Consumer-Directed Home- and Communtiy-Based Services Programs in Five Countries: Policy Issues for Older People and Government

A major innovation in long-term care for older people in the United States and Europe is the development of consumer-directed homecare programs. With government funds, these programs give consumers, rather than homecare agencies, control over who provides services and how these services are delivered. Typically, consumer-directed programs allow the consumer to hire, train, supervise, and fire the homecare worker. In some programs, beneficiaries receive cash payments enabling them to purchase the services they want. In contrast, traditional homecare programs rely on public or private agencies to supply and supervise the workers who serve program beneficiaries. The empowerment philosophy undergirding consumer-directed homecare has been slow to take hold among programs serving older people because of concerns about whether older people either want to direct or are capable of directing their own services. How to assure quality of care without agency oversight and accountability also has been a major concern. This article analyzes the development, design, and experience of consumer-- directed homecare programs in Austria, Germany, France, the Netherlands, and the United States. The U.S. states included in this study are California, Colorado, Kansas, Maine, Michigan, Oregon, Washington, and Wisconsin (Tilly and Wiener, 2000). In all of these countries or states, older people can and do participate in consumer-directed programs. Information for this article comes from two sources. First, we review available quantitative research on program outcomes for beneficiaries, their caregivers, workers, and quality of services from each country. The French and Dutch studies report on demonstration projects that preceded implementation of national programs (Simon and Martin, 1996; Miltenburg et al., 1996). Two other Dutch studies surveyed beneficiaries and workers about their experiences several years after implementation of the new national program (Baarveld et al., 1998; Woldringh and Ramakers, 1998). Similar surveys of program beneficiaries come from Austria, Germany, and the United States (Badelt et al., 1997; Runde et al.,1996; Benjamin et al., 1998). Second, we conducted interviews with representatives of government, beneficiaries, unions, and homecare agencies in each country. In total, forty-seven sets of interviews were conducted with government officials and key stakeholders: fourteen with government officials, ten with advocates for younger people with disabilities, six with advocates for older people, ten with homecare agency association staff, and seven with union officials. We asked the people interviewed to share their views of how consumer-directed programs worked in their countries or states. PROGRAM DESIGN In setting up their consumer-directed programs, each country had to make decisions in such key areas as administration, eligibility, resource allocation, covered services, financing, and cost containment. Table 1 provides detailed descriptions of the consumer-directed homeand community-based services programs in the five countries, based on information from the interviews. It should be noted that agency-- directed programs exist in all of these countries except Austria, which only has a consumer-- directed program. In the Netherlands and the United States, the agency-directed programs dominate the long-term-care systems, while consumer-directed programs dominate in France and Germany. Administration. The entities administering the consumer-directed programs are either subnational insurance funds (Austria, Germany, and the Netherlands) or state or local governments (France and the United States). In no country does the national government administer the entire program. The situation is particularly variable in the United States because states are not required to offer consumer-- directed programs. Functional eligibility. Every country uses some measure of ability to perform daily activities to assess whether applicants are eligible for benefits and what those benefits will be. …