Cash and Counseling: A Model for Self-Directed Care Programs to Empower Individuals With Serious Mental Illnesses

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Cash and Counseling: A Model for Self-Directed Care Programs to EmpowerIndividuals With Serious Mental IllnessesAmanda N. Barczyk MSW a & Jane Arnold Lincove PhD ba School of Social Work, University of Texas at Austin , Austin, Texas,USAb Lyndon B. Johnson School of Public Affairs, University of Texas atAustin , Austin, Texas, USAPublished online: 09 Apr 2010.

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Social Work in Mental Health, 8:209–224, 2010Copyright © Taylor & Francis Group, LLC ISSN: 1533-2985 print/1533-2993 onlineDOI: 10.1080/15332980903405298

WSMH1533-29851533-2993Social Work in Mental Health, Vol. 8, No. 3, Feb 2010: pp. 0–0Social Work in Mental Health

Cash and Counseling: A Model for Self-Directed Care Programs to Empower Individuals With Serious Mental Illnesses

Cash and Counseling in Mental HealthA. N. Barczyk and J. Arnold Lincove

AMANDA N. BARCZYK, MSWSchool of Social Work, University of Texas at Austin, Austin, Texas, USA

JANE ARNOLD LINCOVE, PhDLyndon B. Johnson School of Public Affairs, University of Texas at Austin,

Austin, Texas, USA

Mental illness is the country’s leading cause of disability. However,approximately 60 percent of individuals with serious mental illness(SMI) are not receiving stable, ongoing treatment (Carper, 2005).One approach to combat this problem is to actively involve consum-ers in their treatment. Personal assistance services (PAS) assist indi-viduals with disabilities with their daily living activities, and some,such as cash and counseling (C&C), empower individuals to maketheir own treatment decisions. Self-directed care programs haverecently adapted from C&C programs targeting individuals withphysical disabilities to models targeting individuals with SMI. Thepurpose of this article is to examine the effectiveness of theseprograms, explore their impact on individuals with SMI, and discussthe role of social workers in this new service delivery approach.

KEYWORDS personal assistance services, cash and counseling,self-directed care, serious mental illness, empower

INTRODUCTION

According to the Surgeon General’s Report on Mental Health, approximately20% of adults in the United States are affected by a mental health disorder in

Address correspondence to Amanda N. Barczyk, MSW, School of Social Work, TheUniversity of Texas at Austin, 1 University Station D3500, Austin, TX 78712-0358, USA.E-mail: [email protected]

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210 A. N. Barczyk and J. Arnold Lincove

a given year. The prevalence rates for children, adolescents, and the elderlyare not as well documented. It is estimated that in any given year, 20% ofchildren have a mental health disorder with at least mild functioning impair-ment, and 20% of elderly individuals have a diagnosable mental health dis-order (U.S. Department of Health and Human Services, 1999). It has beenstated that mental illness is the country’s leading cause of disability. In spiteof this, more than 60% of people with serious mental illness (SMI) are notreceiving ongoing, stable treatment (Carper, 2005).

Despite an epidemic-level incidence of mental health problems, utiliza-tion of mental health services is very low in the United States (U.S. Depart-ment of Health and Human Services, 1999) particularly among minoritypopulations (Flaskerud, 1986). The majority of individuals with a diagnos-able mental illness are not receiving treatment (U.S. Department of Healthand Human Services, 1999). Given the large numbers of individuals suffer-ing from mental health problems without treatment, new and innovativestrategies are needed to increase utilization and treatment success. Oneinnovation is new delivery models for personal assistance services (PAS),including cash and counseling (C & C).

C & C was conceived as a way to allow individuals with disabilities tomake their own treatment decisions. While many consumer-directed servicemodels exist, C & C is unique in that it gives consumers financial controlover public funds allocated for disability related goods and services. C & Cdoes not replace existing services, but provides an additional option avail-able to consumers who can benefit from a more consumer-directed model(Simon-Rusinowitz et al., 2001). Consumer-directed services of this kindoriginated more than three decades ago with the goal of assisting adultswith disabilities (DeJong, Batavia, & McKnew, 1992). C & C is a thoroughlyevaluated consumer-directed service. The majority of the research studiescited on this program come from the “Cash and Counseling” Demonstration/Evaluation, a large-scale public policy experiment aiming to evaluate aconsumer-directed approach to financing and delivering PAS to individualswith disabilities, including persons with mental illness (Doty, 1998). TheRobert Wood Johnson Foundation awarded a $7 million four-year grant thatinitially was used to begin C & C in Arkansas, Florida, and New Jersey(Doty, 2004), and twelve additional states are currently implementing simi-lar programs (Alliance for Health Reform, 2006).

