1 Cash and Counseling and N4A Webcast. Hosted by the Administration on Aging, N4A and Cash & Counseling. >> SHARON: Good afternoon everyone. Welcome to today's webcast and teleconference. Cash & Counseling and N4A hosted by the Administration on Aging, N4A and Cash & Counseling. I'm Sharon Finney with ILRU and I just have a couple of housekeeping issues to cover today. For those of you that are on the webcast, to submit your questions, click on the E-mail link on the bottom right-hand side of your screen or you can E-mail them directly to Elizabeth.Maguire .1@bc.edu. Please feel free to E-mail your questions at any point during today's presentation and Elizabeth will voice them when we take questions at the end of the presentation. And for those of you participating today via teleconference, to ask a question, press star 1 on your telephone and you will receive a voice prompt saying your hand is raised. Then Marissa Demaya at ILRU, our operator today, will open your phone line and you will hear a prompt say please ask your question now. At that time, you will have the floor to ask your question and when you're finished, you'll be placed back in a listen-only mode. We will be holding all questions until the end of today's presentation. Should you have any technical difficulties today with the webcast, please feel free to call us at (713)520-0232. And now I'm happy to hand 2 the mic over to Bob Logan. Good afternoon, Bob. >> BOB: Thank you. My name is Bob Logan and I'm the Chief Operations Officer for the National Association of Area Agencies on Aging, and on behalf of our organization, the National Cash & Counseling office, I want to welcome all of you to this webcast on Cash & Counseling this afternoon. We have some great presentations on different variations of Cash & Counseling showing some innovation and creativity. Speakers will be introduced as they are ready to present. I'd like you to bear with us. For some of us, this is our first webcast and we'll try to make it as smooth as possible. The first presentation is entitled: Creation of a consumer-directed program for agency on aging. I would like the next slide, please. Presenting for this program will be myself and Dr. Suzanne Kunkel who is director of the Scripps Gerontology Center, Miami University, Oxford, Ohio, and I want to thank Scripps for working on this program with me. Next slide, please. The program that I'll talk about -- first, before I talk about the program, I want to talk a little bit about the choice of independence grant that the N4A -- and what we found in the assessment which started last summer and ended in September is that in the survey we surveyed 80 percent of the area -- over 80 percent of the Area Agencies on Aging, the majority wanted more information on the Cash & Counseling and 48 percent of them ranked Cash & Counseling as one of their top technical assistance training priorities. So with us in partnership of the National Association of Area Agencies on Aging, in partnership with Cash & 3 Counseling, we decided and planned this webcast. Next slide, please. The slide I need is designing and implementing a consumer-directed care program. The history of my connection with the consumer direction or Cash & Counseling is I work for an Area Agency on Aging in Ohio and it was a unique agency. It had a waiver program, a large one, and it had five counties in this plan and service area, and each of the five counties had a county levy that was voted on by the voters of each county to fund long-term care services for older adults. Next slide, please. We're under the motivation. I apologize for the slide. There is a few typos in it, and that's my fault. I submitted the wrong slide; but the motivations for getting involved in Cash & Counseling really were three: First of all, at the time we were thinking about the Cash & Counseling program, we had an employment rate in Hamilton County which was about 4 percent. So in essence, we had more money than we could spend because of the lack of workers. Southwestern Ohio is a very conservative county and not all the county commissioners were thrilled that we were using tax dollars to pay for older adult services. So there was political pressure on us to use local dollars. If we didn't use the local dollars, we would lose them. And we had clients on waiting lists and money to spend and one of the alternatives for us was to try the innovative program we found out to be called Cash & Counseling. The other incentive for us to get involved in it was just the increased options for older adults and caregivers. Next slide, please. The challenges -- one of the biggest challenges that we had was the societal values of the county and that was paying for 4 family members to do care for their own relatives. After attending a caregiver seminar led by Al Gore and hearing testimony after testimony of caregivers who had to quit their job and care for a relative, it soon changed my mind that it was the right thing to do. The role of the care managers -- our care managers weren't sure that giving the responsibility to people to make their own decision was a good idea. Imagine people deciding what they want. So many of the case managers had to be convinced. When we did start up the program -- and Suzanne will talk about this -- the caregivers we chose to be part of the pilots were the ones that really believed in the program. There of course was universal concerns about fraud and abuse, health and safety, quality of service. I used to say there is ten reasons why we shouldn't do this program, and 100 why we need to. And we have to figure out how we eliminate the ten concerns. Provider concerns -- this is providers even though they couldn't supply enough workers into the field, they were worried that the consumer direction or Cash & Counseling would soon take over their business and that they would be losing business or be put out of business. This is something that we had to deal with over and over. Now it's not really a problem, but in the beginning it was a huge one. With this, I'll turn it over to Suzanne Kunkel and she'll talk about some of the design solutions and some of the changes and challenges and that will get into the next slide. Suzanne... >> SUZANNE: Thank you, Bob. And I assume we're on the slide now that says design solutions to some of the challenges. 5 One of the concerns was, of course, is this going to cost more? So one of the features that was put into place in the program was to use the exact same care planning process as was in place for consumers enrolled in the traditional service program. So theoretically there should have been no way that this program should cost any more because consumers would be entitled to the same care plans whether they went into consumer direction or whether they stayed with traditional services. So that was an important feature to put into place. We also put into place some limits on who could be hired as a paid worker for an older consumer. In particular, the limitation was that spouses could not be a paid worker unless the consumer had no copay, in other words, this is a program that had a sliding scale for the fees and so it would be only for consumers who are poor enough to not have to pay any -- for any of their own services would a spouse be able to be hired. Another part of implementing this program was to do agency-wide trainings, and this was under the leadership of Bob Logan and his management team realizing pretty early on that there were some very legitimate and very deep concerns about what this was going to mean for consumers; and in some cases people were worried about what kind of change this would mean for their jobs. So there were agency-wide trainings for absolutely every employee of the agency and there was -- there were two trainings for case managers. As Bob mentioned, there were some who were quite concerned. No case manager said it's a bad idea to let consumers have more say about their services, but many case managers were concerned about how this would work and what it would be like to turn over control to 6 the consumer while they, the case manager, still felt responsible for the consumer's well-being. So several trainings and discussion groups for case managers turned out to be very, very important. As Bob mentioned, he also brought on board some case managers who were champions for the cause and they became part of an implementation team that included heads of all of the major departments of the organizations and also we were present -- Scripps Gerontology Center were present on the implementation team as evaluators so we would understand how the program was evolving, what its intentions were, what kinds of outcomes it would be important to track. So the implementation team was crucial to thinking this through, to putting things in place and debating about some of the issues that we were hearing from people across the agency. The organization, the AAA also put in place some meetings with providers to deal specifically with this question of what is this new program and what is it going to mean to me? As Bob mentioned, there was concern that people were going to lose clients and that they were going to lose workers. A few meetings with the providers to describe to them what the program is, what the experience had been in other demonstrations about the numbers of consumers who will choose this started to put some of their fears to rest and at the end of the day providers were fine with this program because it turned out that the consumers who chose it were some of their most difficult consumers. And so more on that when we get to the evaluation findings. 