1. Barrett 1 Sandra Barrett Assistant Director

2. Barrett 2 THE CHOICE An Opportunity to Exchange Agency Personal Care Services for A Monthly Cash Allowance

3. Barrett 3 THE SOCIAL EXPERIMENT Classic experimental design with an experimental group receiving the allowance and a control group continuing to receive agency services – both groups are part of the evaluation

4. Barrett 4 THE SOCIAL MARKETING l Open Enrollment l Direct Mail Letters from the governor Letters to participants requesting referrals Notes with copies of news clippings Letters from participants with information about their experience l Public Service Announcements Television Radio l News Releases

5. Barrett 5 THE PLAYERS l Need personal care New to continuing ratio is 30.5% l Willing to participate l Able to make responsible care decisions or have a representative decision-maker 43% use a representative l 18 Years Old or Older 72% age 65 or Older 64% White/33% Black/3% Other 77% female/84% unmarried 62% live in rural area/68% live with others l Receiving Medicaid

6. Barrett 6 CLOSING THE DEAL l Request information l Enter into database l Telephone contact by enrollment staff l Enrollment home visit l Completed signed consent form

7. Barrett 7 SHOW ME THE MONEY! l Allowance Based on personal assistance needs Approximately $8.00 per hour Average allowance is $405.00 a month l Uses of Cash To meet personal care needs Hire personal care assistant Purchase items and services related to personal Care

8. Barrett 8 THE PAY OFF l 82% of the allowance is used to hire a PSA 74% hire a family member Friend/neighbor l 16% of the allowance is used to purchase items traditionally unavailable through Medicaid Personal care items; assistive devices; health and safety items 2% is saved Attractive Program Features

9. Barrett 9 THE SUPPORTING CAST l Bookkeeping Accept cash allowance Disperse cash according to plan Serve as employer agent Maintain employee files Pay payroll Withhold/pay taxes l Counseling Training Reassessments Monitoring Support Resource Develop cash Plan/answer questions

10. Barrett 10 THE OBSERVATIONS * Quantitative Evaluation l Participants and family members express a high level of satisfaction with this program. l 81% say the Program has improved their lives/No one says they are worse off l 99.76% are satisfied with their caregiver relationship l 96% would recommend the program to others. l 97% are happy with the time help is provided 50% receive help before 8 AM 65% receive help after 6 PM 77% receive help on weekends l Participants have more unpaid help than paid help * Preliminary Information Provided by MPR based on 9- month consumer survey – 885 Respondents

11. Barrett 11 THE OBSERVATIONS * Qualitative Study l Interviews were semi- structured, open-ended, face-to-face with consumers/reps, paid workers, counselors l Cross-cutting themes Family context of care Meaning of independence Community context of care Skills and qualities of caregivers Alternate uses of cash Previous agency experience l Widely shared values Flexibility/freedom Control/responsibility Getting out more Securing services from someone who cares about you Securing help that fits the rhythms of life Being about to hire family * Preliminary information based on 27 case studies completed by the University of Maryland Baltimore County

12. Barrett 12 THE OBSERVATIONS * Cost Evaluation l Arkansas Medicaid has spent no more per month on the Treatment Group than on the Control Group l Based on per hour of care delivered, IndependentChoices costs are nearly 10% lower than traditional agency-delivered services. l A higher percentage of each service dollar pays for direct service rather than administrative costs l Treatment Group receives more of the personal care service ordered by the MD l Control Group Beneficiaries did not receive personal assistance services in 40% of the months in which they were eligible compared to 9% for the Treatment Group l Institutional Costs were 18% higher for the Control Group * Comparison of Treatment and Control Groups Randomized During the First 2 Years of Operation

13. Barrett 13 THE LESSONS l Estimating Counseling/Fiscal Agency Reimbursement l Consumers are less interested in cash than previously believed l Consumers want choice and control over who, when and how care is provided l Disenrollments occur in the first few months l Lag time between enrollment and beginning self-direction vary l Consumer-directed models provide better access to authorized service l Consumers in Arkansas have been managing cash budgets responsibly WITHOUT ANY MAJOR INSTANCES OF FRAUD OR ABUSE

14. Barrett 14 THE VERDICT Consumer Direction Works Consumer Direction is Not For Everyone This Model Will Not Replace the Traditional Model Respect for Preferences Should Be a Major Consideration in Program Design and Training

15. Barrett 15 THE FUTURE l Arkansas is currently negotiating with CMS to amend the 1115 demonstration waiver terms and conditions to operate the program without randomization l The Cash and Counseling Program is proposing that CMS modify their definition of personal care to include goods and services in addition to human assistance

16. Barrett 16 IndependentChoices Sandra Barrett Arkansas Division of Aging and Adult Services PO Box 1437 Slot 1412 Little Rock AR 72203 501/682-2441 www.independentchoices.com