C & C represents a significant departure from institutional norms in thedelivery of health and mental health services. In the past, policy obstacleshave complicated efforts to give consumers greater control. Medicaid rulesrequired states to certify and approve all providers, which created a signifi-cant obstacle in the movement toward consumers’ choice. States wanting toimplement these programs had to rely on state funding or partner withprivate donors. Since 2002, a federal policy changed to allow Medicaid tosupport self-directed care, including C & C programs. States can now apply

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Cash and Counseling in Mental Health 211

for an expedited Medicaid waiver under the Independence Plus program,which allows greater flexibility in the standards used to certify providers,thus expanding options for consumers (Crowley, 2003). Although thewaiver process is still burdensome for states, this policy change overcomesa significant obstacle by opening up the possibility of federal funding.

The purpose of this article is to inform social workers of the consumer-directed C & C model. The article will provide an explanation of the modeland its relationship to the empowerment theory. The results of the evalua-tion research conducted with the elderly and individuals with disabilitieswill be reported. In addition, self-directed care programs, which haveadapted the principles of C & C to empower individuals with SMI, will bediscussed as the first attempt to utilize the C & C model with individualswith SMI. Finally, the article will discuss the possibility of expanding theself-directed care model to more mental health systems and the impact thiswill have on social workers.

EMPOWERMENT

According to Rappaport (1987), empowerment means that an individual hascontrol over his or her life and is able to participate in several communitiesincluding schools, churches, and neighborhoods. Empowerment has alsobeen defined as, “a process of increasing personal, interpersonal, or politi-cal power so that individuals can take action to improve their life situations”(Guitiérrez, 1990, p. 149). The philosophy of empowerment underlies theCash & Counseling approach to treatment. Empowerment theory forceshealth care professionals to “think in terms of wellness instead of illness,competence instead of deficit, and prevention as well as treatment” (Peterson& Hughey, 2002, p. 42). In an empowerment model, social workers facili-tate, collaborate, and focus on learning about their consumers. They nolonger take the role as counselor or expert. The role of the social worker isnot to advocate for the client, rather they are to empower their clients toadvocate for themselves and they serve as participants in the process(Zimmerman, 2000).

At an individual level, the empowering process includes participantsexerting control, making decisions, and solving the problems that they face.By experiencing the empowering process, the individual gains a sense ofcontrol, critical awareness, and participatory behaviors from working withothers instead of having others work on his or her behalf (Zimmerman,2000).

One of the main goals of C & C is to give each consumer more controlover services he or she receives. The self-directed financing structure isdesigned to empower consumers to make their own decisions regardingtheir treatment. Studies have shown that individuals with severe disabilities

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and cognitive impairments are capable of expressing their preferences forquality of life and everyday living decisions (Squillace Mahoney, Shoop,Simon-Rusinowitz, & Desmond, 2001). Research has shown that patientsfare better when they are actively involved in their treatment (Selo, 2003).Often, consumer-driven services focus only on involving the consumer in atreatment program that was designed by professionals. The Cash &Counseling Demonstration/Evaluation also involved consumers in everystep of program design and implementation. This expands the conceptempowerment to participation in policy design and ensures that implemen-tation reflects consumer preferences.

The defining characteristic of C & C programs, as opposed to tradi-tional service delivery, is that participants have financial control of fundsallocated for their treatment. The model has demonstrated success withpopulations with physical disability. Adapting this model to empowerindividuals with SMI would enable them to have similar or even greaterbenefits.

