Consumer Directed Care

Not surprisingly, several different models of consumer-directed care have been developed over the years in order to accommodate consumers' differing needs, abilities, and preferences regarding their involvement in the management of their services. These models, going from most to least consumer-directed, are described below.

In the direct pay/cash and counseling program, consumers manage both the funding and the delivery of their services. Consumers may receive an actual check or vouchers to use to pay for their care, and they handle all the employer-related responsibilities. Consumers also are the employer of record, accepting all liability for personal injury (to themselves and their workers) and for employment tax and benefits for their workers.

In the supportive intermediary model, consumers handle as many of the employer-related responsibilities as they want to or are capable of and are the employer of record. An intermediary agency (either the state/program or a third-party agency contracted by the state/program) provides support or assistance with the tasks the consumer is unable or unwilling to assume. Most often this assistance takes the form of doing payroll, taxes, and paperwork for consumers. However, other supports include recruitment assistance, criminal background checks on workers, training workers, and more.

In the last model, self-directed care management/agency with choice, the state/program (or the home care agency) handles the money and most of the service management responsibilities (recruiting, interviewing, hiring, training, paying, and firing workers) and is the employer of record. Consumers may interview and select workers (who are sent out from agencies) and provide performance feedback to workers and agencies.

Finally, relatively few programs offer consumers a range of these models to choose from within a single home care program—what is known as a spectrum intermediary model (Flanagan and Green). This allows consumers to choose the level of responsibility that they wish to assume, rather than force them into a traditional home care program if they do not wish to handle all of the responsibilities associated with one consumer-directed model.