U.S. Department of Health and Human Services

In-Home Supportive Services for the Elderly and Disabled: A Comparison of Client-Directed and Professional Management Models of Service Delivery

Non-Technical Summary Report

Executive Summary

Pamela Doty, Ph.D.
U.S Department of Health and Human Services

A.E. Benjamin, Ph.D., Ruth E. Matthias, Ph.D., and Todd M. Franke
University of California, Los Angeles

April 1999

This report was prepared under contract #HHS-100-94-0022 between the U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation (ASPE), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the University of California, Los Angeles. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The Project Officer was Pamela Doty.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

This report is a non-technical summary of the findings and policy implications of a research study comparing alternative models of delivering in-home supportive services to the elderly and disabled. The full technical report: "Comparing Client-Directed and Agency Models for Providing Supportive Services at Home," Final Report under HHS Contract #100-94-0022, is authored by A.E. Benjamin (Principal Investigator), Ruth E. Mathias (Project Director) and Todd Franke, of the School of Public and Social Research, University of California, Los Angeles with the assistance of Linda Mills, Yeheskel Hansenfeld, Lisa Matras, Ellen Park (UCLA) and Susan Stoddard and Lewis Kraus (InfoUse, San Francisco, CA). DHHS Project Officer: Pamela Doty. Copies of the full technical report may be obtained from the US DHHS Office of Disability, Aging and Long-Term Care Policy, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201; fax 202-401-7733; email DALTCP@osaspe.dhhs.gov.

Elderly and younger persons with disabilities who require help from others to perform many of the most ordinary activities of daily living are said to require "long-term care." These services, when provided in the home or other non-institutional settings, may be termed personal assistance services (PAS), home and community-based services (HCBS), or in-home supportive services (IHSS). This report presents the findings of a study comparing alternative approaches to delivering such services. The purpose of the study was to determine whether there are significant differences, on a wide range of outcome indicators, when publicly-funded supportive services for the elderly and disabled are provided through a consumer-directed (CD) as compared to a professional management (PM) model of service financing and delivery.

The defining characteristic of a consumer-directed model (CDM) of service delivery is that it allows persons with disabilities considerable choice and control over how supportive services are provided and by whom. In particular, a CDM allows public program clients to have an employer/employee relationship with their individual service providers, who are referred to by a variety of different terms such as home care workers, in-home aides, personal assistants, or personal care attendants. A fully developed CDM places virtually no restrictions with regard to clients' hiring decisions; that is, clients may employ anyone they choose, including family members. A CDM may make training opportunities for workers available, but does not limit client choice of workers by imposing training and credentialing requirements as conditions of employment. A CDM typically involves clients in the process of paying workers, at a minimum by having clients sign time-sheets, without having clients take on full employer responsibilities. The most common approach is for a program operating under a CDM to arrange for a fiscal services contractor to process time-sheets and paychecks and ensure that payments to client-directed workers do not exceed program authorized limits.

In contrast, a professional management model (PMM) requires that the individual workers who deliver services to clients be employed by organizations, typically home health or home care agencies, whose characteristics and structure are defined and regulated by licensing or other laws and by contractual arrangement with one or more public financing programs. As employers, the home care agencies and the professionals who run them assume responsibility for and authority over hiring and managing the front-line service providers. Agency methods of recruiting workers make it unlikely that clients will be related to or even previously acquainted with the workers assigned to service them, even when the possibility of an aide being assigned to work for a family member is not specifically banned (which it often is). Public programs reimburse agencies at negotiated rates which include a percentage for agency administrative overhead in addition to the direct costs of service provision. Agency overhead costs are intended to cover the management-related expenses of training, supervising, and scheduling workers as well as pay-rolling functions.

Proponents of each of these models of service delivery argue that client and worker outcomes are better under their preferred approach. That is, they believe that the same resource or benefit levels (e.g., number of service hours) allocated to clients with similar levels of disability and therefore similar service needs are likely to produce different results when delivered through a consumer-directed or professional management model or when clients in the CDM hire family members or others as their aides. Proponents of consumer-direction argue that the consumer-directed model is more likely to produce better outcomes because it offers consumers more choice and control. Proponents of the professional management model argue that this model is more likely to produce better outcomes because, in their view, professional supervision is necessary for quality assurance.

Accordingly, the purpose of the research was to find out whether these alternative modes of service delivery were more, less, or equally likely to bring about a variety of positive outcomes. These outcomes include greater client satisfaction with services, greater client empowerment (i.e., clients' sense that program services enable them to live more normal lives despite their disabilities), improved health status, greater reliability and continuity of service (i.e., lower frequency of worker absenteeism and turnover), greater ability to attract qualified workers, and higher job satisfaction for workers. The research also examined whether one or another of the service delivery models was more likely to produce negative outcomes such as more reported incidents of abuse, neglect, or mistreatment, a higher level of concern for safety among clients, more unmet needs (client reports that services are inadequate to meet their needs for assistance), or poor working conditions for home care workers.

