heterotopic ossification is a common sequela of partial ray resection in an already high-risk patient population. The perioperative use of pharmacologic or radiation prophylaxis in an attempt to minimize amputation-related morbidity should be considered.

Multi-State Survey of Support Brokers in Cash and Counseling Programs

The purpose of this study is to learn how support brokers (program counselors) carry out and are prepared for their roles in participant-directed programs. More specifically, this study looks at support brokers’ self-perceived roles, training, educational backgrounds, and how well they feel they are prepared for their jobs with Cash and Counseling programs. This study involves two phases of data collection. First, a 20-item survey was sent electronically to support brokers in three states ( n = 138) in 2011. Descriptive statistics and t tests were used for the analysis. The second phase involves follow-up telephone interviews ( n = 15) with a convenience sample who agreed to participate. Results showed an inconsistency in role definitions and types of training between and within individual states. Moreover, educational backgrounds had a significant influence on the level of support brokers’ perceived preparedness for given tasks. Finally, this study identifies areas that support brokers believe will help improve their performance.

European long-term care programs: lessons for community living assistance services and supports?

OBJECTIVE

To uncover lessons from abroad for Community Living Assistance Services and Supports (CLASS), a federally run voluntary public long-term care (LTC) insurance program created under the Accountable Care Act of 2010.

DATA SOURCES

Program administrators and policy researchers from Austria, England, France, Germany, and the Netherlands.

STUDY DESIGN

Qualitative methods focused on key parameters of cash for care: how programs set benefit levels; project expenditures; control administrative costs; regulate the use of benefits; and protect workers.

DATA COLLECTION/EXTRACTION METHODS

Structured discussions were conducted during an international conference of LTC experts, followed by personal meetings and individual correspondence.

PRINCIPAL FINDINGS

Germany's self-financing mandate and tight targeting of benefits have resulted in a solvent program with low premiums. Black markets for care are likely in the absence of regulation; France addresses this via a unique system ensuing legal payment of workers.

CONCLUSIONS

Programs in the five countries studied have lessons, both positive and negative, relevant to CLASS design.

Expanding the consumer-directed workforce by attracting and retaining unaffiliated workers

Unaffiliated workers are directly hired personal assistance workers who are not employed through an agency and are not family members or close friends. This article examines the working conditions of unaffiliated workers in a consumer-directed setting in comparison to agency workers and to other consumer-directed workers. Unaffiliated workers earned higher wages than their peers but were less satisfied with these wages and benefits than other directly hired workers. Findings for consumer-directed programs are discussed in terms of the recruitment and retention of unaffiliated workers, implications for consumers and workers, and future research recommendations.

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.

Social marketing principles enhance enrollment in the cash and counseling demonstration and evaluation

PURPOSE OF THE STUDY

Using focus group data, this article discusses the use of social marketing principles to enhance enrollment in the Cash and Counseling Demonstration and Evaluation (CCDE).

DESIGN AND METHODS

Focus groups were conducted in person and by conference call in two CCDE states, Arkansas and Florida. In Florida, Department of Elder Affairs and Developmental Services Program (DS) staff participated in seven focus groups. In Arkansas, four focus groups were conducted with professionals likely to come into contact with Medicaid consumers who are eligible for Arkansas' cash option program. Focus group transcripts were coded according to the project research questions.

RESULTS

Several important lessons emerged including the importance of(a) conducting process evaluation activities, such as the social marketing focus groups, early during program implementation; (b) using multiple approaches and contacts to inform potential consumers and their families about a new, complex program; (c) carefully selecting and training personnel to conduct outreach and enrollment activities; and (d) developing specific messages to include in marketing the cash option.

IMPLICATIONS

Using social marketing principles to examine CCDE enrollment has provided important information to enhance this program.

Consumer-directed care for beneficiaries with mental illness: lessons from New Jersey's Cash and Counseling program

OBJECTIVE

Previous research from the Cash and Counseling Demonstration and Evaluation (CCDE) programs in New Jersey, Arkansas, and Florida suggests that consumers' control over personal care greatly improves their satisfaction with care arrangements and their outlook on life. Still, some argue that consumer-directed care may not be appropriate for consumers with a diagnosis of mental illness. This study examined the effectiveness of the CCDE program for those with a diagnosis of mental illness.

