The
Aging Network
Information Memoranda
August 1, 1997
INFORMATION MEMORANDUM
AOA-IM-97-22
TO: STATE AND AREA AGENCIES ON AGING AND TRIBAL ORGANIZATIONS
ADMINISTERING PLANS UNDER TITLES III AND VI OF THE OLDER AMERICANS
ACT OF 1965, AS AMENDED
SUBJECT: Cash and Counseling Projects
The purpose of this memorandum is to: 1) describe cash and
counseling, particularly those projects recently funded by the
Robert Wood Johnson Foundation (RWJF) and the Office of the Assistant
Secretary for Planning and Evaluation (ASPE), Department of Health
and Human Services; and 2) encourage aging network involvement
in these and other consumer-directed projects. In subsequent IM's,
the Administration on Aging will describe other developments in
consumer-directed services, including the "Independent Choices"
projects funded by RWJF.
All of us in the aging network have reason to be interested in
consumer direction in general, and in the four-state RWJF/ASPE
Cash and Counseling Demonstration and Evaluation Program in particular.
Consumer direction is consistent with the goal of independent
living expressed throughout the Older Americans Act, including
the Title I objective which states that the network is responsible
for assisting older persons to secure the "free exercise
of individual initiative in planning and managing their own lives"
and "full participation in the planning and operation of
community-based services and programs provided for their benefit."
Moreover, consumer-directed care is one of the most significant
innovations in long-term care in the past decade, an innovation
that promises to become an effective option for meeting the needs
of disabled persons of different ages. We all have a stake in
fostering demonstrations of consumer-directed approaches and in
understanding the implications of their results.
Consumer-Directed Services: A General Overview
A distinction is often made in home and community-based services
between those that are "agency-directed" and those that
are "consumer-directed." Currently, elements of these
two approaches are often blended. Traditionally, however, agency-directed
services have featured care delivered by a provider agency, case
management to coordinate services, and public regulation of providers
to assure quality. Service decisions have tended to give heavy
weight to the judgments of the case manager or provider agency
staff.
Consumer-directed services, by contrast, are intended to allow
informed consumers to assess their own needs, determine how and
by whom these needs should be met, and monitor the quality of
services received. Typically, these services are implemented as
personal care services provided by a home care worker selected,
trained and supervised by the consumer. Often, consumers also
have the flexibility to choose other ways, e.g., home modifications
and assistive devices, to meet their needs for personal assistance.
Consumer direction may take place in differing degrees depending
on circumstances. It ranges from individuals independently making
all decisions and managing services directly to individuals using
a fiscal intermediary to assist in managing needed services. The
unifying principle is that individuals have the primary authority
to make choices that work best for them.
Younger adults with disabilities have been the most vocal in
advocating for consumer-directed services, but older persons with
disabilities as well as surrogate decision-makers--including the
parents of disabled children and families of persons with cognitive
impairments and developmental disabilities--have also expressed
a growing interest in this approach. Recent research suggests
that significant numbers of older persons would like to have more
involvement in making key decisions regarding their personal care
and are more satisfied with services when they do. For example,
Glickman, Brandt and Caro (1994) found that at least 24 percent
of elderly Massachusetts home care clients were willing to assume
greater responsibility for their services; and Doty, Kaspar and
Litvak (1996), in their study of elderly home care recipients
in Michigan, Maryland and Texas, found "strong statistical
associations between indicators of consumer choice and indicators
of consumer satisfaction."
Cash and Counseling
Cash and counseling (C&C) is one of the ultimate forms of
consumer direction in which consumers are given the option of
receiving cash payments that they may use to purchase a variety
of support services. Consumers may purchase personal care services
from a home care agency, an adult day care center, a friend or
a relative, or they may use the money to make home modifications
or buy assistive devices that limit their future need for personal
care. Along with the cash, consumers receive information, advice,
and training on how to access and manage their own care. Area
agencies on aging, centers for independent living, or other public
or private organizations, or individuals with interest and expertise
may be appropriate sources to provide a menu of counseling services,
including assistance in hiring, training and supervising workers,
a registry of workers available to provide back-up support, or
assistance in handling tax and accounting responsibilities.
Cash and counseling, or similar approaches, are being used by
several European countries, including Holland, Germany, and Austria,
and interest in the option is rising in this country because national
and state government officials are looking for innovative and
cost-effective approaches to meet the needs of a growing aged
and disabled society. A number of states, including Michigan,
Wisconsin, and Colorado, are currently using state funds to make
C&C one component of their long-term care systems.
Proponents argue that such approaches will increase consumer
satisfaction and autonomy, improve quality of care, and lower
costs, but as yet there has not been sufficient empirical research
to substantiate these claims fully. On the other hand, there are
concerns that some consumers or their family members may spend
the cash benefit inappropriately; that the quality of care could
suffer; that there will be a great increase in the number of people
applying for benefits; or that frail consumers will have difficulty
in resolving the myriad of legal, liability, and employee benefit
issues that come with managing one's own care.
