Consumer and Counselor Experiences in the Arkansas IndependentChoices Program. CONSUMER MANAGEMENT OF PROGRAM RESPONSIBILITIES


IndependentChoices allowed consumers to designate representatives to help them: decide how to spend the allowance (for example, whether to hire a worker, who to hire, and how much to pay); supervise workers, monitor care provided, sign worker timesheets; and handle program paperwork. Program staff reported that when consumers were not able to make decisions, representatives generally sought to learn consumers' preferences. When consumers could make decisions, the consumer and the representative shared benefit-management tasks. IndependentChoices counselors reported that, when a consumer named a representative, they nevertheless worked with both the consumer and the representative and stressed that the consumer was "the boss."

When they enrolled, 41 percent of consumers (26 percent of nonelderly and 47 percent of elderly consumers) had designated a representative to help them manage the IndependentChoices allowance (Appendix Table A.2). Most consumers who required representatives identified that need themselves when enrollment nurses asked them about help they were already getting. Counselors occasionally first brought up the subject of a representative after the consumer was assigned to the treatment group, if work with the consumer was progressing poorly (for example, was having difficulty developing an allowance spending plan). Representatives tended to be relatives who had already been helping consumers (for example, with financial matters). In a few cases, a consumer's need for a representative decreased over time. As the consumer became more secure in the employer role, he or she then took over benefit management from the representative.

Counselors reported that, for about three-fourths of consumers using representatives, the representatives followed consumers' wishes and acted in their best interest. Only for a fraction of consumers (about one percent) did counselors believe that the representative might have been unsuitable or that the representative's interests or wishes diverged substantially from those of the consumer (Appendix Table A.11). In that case, the counselor asked the consumer to name another representative.

Nearly all consumers took advantage of IndependentChoices support services and nearly all doing so found these services to be helpful. About 95 percent reported using the optional bookkeeping services.18 Most consumers reported receiving assistance from counselors with developing spending plans and with hiring and training workers, primarily during the first few months after enrollment, when consumers were not yet familiar with the program. During the first four months after enrollment, more than 80 percent reported getting help from counselors developing spending plans, more than 80 percent reported receiving written materials or advice about recruiting workers, and just over half reported that they got advice about how to train workers. Counselor assistance was also available as consumers continued in IndependentChoices. Nonelderly consumers were somewhat more likely than their elderly counterparts to report getting help revising spending plans or with recruiting during months 5 through 9.19 Nearly all those getting these types of help reported that it was useful. Consumers found counselors' explanations of program rules and help clarifying spending plan priorities particularly useful (Table 2, Appendix Table A.12a, Table A.12b, Table A.12c, and Table A.13).

TABLE 2: Use of, and Satisfaction with, IndependentChoices Services
Of Users, Percentage
Finding It Useful
Used Fiscal Services During First 9 Months 94.7 98.0
Had Help Developing Spending Plan During First 4 Months 83.3 96.3
Received Written Materials or Advice About Recruiting Workers During First 4 Months 80.9 96.2
Received Advice About Training Workers During First 4 Months 54.2 80.0
SOURCE: MPR four-month interview conducted in Arkansas between March 1999 and August 2001 and nine-month interview conducted between August 1999 and January 2002. NOTE: Table includes responses to four-month interview for 924 consumers in the evaluation treatment group and responses to nine-month interview for 885 consumers in the evaluation treatment group. "First 9" and "first 4" months refer to the months following random assignment to the treatment group.

About 85 percent of consumers assigned to receive the IndependentChoices allowance had received it for at least one month by the time of the evaluation's nine- month follow-up interview.20 Nearly 80 percent of consumers reported that they hired at least one worker with the allowance within the first nine months of enrolling in IndependentChoices; most had hired a worker in the first four months. A tenth, however, tried to hire a worker but were not able to. Program staff reported that consumers who had not identified a family member or friend as a potential worker at the time of enrollment had difficulty hiring a worker. Indeed, 80 percent of consumers tried to hire family members as workers, and most were successful; more than three-quarters of all consumers who hired a worker hired a family member. By comparison, only 20 percent hired acquaintances (friends, neighbors, or fellow church members), while 7 percent hired home care agency workers.21 Nonelderly consumers were much more likely to hire an acquaintance: 30 percent, versus 16 percent of elderly consumers. Another tenth of consumers reported that they did not try to hire a worker, perhaps because they chose to meet their personal assistance needs in other ways or disenrolled from IndependentChoices before attempting to recruit one (Table 3, Appendix Table A.14 and Table A.15).

TABLE 3: Recruiting and Training Workers During the First Nine Months After Random Assignment to the Treatment Group
Hired a worker 79.3
Tried to hire a worker, but did not 10.9
Did not try to hire a worker 9.7
Tried to hire  
-- Family member 80.5
-- Friend, neighbor, or church member 30.1
-- Home care agency worker 14.8
Asked family or friend to recommend worker 19.4
Posted or consulted advertisements 5.1
Contacted employment agency 3.3
Hired family member 77.2
Hired friend, neighbor, or church member 20.1
Hired former home care agency worker 7.2
Hired worker recommended by family or friend 6.1
Posted or consulted advertisement 3.2
Contacted employment agency 0.4
SOURCE: MPR four-month interview conducted in Arkansas between March 1999 and August 2001 and nine-month interview conducted between August 1999 and January 2002.
NOTE: Table includes responses for 914 consumers in the evaluation treatment group who responded to either the four-month or the nine-month interview and answered questions about hiring with the allowance.

Even among those who hired a worker, 20 percent reported that the task was hard and that the biggest difficulties were finding interested, qualified applicants and offering a high enough wage with the allowance (Appendix Table A.14). Consumers whose hires did not include any family members were more likely to have found hiring hard: 29 percent, compared with 17 percent of those who did hire family (not shown). Counselors reported that 11 percent of consumers also had serious problems with worker turnover (workers resigning or being fired) (Appendix Table A.16). Just five percent of consumers reported firing a worker hired with the allowance (not shown).

Although nearly 70 percent of consumers gave their workers written contracts or agreements to sign delineating worker responsibilities, few consumers (six percent) offered workers fringe benefits, most commonly free room or food. Health insurance was never offered (not shown). The paucity of fringe benefits was likely a result of the low level of the monthly allowance, the fact that most workers were family members, and the fact that fringe benefits are rare in part-time jobs. (A companion analysis based on a survey of workers indicates that only roughly 20 percent of workers for control group members, almost all of whom were employed by agencies, received fringe benefits. See Dale et al. 2003a.)

A third of consumers who hired a worker provided training for them, almost all by showing the worker how to carry out tasks. A small number arranged for training outside the home. Few consumers who provided training (under 10 percent) found the task difficult (Appendix Table A.14).

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