METHODS

This study examined nonelderly Medicaid beneficiaries in New Jersey with a diagnosis of mental illness and compared and contrasted the experiences of those in New Jersey's CCDE program (N=109) and those who received services provided by an agency (N=119). Logistic regression analyses were performed on baseline and nine-month follow-up data.

RESULTS

By examining outcome measures--including satisfaction with care arrangements, consumers' perceptions of paid caregivers' attitudes, unmet needs, adverse events, and satisfaction with life--this study offers evidence that, from the perspective of consumers, the CCDE program is appropriate for participants with a mental illness diagnosis. For most outcome measures the CCDE program demonstrated a positive effect after baseline characteristics were controlled for. The analysis of measures of adverse events, health problems, and general health status did not yield statistically significant differences between the control group and the treatment group, indicating that CCDE care was at least as safe as agency-directed care.

CONCLUSIONS

Considering the growing need for long-term care services and the limited resources available, a consumer-directed option can be a valuable alternative for persons with a diagnosis of mental illness.

Consumer-directed care for beneficiaries with mental illness: lessons from New Jersey's Cash and Counseling program

OBJECTIVE

Previous research from the Cash and Counseling Demonstration and Evaluation (CCDE) programs in New Jersey, Arkansas, and Florida suggests that consumers' control over personal care greatly improves their satisfaction with care arrangements and their outlook on life. Still, some argue that consumer-directed care may not be appropriate for consumers with a diagnosis of mental illness. This study examined the effectiveness of the CCDE program for those with a diagnosis of mental illness.

METHODS

This study examined nonelderly Medicaid beneficiaries in New Jersey with a diagnosis of mental illness and compared and contrasted the experiences of those in New Jersey's CCDE program (N=109) and those who received services provided by an agency (N=119). Logistic regression analyses were performed on baseline and nine-month follow-up data.

RESULTS

By examining outcome measures--including satisfaction with care arrangements, consumers' perceptions of paid caregivers' attitudes, unmet needs, adverse events, and satisfaction with life--this study offers evidence that, from the perspective of consumers, the CCDE program is appropriate for participants with a mental illness diagnosis. For most outcome measures the CCDE program demonstrated a positive effect after baseline characteristics were controlled for. The analysis of measures of adverse events, health problems, and general health status did not yield statistically significant differences between the control group and the treatment group, indicating that CCDE care was at least as safe as agency-directed care.

CONCLUSIONS

Considering the growing need for long-term care services and the limited resources available, a consumer-directed option can be a valuable alternative for persons with a diagnosis of mental illness.

Partnership insurance: an innovation to meet long-term care financing needs in an era of federal minimalism

In the case of long-term care financing, federal minimalism is not new news. Long-term care has long played a weak "third fiddle" to national health reform concerns about the uninsured and catastrophic expenditures on prescription drugs. The states have been left to struggle with the issue of long-term financing as part of their responsibilities in funding and administering the means-tested Medicaid program. Recently, the environment has become even more challenging. Much of what is on the national agenda for health and welfare reform has been delegated to the states. This "devolution" of responsibilities has created many competing priorities for both the attention and resources of states. This context of evolving federal minimalism calls for creative solutions that balance competing points of view. In this article, we provide some background and insights from one such effort: a collaboration between state governments and private insurers to put into operation an insurance-based approach to long-term care financing that uses Medicaid as an incentive to encourage potential purchasers.

The future of Cash and Counseling: the framers' view

OBJECTIVE

This paper reflects on the progress of the original Cash and Counseling states, and shows how this model has spread, how it has evolved over time, and what is left to improve. It then discusses the generalizability of the Cash and Counseling approach beyond long-term care and ventures some thoughts on what still needs to be learned. Finally, this paper suggests some of the contingencies that could affect the diffusion of this innovation.

DATA SOURCES/STUDY SETTING

Drawing from ten years of experiences with the fifteen Cash and Counseling states, plus their analyses of current trends and future opportunities and threats, the framers of the Cash and Counseling model reflect on future directions.

