Cash And Counseling Demonstration And Evaluation Research Articles

Lessons From the Arkansas Cash and Counseling Program: How the Experiences of Diverse Older Consumers and Their Caregivers Address Family Policy Concerns

This paper addresses four family policy questions that policy makers often ask about consumer-directed services, examining issues such as quality, suitability, and fraud and abuse. Responses to these questions evolved from the experiences of diverse elder consumers and their caregivers who participated in IndependentChoices, the Arkansas site of the Cash and Counseling Demonstration and Evaluation (CCDE) program. Building on CCDE evaluation survey data, this analysis of in-home interviews with participants discussing their experiences of receiving, giving, and managing care demonstrates how the program allows consumers choices so they receive the services they want. At the same time, program flexibility allows policy makers to safeguard both consumers and program resources through the use of supports such as representatives, state consultants, and fiscal intermediaries. This article demonstrates how the Cash and Counseling model can address the needs of both consumers with diverse disabilities and policy makers.

Social Marketing Principles Enhance Enrollment in the Cash and Counseling Demonstration and Evaluation

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). 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. 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. 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

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. 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. 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. 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

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.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.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.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.

State Experiences with Implementing the Cash and Counseling Demonstration and Evaluation Project

ABSTRACT The Cash and Counseling Demonstration and Evaluation (CCDE) tested one of the most autonomous forms of consumer direction for personal assistance services. In the winter of 1996/97, Arkansas, Florida, New Jersey, and New York each received grants to develop and implement CCDE. While Arkansas, Florida, and New Jersey were successful in their efforts of implementing CCDE, New York was unable to do so. Using elements of Hasenfeld and Brock's (1991) political economy policy implementation model, the following sections describe two primary interactions between key policy implementation instruments and internal and external stakeholders that made New York's participation in CCDE not possible. This case study also provides some lessons for other states interested in developing Cash and Counseling models.

Does Mental Illness Affect Consumer Direction of Community-Based Care? Lessons From the Arkansas Cash and Counseling Program

Previous research from the Cash and Counseling Demonstration and Evaluation (CCDE) in Arkansas, New Jersey, and Florida suggests that giving consumers control over their personal care greatly increases their satisfaction and improves their outlook on life. Still, some argue that consumer-directed care may not be appropriate for consumers with intellectual disabilities or mental health diagnoses. This study examined how Cash and Counseling-a new option allowing consumers to manage an individualized budget equivalent to what agencies would have spent on their care-changes the way consumers with mental health diagnoses meet their personal care needs and how that affects their well-being. Using the Arkansas CCDE baseline and the 9-month follow-up data for individuals in the treatment and control groups, we compared and contrasted the experience of elderly consumers with and without mental health diagnoses utilizing logit regression. After examining several outcome measures, including satisfaction with care arrangements and the paid caregiver's reliability and schedule, unmet needs, and satisfaction with the relationship with paid caregivers, this study found evidence that, from the perspective of consumers, the Cash and Counseling program works well for participants with mental health diagnoses. Considering the growing need for long-term-care services and the limited resources available, a consumer-directed option makes sense, and it can be a valuable alternative for persons with mental health needs.

Designing the Cash and Counseling Demonstration and Evaluation.

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

Paying Family Caregivers: An Effective Policy Option in the Arkansas Cash and Counseling Demonstration and Evaluation

Informal family assistance is often a key factor in determining whether a person with a disability can live in a community setting. However, the practice of paying relatives as caregivers remains controversial. This article reports findings from the Cash and Counseling Demonstration and Evaluation (CCDE) in Arkansas, in which consumers receive a cash allowance to purchase personal assistance services. In this comparison of consumers who hired family vs. non-family workers, consumers who hired relatives received more service and had equal or superior satisfaction and health outcomes, as compared to those who hired non-relatives. Findings are further clarified by drawing from worker focus group reports and program experience, and policy issues are specifically addressed.

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.

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

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.

Implementation Issues for Consumer-Directed Programs

Summary 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 Preferences for a Cash Option Versus Traditional Services

The Cash and Counseling Demonstration and Evaluation (CCDE) is a policy-driven evaluation of the basic belief that most people, including the elderly, want a say in matters that affect their daily lives. The evaluation is comparing cost, quality, and satisfaction of consumers receiving traditional personal care services with those receiving a consumer-directed cash benefit and information services. This article presents results from a telephone survey conducted as background research to assess the preferences of elders and adults with disabilities for a cash option versus traditional services in New Jersey, one CCDE demonstration state. This preference study provides information about consumer perceptions and attitudes, need for help or training with service management tasks, and outreach messages to emphasize when promoting a consumer-directed cash option.

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.