CASH AND COUNSELING

The Model

In the traditional clinical model, social workers and/or nurses develop treat-ment plans based on their assessment of the client’s disability, often with alimited number of service options. The health care professionals would thennotify the agencies of the treatment plan, and Medicaid would be billed fora reimbursement upon the delivery of a service (Doty, 1998). C & C func-tions differently than typical services. C & C is a type of personal assistanceservices that extends treatment options with a range of human and techno-logical assistance to assist Medicaid eligible individuals with disabilities,including those with mental illnesses. PAS can include traditional treatment,as well as services that support daily living activities (Doty, 1998; Mahoney& Rusinowitz, 1997). Three methods have been utilized to finance PAS:

1. Cash benefits are paid directly to the beneficiary or their representativepayee (surrogate).

2. Vendor payments enable the nurse and/or social work case manager toarrange and pay for authorized services to be delivered by PAS providers.

3. Consumers receive vouchers, coupons, stamps, or debit accounts topurchase services (Mahoney & Simon-Rusinowitz, 1997; Mahoney,Simon-Rusinowitz, Loughlin, Desmond, & Squillace, 2004).

C & C programs utilize the third approach, giving consumers control overan account of funds for their own treatment. This financing strategy requiresredefinition of the roles of health care professionals. Health care professionals

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provide an intake assessment to identify needs. As consumers selectservices, professionals act as financial gatekeepers and allocate an appropri-ate level of benefits. Consumers are then able to purchase a range of dis-ability related goods and services, as long as they address disability-relatedneeds within the allocated benefit level. As consumers access services, pro-fessionals offer advice on recruiting, hiring, training, supervising, and firingservice providers (Phillips et al., 2003; Doty, 1998). For example, in the dis-ability context, services selected by the consumer include transportation ser-vices, assistive technologies, adult day care, respite services, home andvehicle modifications, and services that assist individuals with their daily liv-ing activities such as bathing, toileting, eating, and dressing (Doty, 1998;Mahoney & Simon-Rusinowitz, 1997). While receiving the cash benefits, acounselor will be available to assist in developing a cash management planand provide other advice. The consumer maintains a benefit account andcan carry over benefits from month to month to create an emergency fundin case of a crisis (Doty, 1998). While consumers have the choice to hirewhomever they desire to provide services, they are required to documentcompliance with Federal Insurance Contributions Act (FICA) and other taxrequirements. In addition, they must turn in worker time sheets and checkrequests before funds will be disbursed in order to prevent abuse of theallowance (Doty, 1998; Phillips et al., 2003).

As previously mentioned C & C was not intended to replace existingservices, but is an available option (Simon-Rusinowitz et al., 2001). C & Cprograms have been targeted for older adults with disabilities 65 years ofage, as well younger adults. Florida also targeted their program to childrenwith disabilities and their parents (Doty, 1998).

Consumers Preferences

Prior to implementing C & C, researchers conducted pre-survey focusgroups, telephone surveys, and post-survey focus groups with individualswith disabilities receiving personal care services in order to:

1. determine preferences for consumer-directed services in general, andspecifically for a cash option;

2. determine the percentage of consumers or surrogates choosing the cashoption versus traditional services;

3. identify reasons for consumer or surrogate preferences;4. identify demographic and background characteristics of consumers and

surrogates with specific preferences;5. identify cash-option features that are attractive or unattractive to consum-

ers and surrogates;6. identify what information consumers and surrogates need to decide

whether to choose the cash option;

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7. identify consumer and surrogate needs for counseling and supportservices; and

8. develop strategies to market the cash option (Mahoney et al., 1998, p. 77).

Approximately 40% of the New York consumers participating in the focusgroups and telephone surveys indicated that they were interested in thecash option. Interest in the program varied across groups (Mahoney et al.,1998, 2004). For example, individuals in their late twenties were found tohave less interest in the cash option when compared to individuals slightlyolder. It was speculated that this may have to do with younger individualsnot having the confidence to deal with tasks associated with the cash optionsuch as managing finances (Mahoney et al., 2004).

Upon evaluating the role of surrogates, it was found that surrogatesadequately represented the views of the consumers regarding satisfactionwith personal care (Squillace et al., 2001). Responses from surrogate deci-sion makers answering for consumers with communication difficulties orcognitive impairments indicated that

• 41% believed the consumer would be interested in the cash option(Mahoney et al., 1998; Squillace et al., 2001).

• 56% percent stated that they liked the idea of a cash option (Mahoney et al.,1998).

Similar findings regarding consumers/surrogates were found in Arkansas,Florida, and New Jersey (Simon-Rusinowitz, 1997; Simon-Rusinowitz et al.,2001; Simon-Rusinowitz, Mahoney, Marks, Zacharias, & Loughlin, 2005b).

