18th National Aging

1
18th National Aging Disability IR
SymposiumHouston, TexasMay 2008

• Presentation by
• William A. B. Ditto, MSW, LSW
• Director
• New Jersey Division of Disability Services

2
Cash Counseling Definition

• Consumer Directed Services
• A philosophy and orientation to the delivery of
  services whereby informed consumers assess their
  needs, determine how these needs should be met,
  determine who can best meet them and monitor the
  quality of services received. The consumer
  exercises substantial control over the resources
  available to meet their needs.

3
Basic Model for Cash Counseling

• Step 1 Consumers receive traditional assessment
  and care plan
• Step 2 A dollar value is assigned to that care
  plan
• Step 3 Consumers receive enough information to
  make unbiased personal choice between managing
  individualized budget or receiving traditional
  agency-delivered services

4
Basic Model for Cash Counseling

• Step 4 Consumer and counselor develop spending
  plan to meet consumers personal assistance needs
• Step 5 Cash allowance group provided with
  financial management and counseling services
  (supports brokerage)

5
Original (Pioneer) Cash Counseling Program
Overview

• Funders
• The Robert Wood Johnson Foundation
• US DHHS/ASPE
• Administration on Aging/DHSS
• Waiver and Program Oversight
• Centers for Medicare and Medicaid Services (CMS)
• National Program Office
• Boston College Graduate School of Social Work
• Original Evaluator
• Mathematica Policy Research, Inc.

6
Original National Cash Counseling Demonstration
Overview

• Demonstration States
• Arkansas, Florida, New Jersey
• Study Populations
• Adults with disabilities (Ages 18-64)
• Elders (Ages 65)
• Florida only Children with developmental
  disabilities
• Feeder Programs
• Arkansas and New Jersey Medicaid personal care
  option programs
• Florida Medicaid 1915c Home and Community-Based
  long-term care waiver programs

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Why Did New Jersey Choose to Undertake this
Project ?

• Demographic Concerns
• Consumer dissatisfaction/agency limitations
• Cost control of Personal Care Assistant (PCA)
  services
• Support of informal caregivers
• Increase personal responsibility empower
  individuals and families
• Create greater flexibility in service delivery
• It is a values driven service system

8
Original and Expansion Cash Counseling States
9
Very Satisfied with Overall Care Arrangements
Percent
Non-Elderly Adults
Children
Elderly Adults






T C NJ
T C NJ
T C FL
T C AR
T C FL
T C AR
T C FL
, Significantly different from control group
at .05, .01 level, respectively.
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Had an Unmet Need for Help with Personal Care
Percent
Non-Elderly Adults
Children
Elderly Adults





T C NJ
T C FL
T C NJ
T C FL
T C AR
T C FL
T C AR
, Significantly different from control group
at .05, .01 level, respectively.
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Very Satisfied with Way Spending Life These Days
Percent
Non-Elderly Adults
Children
Elderly Adults







T C NJ
T C FL
T C NJ
T C FL
T C AR
T C FL
T C AR
, Significantly different from control group
at .05, .01 level, respectively.
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Hallmarks of High Quality Cash Counseling
Programs

• Individual consumer-directed budgets
• Availability of trained, supportive counselors
• Ability to use representatives (surrogates)
• Flexibility in spending plans
• Individual/representative serves as legal
  employer
• Freedom to hire, train and fire employees
• Availability of Fiscal/Employer Agent services
• Mechanisms for Quality Assurance/Improvement
• Participants are involved in all aspects of the
  program

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What Can Potentially Be Covered?

• Employment of friends, relatives and others as
  caregivers
• Purchase of Goods and Services
• Assistive technology
• Household appliances
• House cleaning, laundry other services
• Purchase of Workers Compensation or Liability
  Insurance
• Brokering of Worker Benefits
• Items/services that meet personal care needs in
  creative ways (example Day Care)

14
Personal Preference the NJ Cash Counseling
Demonstration

• Some Details of ONE state CC program
• We cash out a Medicaid State Plan Personal Care
  Benefit
• Does not involve any other Medicaid services
  (waiver or other State Plan services)
• We have a contract for Fiscal/Employer Agent
  (booking services) which participants must use
  for payroll payment of non-labor invoices
• The same contractor also provides the counseling
  services
• Participants prepare a Cash Management Plan
  (CMP) which can be changed monthly, as necessary

15
Personal Preference the NJ Cash Counseling
Demonstration

• Continued
• Monthly allowance is computed using the following
  methodology
• of clinical hours assessed per week X current
  Medicaid PCA reimbursement rate 10
  administrative deduction (to cover F/EA
  counseling costs) Monthly Amount
• Example
• 25 hours (week) X 16.15 (rate) 403.75 X 4.33
  weeks (month) 1,748.24 - 174.83 (10)
• Monthly Grant is 1,573.41

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Personal Preference the NJ Cash Counseling
Demonstration

• Continued
• Representatives allowed and encouraged cant be
  paid!
• No one can overspend because F/EA will only pay
  workers and other invoices as contained in the
  approved CMP
• Cash (not to exceed 10 of total allowance) can
  be sent directly to participant for expenses like
  taxi fare, etc. if shown in CMP
• By having funds go to the F/EA, the participant
  does not have any income or asset that would
  disqualify or limit other benefits (SSI, Food
  Stamps, subsidized housing, etc.)

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Policy Implications

• Can increase access to necessary care
• Greatly improves quality of life (all ages)
• Caregivers also benefit greatly
• Consumers are prudent purchasers
• Participants establish and maintain better
  community connections

18
Questions/Want More Information?

• William A. B. Ditto, Director
• Division of Disability Services
• New Jersey Department of Human Services
• 222 South Warren Street, PO Box 700
• Trenton, NJ 08625-0700
• 609 292-7800
• William.Ditto_at_dhs.state.nj.us