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Table 4 Consumer-directed care

From: A systematic review of different models of home and community care services for older persons

Author (year) Study name/Location; Study design;
Intervention Length
Participant group;
n (% female);
Age (± SD)
Outcomes and Results Quality Rating
Meng (2005) Medicare Primary and Consumer Directed Care Demonstration USA
12 months
≥65 years, enrolled in Medicare A & B, ≥2 ADL or ≥3 IADL limitations and been hospitalized, in residential care or received home health care in last 12 months or ≥2 emergency visits in past 6 months
n = 1394
(70% F)
= 80 ± 8 years
3 intervention groups:
1. Voucher group could choose how to spend ≤$200 p/month, advised and financially managed by voucher specialist
2. Disease management health promotion nurse taught disease management skills, implemented behaviour change strategies, and facilitated conferences with primary care physicians
3. Combination of 1 and 2
Controls received usual Medicare benefits.
The voucher group increased the probability of using personal assistance services (p = 0.002) as did the combination group (p < 0.001). The combination group also increased the probability of use of skilled home health care (p = 0.03). 10
Wiener (2007) Washington,
Medicaid beneficiaries receiving home and community services
n = 513
(72.9% F)
≥65 years: 55%
Participants in the consumer-directed care group were responsible for hiring, orienting, supervising, and finding replacements for their paid caregivers.
Participants in the agency-directed care group included those residing in assisted living and residential aged care.
In subsample of participants ≥65 years, thosereceiving consumer-directed services were more satisfied with paid personal assistance compared to those receiving agency-directed care (p < 0.05). 9
Glendinning (2008) Individual Budgets Pilot Program
6 months
Social service recipients, subsample of persons ≥65 years
n = 263
66% F
Mean age not given
Intervention participants were assigned an individual budget based on a needs assessment which could be spent on large range of services and equipment including hiring family and relatives. They were assisted by a care coordinator. The 13 sites also attempted with varying success to integrate resources from several funding streams.
Controls received standard social care.
At 6 months, there were no significant differences betewen individual budget recipients and controls on quality of life, self or informant-rated health or care needs. Indivdiual budget recipients were significantly more likely to score above the cutoff on a screening tool for psychological morbidity (45%) than controls (29%; p < 0.05).  
Carlson (2006) Cash and Counseling
RCT (evaluation only at 9 months)
Medicaid beneficiaries - subsamples aged ≥65 years in Arkansas and New Jersey and ≥60 years in Florida
N = 2353
Mean age not given
Intervention group could choose how to spend allowance from broad range of equipment and services including hiring relatives - advised by a consultant (counselor).
Control group received Medicaid benefits as usual.
Arkanses and New Jersey intervention participants had significantly higher hours of paid care (p < ≤ 0.001), lower hours of unpaid care (p = 0.036; p = 0.034) and were more satisfied with the way the paid caregiver provided care, with overall care arrangements and way of spending life (all p <.001) than controls. In New Jersey intervention particpants wre more likely to have made an equipment purchase or home or vehicle modification (p = 0.039) and had lower rates of falls (p = 0.009)and development or worsening of contractors (p = 0.002).
There were no differences between groups on bedsore development and rates of uninary tract infections.
In Florida there were few differences between groups which may be because only 39% had received the allowance by the evaluation.
Giannini (2007) Bologna, Italy
2 years
Older persons needing help in ≥2 ADLs or severely chronically ill and MMSE <24/30
n = 121
= 83.7 ± 6.4 years
The primary caregiver received vouchers to buy 4 to 24 hours per day of home care attendance from health providers.
Controls had recently been discharged from hospital and received usual assistance from Public Health and Social Care Services.
Mortality was lower in the consumer-directed care group than in controls at 6 and 24 months (p < 0.05).
At 24 months, there were no statistically significant differences between the changes in the two groups on daily function, cognition, clinical burden of medical conditions, severity of cognitive impairment, behavioral and psychological symptoms, caregiver burden, depression, number of drug used and quality of life.
Benjamin (2000) USA
Adults (>18 years) in the California Management and Information Payrolling System
n = 1095
(72.9% F)
51.2% were
≥65 years
The consumer-directed group recruited and hired their own providers, and trained, supervised, and replaced them as needed. Participants used up to 283 hours of services per month including personal care, household, paramedical, protective supervision and medical transportation.
Participants were placed in the agency-based group and receieved services from home care agencies if judged inappropriate for consumer direction.
Participants in the consumer-directed group reported better outcomes than the agency-based group on sense of security, (p < 0.001), unmet activities of daily living needs (p < 0.05), and service satisfaction (technical quality, p < 0.001; service impact, p < 0.001; general satisfaction, p < 0.001; interpersonal manner, p < 0.001).
The groups did not differ in physical and psychological risk (p = 0.142), unmet instrumental activities of daily living needs (p = 0.199), and provider shortcomings (p = 0.984).
  1. NRCT = Non-randomized controlled trial; RCT = Randomized controlled trial.