STUDY DESIGN

This paper is essentially a policy-driven analysis of how the Cash and Counseling model has been sustained and disseminated, how it is likely to develop, and what still needs to be learned.

PRINCIPAL FINDINGS

The basic Cash and Counseling model appears adaptable to different state environments and populations, but that hypothesis will be severely tested as more and more states seek to replicate. As one step to promote flexibility while capturing and preserving the essence of the model that led to such promising research results, the Cash & Counseling National Program Office developed a "Vision Statement".

CONCLUSIONS

The Cash and Counseling approach is not for everyone, but it is clearly a choice many participants desire. Its development merits monitoring.

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.

Case histories of six consumers and their families in Cash and Counseling

OBJECTIVE

To examine how the lives of consumers and their caregivers were affected by making choices and controlling their own resources with the cash option, this paper focuses on six case studies from the Cash and Counseling Demonstration Program.

DATA SOURCES

Twenty-one consumers, caregivers, and state consultants were interviewed about their experiences in the program.

STUDY DESIGN

The data come from a larger study of over 200 interviews conducted from June 2000 to August 2004. Interview data were analyzed for themes about caregiving and program satisfaction.

PRINCIPAL FINDINGS

Cash and Counseling benefited consumers and caregivers by allowing consumers increased continuity and reliability of care, increased ability to set hours of care, more satisfaction with how caregiving is offered and more satisfaction with the quality of care.

CONCLUSIONS

The cash option allowed consumers to create, schedule, and manage their own model of care. Some consumers faced challenges in the program with paperwork, accounting, worries about receiving care, and some ineffective state consultants who could have been more helpful.

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.

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

OBJECTIVE

To assess Medicaid consumers' interest in a consumer-directed cash option for personal care and other services, in lieu of agency-delivered services.

DATA SOURCES/STUDY SETTING

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.

STUDY DESIGN

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.

DATA COLLECTION/EXTRACTION METHODS

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.

PRINCIPAL FINDINGS

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.

CONCLUSIONS

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.

Cash and counseling and managed long-term care?

This article presents the results of a survey on the interest of managed care organizations (MCOs) in developing a "cash and counseling" (C&C) option for delivering long-term personal assistance services. Forty-five percent of the respondents expressed interest, at least for some clients. Although specific experience with consumer direction did not have an effect, three organizational factors--larger size, non-PACE, and not limited to the elderly--predicted MCOs' willingness to consider this option. Respondents' comments give insights on concerns and benefits. This study provides a baseline that can inform further investigation of the compatibility of managed care and "Cash and Counseling."

Implementation Issues for Consumer-Directed Programs

An increasing number of aging community providers and consumers support consumer-direction (CD) in long-term care services. In regard to devolution, consumer-direction goes beyond the usual approach of shifting responsibilities from the federal government to state governments to bring programs "closer to the people." Consumer-direction goes even further by placing resources directly in the hands of consumers. Yet, many questions remain unanswered regarding how to implement CD personal assistance services in general, and especially for older persons. This article describes the importance of examining views from multiple key stakeholders involved in implementing CD programs. We report on three background studies that have informed the Cash and Counseling Demonstration and Evaluation (CCDE) design and implementation-policy expert interviews as well as surveys and focus groups with consumers and representatives. As a fourth data source, we drew upon experiences in designing the CCDE and initial results from the first year of implementation. Each of the three studies on its own provided essential information for planning the CCDE. However, when we examined the studies together, and added CCDE design and implementation experiences, views expressed by the different stakeholders formed a type of multi-perspective "dialogue" that expanded our knowledge about implementing CD services. We hope this increased knowledge will help expand the availability of such services for consumers of any age who want to direct their own care.

Consumer direction in managed long-term care: an exploratory survey of practices and perceptions

PURPOSE

This article presents results of a survey of the attitudes and practices of managed care organizations (MCOs) concerning consumer direction. The study focused on understanding several alternative measures of consumer direction and the factors that are associated with the MCOs concerning those measures.

DESIGN AND METHODS

The MCOs that were surveyed provided capitated managed long-term care benefits to their Medicaid-eligible clients and were chosen because personal assistance service is a likely area for consumer-direction interest or practice.