In recent years, there has been a growing push for consumer-direction among client advocates, especially those who represent younger adults with disabilities. (DeJong, Batavia, and McKnew, 1992; Simon-Rusinowitz and Hofland, 1993). This movement has led policymakers at all levels of government to consider designing new programs based entirely on the CDM and/or to explore ways of incorporating an optional CDM into programs which currently use a PMM exclusively. (Nadash, Rosenberg, and Yatsco, 1999). Neither of the two models is new; examples of public programs organized along CDM or PMM lines have existed for many years (Litvak and Kennedy, 1991; Flanagan and Green, 1994; Cameron and Firman, 1995; Sabatino and Litvak, 1995; Flanagan and Green, 1997). Various advantages and disadvantages have long been claimed for each model by its proponents, but little systematic evidence has been available to judge the merits of these arguments (Doty, Kasper and Litvak, 1996; Feinberg and Whitlach, 1996; Feinberg and Whitlach, 1998) . To begin to fill this knowledge gap, the U.S. Department of Health and Human Services funded the University of California at Los Angeles (UCLA) to compare outcomes of alternative service delivery models in the context of California's In-Home Supportive Services (IHSS) program. IHSS is one of the few state long-term care programs that provide client-directed as well as agency services to substantial numbers of clients, both older and younger, with mild, moderate, and severe disabilities resulting from a wide range of underlying medical conditions. Using California's IHSS as the research locus therefore permits a direct comparison of outcomes across the two models while controlling for what would otherwise be confounding variations in eligibility, coverage, and payment rules between two or more programs within a state or across states. The design of the present study also benefitted from previous research on the quality of services provided under the IHSS program that sponsored by the state of California (Barnes and Sutherland, 1995).

The UCLA study compared the CDM and PMM on a range of client and worker-related outcomes, using a sophisticated sample design and multi-variate analyses to adjust for variations in clients' severity of disability and other differences in client characteristics so as to isolate these effects from those attributable to the alternative service delivery models. Although both models had positive outcomes overall, the study's principal finding is that clients in the CDM had more desirable outcomes than clients in the PMM within three broadly defined areas: satisfaction with services, empowerment, and quality of life. No significant differences were found in outcomes between the two models in two other areas: client safety and unmet needs. Altogether, the CDM had significantly better outcomes on six of fourteen specific outcome measures. On none of the fourteen measures was the PMM associated with significantly better outcomes.

The study also compared outcomes for CDM clients who hired family members as paid workers with those of clients who employed non-family members. No differences were found with respect to the frequency of reported unmet needs or on quality of life measures. However, clients who hired family members had more desirable outcomes on some measures in the areas of safety, satisfaction with services, and empowerment. Specifically, clients whose aides were family members reported a greater sense of security, having more choice about how their aides performed various tasks, a stronger preference for directing their aides, and a closer rapport with their aides.

With respect to home care workers, the study found significant differences between the two models in pay and benefits. Workers in the PMM received, on average, higher hourly wages and were also more likely to receive health and other benefits from their jobs than workers in the CDM. A significantly higher percentage of CDM as compared to PMM workers had jobs in addition to their IHSS work. However, workers in both models reported generally high levels of job satisfaction and there were no significant differences between CDM and PMM workers on these measures. Results were mixed on measures of stress and burden. CDM workers reported better relationships with their clients and greater acceptance of assertiveness on the part of clients. However, PMM workers reported more positive emotional states and also reported experiencing less concern about client safety. Some of these differences appear to be related to the frequency of family members as workers in the CDM because family providers in the CDM were found to be more likely than non-family providers to report having close relationships with clients and to be more concerned about client safety.

The main conclusion of the report is that, whereas both the consumer-directed and professional management models of delivering supportive services to the aged and disabled produce positive client outcomes overall, the consumer-directed model outperforms the professional management model on several key measures of client satisfaction, empowerment, and quality of life. Critics of consumer-directed models of service delivery have expressed concerns about client safety under this model and have generally taken the view that consumer-direction should be restricted to a minority of clients (primarily younger adults) who social workers judge to be capable of hiring, firing and giving direction to their workers. This study provides no evidence in support of restricting availability of the consumer-directed model. Critics have also questioned the appropriateness of allowing public program clients to hire family members as providers. This study's findings support the option of hiring family members as providers because the data indicate that, on average, family providers are more likely to provide a higher quality of service than unrelated workers.