Self-Direction: A Medicaid Long-Term Care Model
Self-direction is a Medicaid long-term care model that supports the chronically ill, older adults, and those with a disability at any age to remain at home and in their community. It empowers individuals to live the lives they want to live. To stay safe in your home, you or your loved one may need additional personal care support to complete everyday activities like cooking, cleaning, and bathing. The model is founded on the principle understanding that older adults and those with a disability understand their needs and can plan and manage their services and supports. A key reason many people choose to self-direct is to hire someone they trust to provide their personal care. Unsurprisingly, many participants feel more comfortable hiring a family member or friend to provide care.
Although every State has slightly different rules and approaches to implementing self-directed services in their waiver and grant-funded programs, some common consistencies are often seen. When weighing service delivery options and embarking on self-direction, it is important for an individual to feel empowered and knowledgeable about what roles and responsibilities they will play when directing and managing their care. Self-direction is often delivered through two distinct models: Fiscal Employer Agent (F/EA) or Agency With Choice (AWC). Both models will incorporate the support of a Financial Management Service (FMS) or Agency provider to assist with administrative and management tasks as designated in the program policies and guidelines. Depending on the model, the individual receiving care may have more or less responsibility and support with the direction and management of their services.
Roles and responsibilities for a self-directing employer may include:
Recruiting, Interviewing, and Selecting Caregivers: Prior to recruiting a worker, it is important for self-directing employers to consider what tasks need to be performed and what knowledge or skills a person needs to have in order to complete the tasks. Finding the right worker can take time and patience. Even when a self-directing employer is fully staffed, it is important to always be mindful about recruiting and planning for unforeseen circumstances such as a caregiver quitting or being ill. Depending on the model of service, the FMS may be able to provide you with resources and tools for recruiting, including a pool of already employed caregivers.
Hiring: Work with your FMS to determine the process for hiring and onboarding your selected caregivers. This process can often include completing paperwork, submitting documentation, and completing State and Federal background checks. It is important to fully understand the onboarding process for your FMS and ensure you do not communicate the ability for a worker to start before your FMS/Agency has provided you with the verification or good-to-go.
Training: Providing care is very personal to each individual, which is why training is often a task delegated to the self-directing Employer. Some programs may require caregivers to obtain specific training like CPR and First Aid certification, while other programs focus on the individual who needs care, relaying their preferences and educating the worker about their routine and lifestyle to meet their needs best. Depending on the program, the FMS/Agency may provide ongoing training or review verification of credentials regularly. Regardless of the program, it is essential that all caregivers receive information about universal precautions and safety to ensure a safe working environment is always maintained. In addition, a detailed orientation of the home, including a review of any equipment and medical devices used, will ensure everyone is set up for success.
Managing/Supervising Employees: Depending on the program parameters, managing employees may be solely the Employer’s responsibility or a shared responsibility with the fiscal agency. Within self-directed models, scheduling is often delegated to the self-directing Employer to ensure the care they need is obtained at a time that works best for them. In addition, program policy may require self-directing employers to document the caregiver’s performance to ensure quality services are delivered in alignment with the established and approved service and support plan.
Performance Reviews: Regularly evaluating the performance of those providing care is critical to the long-term success of a healthy working relationship. Although it can be difficult for a self-directing employer to evaluate caregivers they may be close to, such as a family member or friend, making performance reviews a regularly anticipated event can ease anxiety and ensure a safe place to address any issues or concerns. It is also a great mechanism for ensuring caregivers who provide excellent care and support are thanked and praised for their work. If performance issues arise, self-directing employers should communicate openly about the problems, document conversations, and agree to improvement plans within their caregiver’s files. Depending on the program’s level of oversight, the FMS/Agency may also play a role in addressing issues with caregiver performance.
Termination: If a self-directing employer decides that the services and supports a caregiver provides are no longer meeting their needs, they may choose to terminate or dismiss the Caregiver. When doing so, it is important that the self-directing Employer communicates calmly and directly about the issues that have arisen and makes clear they no longer want the person to work for them. Safety is an important consideration, and dismissal should be done with a trusted support individual or over the phone if necessary. Depending on the program policies, release from a specific self-directing employer may or may not terminate them entirely from their role as a caregiver with that FMS/Agency. It is important to communicate to the FMS/Agency immediately about the termination/dismissal and complete any required documentation that the FMS/Agency requires.
Following Employment Laws and Program Rules: It is critical that self-directing employers are educated and well-versed in the employment laws that affect them. Common themes include minimum hourly wage requirements, limits on work hours, overtime compensation, and paid sick leave. Federal laws prohibit employers of all kind from discriminating against against someone (applicant or employee) because of that person’s race, color, religion, sex (including gender identity, sexual orientation, and pregnancy), national origin, age (40 or older), disability or genetic information.
Preventing and Reporting on Fraud, Waste and Abuse: Self-directing employers should always be mindful of the laws and rules on fraud, waste, and abuse to ensure program integrity and prevent issues. Submitting false information, overusing services outside of what has been approved and allocated, and paying for services that are not allowed are all infractions that can result in program termination and further legal action. If an issue arises, it is always important to report the issue as soon as possible to your FMS or Case Management staff.
Self-directing care comes with a ton of freedom and independence to get care needs. Many programs will permit the individual service recipient to delegate tasks outlined above to an authorized representative or surrogate if they choose to. Delegating tasks to a trusted family member or friend who is capable and willing to provide the assistance is a great way to take advantage of all self-direction has to offer and stay within the limitations an individual may have when dealing with their own illness and disability needs. Speak to program staff to understand your options and criteria a representative must posses to serve in this capacity.
Also, don’t forget about your FMS! The FMS/Agency can provide various resources and support depending on how the program is structured.
by Lexi Harris
Director of Arkansas Support Coordination