Self/Family Directed Home and Community-Base

Transcript:Self/Family Directed Home and Community-Base:
Self/Family Directed Home and Community-Base Services and Supports in the United States: Spotlight on the “Cash & Counseling” Model Pamela Doty, Ph.D. Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services Public Financing for Long-term Care in the United States Public funding for LTC in the U.S. is primarily via Medicaid, a means-tested, federal/state financed and administered program that began in 1965. Covers people of all ages and physical/mental disabilities in need of LTC. For the first 20 years, 90% of funding went toward institutional care. Spending on home and community-based services (HCBS) exceeded 50% only in 2013. Currently at 57%. Latin American countries planning to invest in public Long-Term Care Systems have few nursing homes, giving them the opportunity to prioritize HCBS from the getgo! Alternative Modes of HCBS Service Delivery Two modes of HCBS delivery (every state offers both): Formally organized, professional managed services typically involve a service plan written by a case manager and services delivered by formal organizations (e.g. aide services from home care agencies). ”Self/family-directed” services (optional alternative) offer individuals and families more choice and control over the services they receive and their service providers. Typically, paid aides are individuals who may be persons they already know and trust, including family, friends or neighbors. About 1.2 million Medicaid HCBS users (1 in 4) “self-direct.” Research found self-direction correlates with “re-balancing” toward HCBS and lower rates of transition from the community to institutional care. Two “Self/Family-Directed Modes of Service Delivery: Employer vs. Budget Authority “Employer Authority” Self-Direction limits beneficiary/family choice and control to hiring/firing and supervising individual aides of their choosing. Number of hours and hourly wage rate is set by the program. Began in California in 1974, due to strong advocacy by the Independent Living Movement of disability rights advocates. “Budget Authority” Self-Direction provides beneficiaries and families with a flexible “budget” – a monetary allowance, which they can decide how to spend within certain rules and regulations. Began as Cash & Counseling Demonstration and Evaluation in 1998. Budget holders may negotiate hours and hourly wage rates so long as they comply with labor law (e.g. pay at least minimum wage). The budget may also be used to purchase other goods and services, some “unorthodox” so long as these address disability-related needs. The “Cash and Counseling” Experimental Demonstration The RWJF/DHHS-sponsored demonstration and evaluation in three states, 1998-2000, followed by