Consumer and Counselor Experiences in the Arkansas IndependentChoices Program. HOW CONSUMERS TOOK ADVANTAGE OF INCREASED FLEXIBILITY


Most consumers used the allowance to hire personal assistance workers. As noted, nearly 80 percent of consumers responding to the evaluation's follow-up interview hired a worker with the allowance during the nine months following enrollment. According to program records, consumers used most of the allowance (three-fourths) to pay workers. Of those who had paid personal assistance at home in the most recent two weeks they were at home before the evaluation's nine-month follow-up interview (simply referred to below as "the past two weeks") and who had used the allowance to hire a worker (just under 600 consumers), a third had hired more than one worker, although nonelderly consumers were more likely to have hired just one (Table 4, Appendix Table A.17 and Table A.18a).

TABLE 4: Assistance from Paid Workers Nine Months After Enrollment Among Those Who Used the Allowance to Hire a Worker
Age 65
Age 65
or Older
Had 1 Worker 67.8 81.8 61.4
Had 2 or More Workers 32.2 18.2 38.6
Helped With Houseworka 97.8 98.4 97.6
Helped With Personal Careb 94.8 95.2 94.7
Helped With Routine Health Carec 78.3 78.5 78.4
Provided Transportationd 58.7 75.8 51.0
At Least 1 Worker Lived With Consumer 39.1 28.9 43.7
At Least 1 Worker Did Not Live with Consumer 72.5 75.9 70.9
Helped on Weekends 77.0 74.3 78.2
Helped After 8:00 P.M. on Weekdays 64.2 61.0 65.7
Helped Before 8:00 A.M. on Weekdays 49.1 43.9 51.5
SOURCE: MPR nine-month interview conducted in Arkansas between August 1999 and January 2002.
NOTE: Table includes responses for 599 consumers (187 nonelderly and 412 elderly) in the evaluation treatment group who hired a worker with the monthly allowance during the nine months following random assignment and who had paid personal assistance in the most recent two weeks before the evaluation's nine-month follow-up interview during which the consumer was at home. Roughly five percent of consumers in this table had disenrolled from IndependentChoices and were likely reporting about PAS received from agency workers.
  1. Housework includes light housework, yard work, meal preparation, and shopping.
  2. Personal care includes bathing, transfer from bed, eating, and using the toilet.
  3. Routine health care includes taking medications, checking blood pressure, and doing exercises.
  4. Transportation includes both medical and nonmedical transportation.

Most consumers received between one and three hours of paid care per day, on average; their workers helped with a variety of tasks. Most frequently, workers helped with housework and personal care. However, many helped with routine health care (such as taking medications or checking blood pressure) or provided transportation (for example, for shopping, a service that Arkansas Medicaid did not permit agency workers to provide). Nonelderly consumers were markedly more likely than elderly ones to have help with transportation from a worker (Table 4, Appendix Table A.17). A substantial proportion of consumers (particularly elderly ones) hired someone who lived in their households, but the majority did not. As already noted however, most consumers made use of the flexibility of the allowance by hiring someone already known to them--a relative, former agency worker, or other acquaintance--rather than a stranger. A companion analysis found that three-quarters of workers hired by consumers also provided unpaid care. (See Dale et al. 2003b.)

Many consumers received help from paid workers at times when it is often difficult to get help from an agency. More than three-quarters had help on weekends, nearly two-thirds had help weekday evenings, and half had help early on weekday mornings (Table 4, Appendix Table A.17).

The flexibility of the IndependentChoices allowance permitted consumers to meet care needs in other ways as well. According to records the IndependentChoices bookkeepers kept for the eighth month after random assignment, nearly half of all consumers used a portion of their allowance to purchase personal care supplies, although such purchases used only about a tenth of the monthly allowance, on average. Roughly a third took advantage of the ability to get up to 10 percent of the allowance in cash for incidental expenses (just over $30 per month, on average). Anecdotally, the allowance was also used to purchase prescription and over-the- counter medications that the Medicaid pharmacy benefit did not cover. (Arkansas Medicaid covers only three prescriptions per month. If beneficiaries apply for an exception to this cap, they can receive six per month.) Few used the allowance to purchase assistive equipment or to make home or vehicle modifications, perhaps because these were costly and the benefit level was relatively low. However, nonelderly consumers were more likely than elderly consumes to modify their homes or purchase equipment. None used the allowance to purchase services from home care agencies (Table 5, Appendix Table A.18a, Table A.18b, and Table A.18c).

Counselor reports about the content of most consumer spending plans were largely consistent with bookkeeper records of spending in month 8. In addition, counselors were asked to describe particularly creative consumer purchases. Few such purchases were noted, but counselors did mention consumers using the allowance to pay for an Internet account to join an on-line support group and paying for professional housecleaning services (Appendix Table A.19 and Table A.20).

TABLE 5: Uses of the Allowance During Month 8
  Percentage Consumers with Type of Use
Age 65
Age 65
or Older
Paid A Worker Hired Directly By Consumer 88.3 87.7 88.6
Purchased Personal Care Suppliesa 48.7 51.8 47.4
Received Petty Cash Disbursementb 36.5 38.6 35.5
Purchased Community Servicesc 15.0 18.6 13.5
Purchased Equipmentd 4.3 8.2 2.6
Received Cash for Emergency Expensese 2.1 2.3 2.0
Purchased Home Modification 1.5 2.3 1.2
Purchased Vehicle Modification 0.6 0.0 0.8
Purchased Home Care Agency Services 0.0 0.0 0.0
Purchased Other Goods or Services 1.0 0.9 1.0
SOURCE: Arkansas IndependentChoices bookkeeper records for month 8 after random assignment.
NOTE: Table includes records for 718 consumers (220 nonelderly and 498 elderly) in the evaluation treatment group. Records include 32 for consumers who were still enrolled in IndependentChoices but who had no spending during the month.
  1. Supplies include diapers or pads to protect bedding, ostomy supplies, and feeding equipment.
  2. Consumers could request a check, limited to 10 percent of the allowance each month, for petty cash to pay for goods and services directly. Petty cash may have been used to purchase personal care supplies.
  3. Community services include day care, day programs, medical and nonmedical transportation, home- delivered meals, food from commercial establishments, congregate meals, chore services, grocery delivery, and laundry services.
  4. Equipment includes that to assist with mobility, transfer, bathing, communication, personal safety, meal preparation, or housekeeping.
  5. Emergency funds were used to pay for clothing, pest control, and utilities.

Although IndependentChoices spending rules were fairly flexible, consumers sometimes requested goods or services that were not permitted. Counselors reported having to deny the use of the allowance to purchase furniture and appliances or make home or vehicle modifications not related to disability, to pay utility bills, and to purchase recreational goods, services, cigarettes, and alcohol. For their part, 12 percent of consumers reported that program spending rules kept them from getting things that would have enhanced their independence, although only a handful of consumers actually disenrolled for that reason (Appendix Table A.6 and Table A.20).

As noted, counselors compared all check requests with spending plans and reviewed receipts for all consumer purchases (other than those incidental expenses) to ensure the program allowance was not misused. There was no evidence that consumers or their representatives materially misused the allowance. Five of seven counselors, however, reported that a small number of their consumers did purchase nonpermissable goods or services or had a worker do so for them. Three of seven counselors reported that a small number of consumers did not keep adequate spending records; the same three counselors also noted that a few consumers did not report worker hours in a timely way (Appendix Table A.21).22

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