7 Another feature of the program that the Council on Aging put in place was an independent evaluation conducted by the Scripps Gerontology Center so that there would be credible data about how well the program worked and how -- whether any of the things that people were worried about came to pass. Those were some of the important design features that we think helped preempt some of the challenges and concerns that people were concerned about. Next slide, please. The model that was put in place at the agency in southwest Ohio was a little bit different from the Cash & Counseling model, but the most important features are that the consumer is the employer of record. The consumer is legally the employer of record, meaning that the consumer hires, manages, supervises their own workers, they sign the time sheets and distribute the paychecks. So they are the employer of record in every practical and legal sense. But consumers were not turned loose, and we didn't wish them good luck and say we hope this works. There were supports put in place very intentionally including a fiscal intermediary agency. There were no options for this. Everyone who wanted to be self-directed, who wanted to manage their own services was -- had a fiscal intermediary. The case managers were still very involved with these clients and this was a very important feature of the program to, again, address some of the concerns that we were putting consumers out there on their own, but in fact case managers were very involved, very much at the same level of involvement, but with a slightly different role. Well, actually a very different role, more as a coach, more as a resource person, but they still 8 stayed in touch with their consumers. The consumers had the opportunity to be more in charge of how often those contacts took place, but the case managers were still a very important part of the supports in place for the consumer-directed participants. There was an extensive consumer planning process that the case managers were involved in and the fiscal intermediary were involved in. There was a handbook where they could look up the section about how to hire a worker or how to talk to your worker about -- if you have problems with the way the services are being provided. So lots of resources in place and supports in place for consumers. It was also the case that many of these consumers had authorized reps. This turned out to be a bit of a surprise for us. We thought that this choice was going to be -- this option was going to be chosen by consumers who were younger, more vocal, self-advocates, but in fact some of them were quite frail and had authorized reps in place. Another key feature of the program is that the authorized rep could not be the paid worker for the consumer. Next slide, please. The evaluation was designed to collect some baseline information on people before they went in to the consumer-directed option and we followed up with them at about six to eight months. So we looked at how things changed for people after they enrolled in the program, and we also compared them to a sample of consumers who chose to stay in their home care program. I want to talk a little bit about results because it's a pretty 9 interesting story, focusing on consumer profiles, what consumers had to say about how this worked for them and also what this meant for the families and caregivers of these consumers. Next slide, please. So we have a table of just a few characteristics of who chose this consumer-directed option and who chose to stay in traditional services. In terms of age and gender balance, there is not a lot of difference, but the people who were in the consumer-directed option actually were less likely to live alone than those in the traditional options. So a picture is starting to emerge here of the consumers who chose this and if I can jump ahead to our punch line, they succeeded very well in this option. So they were less likely to live alone, more likely to live with other people. They were more likely to have an authorized rep. They were very much more likely to have Alzheimer's or some form of dementia which was a bit of a surprise. So we're seeing pretty frail people who aren't living alone, who need quite a bit of help, and the next slide, please, will help illustrate that point even more. Looking at the impairment levels of people who chose consumer direction versus those who stayed with traditional services, the picture becomes clearer and clearer. These are very frail people. The consumer-directed clients, the participants were likely to have four or more ADL impairments than the traditional consumers. They had higher average levels of ADL impairments and very much the same story with IADL impairments, significantly more impaired. So we have -- and this project happened six years ago or so. At the time, as I said, our expectations were not what we found. This was not the 10 younger, vocal, self-advocating, living alone consumers. These were very frail people who already had a lot of help in place and needed more help than they were getting. Next slide, please. We asked consumers about their satisfaction with choice and control and this is a pretty powerful story. All of these differences are significant. Looking at what the consumer-directed participants had to say about how satisfied they were with the choice they had over the person who takes care of them, we see a dramatic increase in the percent who are satisfied after six months of being in this new program, and they are significantly more satisfied with their choice over who takes care of them than the traditional consumers where similar pattern with the kinds of services that they were getting and how their services were going to be delivered, their satisfaction levels went up significantly and met or exceeded the satisfaction levels of those in the traditional programs. So this is clearly an important option for a small proportion, but a very important segment of the population being served by this program. Next slide, please. Some additional findings -- what one of the concerns was that this program would erode family caregiving, the voluntary and sort of obligatory nature of family caregiving. That turned out not to be the case at all. Even after these consumers were enrolled in self-directed services, the unpaid caregivers still spent an average of seven hours a day providing unpaid care. So families were getting a little bit of help to continue doing an enormous amount -- to provide an enormous amount of care for their family members. 11 We realized that this was an important feature of the program, so we actually did some surveys with the caregivers and 100 percent of them said they would recommend this program to others. Two things about the cost of the services, even though we had built in this -- what we thought was a safeguard to prevent the cost of the program exceeding the cost of traditional services, it turned out that the costs were slightly higher, partly because these were more frail and more impaired people, but also because the self-directed participants were able to use more of their authorized care plan costs. There were fewer call-offs, fewer no shows from the workers because the worker was someone who worked directly for the consumer. Even though the costs were slightly higher, they received three times as many units of service per dollar as the participants in the traditional program. So our final slide -- I'm sorry, I forgot to say the next slide. We're on the lessons learned slide. Just to sum up, older, frail, cognitively impaired consumers can and did succeed in consumer-directed services. The program turned out to be a benefit to consumers and also to their families. And case managers played a crucial role in explaining the program to consumers and helping them understand what is entailed and helping them to succeed. Bringing along a team of case managers who were committed to the program turned out to be crucial. Bob Logan had originally intended for all case managers in his agency to work with self-directed clients and decided midway that that was not going to work very well. So instead, there was a specialized team of case managers who worked with self-directed clients. 