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An Experiment in Consumer-Direction

Sandra BarrettAssistant Director

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THE CHOICE

An Opportunityto Exchange Agency Personal Care Services for A Monthly Cash Allowance

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THE SOCIAL EXPERIMENT

Classic experimental design with an experimental group receiving the allowance and a control group continuing to receive agency services – both groups are part of the evaluation

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THE SOCIAL MARKETING

Open Enrollment Direct Mail

• Letters from the governor

• Letters to participants requesting referrals

• Notes with copies of news clippings

• Letters from participants with information about their experience

Public Service Announcements• Television• Radio

News Releases

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THE PLAYERS

Need personal care• New to continuing

ratio is 30.5% Willing to participate Able to make

responsible care decisions or have a representative decision-maker• 43% use a

representative

18 Years Old or Older• 72% age 65 or

Older• 64% White/33%

Black/3% Other• 77% female/84%

unmarried• 62% live in rural

area/68% live with others

Receiving Medicaid

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CLOSING THE DEAL

Request information Enter into database Telephone contact

by enrollment staff Enrollment home

visit Completed signed

consent form

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SHOW ME THE MONEY!

Allowance• Based on personal

assistance needs• Approximately

$8.00 per hour• Average

allowance is $405.00 a month

Uses of Cash• To meet personal

care needs• Hire personal care

assistant• Purchase items

and services related to personal Care

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THE PAY OFF

82% of the allowance is used to hire a PSA• 74% hire a family

member• Friend/neighbor

16% of the allowance is used to purchase items traditionally unavailable through Medicaid• Personal care items;

assistive devices; health and safety items

• 2% is saved

Attractive Program Features

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THE SUPPORTING CAST

Bookkeeping• Accept cash

allowance• Disperse cash

according to plan• Serve as employer

agent• Maintain employee

files• Pay payroll• Withhold/pay taxes

Counseling• Training• Reassessments• Monitoring• Support Resource

• Develop cash Plan/answer questions

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THE OBSERVATIONS*Quantitative Evaluation

Participants and family members express a high level of satisfaction with this program.

81% say the Program has improved their lives/No one says they are worse off

99.76% are satisfied with their caregiver relationship

96% would recommend the program to others.

97% are happy with the time help is provided• 50% receive help before

8 AM• 65% receive help after 6

PM• 77% receive help on

weekends Participants have more

unpaid help than paid help*Preliminary Information Provided

by MPR based on 9-month consumer survey – 885 Respondents

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THE OBSERVATIONS*Qualitative Study

Interviews were semi-structured, open-ended, face-to-face with consumers/reps, paid workers, counselors

Cross-cutting themes• Family context of care• Meaning of independence• Community context of care• Skills and qualities of

caregivers• Alternate uses of cash• Previous agency experience

Widely shared values• Flexibility/freedom• Control/responsibility• Getting out more• Securing services from

someone who cares about you

• Securing help that fits the rhythms of life

• Being about to hire family*Preliminary information based on 27 case

studies completed by the University of Maryland Baltimore County

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THE OBSERVATIONS*Cost Evaluation

Arkansas Medicaid has spent no more per month on the Treatment Group than on the Control Group

Based on per hour of care delivered, IndependentChoices costs are nearly 10% lower than traditional agency-delivered services.

A higher percentage of each service dollar pays for direct service rather than administrative costs

Treatment Group receives more of the personal care service ordered by the MD

Control Group Beneficiaries did not receive personal assistance services in 40% of the months in which they were eligible compared to 9% for the Treatment Group

Institutional Costs were 18% higher for the Control Group

*Comparison of Treatment and Control Groups Randomized During the First 2 Years of Operation

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THE LESSONS

Estimating Counseling/Fiscal Agency Reimbursement

Consumers are less interested in cash than previously believed

Consumers want choice and control over who, when and how care is provided

Disenrollments occur in the first few months

Lag time between enrollment and beginning self-direction vary

Consumer-directed models provide better access to authorized service

Consumers in Arkansas have been managing cash budgets responsibly WITHOUT ANY MAJOR INSTANCES OF FRAUD OR ABUSE

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THE VERDICT

• Consumer Direction Works• Consumer Direction is Not For Everyone• This Model Will Not Replace the Traditional

Model• Respect for Preferences Should Be a Major

Consideration in Program Design and Training

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THE FUTURE

Arkansas is currently negotiating with CMS to amend the 1115 demonstration waiver terms and conditions to operate the program without randomization

The Cash and Counseling Program is proposing that CMS modify their definition of personal care to include goods and services in addition to human assistance

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IndependentChoices

Sandra BarrettArkansas Division of Aging and Adult Services

PO Box 1437 Slot 1412Little Rock AR 72203

501/682-2441www.independentchoices.com