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Abstract
Long-term care programs that offer home and community services can do so through agency and/or consumer-directed models. Most long-term care home and community programs for older adults use the agency model, where payers contract with agencies to find and manage workers, because of a belief that this model is better for older adults. This dissertation addresses the question: are consumer-directed home and community services appropriate for older persons?
Methods for this dissertation consisted of reviews of the literature and analyses of qualitative interviews conducted at ten sites with consumer-directed programs serving older persons. Interviewees included government officials, representatives of older and younger adults with disabilities, home care agencies and workers.
The literature suggests that quality is best when consumers direct workers and stakeholders' views were consistent with the literature. However, the majority of stakeholders reported that quality for those with cognitive impairment is a concern under consumer-direction because this population does not have the capacity to manage services.
The literature also suggests that consumer-directed workers are more responsive to consumers' preferences regarding services than agency-directed workers. Stakeholders agreed with this literature.
The literature on worker preparedness favors the consumer-directed model, but stakeholders reported the opposite. Stakeholders believed that agency workers have more formal training than consumer-directed workers. Stakeholders also reported that recruiting home care workers is difficult for both consumers and agencies given the difficult nature of the job and low wages.
The literature suggested that half or less of older persons prefer consumer-direction and three of five stakeholder groups agreed saying that older persons do not want worker management responsibilities. Stakeholders also doubted that older persons were as capable of management as younger people because they asserted that older persons are weak, tired and thus have a difficult time managing workers. Altogether, this dissertation reports that consumer-directed home and community services may be appropriate for some, but not all, older persons.