12 And as I hope we've shown, program planning and designing the program can preempt or at least minimize some of the challenges and concerns that were voiced by people in the agency. And the last lesson learned goes back to Bob Logan. >> BOB: The political process leading for change with the agencies are crucial. It's just important if you're going to do this, you have to consider the funding source and with the funding source, you have to consider the constraints of the funding source and you have to make sure that your funders have the buy-in. So that's very important. That concludes our talk. And I'll get right in to introducing Dr. Kevin Mahoney. Kevin asked me -- he said please don't mention my Nobel peace prize or my boxing medal. So I'll just introduce him as the National Program Director of the Cash & Counseling Program. Kevin... >> KEVIN: Thank you, Bob. We're pleased to be here you know from the National Program Office for Cash & Counseling here at Boston College and so the next 15 minutes, all I really want to do is give sort of an overview of the Cash & Counseling program and the research results. Some of you I know are really familiar with this. Others, it's a first time. So I'll try and hit a middle ground. But today in most states, whether you're elderly or a younger person with disabilities, if you need help with such basic activities as bathing, dressing, getting out of bed, it's rare that you have a choice about who helps you. Sometimes it's very hard to have any say on what time of day people come for a shower, to get you out of bed, and agencies have many 13 restrictions on what they can do. So the origin of the Cash & Counseling demonstration was really people in the disability community saying if I had more control over these basic personal assistance services, I think my life would be a lot better and I think I could do it for the same amount of money. And that really -- Cash & Counseling was a policy driven test. That's how it started out of those clients in the disability community. There were four things unique about the original demonstration. We wanted to test it on a large scale, and that meant people from three whole states, Arkansas, New Jersey, Florida, and there were 6,700 people involved in the original test. Secondly, we wanted to evaluate it with the strongest methodology we knew, you know, knowing that this was an area that was controversial. We used an approach of random assignments. So half of those people stayed with traditional agencies and half got the chance to self-direct. The third thing unique is we were going to test consumer direction, we wanted to test one of the ultimate forms and we used an approach, you know, where people literally had control over a budget that was roughly equal to what an agency would have spent on their behalf. And finally, the original test cut across age groups and disability types. So if I look at the first slide, the one that says program overview, you know, this was right from the beginning funded by the Robert Wood Johnson Foundation, the Assistant Secretary for Planning and Evaluation at the Administration on Aging. The original demonstration involved close oversight by the Center for Medicare and Medicaid Services and was done with Medicaid waivers. We at Boston College oversaw the 14 evaluation, provided direction for it and technical assistance to the states and the outside evaluator was Mathematica Policy Research. In the next slide you see again the original three states, and I'll dwell on this for a minute. Every single one of these states wanted to test this idea with the elderly. Every one of them tested it with adult was disabilities, and Florida also had 1,000 children with developmental disabilities. Some people had real doubts about would elderly be interested and I'll use Arkansas as a great example. If I'm right, I think about 73 percent of all the people who signed up in Arkansas were elderly. And that's roughly the proportion they were in their personal care program. In Arkansas and New Jersey, the original demonstration was an alternative to the Medicaid personal care option and in Florida it was an alternative to three different Medicaid waivers. So then I go on to the overheads about the basic model, I do this for a reason. Every state, as you know, is so different. Its delivery system, its history, its culture, its leadership its Medicaid program, but these were elements that were sort of basically constant across the states and I found these five steps make it easier for people to picture it. So you know sort of in step one the participant, the consumer entered the system much as they always did and got the assessment and care plan in that state. And the second step is a science, but a dollar value was assigned to that consumer's own individualized plan. So there was an attempt to be equitable. The budget was roughly equal to what that individual would have gotten in that state that would have been spent on their care. 15 Step three is also a real art, and people are really getting good at it, but it's how to present to the consumer and usually with their family enough information that they can decide what's right for them. Cash & Counseling is not for everyone. It never will be, never should be, but to present people with enough information they can make a good choice and they know they can return to the traditional system any time they want to. Step four for people that go forward, you know, and say I really want to do this, it wasn't then like sending out an SSI check, cash in the mail. Every state basically has done it. The consumer had to develop a plan for how to use that money. It could be very flexible. They could hire who they want, including relatives. They could buy a range of goods and services, assistive devices, home renovations. The litmus test was basically they had to show the plan had to meet their personal assistance needs to help them remain independent in the community and then the next part just echoing what Suzanne said, people weren't left alone. In fact, we had the chance in the original demonstration to do focus groups with people and survey a representative sample of home care clients to see what supports they wanted and needed. And just as we suspected, 99 percent of them didn't want the cash. It would be such trouble to keep the books and handle tax issues and the fiscal management services become a real hallmark of Cash & Counseling as has the care managers switching from a professional medical model to an empowerment model which is at the base of so many of our professions. I'm in the school of social work, but it's how do I think broadly about my needs, finding resources, workers, develop a back up plan, think about training my workers and think about firing my 16 mother. And as Suzanne said again, it was the idea that people could have a representative that could help them manage that didn't feel they could do it all on their own became really important. The next slide is a map, and you can see depending on how you're going at this the original states are darker, Florida, Arkansas, New Jersey, and then in 2004 we had the chance to expand this option with Robert Wood Johnson funding and the help of our HHS partners to an additional 12 states, and I'm really proud to say 11 of those 12 are up and running, and Pennsylvania is aiming for April 1st. So every one of them will be up and running, and some of them even have thousands of clients already. I want to do the research results, and that's the next slide. But I'll take a second to give you the keys to it so you can look at these at your own pace. All of this data and reports are on Cash & Counseling.org, our website. So you can look at these any time with more time, but what you see here are we divided up the results for the elderly so you could look at them alone, the nonelderly and children. We divided them by state and the T. stands for the treatment group which means people that got to manage their own allowance. The C. is the control group stayed with traditional agencies and you'll see all these stars, that's every time you have statistically significant results, but just to make this come to life, I'll explain this one. That is one of our most important effects and it shows how Cash & Counseling affected access to services in an environment that often had worker shortages like Bob described. If you look at Arkansas, you can see for the nonelderly, when we asked 17 people at nine months into the survey, did you get any personal care services in the last two weeks? 95 percent of the nonelderly that got to manage their own allowance said, yes, I got it. Whereas only about two-thirds of the people in the agency mode got the services that had been in their prescribed care plan. When you look over at the elderly, you see 94 percent of the people who managed their own allowance were able to have the personal care needs dealt with, only about 80 percent in the control group. And maybe to a large extent that people could draw in family, neighbors, relatives, people from their churches, people that cared especially about them. I'm going to do these other results quickly, but here is the framework for ways of looking at quality and it had to do with satisfaction, with key aspects of your care, unmet needs, 11 different health outcomes and overall life satisfaction. When you look at the satisfaction results, Randy Brown who was the principal investigator at Mathematica said he had never seen results this strong in his whole life. People were a lot more satisfied. When you look at the next slide and you don't have to look at all the numbers, just notice the pattern is always the same, people had far fewer unmet needs when they could individualize and tailor the plans to themselves. If you look at the next PowerPoint on contractures, I'll take a step back because this is just an example. We had 11 health outcomes, things like decubitus ulcers, contractures, falls, there were 11 of them. In no case did the people in the traditional agency mode do better on a statistically assistant better, and a third of all of these 77 measures -- 18 in a third of the cases not only did the people who managed for themselves do better, they do 20 to 50 percent better. And that really gave us pause because we didn't know how people would do. You know, people would say, gosh, these workers weren't as well trained or they didn't