These concerns are beginning to be addressed successfully in
current state programs through such means as counseling and fiscal
intermediary services. However, many officials and researchers
think that before the cash option is utilized on a large scale
in this country, the C&C approach needs to be evaluated against
more traditional models of service provision.
The Cash and Counseling Demonstration and Evaluation
Program
Essentially, the Cash and Counseling Demonstration and Evaluation
Program is a policy-driven evaluation of the C&C approach.
Under this RWJF initiative, four states were funded in 1996--Arkansas,
Florida, New Jersey and New York--to test the idea of giving elderly
and younger Medicaid recipients with disabilities the choice of
traditional services or cash, along with counseling assistance,
to help consumers manage the benefits and make sure the funds
are well spent. The University of Maryland Center on Aging was
designated to be the national program office responsible for directing
and coordinating the demonstration, providing technical assistance
to the states (in collaboration with the National Council on the
Aging), and supervising the work of the evaluation contractor,
Mathematica Policy Research, Inc.
The state demonstrations will run for three years. Enrollment
will be open for one year. In the research design, eligible volunteer
participants will be randomly assigned to one of two groups: the
control group will receive "traditional" benefits, i.e.,
agency-provided, home and community-based services; the C&C
group will receive cash to pay for attendant care, home modifications,
and other personal assistance along with the counseling supports
that will help them live independently in the community. Volunteer
participants assigned to the "cash" option can return
to the "traditional system" at any time.
The Mathematica evaluation, funded by ASPE, will measure differences
between the groups in terms of such outcomes as cost, quality,
consumer satisfaction, caregiver satisfaction, and type and amount
of personal care received. It also will look at other important
aspects of the demonstrations such as service mix and the varying
characteristics of the consumers, e.g., age, disability, and family
support.
The state projects are currently developing their specifications
for the counseling contracts. This summer, they will seek a 1115
Research and Demonstration Waiver through the Health Care Financing
Administration to allow the C&C participants to receive Medicaid
funds in the form of cash and to allow recipients to pay family
caregivers. Authority is also being sought to assure that the
cash-out of Medicaid home care benefits will not affect consumers'
eligibility for, or benefits under, other federally-assisted programs
such as SSI, Food Stamps, or various housing programs, etc. The
target date for enrollment in the Cash and Counseling Demonstration
Program is April 1998.
For more information on the RWJF/ASPE program please contact:
Nat'l Program Office: Kevin J. Mahoney, Ph.D.
Program Director
University of Maryland Center on Aging
1240 HHP Building
College Park, MD 20742
(301) 405-2549
WEB SITE: http://www.inform.umd.edu/aging
Arkansas: Suzanne Crisp, Assistant Director
Division of Aging and Adult Services
Department of Human Services
P.O. Box 1437, Slot 1412
Little Rock, AR 72203-1437
(501) 682-2441
Florida: Kerry Schoolfield, Director
Strategic Long-Term Planning
Florida Consumer-Directed Care
Department of Elder Affairs
4040 Esplanade Way
Building B, Suite 152
Tallahassee, FL 32399-7000
(904) 414-2087
New Jersey: William A.B. Ditto
Acting Assistant Director
Office of Disabled Affairs
Division of Medical Assistance
and Health Services, CN-712
New Jersey Department of Human Services
Trenton, NJ 08625-0712
(609) 588-2622
New York: Ann Hallock, Project Manager
Cash and Counseling
Bureau of Program and Data Analysis
Office of Medicaid Management
New York State Department of Health
Room 2038, Corning Tower
Empire State Plaza
Albany, NY 12237
(518) 474-9265
The Aging Network and Cash and Counseling
Many state and area agencies on aging are already involved in
the RWJF or state-funded C&C projects, and we encourage them
to continue to take an active role in their implementation. Aging
network agencies in states where projects have not been started
are urged to consider appropriate ways they may help to promote
consumer direction. Among the roles that state and area agencies
on aging may play include:
· administering programs;
· serving on advisory committees;
· providing outreach and information and referral; and
· promoting counseling and fiscal intermediary services.
Cash and Counseling may not be the service approach of choice
for all older persons, but it can be an important and valuable
new option for many of the people we serve and represent. For
these C&C demonstrations to receive an adequate evaluation,
they need the active involvement of our network. The quality of
the outreach, screening, counseling and monitoring undertaken
by the projects will, in part, depend on the expertise and commitment
we bring to bear. Again, we all have a stake in fostering demonstrations
of this kind and in understanding their results, especially in
terms of future long-term care policy.
William F. Benson
Acting Principal Deputy Assistant
Secretary for Aging
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