Purpose: Supportive services at home are essential for older people with severe chronic impairments. Newer "consumer-directed" models of organizing home-based services rely heavily on service recipients rather than home care agencies to arrange and direct care at home. This study examined differences in service experience and outcomes between recipients over and under age 65 who direct their own services in one large Medicaid program. Design and Methods: A random sample of 1,095 recipients of In-Home Supportive Services in California was selected and interviewed by telephone. Interviews were conducted in English, Spanish, and three Asian languages; those with severe cognitive impairment were excluded from the study. Results: Findings indicate that although younger recipients embrace self-direction more enthusiastically than older ones, age differences are small on a majority of service outcomes. On average, older users embrace this model and manage within it much like younger users. Some differences emerge between the young-old (65-74) and old-old (75 ϩ ), but these are neither consistent nor determinative. Implications: Old age is far from an inevitable barrier to self-direction. As with other age groups, there are opportunities and obstacles to be addressed as this newer approach to home care is disseminated.

The past decade has produced a wave of new state programs that have introduced consumer direction into home-based services for persons with chronic impairments. Building upon earlier models developed for younger adults with physical disabilities, consumer-directed models are now being adapted to recipients of all ages with federal, state, and foundation support. These models shift responsibility for key service decisions from professionals to recipients and challenge the traditional home care agency model. Research evidence on the impact of consumer direction is just becoming available to policymakers. This paper reviews what we have learned from program and research activity so far, and what key issues and challenges remain.

On most dimensions of stress and satisfaction, consumer-directed workers report outcomes equal to or more positive than agency workers. Efforts to improve the work life of home-care workers should acknowledge the strengths of consumer-directed approaches and target all workers across models.

No abstract

Because a growing number of Americans receive long-term care at home, social workers face new challenges in referring clients to either agency-based or consumer-directed care models. Traditional agency-based home care often is considered safer for disabled clients because workers are professionally trained and monitored; newer, client-directed home care models offer more autonomy and flexibility. This study examined differences in worker abuse and neglect of clients across agency and consumer-directed models. Analyses showed that family ties, race or ethnicity, social supports, language compatibility, and provider turnover were more relevant than model of care to understanding worker abuse and neglect of clients. These findings suggest that clients in consumer-directed models are at no higher risk than agency clients. Implications are considered for social work practicitioners.