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State Long-term Care Programs: Balancing Cost, Quality, and Access

Cashing Out Services


Sandra Barrett, Assistant Director, Arkansas Division of Aging and Adult Services, Little Rock, AR.

Cash and Counseling is a three-State (Arkansas, Florida and New Jersey) demonstration program co-sponsored by the Centers for Medicare & Medicare Services and the Robert Wood Johnson Foundation. The program offers beneficiaries cash rather than agency-based services. Participants may hire friends, relatives, and neighbors, with the exception of a spouse or legal guardian, to assist them with daily personal care services. Participants are not limited to specific services and may purchase other services or items related to their personal care.

Sandra Barrett, Director of the Arkansas program, reported that the State used direct mail, public service announcements, and news releases to reach eligible participants. Seventy-two percent of the actual enrollees were 65 years of age and older. Home visits are made to explain the program and enroll participants. The actual monthly allowance is based on the assessed needs for personal assistance and averages $405 a month. Ms. Barrett reported that 82 percent of the allowance is used to hire personal care attendants and 74 percent of the participants hire a family member or friend.

Arkansas selected one agency to provide counseling and to handle the bookkeeping functions. Only a few participants actually receive the cash with most enrolling because of the flexibility of the program; cash transactions are handled by a fiscal intermediary.

Participant surveys conducted nine months after enrollment found very high satisfaction. No significant instances of fraud or abuse have been found. Institutional costs were 18 percent higher for similar beneficiaries who were enrolled in the control group and received services through the traditional program.

Based on a per hour basis, costs for Cash and Counseling participants are almost 10 percent lower than agency-based services. However, Cash and Counseling participants receive a much higher proportion of planned services than consumers receiving care from an agency. This difference is attributed to worker shortages and "no-shows" for agency providers while consumer directed participants are better able to find and schedule workers.

Additional Resource

Burness Communications. Cash and counseling. College Park (MD): University of Maryland Center on Aging; 2002 Mar.

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