1. What is Participant Direction?

Participant-directed services are home and community-based services that help people of all ages across all types of disabilities maintain their independence and determine for themselves what mix of personal assistance supports and services work best for them. Participant-directed services are sometimes referred to as consumer-directed or self-directed services.

2. Are there variations in the design of Participant-Directed programs?

Participant direction has two basic features, each with a number of variations. The more limited form of participant direction—which the Centers for Medicare & Medicaid Services (CMS) refer to as “employer authority”—enables individuals to hire, dismiss, and supervise individual workers. The comprehensive model—which CMS refers to as “budget authority”—provides participants with a flexible budget to purchase a range of goods and services to meet their needs. Within each of the two basic participant direction features—employer authority and budget authority—policymakers and program administrators have to make several important design decisions, such as use of representatives, participant’s status as “Employer” or “Co-Employer” and what supports are provided including the type of financial management services.

3. What are the benefits of participant direction to enrollees?

Participant direction offers more control, more flexibility, and more independence to people who receive personal assistance services at home.

Control: Participant direction lets participants decide who provides their services, when the services are delivered, and what assistance they need.

Flexibility: Participant direction lets participants buy the things they really need, when they need them.

Independence: Participant direction helps participants who need daily assistance maintain their independence at home.

4. What types of guidance and counseling can a participant receive?

In addition to financial management services support (described in the next question), participants receive counseling services which take the place of traditional case management services. States use a variety of terms to describe the counselor’s role, including support broker, service coordinator, flexible case manager, consultant, advisor, and community guide. Counselors must be able to work with a wide range of participant skill sets, practice person-centered planning, and assist individuals to make informed choices that are consistent with their needs and will help them achieve their goals.

In addition, participants may elect to use a representative to assist them with the different elements of participant direction.

5. What are financial management services and how do they help the participant?

There are different forms of financial management services used by programs to support the participant as they self direct. The primary duties of a Financial Management Services Agency (FMSA) are:

• Make financial transactions on behalf of participant directing individuals in accordance with spending plans, authorizations and/or program rules. This could include paying workers, agencies, or other goods and services vendors
• Generate reports for individuals and program administrative agencies showing financial transactions, spending plan data and other information as applicable to the program

For more info please see FMS conference materials

6. Can participants purchase whatever goods they want? Can participants hire whomever they want?

States vary with regard to the items that participants may purchase with funds from their individual budget. CMS guidance for the purchase of goods and services states that purchases must:
… address an identified need in the service plan (including improving and maintaining the participant’s opportunities for full membership in the community) and meet the following requirements: the item or service would decrease the need for other Medicaid services; AND/OR promote inclusion in the community; AND/OR increase the participant’s safety in the home environment; AND, the participant does not have the funds to purchase the item or service or the item or service is not available through another source.

States also differ in who the participant can hire. Some states require background checks or set limits on hiring legally liable family members.

Does having the participant direction option increase participants' demands for services?

Participant direction does not increase the need for personal care. Some people, however, would forgo services if they had to use an agency. Sometimes the agencies cannot keep up with the labor demands and are unable to send workers to provide services. Keep in mind that we're talking about very personal services - bathing, dressing, cooking, and eating, and some people feel uncomfortable getting those kinds of services from strangers. Participant direction gives these people an alternative to receiving traditional provider-driven services and allows them to access personal care services from people they choose and trust. Under participant direction more people may be accessing the services that they were assessed as needing. Some states, however, have demonstrated reductions in nursing home usage as high as 18% as a result of participant directed options.

1. How is Cash & Counseling Related to the Participant Directed Services?

Cash & Counseling (C&C) is the project name for the demonstration and replication projects supported by the Robert Wood Johnson Foundation (RWJF) and the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE), the Retirement Research Foundation (RRF), and the Administration on Aging (AoA).The term "Cash & Counseling" is used to describe a specific participant direction model that offers participants maximum flexibility and an individual budget. The Cash & Counceling Vision Statement is available for download here.

2. Do states need waivers to operate a Participant Directed Program?

In 2007, section 6087 or 1915(j) titled “Self-Directed Personal Assistance Services Program Option (Cash & Counseling)” made it possible for states to develop PD Programs with out waivers. State participation in this provision is optional. Please continue to check our Current News and Publications & Resources for updates on the DRA.

Q. What programs exist to support PD?

AoA’s Community Living Program (CLP) funds states to develop participant directed programs that help individuals who are at risk of being admitted to a nursing home to remain at home through the provision of home and community-based services and supports. The CLP grants are administered through the State Units on Aging (SUAs), in partnership with Area Agencies on Aging (AAAs) and in collaboration with community service providers, and other key long-term care stakeholders. This program began in 2007 and was continued in 2008 and 2009.

The Veteran’s Health Administration partnered with AoA to offer the Veteran’s Directed Home and Community-Based Services (VDHCBS) program through the Community Living Program beginning in 2008.

http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/NHD/index.aspx#grantees

What resources are available to help explain all of the program elements of participant direction?

Developing and Implementing Self-Direction Programs and Policies: A Handbook was developed to provide state staff, policymakers, service providers, program participants, and other stakeholders with a single comprehensive source of information about self-direction programs and policies. Its primary purpose is to explain how States can increase program participants’ choice of and control over their services and supports. The Handbook is edited regularly and available online.