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Participant-Directed Services in Managed Long-Term Services and Supports Programs: A Five State Comparison

Publication Date



Participant-Directed Services in Managed Long-Term Services and Supports Programs: A Five State Comparison

Executive Summary

Mark Sciegaj
College of Health and Human Development, Penn State University

Suzanne Crisp, Casey DeLuca and Kevin J. Mahoney
Graduate School of Social Work, Boston College

August 23, 2013


Since 2004, the number of state Medicaid programs that have integrated health and long-term services and supports (LTSS) for elders and persons with disabilities through various types of managed care programs grew from eight to 16. During the same time period, the number of individuals receiving managed LTSS (MLTSS) increased from 105,000 to 389,000. Of the current 16 states that have MLTSS programs, 13 offer participant direction.

To gain a more thorough understanding of how MLTSS programs have implemented participant direction, researchers from the National Resource Center for Participant-Directed Services conducted an in-depth examination of participant-directed MLTSS (PD-MLTSS) programs in the following five states: Arizona, Massachusetts, New Mexico, Tennessee, and Texas. This examination revealed wide variation in:

  1. State requirements for PD-MLTSS: Two states had specific contract language and two others reported relying on policy and procedure manuals or handbooks for communicating their requirements for PD-MLTSS. The fifth state (Massachusetts) prefers to avoid detailed documents and communicates its expectations orally to the managed care organizations (MCOs). Massachusetts state officials feel this allows for a better exchange of ideas.

  2. How PD-MLTSS programs are developed and managed: Most of the MCOs in this study are given broad discretion in developing and managing PD-MLTSS service delivery options. This discretion means that there is variance in the features and flexibility of the PD-MLTSS program and the definition of "participant direction."

  3. The numbers of participants enrolled in PD-MLTSS: Only Tennessee has clear enrollment expectations, and a review of the state's enrollment targets illustrates how the program has grown. Without such expectations, even states with a historical commitment to participant direction leave the future growth of PD-MLTSS to the discretion of MCOs (which may or may not be committed to such growth).

  4. How PD-MLTSS quality is monitored: While all of the states required formal quality assurance and improvement plans prior to MLTSS implementation, few reported having specific quality performance measures or quality monitoring procedures for PD-MLTSS.

  5. The roles and functions of financial management service (FMS) agencies: The FMS agencies across the five states fulfill the basic payment, management, and reporting functions. However, states varied in other types of FMS support (e.g., ongoing information and assistance, assistance with worker recruitment, providing training for participants and/or workers, etc.).

The implications of this five state examination include:

  1. States play a major role in how PD-MLTSS is operationalized: How PD-MLTSS is shaped and operated in a given state is determined by either the presence or absence of state policies and procedures that emphasize participant direction in MLTSS.

  2. There are examples of how the principles of managed care and participant direction can be integrated: Well-designed PD-MLTSS programs can achieve the common goals of MLTSS and participant direction: (1) the improvement of participant health and well-being; (2) the improvement of service satisfaction; and (3) the reduction of service costs).

  3. Training for MCO service coordinators is vital: The low take-up rates for PD-MLTSS across the five states suggest the need for additional professional development training in participant direction. This observation was confirmed by a number of key informants across the five states. Throughout the five states the number and type of MCO staff varied greatly. Too often, MCO staff training was restricted to the mechanics of presenting the participant direction option to the member.

  4. How PD-MLTSS is presented to participants is critical: Respondents across a couple of the states remarked that participants are overwhelmed with materials about participant direction and tend to be apprehensive. While each state required MCOs to have person-centered processes in place, it does not appear that all MCO service coordinators receive training on person-centered planning or participant direction that could reduce the participant's sense of feeling overwhelmed. Beyond training of professional staff, the use of peers is an undeveloped resource that could help people become comfortable with PD-LTSS.

  5. PD-MLTSS would benefit from clarity in the roles and responsibilities of the different PD-MLTSS supports: In some states, this lack of clarity is due to the lack of specificity in state contracts with MCOs (or absence of policy and procedure manuals) regarding participant direction, participant-directed services, and necessary supportive services such as FMS. This lack of specificity can lead to important support functions not being readily available.

  6. FMS is a key PD-MLTSS support element: The five states used the FMS agencies in various ways. In all states, the FMS provided traditional financial management support, but some states had the FMS provide other types of support as well.

  7. MCOs would benefit from increased engagement from participants: The idea of involving participants in the design and evaluation of LTSS has been promoted for decades. Each of the states and MCOs in this study described various ways participant involvement is sought (e.g., public forums, town halls, member surveys, and advisory boards). However only New Mexico reported participant input specifically focused on PD-MLTSS.

The Full Report is also available from the DALTCP website ( or directly at