Many of the consumers with disabilities liked the idea of taking morecontrol in their lives and having more independence. However, some con-sumers were skeptical about C & C. Consumers reported the followingopinions and concerns:

• Consumers were attracted the idea of selecting their own workers, buthad concerns about finding appropriate candidates.

• Participants were confident about their ability to create schedules for theirworkers.

• Participants had mixed views on the option to hire friends or family membersas workers.

• Some consumers did not believe money mixed well with family orfriends.

• Some consumers believed it would be good to be able to pay their friendor family member who was already assisting them.

When consumers and surrogates were asked about the services they were mostinterested in purchasing, transportation services were the most desired service

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followed by someone to keep them company, exercise equipment, more hoursof personal care, and housekeeping services (Simon-Rusinowitz et al., 2001).

Researchers asked consumers with disabilities who participated infocus groups to discuss their current PAS in addition to their interest in par-ticipating in C & C. In general, older consumers and their surrogates weremore satisfied with PAS than younger consumers. Younger consumers didnot believe their current PAS was designed to meet their needs and did notfacilitate independence. In addition, younger consumers were frustrated bynot having a say in the services they were provided or their workers’ sched-ule. Younger and older consumers had a general distrust for their agenciesand believed personal care workers were not always adequately trained andsupervised (Simon-Rusinowitz et al., 2005b).

EFFECTIVENESS

Greater consumer satisfaction with services has been reported in programsgiving consumers control over managing and hiring attendants (Doty, 2000).The consumers with disabilities participating in C & C were found to behighly satisfied with their care arrangement (Schore, Foster, & Philips, 2007).The quality of life of consumers was also reported as improving due to C & C(Foster, Dale, & Brown, 2007).Very few workers or consumers reported beingexploited and the fraudulent use of the cash benefit was extremely rare(Schore et al., 2007). The Arkansas C & C evaluation team has found thatparticipation in the program resulted in good health outcomes (Krahn &Drum, 2007; Simon-Rusinowitz, Mahoney, Loughlin, & Sadler, 2005).

C & C has been found to be slightly more expensive than traditionalagency-based services. After the first two years, total Medicaid costs were8% to 12% higher for participants of C & C. However, C & C has variousextra benefits when compared to traditional agency-based services includ-ing the fact that C & C empowers consumers to make their own servicedecisions. This is likely to benefit the consumer’s recovery more so than tra-ditional agency-based services. For example, it is expected that for olderadults the additional cost of services will decline significantly as fewer par-ticipants in C & C are being admitted to nursing homes, which would gener-ate a 18% cost savings (Alliance for Health Reform, 2006). With a greaternumber of older adults having the ability to choose services and remain athome for care due to the C & C program, the number of individuals admit-ted to nursing homes may decline further in the future.

Family Members as Workers

The majority of C & C consumers used their allowance to hire workers. Ofthe consumers who hired workers with their allowance, most used their

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workers to assist with housework and personal care. Between 73% and 93%received assistance with routine health care needs such as taking medica-tion. Another common service was transportation assistance (Schore et al.,2007). The majority of consumers who hired workers selected a familymember, often an adult child or parent. Black consumers were found to bemore likely to hire a family member compared to consumers of other race/ethnic backgrounds (Simon-Rusinowitz et al., 2005a). In general, when hiringany worker, family member or not, hired workers were much more likely tobe of the same race as the consumer when compared to agency workersassigned to consumers (Foster et al., 2007). From this information it is evidentthat cultural issues play a role satisfaction and preference of C & C.

It was reported that family members did more for consumers overall anddid not complain about working extra hours (San Antonio, Eckert, & Simon-Rusinowitz, 2006). Consumers who hired a family member to be their care-giver received care during non-traditional hours more often than consumerswho did not hire a family member to be their caregiver. Despite workingnon-traditional hours, consumers who had family members as their hiredworkers still continued to receive the same amount of unpaid care as the con-sumers who did not hire a family member (Simon-Rusinowitz et al., 2005a).