have the supervision of agencies. Never did the traditional agencies do better. In a third of the cases, the people managed for themselves had much better results. When you look at the next slide about very satisfied -- I'll just say this: This is an overall global measure of how satisfied am I with the way I'm spending my life. It isn't just that the people who managed for themselves are more satisfied and much more satisfied, it's like when I realize that the average benefit in the state of Arkansas was only $340 and I say that affected people's total life satisfaction, I think it's amazing. The next PowerPoint on the informal caregivers, this echos what Suzanne and what they found in southwestern Ohio. The caregivers had less financial, physical and emotional strain and they were much more satisfied. When you get to costs, I've broken these down into how did it affect the costs for the personal care services, just the personal care themselves, how indict affect all other Medicaid costs like nursing homes, hospitals, and then what was the overall effect? When you looked at personal care -- and remember here, we're comparing large numbers of people that were randomly assigned, you basically had higher costs on personal care, and the single biggest reason was that the traditional agencies weren't able to deliver all of the care that was in the prescribed care plan. Remember, think back to those results from 19 Arkansas. But when you get to -- then what happened with nonMedicaid costs, nonpersonal care costs, which is the next overhead, you basically found in every state the costs for other services was less. The most dramatic result, we even went back and got a third year of cost data. We reflected all data for three years in Arkansas and found an 18 percent -- 18 percent reduction in nursing home costs comparing the treatment and control. So when you go to that next one on total Medicaid costs, the next overhead, you basically have a wash. This wasn't intended to save money. It just was a break even in Arkansas. The other states, there was a modest cost increase, but one of the things -- and you'll find this on our website -- a lot of our implementation lessons and in fact we're coming out very soon with a handbook that will describe even more lessons for how to control the costs for supportive services and how the manage this so that we feel that there is no need that this costs more money. And so you get to the last slide on policy implications and it's sort of -- our take away was dramatic increase in access to care, could improve quality of care and caregivers benefit and you have to pay attention to costs, but they need not be higher. I know I've rushed a little, but part of it is so we can now change pace as you probably heard enough of us all talking. And one of the things we thought might be interesting is to show a five-minute video that was done in Minnesota that really features, you know, not only an elderly couple that were involved in Cash & Counseling, but it talks to their care manager who thought this was a crazy idea at the beginning and then changed 20 her mind. So the video, please. (Video Playing). BRENDA: I'm Brenda Edelman. I'm a social worker for Big Stone County Family Services. I arrange services for people so they are able to stay in their homes and live independently as long as possible. Cash and Counseling in Minnesota is called Consumer-Directed Community Supports. And my clients with Cash and Counseling have much more freedom and flexibility to hire the people that they want to provide their care. AMBER: My name is Amber Amdell. I'm a public health nurse, and I work for Countryside Public Health in Martinville, Minnesota. I am a cold case manager with Brenda Edelman, and I am Wilford and Arlene Wallace's case manager. BRENDA: Hello. AMBER: Hi. BRENDA: Hi, there. Hi, Wilford. How are you doing today? WILFORD: Fine. Fine. BRENDA: Oh, you've got a Diet Coke. Looks good. Hi, Arlene. How have you been feeling? ARLENE: Good. BRENDA: Good. AMBER: With Arlene and Wilford, they were in 24 hour nursing supervision. So what I looked at with the Cash and Counseling was would 21 they be able to be safe in a home environment without that 24 hour nursing piece. BRENDA: I think Wilford was bored out of his mind in the nursing home. He had started kind of having some acting out behaviors. He would pull a fire alarm just to see what would happen. He gave another resident a haircut without permission. So he was getting in a bit of trouble. Arlene had kind of folded in on herself. She just sat in her room and read books and didn't want to go out to any activities. Linda, their daughter, had heard about the CDCS program. We went into the nursing home and did an assessment to make sure that they would be safe and their needs would be met if they left the nursing home. AMBER: We were worried about the 24 hour supervision of the nurses, the aides and if somebody could come in and do that, and they did not need that 24 hour piece. They needed assistance, and the assistance they needed, Linda was able to provide for them. When you went to the doctor, you had some blood work done, and I got a copy of it. It looks pretty good. LINDA: Under the Cash and Counseling program, the parents -- my parents were able to decide who they -- and hire who they wanted to help them. There is your pills. There is four of them right there. As my parents' caregiver, I fix their meals, give them their medications, give them their insulin shots. I help with their bathing. I clean their apartments. AMBER: For me as a nurse, it means healthier clients on the Cash 22 and Counseling because they had a more positive outlook. They are being in charge and their health and safety needs are being met. LINDA: I feel with my parents it's giving them a better quality of life than to be basically stashed away in a nursing home. ARLENE: The independence is very important -- to me, anyway -- and you don't have somebody telling you what to do and what to eat and that's the best part. WILFORD: It's just better is all. BRENDA: For Wilford and Arlene, it's a whole new lease on life. They can go out and watch T. V, you know, and do whatever they want to do. Wilford can go outside and putter in the yard. That's very important to him. LINDA: They've got the independence to do what they want to do when they want to do it and not having somebody telling them what they have to do. BRENDA: I feel much more confident that Cash and Counseling could probably benefit more of my clients. Cash and Counseling would come to the forefront of my mind much sooner now. I think I'd be more willing to look at it in places where I probably wouldn't have looked before. It was nice seeing you again. Thanks for visiting with us. AMBER: The thought of it is a little scary. The outcome is great for both the client and the case managers. It is a lot easier and a lot nicer to come into somebody's home when they are in charge and they have a positive outlook on everything that's going on. It's just a very positive experience for all of us. 23 LINDA: I have to remind my parents every once in a while, especially my dad, that, you know -- dad, let me do this for you. You took care of me and the boys all those years. Now it's our turn to take care of you. And this program has allowed me to be able to do that. (End of Video). >> KEVIN: Okay, I hope everyone you know found that interesting. This video and numbers of other videos are up on that Cash & Counseling.org website along with various tools and forms, various states have developed, some of the data you can look at for yourself on that website. But now one of the things that we really thought would be perhaps the most important on this call was to take some time to talk with, you know, some of the Area Agencies on Aging who have had actual experience with consumer direction, with Cash & Counseling. To hear not only what some of their experiences are, but to be able to share with so many of you what roles are there for Cash & Counseling -- what roles are there for Area Agencies on Aging and Cash & Counseling and consumer direction. What important part can area agencies play? We have with us, you know, on the speakers list area agencies from Pennsylvania, Kentucky and Illinois. Each of them will speak for roughly five minutes, but the first online are Pearl Graub and Ann Orcutt from the Philadelphia Corporation for Aging in Pennsylvania. And whereas Pennsylvania is just on the cusp in getting ready to implement, I think to the credit of the area agencies, in a state like Pennsylvania they played 24 the real -- a real leadership role in making this happen and keeping people pushing forward. So it's a pleasure to introduce Pearl and Ann. >> PEARL: Thank you, Kevin. This is Pearl Graub, and AAA's in Pennsylvania have been involved with consumer choice and direction for some time. In terms of consumer choice, we've been involved through our Medicaid waiver and consumers have been choosing between where they would receive services, community versus nursing home, their services and their provider. We've done this through as Kevin described an empowerment model whereby care managers are providing information and empowering consumers to make informed decisions. And the way that happens is we are able to create provider profiles and give to the consumer the results of we have consumer satisfaction survey ratings, consumers if they are interested