IndependentChoices counseling and fiscal services were offered at no direct charge to consumers and provided them with support to self-direct their PAS. Counselors helped most consumers develop mandatory spending plans for the allowance and then were required to review those plans. IndependentChoices permitted counselors to authorize the inclusion of a pre-approved list of goods and services in the plan. State IndependentChoices staff reviewed all requests for goods and services not on the list to determine their relevance to promoting the consumers independence. Counselors also monitored whether the allowance was used appropriately. They did this by comparing worker timesheets and requests for other purchases against the spending plan, as well as by reviewing receipts for all purchases except those made with funds for incidental expenses (which were intended for purchases that could not be readily invoiced and which could not exceed 10 percent of the monthly allowance).
Counselors provided different types of advice and support to consumers. They were available to explain program rules to consumers and their families, help with program paperwork, and provide information about other public programs for which the consumer might be eligible. For consumers who decided to hire workers, counselors were available to train them on employer responsibilities such as how to hire, train, assess, and potentially fire workers; how to set an hourly wage, taking into account the cost of state and federal taxes and unemployment insurance; and how to keep and submit worker timesheets. Counselors occasionally helped consumers recruit workers or find emergency back-up workers and generally provided encouragement and support to consumers.
Counselors also monitored consumer well-being through monthly telephone calls and quarterly (later, semiannual) in-person visits. Program staff reported that information or impressions gathered during telephone calls sometimes prompted home visits, occasionally unannounced, to investigate potential problems in the home environment or with the use of the allowance. The regular quarterly home visits were reduced to semiannual ones when staff learned that most consumers did not need regular visits that frequently.
An optional fiscal service, or bookkeeper, was available, at no direct charge to the consumer, to write checks for goods and services included in the spending plan, provide monthly statements to consumers, and, for those who hired workers, manage payroll taxes and unemployment insurance and file documents required of the consumer as the employer of record. When the consumer wished to make a purchase, he or she requested a check be made out in the needed amount payable to a specific vendor. The bookkeeper cut the checks and sent them to the consumer, who, in turn, paid the worker or vendor.
Arkansas issued a formal solicitation to select organizations that could provide both counseling and bookkeeping, recognizing the need for staff providing these services to communicate frequently with each other. The state made awards to three organizations each covering a different region: a rehabilitation services agency, a provider of education and support services to children and adults, and an AAA that provided Medicare home health and Medicaid home care. The AAA withdrew from IndependentChoices a few months after enrollment began, citing cash flow difficulties. It was replaced by the already selected rehabilitation agency, which then served consumers in three-fourths of the state, with the other agency serving the largely rural, northeast quarter of the state. Counselors and bookkeepers were trained by IndependentChoices state program staff and received technical assistance from two consultants. Technical assistance with fiscal matters was particularly important, as neither agency had extensive experience in providing accounting or tax preparation services to the public. IndependentChoices hired a local certified public accountant to provide technical assistance, and the National Program Office also provided a consultant to audit accounting and tax preparation procedures in all three demonstration programs.11
Counseling/fiscal agencies received a monthly payment for each consumer. The payment for both counseling and fiscal services began at $115 per month for the first six months after enrollment, when consumer planning and training were expected to be most intense. It then fell at 6-month intervals until the 18th month after enrollment. Thereafter, the monthly payment per consumer was $75 per month. This monthly payment was meant to cover all the counseling/fiscal agencies' IndependentChoices administrative and consumer-specific costs. In the early months, when the caseload of consumers was small, agencies reported cash flow problems. However, IndependentChoices staff concluded that in the long run this monthly per-consumer payment overpaid agencies.12
Counselors, most of whom worked full-time on IndependentChoices, had many responsibilities, as already noted.13 They reported that they spent most of their time (20 percent or more in a typical week) on relatively few tasks, however: helping with spending plans, providing advice about worker payroll issues (like setting wages), and conducting administrative activities such as record keeping and contacting other program staff. Nevertheless, counselors felt that consumers valued a range of counseling services, including help with program paperwork, encouragement and support, and help with emergency back-up arrangements (Appendix Table A.7). Counselors reported that relatively few consumers (about 20, on average, in each caseload) required extensive monitoring due to concerns about their safety or ability to manage the allowance (Appendix Table A.8).14
A key concern about consumer direction is that, without home care agency supervision, consumers may be exploited or abused or their safety compromised--however, almost no such instances were identified among IndependentChoices consumers.15 Four counselors reported having about three consumers for whom they had evidence of self-neglect or for whom they had evidence of neglect by representatives or workers (Appendix Table A.9). That evidence prompted counselors to first consult with the state program staff, then conduct home visits (sometimes unannounced) and increase telephone monitoring until the problem was resolved. The program could also have required a consumer in this situation to take on a representative (or to change an existing one) or could return the consumer to agency services.