Health and quality-of-life benefits resulted when a family member washired by the consumer. When a family member was hired as a worker, con-sumers had fewer bed sores or pressure sores, respiratory infections, andfalls compared to workers who were not family members. Consumers alsoreported that they had fewer unmet needs. Some areas did not differ basedon whether the worker was a family member or not. For example both fam-ily and non-family workers in C & C reported high levels of worker satisfac-tion. In addition, consumers reported being equally satisfied with theirrelationship with the family and non-family workers, but family workerswere more likely to indicate that the client lacked respect (Simon-Rusinowitzet al., 2005a). It appears that having the option to hire a family member isextremely appealing to consumers and therefore is a vital component to thesuccess of C & C.

Utilizing family members as workers is a controversial topic both inC & C programs and other consumer-directed models. These providers arenot necessarily licensed or trained, fall outside of the supervisory capacityof state agencies, and are not subject to professional codes of ethics. Theissue of oversight is a serious concern, and cases of physical abuse, neglect,and financial exploitation have been reported. Financial fraud is one of themost common types of abuse and occurs when a family member collectspayment for services that were not delivered or takes the pension or SocialSecurity check of the consumer (Blaser, 1998). However, consumers experi-encing abuse or fraud has been rare (Simon-Rusinowitz et al., 2005a), andwith proper training and monitoring, the possibility of exploitation or abusecan be decreased (Blaser, 1998).

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Adaptation to the Mental Health System

The New Freedom Commission on Mental Health was announced by Presi-dent Bush in February 2001 with the goal of breaking the barriers individu-als with disabilities face in America. One of the goals outlined was to havemental health care be consumer and family driven (White House DomesticPolicy Council, 2004). The Commission recommended expanding consum-ers’ and family members’ roles in managing the funding for their supports,treatments, and services, which would lead to an increase in their choices(New Freedom Commission on Mental Health, 2003). Through PresidentBush’s New Freedom Initiative, the Centers for Medicare and Medicaid Ser-vices are working with the Substance Abuse and Mental Health ServicesAdministration and constituent representatives to organize a self-directioninitiative (White House Domestic Policy Council, 2004). One component ofthese reforms is added flexibility in Medicaid rules to allow self-directedcare models. Despite this interest in self-directed care at the federal level,fewer than 400 consumers are participating in self-directed care programs inthe United States (Alakeson, 2008). Given the effectiveness of C & C whentargeted at individuals with disabilities, restructuring C & C to specificallytarget individuals with mental illnesses may increase the utilization of self-directed care programs.

The New Freedom Commission facilitated the spread of self-directedcare programs by developing the Independence Plus program, whichrelaxes stringent provider certification requirements to allow Medicaid fundsto support C & C models. States can apply for a waiver of provider certifica-tion requirements opening up the possibility of using family members andother nontraditional providers. Medicaid funded programs must continue tomeet other federal requirements including providing state matching fundsand demonstrating adequate checks and balances to prevent fraud. Theprograms must also demonstrate “budget neutrality,” meaning that C&C ser-vices must not be more expensive than traditional service delivery and thatall Medicaid caps continue to apply.

Adapting C & C for individuals with mental illnesses requires attentionto the specific needs of the population. While an individual with a physicaldisability may need assistance getting dressed, eating and preparing food,and bathing, an individual receiving behavioral support may need the assis-tance of a counselor or a peer support group (Nerney, 2004). A key differ-ence between individuals with physical disabilities and psychiatricdisabilities is that individuals with psychiatric disabilities are subject toshort-term acute crises. While in a crisis, the individual’s decision-makingskills may be impaired for a short time and particularly his or her ability toassess long-term consequences. However, the crises are often brief and theindividuals are likely to resume their previous level of functioning. Whilethis is a concern, advanced planning can alleviate worries about the individual.

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A plan of action can be developed by the individual in and a surrogatedecision maker can be selected in case a crisis occurs (Stefan, 2004).

Some states have already begun implementing programs aimed atempowering consumers and their family members to play a larger role inmental health recovery (Hendry, 2008; Michigan Department of CommunityHealth, 2003). Florida, Maryland, Oregon, and Tennessee currently haveself-directed care pilot programs, Iowa recently completed one and Texasand Pennsylvania are in the process of developing new programs (Alakeson,2008). States programs differ in eligibility criteria. While some researchersbelieve self-directed care should not exclude individuals based on theirfunctioning or symptomatology, others exclude individuals who are underguardianship, and often concerns are raised about an individual consumer’sability to participate in the program. For example, an individual may beexcluded if he lacks the capacity to manage choices (Stefan, 2004). In addi-tion, each state program differs in the amount of control consumers have.Florida, Maryland, and Michigan allow consumers broad freedom to selectservices and providers, while Oregon and Iowa allow consumers to pur-chase recovery supports, but do not allow consumer-directed changes to anexisting, traditional service plan.

