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International Consumer-Directed Programs: Implications for Beneficiaries, Caregivers, and Workers. Jane Tilly and Joshua Wiener supported by The Commonwealth Fund. Research Design. Case studies of programs 2+ years old serving 65+. Austria, France, Germany, Netherlands, US.

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international consumer directed programs implications for beneficiaries caregivers and workers

International Consumer-Directed Programs: Implications for Beneficiaries, Caregivers, and Workers

Jane Tilly and Joshua Wiener

supported by The Commonwealth Fund

research design
Research Design
  • Case studies of programs 2+ years old serving 65+.
  • Austria, France, Germany, Netherlands, US.
  • Interviews with government, beneficiary, agency, and worker representatives.
overview of programs
Overview of Programs
  • Eligibility: assessment of ADLs & IADLs. Austria & Germany -social insurance, Netherlands - non-means-tested. France & US - means-tested.
  • Benefits: limited by hours of care or dollar limits.
  • Program scope: country-wide in Austria, Germany, Netherlands, & France. Varies by state in US.
overview cont
Overview (cont.)
  • Consumers: can receive assistance with management tasks in most countries.
  • Workers: can hire family, generally with exception of spouses. Individual workers often receive fewer fringe benefits than agency workers.
  • Quality assurance: generally minimal monitoring.
who wants to direct services
Who wants to direct services?
  • Govt & consumers: all ages who are assertive w/ informal support.
  • Agencies & unions: older people can’t handle CD.
  • People w/ CI need assistance.
how does cd affect beneficiaries
How does CD affect Beneficiaries?
  • Govt. & consumers: CD consumers have more control and get better quality; agencies are unresponsive due to scheduling & staffing.
  • Agencies & unions: quality of CD and agencies equivalent; CD increases consumer burden.
how does cd affect caregivers
How does CD affect Caregivers?
  • Beneficiaries often hire family workers. These workers provide better care but are overburdened.
  • Agencies and unions: family workers need same training, benefits, and oversight.
  • Some agencies believe that hiring family is not good policy.
what are workers experiences in cd
What are workers’ experiences in CD?
  • Individual workers have better relationships w/ consumers than agency workers.
  • Individual workers have more control over their work, schedules, and tasks. Some union disagreed.
  • Individual workers are isolated, lack backup and fringe benefits.
what about quality and fraud
What about quality and fraud?
  • No reports of major quality or fraud problems in CD.
  • Govt. & consumers: consumer ability to fire workers assures quality.
  • Agencies & unions: consumers more vulnerable to abuse under CD.
caveats
Caveats
  • Data are expert opinion only. However, survey results from Germany, the Netherlands, and the US indicate better quality of life for beneficiaries with consumer-directed services compared to those with agency services.
  • Case study sites have well-established programs. Results could vary in other sites.
policy implications
Policy Implications
  • We cannot assume that older people do not want or are not capable of CD.
  • Consumers who are cognitively intact, assertive, and have informal support networks are likely to do well with CD.
  • Experiences of caregivers need further investigation because of potential overburden.
policy implications cont
Policy Implications (cont.)
  • Individual workers are at a financial and perhaps emotional disadvantage compared to agency workers.
  • Quality may not be a major problem but insufficient data to determine if quality problems exist.