RESULTS

Although the majority of the responding MCOs were found to be practicing some form of consumer direction, the experience is limited and underdeveloped. Two areas of concern seem to be most important in an organization's decision to adopt a consumer choice or consumer-direction model: the balance of concerns about unprofitability and the perceived interest and benefit of the clients.

IMPLICATIONS

This study suggests managed care and consumer direction can work together and provides a baseline to assess further development of their compatibility.

Consumer and surrogate preferences for a cash option versus traditional services: Florida adults with developmental disabilities

As long-term service expenditures have risen, policymakers have sought ways to control costs while maintaining consumer satisfaction. Concurrently, there is increasing interest in the disability community in consumer direction. The Cash and Counseling Demonstration and Evaluation (CCDE) seeks to increase consumer direction and control costs by offering a cash allowance and information services to persons with disabilities, enabling them to purchase needed assistance. Because the disability community is composed of diverse subgroups, needs of these consumer communities must be assessed individually. Results from a telephone survey conducted to assess the interest in a cash option for Florida adults with developmental disabilities is presented, the three-state CCDE described, how survey findings can inform consumer information efforts discussed, and policy issues highlighted.

Cash and counseling demonstration and evaluation. Start-up activities

One possible approach for making long-term-care systems more consumer-directed is to provide the consumer with a cash alternative. Advocates have touted the possible advantages of this approach, while nay-sayers have worried about the potential for abuse and questioned the claims of cost savings. This article describes the Cash and Counseling Project, a large-scale demonstration project with a rigorous, policy-driven evaluation built into it. Written prior to the project's actual implementation, this article specifically reviews the major evaluation questions, and the state selection process.

Determining consumer preferences for a cash option: Arkansas survey results

As long-term care (LTC) expenditures have risen, policymakers have sought ways to control costs while maintaining consumer satisfaction. Concurrently, there is increasing interest within the aging and disability communities in consumer-directed care. The Cash and Counseling Demonstration and Evaluation (CCDE) seeks to increase consumer direction and control costs by offering a cash allowance and information services to persons with disabilities, enabling them to purchase needed assistance. The authors present results from a telephone survey conducted to assess consumer preferences for a cash option in Arkansas and describe how findings from the four-State CCDE can inform consumer information efforts and policymakers.

Obstructive jaundice associated with polysplenia syndrome in an older child

Polysplenia syndrome includes malrotation and various forms of heterotaxy. Associated with this and malrotation are extrahepatic biliary anomalies. Actual obstruction, other than in associated biliary atresia, is extremely rare, and rarer still in older children. An 11-year-old girl presented with obstructive jaundice, malrotation, and heterotaxy, which were found in association with common bile duct anomalies and intermittent common bile duct obstruction. This case illustrates that the differential diagnosis of obstructive jaundice, even in older children, should include congenital anomalies, and that biliary anomalies should be considered in cases of malrotation and heterotaxy.

Public-private partnerships: the Connecticut model for financing long-term care

Responses to the growing crisis in long-term care financing have included efforts to negotiate partnerships between the private and public sectors for the purpose of developing innovative models for long-term care insurance. One such set of models has been encouraged by support from the Robert Wood Johnson Foundation's "Long Term Care Insurance Program" grants. The Connecticut Partnership for Long Term Care uses a cooperative approach to encourage the development of private sector long-term care insurance products that are integrated with Medicaid eligibility determinations. The Connecticut model is described, accompanied by a history of its development, and a comparison is made with other models currently under consideration by national policy analysts.

Financing long-term care with limited resources: combining the resources of the public and private sectors

Under Connecticut's recently implemented public/private partnership to finance long-term care, individuals will no longer need to impoverish themselves in order to receive Medicaid assistance. To encourage those people who can afford to buy a private long-term care insurance policy to do so, the state promises to shield one dollar in assets from Medicaid "spend-down" rules for every dollar a private policy pays out for Medicaid-covered services. This article describes the Partnership, shows how dwindling resources and budget constraints affected the development of this model, and then contrasts Connecticut's experience with that of other states and describes what can be learned from this demonstration.