The Florida self-directed care program, supported by the FloridaDepartment of Children & Families, is similar to a C & C program and is thelargest such program in the United States, with approximately 200 consum-ers (Alakeson, 2008). Participants are provided with a life/recovery coachwho familiarizes the consumer to the program, provides referral informa-tion, assists the consumer in developing personal recovery goals and assiststhe consumer to prioritize and plan the budget. A Life Analysis is then con-ducted, which is a self-assessment that helps the consumer create a plan oflife activities and a path to reach his or her goals. A Life Action Plan is thencreated, which provides the details of the budget and plan to achieve theconsumer’s goals. Clinical Recovery Services (i.e., traditional mental healthservices), Recovery Support Services (i.e., alternatives to traditional mentalhealth services), and Recovery Enhancement Services (i.e., clothes, personalhygiene products, tuition, car repairs, and office supplies) are all eligible tobe included in the budget Hendry, 2008).

The following is a breakdown of how participants in Florida’s self-directed care program utilized their funding:

• 47% was spent on traditional clinical recovery services (e.g., counseling,therapeutic, and psychiatric services)

• 13% was spent on recovery support (e.g., self-help, wellness, and exercise)• 29% was spent on tangible services (e.g., food and clothing)• 5% was spent on dental services• 3% spent on ophthalmology or optometry services• 3% was spent on transportation

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Participants in this program on average only spent about a third of thefunds allocated to them, which alleviated concerns that consumers wouldoverspend the allocated budget (Cook, Russell, Grey, & Jonikas, 2008).

Findings

The Cash & Counseling Demonstration/Evaluation provides preliminary evi-dence that C & C is effective for individuals with mental health problems, assome demonstration programs included this population as well as individu-als with physical disabilities. Results from the Arkansas evaluation showedthat C & C worked as well for individuals with mental illness as it did withindividuals without mental illness along outcome measures including: satis-faction with paid caregiver’s relationship and attitudes; satisfaction with life;satisfaction with care arrangements and unmet needs; and adverse events,health problems, and general health status (Shen et al., 2008). These posi-tive outcomes suggest that adapting the model to be targeted toward indi-viduals with SMI is not only possible but will likely yield positive results.

Self-directed care programs are the first attempt to create a programequivalent to the C & C program within the mental health system. Self-directed care programs are designed to serve uninsured and low-incomeadults with serious mental illness (Coakley, n.d.). They give the consumercontrol of his or her budget to choose goods and services that will meet hisor her individual needs (Alakeson, 2008). The Federal Centers for Medicareand Medicaid Services (CMS) developed services and supports that are usedin conjunction with Medicaid programs in order to provide the self-directedcare options. CMS believes four elements are necessary when implementinga self-direction program including: person-centered planning, individualbudgeting, financial management services, and supports brokerage (Cook,Terrell, & Jonikas, 2004).

An evaluation of Florida’s self-directed care program showed positiveoutcomes for participants in terms of residential stability and communityintegration. Participating consumers utilized less crisis stabilization andother crisis support services when compared to non-participants. Partici-pants also had a higher number of assessments and medical services includ-ing supported employment, outpatient psychotherapy services, andpsychiatry (Hendry, 2008). Participants of the Florida self-directed care pro-gram spent significantly less time in criminal justice settings, spent signifi-cantly less time in psychiatric inpatient settings, and showed significantlyimproved functioning (Cook et al., 2008). According to a review of the liter-ature by Alakeson (2008), satisfaction levels have also increased in consum-ers of the self-directed care program in comparison to consumers oftraditional services.

