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Since 1995 an initiative known as Cash and Counseling has been beckoning a long-term care transformation. Centered around a concept called consumer direction, these programs, along with similar ones they have inspired, promote a new way of looking at long-term care service options for the disabled, the developmentally impaired and others in need of support. In short, they stand as power brokers, displacing traditional modes of service provision and increasing the control of such services for the patients who require them.

“These are service delivery models designed to empower people with chronic disabilities and their families,” says Pamela Doty, a senior policy analyst with the Office of the Assistant Secretary for Planning and Evaluation with the Department of Health and Human Services. Doty was the lead author of New State Strategies to Meet Long-term Care Needs, a study on consumer direction that appeared in a recent issue of policy journal Health Affairs. “They gain considerably more choice and control over the who, what, where, when of their home and community-based long-term services and supports than they would have in a more traditional ‘provider-driven’ system,” she continues.

The question is, what role does case management play in this new framework? And where there are fissures, can traditional case management and consumer-directed models of care work together equitably? First, let’s take a deeper look  into what consumer direction really is.

A relatively new concept, at least in practical application in the U.S., consumer-directed services took root in the mid-1990s when the Robert Wood Johnson Foundation commissioned a controlled experiment to test the idea, which was basically to give consumers, or patients, control over a budget for which they could research and procure the services necessary to their situation. This, instead of an agency performing an assessment, monitoring and judging need.

“The idea comes from when we need such personal care as bathing, dressing, getting out of bed,” says Kevin Mahoney, a faculty member of Boston College’s Graduate School of Social Work and director of the National Center for Participant-Directed Services at the college. “The typical mode in the U.S. is going through agencies. What people in the disability community were says is, ‘If I had more control over my services, I think my life  would be a lot better and I think I could do it for the same amount of money or even less.’”

Pilot projects launched in the states of Arkansas, Florida and New Jersey involving nearly 7,000 people from 1998 to 2003. Overall, the results showed promise. Health outcomes were better or equitable. Families showed comparative success. And importantly, the program witnessed savings. Nursing home costs in Arkansas fell by 18 percent during the study period, Mahoney says.

Twelve additional states joined the program for a second phase between 2004 and 2008. “State policymakers now see these alternatives to professionally managed services as desirable—or at least worthy of consideration,” write the authors of the study. This has resulted in a policy shift away from a study of the effectiveness of consumer-directed programs to providing training for their implementation. According to researchers, 180 consumer-directed Medicaid programs existed as of October 2009, though there is no repository of total consumer enrollment (something Mahoney and others are currently at work on).

Two forms of consumer-directed services are recognized by CMS—what are known as employer authority and budget authority respectively. The original model, employer authority, gives patients the choice to name their representatives of choice. Budget authority allows consumers to control the spending of costs associated with their needs. (See the accompanying Q-and-A session with Pamela Doty for greater explanation of these models, as well as a thorough analysis of other areas of consumer direction.)

Where does this all fit with case management? It does so in a sensational, sometimes jarring, way. For the model of care in consumer direction in some senses is a breach with traditional modes of case management. “For some care managers, this is a real paradigm shift,” says Mahoney. In the Health Affairs article, the authors identify “four major challenges” facing the consumer direction movement. The first is adverse budget conditions. The second is personnel shortages and changes. The third is a lack of infrastructure. And the fourth is “resistance…from traditional service providers and case managers.”

For a model that shifts the role that case managers typically engage in to a second party—and to a consumer nonetheless—the resistance should not be surprising. The way the model is designed, case managers essentially become “counselors,” according to Doty, which can lead to a sort of identity crisis. “This may appear to some as a demotion of sorts and cause them to resist referring clients to self-directed service options,” she says.

Yet the authors of the Health Affairs study, including Doty, make the argument that the change in consumer-directed services does not necessarily hinder a case manager’s stated goal. “Case managers’ resistance to consumer direction is largely philosophical, rooted in adherence to a model in which service provision is professionally managed,” the authors write. Still, the authors go on to cite pragmatic reasons for case managers’ ambivalence, providing examples of case managers who deemed the program too complex for seniors and a system ripe for fraud and abuse.

For Doty, these differences vanish when considering the upshot of consumer direction—even for case managers. “The best case managers find that the change in role empowers them as well,” she says. “This is because the best case managers are acutely sensitive to the needs and preferences of their clients and feel quite frustrated when all they can put into a care plan are the standard  offerings on the traditional ‘menu’ of covered services.”

Whether the two models can find common ground on a large scale remains to be seen. But the trend of consumer direction is gaining steam, and it ought to be recognized by the case management community.

To read the full interview with Pamela Doty, click here. If you would like to learn more about the Cash and Counseling programs and consumer direction in general, visit cashandcounseling.org and participantdirection.org. To view the original Health Affairs study, click here. To send comments or feedback to the author of this article, contact Richard Scott here.