THE CHOICE

1
Sandra Barrett Assistant Director
2
THE CHOICE

• An Opportunity
• to 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

• 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

• 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

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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
Attractive Program Features

• 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

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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 OBSERVATIONSQuantitative 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 OBSERVATIONSQualitative 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 OBSERVATIONSCost 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 Barrett
• Arkansas Division of Aging and Adult Services
• PO Box 1437 Slot 1412
• Little Rock AR 72203
• 501/682-2441
• www.independentchoices.com