While self-directed care programs appear to be effective, the evaluationof the program and the involvement of consumers in the process have been

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minimal in comparison to the C & C program. In order to successfullyimplement this program, it will be beneficial to use C & C as a model,including the process through which C & C was implemented and evalu-ated. Consumers preferences should be assessed in pre-surveys to ensureconsumers are in fact interested in the cash option and to determinewhether age, race/ethnicity, or gender have an impact on their interest. Inaddition, evaluation tools will need to be developed to evaluate where con-sumers used their money, consumers satisfaction, family/caregivers satisfac-tion, employment stability, residential stability, medical services utilized,hospitalization rates, and other factors that would indicate the effectivenessof the program.

IMPLICATIONS FOR MENTAL HEALTH SERVICES AND SOCIAL WORKERS

As noted from the research in this article, C & C has been extremely suc-cessful for the individuals with disabilities. Is it possible to transfer thismodel to other populations? Evaluations of current self-directed care pro-grams for SMI indicate that it is possible to provide C & C for this popula-tion with significant benefits. Traditional perceptions of SMI were notsupportive of the empowerment model, and may have prevented the imple-mentation of consumer-driven models such as C & C. However, recentlymore emphasis has been placed on dispelling assumptions that individualswith mental health problems are incapable of making their own treatmentdecisions. Increasing attention has been given to benefits of having a con-sumer-driven system. Social workers have responded to empowermenttheory by transitioning to a recovery-based model of case management,where the traditional treatment approach is replaced a focus on consumerindependence and self-sufficiency. This approach also alters the practice ofsocial work to fit new consumer-directed models of service delivery.

Consumer-driven services are advocated by mental health advocates,social workers, and many other mental health professionals. For instance,the Mental Health Transformation Grants awarded by the Substance Abuseand Mental Health Administration to states require consumer participationthroughout the process of transforming the mental health systems in theirstates (National Governors Association Center for Best Practices, 2007). C &C and self-directed care are the first steps in changing our current system toone that is more consumer-driven.

The role of social workers will change in a consumer-driven system.Social Workers will work to actively involve consumers in every step of therecovery/treatment process. No longer will decisions be made on behalf ofthe clients, rather the clients will be making their own decisions. Treatmentplans will continue to be a joint effort but consumers will take more of a

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leadership role while social workers will take the role of an educator andinform consumers about treatment options in order to assist the consumerin deciding which treatment option is most appropriate for them.

The role of social worker will also change in response to the new reg-ulations allowing Medicaid funding for self-directed care. If Medicaid fundsare included, social workers will need to understand federal caps and over-sight requirements. In addition, social workers can educate consumers toprevent fraud and abuse by providers.

It is well documented that social workers have an extremely large caseloads. By changing the role of the social worker this caseload may becomemore manageable, as some consumers will choose to take more control oftheir treatment freeing up time for the social worker to work with theirother consumers. This could be beneficial to all consumers, as social work-ers may also have more time to dedicate to traditional consumers. Despitethe changes that will be necessary to fully integrate C & C/self-directed careinto the mental health system, it is a necessary step toward creating a sys-tem that focuses on recovery and empowering individuals to controllingtheir own recovery.

CONCLUSION

Social Workers need to be aware of the effectiveness of consumer-drivenservices, such as C & C. Therefore, it is imperative that schools of socialwork begin to expose social workers to C & C as well as other effectiveconsumer-driven services. As mentioned previously, C & C is not meant toreplace existing services but rather to be an option for consumers whochoose to take more control of their treatment. C & C has been evaluatedfor providing services to individuals with disabilities and consumers haveshown an increased quality of life and satisfaction with the services.Enabling consumers to hire family members as their workers is an addedbenefit that has attracted many consumers to C & C. Self-directed care pro-grams have begun implementing a similar model to individuals with SMI.The preliminary results of self-directed care programs are showing the sameeffectiveness but further evaluation is necessary.

Given the large number of individuals in the United States with mentalhealth problems, adapting this model to treat individuals with SMI may sig-nificantly improve their quality of life and satisfaction with services. Inorder for this to occur, social work will need to focus on empowering con-sumers to control their own treatment. With consumers making more oftheir own treatment decisions, social workers, nurses, and other healthcare professionals will be able to better handle their growing case loads.This is not to say there is no role for social workers in the treatment pro-cess. Rather, social workers need to change their existing role to a more

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consumer-directed approach which may enable consumers to be more sat-isfied with services and have a higher quality of life.

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Documents

Cash and Counseling: A Model for Self-Directed Care Programs to Empower Individuals With Serious Mental Illnesses