can receive the price or cost per unit, results of the last quality assurance audit and the results of our care manager satisfaction survey ratings. As Kevin described, we are gearing up for Cash & Counseling in Pennsylvania. We're calling it Services My Way. And consumer direction has been realized through a program we've had for several years called personal assistant services and the benefits that we see for Cash & Counseling that we've realized through consumer direction with this personal assistance service is to have flexible hours. Caregivers available traditionally are not available on weekends and nights, and that's been an excellent asset. A familiar person care giving, routinely and formal caregivers, informal supports, family, friends, neighbors. Language capability has 25 been a critical element. There is a large Russian speaking population in Philadelphia and we have a growing population of Chinese speaking and Spanish speaking so that this familiar individual caregiver speaking the consumer's language is so very important. And we're hoping through more informed and empowered consumers' decisions that this will lead to more satisfied consumers, and it seems the research has shown that already. And a flexible care plan -- the built in economies of the consumer very involved, directing their care planning and saving to purchase certain goods and services, the built in economy, but also creativity. And then health maintenance activities such as medication management, to feeding, finger sticks, et cetera. Now to gear up for Cash & Counseling we have -- we conducted focus groups that involved consumers and staff and then we were able to train staff, and as you heard, we hope to be proceeding soon. Ann, if you'd continue. >> ANN: I'm just going to build on what Pearl said and go on a little bit more about the personal assistance service as we provide it. Personal assistance service is hands on assistance with activities of daily living and instrumental activities of daily living. The consumer must be cognitively intact and be able to direct their own care. If there is a cognitively impaired consumer who cannot, they may have a caregiver or a legally authorized surrogate to direct the care for them. The person that's directing the care for them cannot be the personal assistant. The personal assistant can be a friend, family member or 26 acquaintance, as long as they are age 18 or over. They cannot be a spouse. Once the care manager has developed a care plan, and authorized a personal assistance service, a referral is made to a provider agency. That provider agency is the fiscal agent. They make a home visit so the consumer can sign the necessary forms and to be set up as an employer as described as they do in Ohio. They then provide the consumer with the time slips that both the assistant and the consumer sign to document the hours of care provided. The provider agency then pays the personal assistant for the hours worked. The provider agency also has to have a registered nurse available as needed to teach any of the health maintenance activities that may need to be done for the consumer. When the consumer -- the consumer is also responsible to have a backup plan in place in case their assistant is unavailable on any given day. When they have the traditional personal care services, the agency may have been able to do this for them, but now that does become the responsibility of the consumer. This model does pose some challenges for care managers. As part of the traditional personal care service, there is a field supervisor for the personal care agent who made routine monitoring visits. Personal assistant services does not have this kind of oversight. The care manager needs to make careful observation and ask more questions to ensure the consumer is receiving the care expected. The consumers that have hired a family member may be reluctant to discipline or terminate this person if they are not providing the care as directed. At each visit the care managers is having a conversation with the consumer as to their satisfaction with the service 27 and if it continues to meet their needs. And we currently have approximately 1200 consumers under the personal assistance service. That's about 25 percent of our waiver program in Philadelphia. And Ann has a case exam, if we have time -- >> KEVIN: Maybe just a minute or so. >> ANN: I'll make it quick. Mr. and Mrs. A. are husband and wife both receiving services. They live with their daughter, son-in-law and two grandchildren. This couple arrived from the United States from an Asian country a few years ago and do not speak any English. Mr. A. is physically impaired and wheelchair bound while his wife is mobile but has moderate dementia and cannot be left unsupervised. The first year the family struggled with services with personal care agencies because they didn't have enough aid to provide the physical care, especially needed by Mr. A. on the weekends. And only one agency had aides that spoke their language. Eventually daughter was able to locate a woman in the community who was fluent in their language and agreed to become their personal assistant. The care manager then changed the service, changed to personal care to personal assistant service with the daughter's -- the couple's daughter becoming the person directing the care. Mr. A., needs care in the evening and nights so his son-in-law who works during the day was also hired to provide care in the evening and nights. After putting Mr. A. to bed, his son-in-law sets his alarm clock and gets up twice during the night to change and reposition the consumer. As a result of being able to use this service, the family was able to take on the responsibility of finding their 28 own person that met their needs. >> KEVIN: I appreciate your doing that because I think it's an example that is what brings this to life for many people. So thank you to Pearl and Ann. The next state that we asked to really share their experience was Kentucky. And not only has it been amazing the growth of the consumer-directed, the Cash & Counseling option in Kentucky, if I think they must be a little over a year, over a thousand consumers, but the area agencies played a role as both support broker and fiscal management agency. So it's a pleasure to introduce Vivian Craig and Jennifer Williams from the Green River Area Development District which I believe is western Kentucky. BRENDA: >> VIVIAN: Yes, we're in Owensboro Kentucky. In Kentucky the Cash & Counseling program is known as consumer-directed option. We also have 15 Area Agencies on Aging in Kentucky and each of those is located in an area development district. The area development district is a regional planning and development agency with five departments. So that we are able to do both the support broker function and the fiscal intermediary function within the area development district. Actually, the Area Agency on Aging provides the support broker and our finance department provides the fiscal intermediary function. The program actually started on September 30th of 2006 and we now have over 1,000 clients in Kentucky. And I'm going to turn it over to Jennifer with some more specifics. >> JENNIFER: Well, some of the things that the agency has been able to do was having both the support broker and the fiscal intermediary 29 within the same agency is to be able to help us to monitor budgets, to make sure that the consumers are staying within their budget for services. We have the support brokers of course in-house that go out and do the monthly visits. They act as liaison between the consumer and Medicaid, but also the consumer and the fiscal intermediary. Again, to track those budgets to make sure time sheets get turned in, employee personnel, paperwork, those types of things to make sure that both sides have what they need. They provide training for both the employees and the consumer about the program, about what consumer-directed option is, about what to expect, how to watch for abuse, neglect, those types of things. We also work with the consumers to make sure that they have an emergency plan in place. The support brokers review all of the time sheets as they come in and turn those over for payment by the fiscal managers. We've recently also begun working with the consumers for goods and services, which has been a new service for us up to this point we have just done personal care, home making, respite, personal attendant services, and now we're doing goods and services, and our traditional providers up to this point have been doing our assessments and reassessments. The support brokers are now going to begin doing those assessments and reassessments as well. >> KEVIN: So I'm in awe of what you have accomplished in such a short time in Kentucky. I get to go to Kentucky on Monday so I want to hear more about how things are going, but thank you to Vivian and Jennifer. And you get to go to Illinois on Wednesday, but our next speaker is Joy Paeth from the Area Agency on Aging of southwestern Illinois, and you 30 know whereas Cash & Counseling is up and running in Illinois, I note at this stage Joy's best experience to share today is with consumer direction in general. So I'll turn it over to Joy. >> JOY: Good afternoon. Thank you very much. Yes, we're right outside of St. Louis, so I hope you're in our area. The Older Americans Act is where we've done most of our consumer direction and it's