4 minute read

Consumer Directed Care

Implications And Future Issues

Consumer-directed care provides a long overdue opportunity for consumers to have more control over their management and delivery of their home care services and for home care programs to become more responsive to clients' needs and preferences. Nevertheless, it is not without significant implications for both consumers and state administrators wishing to implement consumer-directed care.

For consumers, this model offers them the chance for increased autonomy and choice with regard to their services. This may include more hours of service, more flexibility in scheduling those hours, more input into who provides those services, and possibly better quality of care. However, with this autonomy also comes responsibility. First and foremost, consumers must know what they want and need in terms of services and providers and must have realistic expectations about these. In addition, the employer-related responsibilities associated with consumer-directed care can take a great deal of time and energy. Recruiting and hiring care providers are difficult tasks, especially in this era of worker shortages and low wages for workers. And while the option of hiring family members or friends may alleviate this problem, consumers who do so may also be faced with the uncomfortable prospect of combining a business relationship (i.e., employer to employee) with their personal relationship. Consumers must also have reliable back-up plans for when independent providers are unable to show up for work.

For state officials, consumer-directed care also has some significant implications. Consumer-directed care has the potential to ease the provider shortage through the use of independent providers, but with the low wages and lack of benefits that are still likely to exist in such programs, retaining quality workers will remain a challenge. Enabling consumers to hire independent providers may also allow for better matches between clients and workers and consequently improved consumer satisfaction for both consumers and workers. However, as in the present long-term care system, the potential for fraud and abuse still exists, particularly if the state has a more limited role in quality monitoring.

Consumer-directed care also has the potential to reduce home care costs by utilizing independent providers, which cuts out the administrative overhead charged by home care agencies. Such savings may allow home care programs to serve additional clients. However, these cost savings may be offset by other costs associated with consumer-directed care, such as the cost of training clients as to their service management responsibilities. Many consumers may not have prior experience with such responsibilities, and thus may require some type of training or guidance.

Finally, there is the issue of liability. Despite the fact that there has been very little in the way of litigation against agencies or privately hired providers, this nonetheless is a significant concern for states (Lagoyda et al.; Kapp). States thinking about implementing consumer-directed care may also need to revisit their Nurse Practice Acts in order to allow for the delegation of nursing tasks to unlicensed personnel such as independent providers.

Consumer direction is still in its infancy within the world of aging services. There is still much research to be done, especially with regard to cost effectiveness and quality of care. The results of demonstrations such as the Cash and Counseling Demonstration and Independent Choices Programs are likely to provide some results that may provide further evidence of the viability of consumer-directed care as a long-term care policy option.



BATAVIA, A. I.; DEJONG, G.; and MCKNEW, L. B. "Toward a National Personal Assistance Program: The Independent Living Model of Long-Term Care for Persons with Disabilities." Journal of Health Politics, Policy, and Law 16 (1991): 523–545.

EUSTIS, N. N., and FISCHER, L. R. "Common Needs, Different Solutions? Younger and Older Home Care Clients." Generations 16 (1993): 17–22.

FLANAGAN, S. A., and GREEN, P. S. Consumer-Directed Personal Assistance Services: Key Operational Issues for State CD-PAS Programs Using Intermediary Service Organizations. Washington, D.C.: MEDSTAT, 1997.

KAPP, M. B. "Improving Choices Regarding Home Care Services: Legal Impediments and Empowerments." St. Louis University Public Law Review 10 (1991): 441–484.

LAGOYDA, R.; NADASH, P.; ROSENBERG, L.; and YATSCO, T. Survey of State Administrators: Consumer-Directed Home and Community-Based Services. Washington, D.C.: The National Council on the Aging, Inc., 1999.

LITVAK, S.; ZUKAS, H.; and HEUMANN, J. E. Attending to America: Personal Assistance for Independent Living. Berkeley, Calif.: World Institute on Disability, 1987.

MICCO, A.; HAMILTON, A. C. S.; MARTIN, M. J.; and MCEWAN, K. L. "Case Manager Attitudes Toward Client-Directed Care." Journal of Case Management 4 (1995): 95–101.

National Institute on Consumer-Directed Long-Term Services. Principles of Consumer-Directed Home and Community-Based Services. Washington, D.C.: The National Council on the Aging, Inc., 1996.

ROSENBAUM, S. Olmstead v. L.C.: Analysis and Implications for Medicaid Policy. Princeton, N.J.: Center for Health Care Strategies, 2000.

SCALA, M. A.; MAYBERRY, P. S.; and KUNKEL, S. R. "Consumer-Directed Home Care: Client Profiles and Service Challenges. Journal of Case Management 5 (1996): 91–98.

SCALA, M. A., and MAYBERRY, P. S. Consumer-Directed Home Services: Issues and Models. Oxford, Ohio: Scripps Gerontology Center, 1997.

SIMON-RUSINOWITZ, L.; MAHONEY, K. J.; DESMOND, S. M.; SHOOP, D. M.; SQUILLACE, M. R.; and FAY, R. A. "Determining Consumer Preferences for a Cash Option: Arkansas Survey Results." Health Care Financing Review 19 (1997): 73–96.

Additional topics

Medicine EncyclopediaAging Healthy - Part 1Consumer Directed Care - Which Services Do Consumers Direct?, What Does Service Management Involve?, History Of And Trends Toward Consumer-directed Care