Home and Community-Based Care
Lessons from Abroad: AARP International Research in Home and Community - Based Care Initiatives
Research Report
March 2003
Sheraton Chicago Hotel and Towers, Chicago, IL Embassy Suites,
Mississippi River 1
March 14, 2003, 8:00 to 10:00 AM
Lessons from Abroad: AARP International Research in Home and Community-Based Care Initiatives
During the 2003 joint conference of the National Council on the Aging & the American Society on Aging in March in Chicago, Joshua Wiener of the Urban Institute presented initial findings from a project on consumer-directed home care in the Netherlands, the United Kingdom, and Germany. Speaking to an audience of international and national gerontologists, researchers, policymakers and service providers, Wiener drew out the implications of experiences in these countries for U.S. efforts to move toward greater consumer empowerment in long-term care. AARP's Public Policy Institute will publish a full report on findings in late August 2003.
Respondents Sandra Barrett, Assistant Director of the Arkansas Department of Human Services, and LaRhae Knatterud, Planning Director for the Aging Initiative of the Minnesota Department of Human Services, reacted to these findings from the perspective of two states in the U.S. actively developing innovative long-term care programs.
In introductory remarks, AARP Board Member Jack Brice underscored that we are all members of an interdependent world community, and that aging issues cross all national boundaries. One such issue, he said, is how to give older individuals more control over the type and quality of supportive services they receive in their homes and communities.
Consumer Choice
Consumers in Germany, the Netherlands, and the U.K. have a choice
between either agency-directed home care or consumer-directed
home care in which funds go directly to consumers. Among the
issues addressed in Wiener's presentation were:
- How long-term care services in general are funded in the three countries.
- How consumer-directed options are structured, e.g., whether consumers' use of funds are restricted.
- Who the beneficiaries are, and how widely consumer-directed options are used.
- Who provides the services, e.g., informal caregivers versus other independent providers.
- How the programs are administered, and how much help beneficiaries receive in handling management tasks.
- How workers are protected, and other labor force issues, such as labor force shortages.
- How quality is monitored.
- How costs are contained.
- How more consumer direction has impacted beneficiaries, both positively and negatively.
Consumer-Directed vs. Agency-Directed Programs
The extent of consumer control over services is a key issue in
the design of publicly funded home and community services
programs in Europe as well as in many U.S. states, observed
Wiener. Consumer-directed home care programs give consumers,
rather than home care agencies, control over who provides
services, when they are provided, and how these services are
delivered. Typically, in consumer-directed programs:
- The consumer is responsible for hiring, training, supervising, and firing the home care worker.
- The beneficiaries in some cases receive direct cash payments, enabling them to purchase the services they want.
In contrast, traditional home care programs rely on public or private agencies responsible for hiring and firing home care workers, scheduling and directing services, monitoring quality of care, disciplining workers if necessary, and paying workers and applicable payroll taxes. In this agency-directed model, clients can express preferences for services or workers, but have no formal control over them.
Conclusions
Wiener observed that consumer-directed care is growing in all
three countries. Not only do older clients participate but also
younger persons and persons with a wide range of disabilities.
Furthermore, all three countries have labor shortages, and family
caregivers play large roles as providers of in-home services.
Quality assurance mechanisms are generally minimal, in part
because of the extensive use of family caregivers. Compared with
states in the U.S. in which such programs have been implemented,
consumers are generally given less help in coping with the
administrative tasks, such as bookkeeping, inherent in consumer
direction. The programs vary, however, in the extent of consumer
control over the benefit and its administration, as well as in
administrative burdens experienced by consumers.
Barrett of Arkansas, the first state to implement a consumer-directed "cash and counseling" program in the United States, noted that the program offered beneficiaries more choice and control, expanded the workforce, provided income to family caregivers thereby benefiting the entire family, and provided tangible improvements in the approach to disability issues. Knatterud of Minnesota talked about the challenges of developing new approaches to quality assurance in consumer-directed models, as well as changing traditional patterns of service delivery.
The ensuing discussion centered on differing national and state perspectives on two of the most controversial issues surrounding consumer-directed models of home care: expectations about women's roles as family caregivers and as participants in the labor force, and the extent to which quality should be monitored.
Program/Speakers
Jack Brice, AARP Board Member
Opening
Remarks
Mary Jo Gibson, Senior Policy Advisor, AARP Public Policy
Institute
Introduction and Moderator
Joshua M. Wiener, Principal Research Associate, Urban
Institute
Presentation of Preliminary Research Findings
Sandra Barrett, Assistant Director of the Arkansas Dept. of Human
Services
Respondent
Larhae Knatterud, Planning Director, Minnesota Dept. of Human
Services
Respondent
Resources
AARP, Public Policy Institute
www.aarp.org/ppi
Urban Institute
www.urban.org
Arkansas, Division of Ageing and Adult Services
www.independentchoices.com
Minnesota, Aging Initiative of Department of Human Services
www.dhs.state.mn.us/agingint/default.htm
For more information, please contact:
Jessica Frank
AARP Office of International Affairs
Tel: +1 (212) 407-3710
Fax: +1 (212) 759-2277
Email: jefrank@aarp.org