INDEPENDENT CHOICES: A National Symposium on Consumer-Direction and Self-Determination for the Elderly and Persons with Disabilities. Elder Preferences for Consumer Directed Community Care: Implications for Policy and Management

Mark Sciegaj, PhD, MPH
Brandeis University
A project funded by the Robert Wood Johnson Foundation

Why This Project

  • Importance of providing elders with opportunities to make meaningful choices.
  • Little empirical data on:
    • The extent of elder desire to participate in the management and supervision of services
    • How decisions/needs might vary by race/ethnicity or gender

Project Objectives

  • Develop and test measures of elder preferences for consumer direction
    • Service Control Scale
    • Worker Control Scale
    • Decision Control Scale
    • Desire for Information Scale
  • Explore possible sources of variation
    • Health/functional status scales
    • Service satisfaction scales
    • General locus of control scale
    • Availability of informal supports
    • Age
    • Gender
    • Race/ethnicity

Project Methods

  • Survey Development/Translation
  • Elder Recruitment
  • Interviewed 731 elders currently receiving care
    • 200 Chinese
    • 200 African American
    • 131 Latino
    • 200 White (Western European)
FINDINGS: RACIAL/ETHNIC LIFE SITUATION VARIATION
(n=731)
  African
American

(A)
Chinese
(B)
Latino
(C)
White
(D)
Living Alone*** 88% 61% 66% 80%
Health *** (Excellent-Good) 29% 11% 1.5% 22%
Functional Status*** 16.83
(B,C)
15.47
(A,D)
13.25
(A,D)
17.22
(B,C)
Age** 77.42
(B,C)
80.07
(A,D)
74.75
(A,D)
77.17
(B,C)
**<.01; ***<.001

 

FINDINGS: RACIAL/ETHNIC LIFE ATTITUDE VARIATION
(n=731)
  African
American

(A)
Chinese
(B)
Latino
(C)
White
(D)
Locus of Control*** 16.17
(B,C,D)
17.33
(A,C,D)
13.31
(A,B,D)
15.39
(A,B,C)
Service Control*** 1.03
(B,C,D)
.26
(A,C,D)
2.44
(A,B,D)
.73
(A,B,C)
Worker Control*** .92
(B,D)
.30
(A,C)
.73
(B,D)
.40
(A,C)
Decision Control** .72
(B,C,D)
.23
(A,D)
.29
(A,D)
.39
(A,B,C)
**<.01; ***<.001

New Approach 1: Cash & Counseling Model

In this approach, you will receive a monthly cash payment, along with some information, training, and advice to help you plan and manage your own care services. In this approach you can also get advice and training from a counselor to learn how to locate, hire, train, schedule, and manage your worker. If you choose, you can also learn how to fill out tax forms for the worker and perform other duties of being an employer. Or, you may have an expert fill out tax forms and do the payment part of the job for you.

New Approach 2: Social HMO Model

In this approach, the agency gives you a set budget based on your needs. Together with the agency you decide what services and what schedule you want. In this approach, the agency would then take the responsibility for finding and purchasing the services with you.

New Approach 3: Traditional Care Management Model

After speaking with you, the agency would decide what services and schedule you will get. In this approach, the agency would take the responsibility for choosing, finding and purchasing the services you need.

FINDINGS: RACIAL/ETHNIC PREFERENCES FOR CARE MANAGEMENT MODELS
(n=731)
  African
American
Chinese Latino White
Approach 1: Cash & Counseling 9% 3% 1.5% 8%
Approach 2: SHMO 17.9% 47% 7.7% 16%
Approach 3: Traditional Model 73.1% 50% 88.5% 78.6%

 

FINDINGS
(n=731)
Significant Items B
Preference for Care Management Model (1=Traditional Model)
Service control -.3527*
Living alone .5159*
Chinese -3.5848***
African American x Worker -3.894**
Chinese x Locus of Control .1305*
Latino x Worker -.9003**
Latino x Service 1.1814***
*<.05; **<.01; ***<.001

 

FINDINGS
(n=731)
Significant Items B
Cash and Counseling Model vs. SHMO Model (1=Cash and Counseling Model)
Chinese x Living alone -3.0369*
Decision control .3060*
*<.05; **<.01; ***<.001

 

CARE DELIVERY APPROACH COMPONENTS
  Approach 1
(C&C)
Approach 2
(SHMO)
Approach 3
(Traditional)
More Choice 76.2% 76.2% 67.2%
Easier to get help 73.8% 96.4% 97.5%
Easier to get advice 78.6% 92.3% 96.5%
Little worries 50% 87.6% 91.2%
Enough Information 71.4% 91.1% 94.8%

 

WANT AGENCY PARTICIPATION...
  Cash & Counseling Model
(n=42)
SHMO Model
(n=169)
Traditional CM Model
(n=520)
Schedule 35.7% 72.8% 80%
Recruit Worker 52.4% 80.5% 86%
Hire/Fire Worker 57.1% 74% 78.5%
Train Worker 61.9% 84% 88.3%
Pay Worker 61.9% 85.8% 87.9%

 

WANT COMPLETE CONTROL OVER...
  Cash & Counseling Model
(n=42)
SHMO Model
(n=169)
Traditional CM Model
(n=520)
Service selection 66% 27.8% 34.2%
Service decisions 69% 27.2% 33.8%
Service schedule 59.7% 19% 31.9%
Recruiting worker 31% 10.7% 9%
Hiring/firing worker 28.6% 10.1% 6.3%
Training worker 31% 8.3% 5%
Paying worker 26.2% 6.5% 2.3%

 

FINDINGS: RACIAL/ETHNIC PREFERENCES FOR CARE MANAGEMENT COMPONENTS
  African
American

(n=201)
Chinese
(n=200)
Latino
(n=131)
White
(n=201)
All
(n=731)
CASH & COUNSELING
Easier to get help 26% 4% 24% 18% 23%
Less to worry about 23% 4% 26% 8% 18%
SOCIAL HMO
Easier to get help 58% 49% 50% 56% 55%
Less to worry about 35% 47% 37% 31% 34%
TRADITIONAL CARE MANAGEMENT
Easier to get help 88% 51% 96% 88% 90%
Less to worry about 76% 51% 95% 79% 82%

Implications for Policy and Practice I

  • Heterogeneity within racial/ethnic elder groups
    • Programs and services should not make assumptions based on racial/ethnic group membership
  • Distributing risks for care maintenance and responsibilities
    • Programs and services should be flexible in terms of how they structure care management approaches

Implications for Policy and Practice II

  • Closing the gap between elder preferences and professional judgments
    • It is possible for care managers to solicit valid consumer perspectives on care preferences
  • Service Quality and Consumer Satisfaction
    • Addressing consumer preferences may have important and positive implications for quality and satisfaction