been with respite services from the caregiver support program. We designed our program originally very basic to receive the service of respite, caregivers were assessed by case managers. Caregivers who were eligible for respite could use an in-home agency. It wasn't consumer-directed at this point. They were allowed 50 hours, you know, for six months at a minimum of four hours for each contact. And the service was offered seven days a week. The cost to the area agency was $13 per hour. The interesting thing was no one used the service. You would think that it would be highly -- what a great option for caregivers. So we wanted to find out why and sent a survey and did some focus groups with caregivers and they stated simply what everybody else has said today that they didn't want strangers in their home. The program was highly structured and they didn't always need four hours of care at one time. So we knew we had to make a change. So our goals with any of the changes with this program was to, number one, minimize any confusion and enhance the decision-making process for the consumer and increase their control. We searched and we looked at other similar programs that were operated in a consumer-directed way without Cash & Counseling dollars attached to 31 it. And we developed the program that we have in place today. And this is how this new improved consumer-directed program works. We've been actually doing it since 2002. After an assessment, caregivers are given a stipend of $100 a month. We kept the money very minimal because we wanted to stay under that tax threshold so people didn't have to declare taxes. And then we paid for the services after they are used, but the caregiver manages and sets the work requirements. A person who is doing the care cannot live with the care receiver. It is respite. So that's the reason for that. And once again as was said by Suzanne, the employer -- the caregiver is the employer of record. And that is critical. We are not setting the work requirements. So we kept the stipend under that amount so we eliminated that need for the fiscal intermediary, and that was helpful for us. And in ten months of starting the new program, our utilization went up 800 percent and the costs dropped 51 percent, and we were able to serve an additional 71 people. So this is very, very good and it's kind of the theme we're hearing with consumer direction. People are very wise with their resources, and I think allowing them to use them in the manner they would like is great. We were of course concerned -- I think Bob had mentioned about possible misuse, but we've seen little with this program. And we have a system in place to administer and pay the individuals monthly expenditures. It's a bit less complicated because we've capped that taxable amount and currently we have a waiting list for the service. So that's a true telling 32 story there. We have 165 people who are currently using the service. It is Title IIIE money so there is not a tremendous amount of dollars in that. We have an average hourly cost of six dollars per hour for the service which is half of the original cost, and the services to be utilized for respite are primarily family or friends who are not living with that caregiver. So if we could do the same thing with Title IIIB funds I'm sure we would see the same results and hopefully we can see the flexibility with Older American Act funds that will allow this type of consumer direction with other titles in the act. And that's what I have for you. Thank you . >> BOB: Thanks, Joy. This is Bob Logan back. I want to introduce Linda Velgouse who is with the U.S. Administration on Aging who is the Aging Program Specialist at the Office of Spending and Policy Development. And she'll lead the discussion on the nursing home diversion grant. Linda... >> LINDA: Hi, good afternoon. Joy, you couldn't have given me a better segue. The nursing home grants will help create the flexibility in Title IIIB and other Older Americans Act. I am going to talk about the Administration on Aging Nursing Home Diversion Grant program and I'm going to give a as brief an overview as possible and try to highlight specifically the elements. I want to be sure that my Arkansas associates have enough time to tell you about the nursing home diversion grant program being developed in their state. You'll hear from Debbie Ellis who is the nursing home diversion project director and she is also the program administrator for home and community-based services. She's with the division of aging and that's part 33 of the Department of Human Services and Jerry Mitchell who is the Executive Director of the Northwest Arkansas Area Agency on Aging which is one of the pilot sites. Next slide. The key messages -- nursing home diversion grants begin to implement the third component of the new long-term care provisions in the Older Americans Act. These provisions include authorizing the assistant secretary to promote comprehensive, coordinated systems that respond to the needs and preferences of older individuals and their family caregivers and to provide services through self-directed models. And the self-directed models, the definition actually is similar or almost exactly the same as Cash & Counseling. And the nursing home diversion grants provide broad national state of the art standards for the aging networks nursing home diversion program and provides states a great deal of flexibility in those standards. The grants encourage State Units on Aging as with their partner Area Agencies on Aging to transform existing Older Americans Act, Alzheimer's disease, demonstration grant funds and state revenue dollars into flexible funding options for consumers. The grants give states an additional tool for rebalancing, and I just need to add a major goal for the grants is really to test the standards and to develop models and best practices that can be replicated in others states. Next slide, please. Key parameters -- we had enough money to award 12 grants at approximately $500,000 per grantee. State Units on Aging were the only eligible applicants because what we really wanted to do is provide 34 the incentives and supports, the aging network, to really able to modernize their long-term care systems. The State Units on Aging had to work or partner with at least one area agency as well as other community and Medicaid stakeholders because we want this to be a program that can grow in the state. The funds can be used to transform existing funding or to expand services and the states must meet certain minimum expectations by the end of an 18-month grant period. As mentioned earlier, we developed broad state of the art standards, and these were developed as guides to states. These included service and system elements. So the service elements included flexible service dollars in targeting individuals who are at risk of nursing home placement and at risk of spend down to Medicaid. We wanted to make sure the services include giving all clients the option of Cash & Counseling and you remember these are standards. So the states didn't necessarily have to do that. And also to use funds to complement resources of families in other programs. Next slide, please. We did request or require that states include targeting criteria that include all of the four elements you see on the slide that are functional, health and cognitive status as well as the status of informal support system of the consumer. We also request that states target people at risk of spend down to Medicaid. And they can -- they are flexible to consider income and/or assets, but to come up with a formula will help them decide who may be near Medicaid spend down. And states have a lot of flexibility in developing or 35 adapting tools and parameters for their targeting activities. The second set of standards are system elements. And these system elements include single point of entry, which many states have already or are developing, and many states have ADRC's which are single entry points and they are using those to have an infrastructure for support of consumer direction including a Cash & Counseling model, and to have systems to ensure quality assurance in performance, measurement and evaluation. Next slide. So we developed these standards, but we gave states a lot of flexibility, and what we really ask states is that they can choose among all those different standards and activities, but at a minimum at the end of the 18-month period, and I'm going to kind of do these just the opposite way, at the end of the 18-month period they must be using a single entry point to streamline access that can target individuals at risk of nursing home placement and spend down to Medicaid and they must be serving the consumers with flexible service dollars. Next slide. The use of the grant funds in the nursing home diversion grant can be for all development and support activities as well as for some direct services. And again, no one size fits all. This is a flexible program. All states have different starting points, so we're expecting a lot of different models. Next slide, please. This is just the 12 grantees and I won't -- well, I will. Arkansas, Connecticut, Illinois, Kentucky, Maryland, Michigan, Minnesota, New Hampshire, New Jersey, Vermont and West Virginia. Those were the 12 grantees that were awarded their grants in September 2007. Now, consumer direction in the nursing home diversion modernization 36 