Comparing consumer-directed and agency models for providing supportive services at home

To examine the service experiences and outcomes of low-income Medicaid beneficiaries with disabilities under two different models for organizing home-based personal assistance services: agency-directed and consumer-directed.

A survey of a random sample of 1,095 clients, age 18 and over, who receive services in California's In-Home Supportive Services (IHSS) program funded primarily by Medicaid. Other data were obtained from the California Management and Payrolling System (CMIPS).

The sample was stratified by service model (agency-directed or consumer-directed), client age (over or under age 65), and severity. Data were collected on client demographics, condition/functional status, and supportive service experience. Outcome measures were developed in three areas: safety, unmet need, and service satisfaction. Factor analysis was used to reduce multiple outcome measures to nine dimensions. Multiple regression analysis was used to assess the effect of service model on each outcome dimension, taking into account the client-provider relationship, client demographics, and case mix.

Recipients of IHSS services as of mid-1996 were interviewed by telephone. The survey was conducted in late 1996 and early 1997.

On various outcomes, recipients in the consumer-directed model report more positive outcomes than those in the agency model, or they report no difference. Statistically significant differences emerge on recipient safety, unmet needs, and service satisfaction. A family member present as a paid provider is also associated with more positive reported outcomes within the consumer-directed model, but model differences persist even when this is taken into account. Although both models have strengths and weaknesses, from a recipient perspective the consumer-directed model is associated with more positive outcomes.

Although health professionals have expressed concerns about the capacity of consumer direction to assure quality, particularly with respect to safety, meeting unmet needs, and technical quality, our findings suggest that the consumer-directed service model is a viable alternative to the agency model. Because public programs are under growing pressure to address the long-term care needs of low-income people of all ages with disabilities, the Medicaid personal assistance benefit needs to be reassessed in light of these findings. Consumer-directed models may offer a less elaborate and possibly less costly option for organizing supportive services at home. Study limitations may limit the generalizability of these findings. This was a natural experiment, in which only some counties offered both service models and counties assigned recipients to a service model. The use of a telephone survey excluded important recipient subsets, notably people with severe cognitive impairments. A more definitive study would include direct observations as well as survey approaches.