A normative analysis of home care goals

Home- and community-based services (HCBS) can contribute to full social and economic participation in society by people with disabilities. Of 16 client-level and system-level HCBS goals, three are emphasized; targeting the neediest, individual choice, and strengthening informal systems. Projections are made of how selected goals would play out under two different resource conditions. Efforts to expand and strengthen HCBS involve trade-offs--for example, increasing access and comprehensiveness undermines affordability, increased targeting to the neediest means less access for those below the need threshold, and expanding client choice raises fears about trade-offs with quality and effectiveness. Targeting and choice seem to represent central and compatible goals for the design of an HCBS system. The combination minimizes trade-offs with affordability and enhances political feasibility.