grant, most of the grantees actually decided that they were going to develop a Cash & Counseling model. And you'll see that many of the states are current or former Cash & Counseling states, including Arkansas, Illinois, Kentucky, Michigan, Minnesota, New Jersey, Vermont -- oh, I had Michigan twice -- that are expanding or replicating their current Cash & Counseling programs into the nonMedicaid populations. States are using different funding sources. Most all states are using Title IIIE and actually as Joy mentioned, a lot of states had already started developing programs with Title IIIE funds and now many of the states are also including Title IIIB funds. Other funds that are being used are state funds and the Alzheimer's Disease Demonstration Grant to state funds. Next slide, please. So I'm just going to go through quickly a couple of state examples just to give you a sense of what some of the states are doing. Starting out with Georgia, Georgia is transforming state respite and Title IIIB funds and using some grant funds for services. They are piloting through one AAA which is the regional council -- commission, and it's also an ADRC. So they have their single entry point and they anticipate screening about 200 people and having at least 50 people in the end -- by the end of the grant period. In Minnesota, next slide, they are transforming Title IIIB, Title IIIE and the Alzheimer's Disease Demonstration Grant funds. They are piloting through two AAAs, two area agencies, Arrowhead and Central Minnesota and they expect to provide consumer-directed options to 50 to 75 consumers and caregivers, and about a fourth of those are going to be targeted to people 37 with Alzheimer's. And they do plan to also identify 200 to 300 at risk older adults and 150 to 200 caregivers for future services. And I must say that Minnesota is also a Cash & Counseling state and it has been doing a lot of consumer direction in many of their other programs, including alternative care. Vermont, next slide, another state will transform Title IIIB, Title IIIE, state revenue and local revenue funds in their program. They plan to provide options counseling, training, or flexible services to 200 persons, and about a third of those will be targeted -- a third of that services in funding will be targeted to people with Alzheimer's. They are expecting to involve all five of their AAA, put they currently have an RFP out to actually pilot the program with two to three AAA's. My last state example is West Virginia. They are transforming their family Alzheimer's in-home respite plus program funds. They are piloting through one AAA, the Potomac Area Agency on Aging, and they expect to provide services to 50 consumers and caregivers affect by Alzheimer's by the end of the grant. They also plan to expand the program to other parts of the state in 2010 to 2011. Now I have Arkansas here as a state example, but I'm not going to go into it because I'm going to let Debbie Ellis and Jerry Mitchell talk much more specifically about their program. And my last slide at the end is just for more information, please feel free to contact me or go to the website at the Administration on Aging website for more information on the nursing home diversion. Thank you. Now it's Debbie. Debbie Ellis, are you there? Or Jerry Mitchell? 38 >> BOB: We may have lost them. You want to see if they'll come back on and do your last state example. >> LINDA: I'll do the last state example. Arkansas is implementing a Cash & Counseling model in two of their Area Agency on Aging sites, in central Arkansas and northwest Arkansas. They are transforming funds including Title IIIE and state general funds and they are developing and testing a Medicaid spend down screening tool. They do expect to serve up to 150 consumers. And when I was talking with Debbie and Jerry earlier, Jerry who was -- I keep thinking I'm hearing them -- Jerry had mentioned that they are already beginning to identify consumers to serve. And that particular Area Agency on Aging is a provider, and so they are going to act as the fiscal intermediary and provide a budget to these people that they are currently identifying and that should be starting very soon. I guess if they don't come on -- >> BOB: We'll just go for questions. >> LINDA: Yes. >> ELIZABETH: Okay I have a couple of questions that have come in online so we'll take a few of those and then maybe open up the phone lines to see if anyone has other questions. The first question is about authorized representatives. The question is did authorized representatives become the de facto case manager and are only family members able to become representatives? >> BOB: Okay, who would like to answer that question? >> KEVIN: It's Kevin. I can start and then some of the states can give real examples. 39 Let me make sure I understand the question. Certainly representatives can be a range of people, not just family members although family is more typical and most states have standards for representatives as far as that they see the person regularly and, you know, and have other standards and you can see some of these on our website. What was the first part of the question I may have missed? >> ELIZABETH: Do they become the de facto case manager? >> KEVIN: Not the case manager. The job of the representative is really to help the consumer voice his or her own wishes. You know, so the representative is really there to help manage with -- and therefore for the consumer, but there is still a support broker involved. >> BOB: Okay, others that wish to jump in on this? >> SUZANNE: This is Suzanne Kunkel, and in Ohio there was a project that was very much the same way. The case managers were still involved and sometimes case managers had to help just ensure that the authorized rep was in fact speaking for the consumer. So case managers actually took on a new kind of responsibility in the case of authorized reps in consumer direction so they were -- case managers still played a crucial role. >> BOB: Okay. Thank you. We have a short time for questions. Elizabeth, do we have another one? >> ELIZABETH: The next question is how was the costs contained in each state? Was there a cap on hourly wage for each service or is this set by the consumer? >> BOB: All right, who wants to jump in on this one? 40 >> KEVIN: Again I can start. It's Kevin. But it's a multipart question. Consumers in all of these states really could set the wage for their own workers as long as they paid at least the minimum wage, and consumers used that very flexibly so that they might have paid less if it was a service you know around homemakers or shoveling snow and more for a service like personal care. One of the things we ended up finding was at least in New Jersey and Florida, consumers paid about a dollar more per hour than agencies were paying. How was the costs contained -- well, the consumer had a budget that was kept and that was their budget. And they had to live within that and manage it and, you know -- whereas maybe a few of the states, you know like I think in West Virginia they didn't want people to spend more than $1,000 overall on goods and services. In all of the original states and the model at its purest, the consumer's choosing and they are governed by what the total budget is. >> BOB: All right. Others? Other area agencies? >> ELIZABETH: I was going to say if there aren't any other comments on this one, maybe we can see if there is a question on the phone end. >> BOB: Sure. >> OPERATOR: Hi, this is Marissa. At this time we have no questions in the queue. >> SHARON: For those of you on the phone who would like to ask a question, you need to press star 1 on your telephone and you'll receive a voice prompt saying your hand is raised. Then Marissa will open your phone 41 line and you'll hear a prompt saying please ask your question now. We do ask that you introduce yourself when you have the floor. When you are finished with your question, you'll be placed back in a listen-only mode or you can press pound -- the pound key to lower your hand if that question has already been asked. So again, for those of you on the teleconference today, if you do have a question, you need to press star 1 now on your telephone. >> OPERATOR: Sharon, I believe we have our first question. This is from the 615 area code. >> CALLER: Hello. >> BOB: What is your question? And can you identify yourself? >> CALLER: This is Jerry Mitchell. I was one of your presenters and I got muted out of your conference from Arkansas. >> LINDA: Well, welcome back, Jerry. >> JERRY: And we've been listening in without any problem. So anything you'd like for me to try to present or answer, I'll do so. >> LINDA: Can Jerry have five minutes to add to -- anything you would like to add to what I had said before, Jerry, would be wonderful. >> JERRY: Well, you did a great job of covering what we were -- what we had talked about. We've had experience in Cash & Counseling and what we wanted to do was to go after those people -- we were using a Medicaid waiver, and we wanted to go after the group that's right above the Medicaid waiver in income and that are not eligible for Medicaid and try to help those people out. And when this came along, it was just wonderful. And the county that we identified to do this in is a rural county and it 42 has about -- I have somewhere around 8,000 people above did age of 60 years of age. And of that, about 1,000 of them would be considered low income. So we thought this would be ideal. And a lot of these people -- they need help. There is a pretty good utilization of the nursing home. We have three nursing homes in a town with a population of about 13,000. So there is a lot of that. What we were trying to do is get some of the rebalancing of the nursing home population and let them use community and home-based services. And we're really excited about it. I think you covered most of the other information. We're going to copy -- or lean heavily on what we've learned with the Medicaid waiver independent choices program which is a Cash & Counseling model, and you know this allows people in Medicaid to choose how, when and whom the services will be provided by, and that's the same option we're going to use here. What we're going to use for funding will be some of the IIIB money, some of the state money that we get, and the agency will probably absorb some of the money as in-kind, and we're really excited about the screening tools that we're going to be testing out, both the financial tool and the assessment tool, and we do plan to be the physical agent for the program. We've had quite a bit of experience since we do a lot of direct services. >> LINDA: Thank you. >> SHARON: We have more questions in the queue. >> OPERATOR: Going back to that 615 area code. >> SHARON: And please introduce yourself. Good afternoon. >> CALLER: Good afternoon. 43 >> BOB: And who is speaking? Hello? >> OPERATOR: Maybe we can try the next person. >> CALLER: Hello, can you hear me? >> BOB: Yes, we can. >> CALLER: This is the 615 area code. We've been trying to let you hear us, but we didn't know how to implement it. My name is Jane Young with the Greater National Regional Council, and I have a question that originated from Pearl and Ann's handout. The question is from the consumer's point of view. You mentioned that you meet with the consumer -- the fiscal agent meets with the consumer to have the necessary funds enabling them to become an employer of the personal assistant. Are you speaking in terms from the consumer's point of view becoming an employer as defined by I. R. S. and getting the I. R. S. employer number? And the second question, if that is so, how does I. R. S. treat the funds that are paid to the service provider, the personal assistant? Do they treat that as income for the consumer or, you know, how does this impact the consumer's tax issues? >> ANN: Okay, I'll try to answer that. This is Ann. They do get an employer identification number. So they go through all the forms that are needed to make someone under the I. R. S. rules an employer. The funds, however, don't go to the consumer. They go to the fiscal agency that does this. So they are not considered as income for the consumer. And the fiscal agent then pays the personal assistant. >> PEARL: Is that clear? >> CALLER: Yes, thank you. 44 >> BOB: One of the areas many people have questions on is the whole management of the fiscal employer agent and you'll find things on that Cash & Counseling.org website, and we'll have out by the summer a handbook that describes basic operations, but we've started running annual conferences to both train fiscal employer agents on how to work with the I. R. S., workers' comp, et cetera, but we're also trying to do sessions to help states learn how to manage and oversee the fiscal employer agent. >> BOB: Any other comments? Elizabeth, do we have any more questions? >> ELIZABETH: We do. And just before -- I think we probably have time for at least one more question, but any of the ones that have been submitted online that we don't get to, I'll be sure to follow up with everyone. >> BOB: Thank you. >> ELIZABETH: The next question is, is there a maximum amount of funds that can be authorized per consumer? >> BOB: All right. Who wants to take this question? >> KEVIN: Again, it's Kevin. It may vary by state, but it depends on the generosity of that state. So, you know, what the maximum amount is what would that individual have received in that state. So I'll use Florida as an example. The average benefit as I understand it for the elderly during the deem on station was around $900 a month. The average benefit for people with developmental disabilities was $1,800 a month. The average benefit in New York or New Jersey is much higher than it is in some southern states. 45 >> BOB: Okay. Others? >> LINDA: Actually this is Linda from the Administration on Aging, I'll say the nursing home diversion grants, we're leaving that up to some states and some states are setting maximum amounts but they are going to vary and the program is still early and we'll be getting more information out, but the answer is it's up to the states and it will vary. >> BOB: Thank you, Linda. Anybody else? >> SHARON: Bob, we have four more questions on the telephone. >> BOB: Okay. >> OPERATOR: Our next question comes from the 931 area code. >> BOB: Hello? >> CALLER: I'm Judy Roberson, I'm from Tennessee. And I wanted to ask about the education for your case managers in these programs, the requirements and also how often do they go out to the consumers? >> KEVIN: Again, I don't want to hog this, this is Kevin Mahoney, but to answer succinctly, we've gotten a grant at one point from the centers for Medicare and Medicaid services to begin developing training modules for retraining care managers for an empowerment model and that's one of the things you can find on our Cash & Counseling website and we're trying to develop additional modules and to put up examples of state training. On a different point you asked about how much they monitor. One of the other things you might find on our website is a piece that was done for us by Scripps Gerontology Center and it's something like ensuring quality in a consumer-directed environment and some of the appendices there, the 46 people from Scripps have actually listed very specifically for each of the original states how much monitoring was done, was it monthly home visits that became monthly phone calls but all of that you can read from the website. >> BOB: Thanks, Kevin. Elizabeth, it's growing close to the end. Do we have time or what do we do here? >> ELIZABETH: Let's take one more question and then I'd ask others to follow up by E-mailing me any questions and we'll get you answers. >> BOB: All right, thank you. >> OPERATOR: Our next question comes from the 609 area code. >> BOB: Hello? Could you give us your name, please? >> CALLER: Yes, Hi, this is Suzanne from the state of New Jersey, the Division of Aging and Community Services. I'm just wondering whether or not most states require criminal background checks or investigations for the workers, including those who are family members? >> BOB: Good question. Who would like to answer that? >> KEVIN: I'll give you a framework. That varies by state. Some people in the disability community, some states feel very strongly that that should be an option and that especially consumers -- you know who like maybe a family member if they get a criminal background check that it should be one of the things they consider in hiring. Other states feel much more strongly that it should be the same approach that's used in agencies, but the thing is very -- the people in the disability community, many of them do feel strongly that this should be their choice. 47 >> BOB: Okay, anybody else? >> OPERATOR: We have one more question if you guys would like to continue, it's up to you. >> BOB: Elizabeth, do we have time? >> ELIZABETH: Sure, why not. >> BOB: All right, last question. >> OPERATOR: This is from the 501 area code. >> CALLER: This is Debbie Ellis from Arkansas. Hello. >> BOB: Hi, Debbie. What's your question? >> DEBORAH: It's not really a question. I just wanted to share that so many people have talked about the unexpected experiences that have occurred with a consumer-directed program, and I think that, you know, here in Arkansas we're really looking forward to the partnership that we have with AOA and with both of our AAA's and working and sharing our experiences that we've had with consumer direction and offering this opportunity to persons who are not Medicaid eligible, but nearing nursing home placement. I just think that quality of life for these people which will be 150 people here in Arkansas will add, you know, for those last days and years, you know, will really improve the quality of life and their experiences toward the end. And it's just great to be able to have this in Arkansas and work with central Arkansas AAA and north west Arkansas. >> LINDA: Thanks, Debbie. Glad you got back on. >> BOB: I think that concludes the program. If you have questions, please E-mail them in. I just want to say on behalf of the National Association of Area Agencies on Aging, Cash & Counseling, I wanted 48 to thank, one, the participants who took part in this today and also all those who dialed in and took part, consumers and listeners, we appreciate your time and effort. We think this is a marvelous program. And I can tell you N4A will be doing lots to promote it in its next conference in Tennessee. So stay tuned and thanks everybody for all the great work. >> KEVIN: We will try and post this so the people who may have missed it can watch it also. >> SHARON: We'll post the archives and all the materials Friday on the Cash & Counseling website at www.Cash and Counseling.org. Everyone thank you for joining us and have a good afternoon.