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Self-service

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Associate professor Kevin Mahoney, of Cash and Counseling. By Lee Pellegrini

BC's Kevin Mahoney develops new choices for the elderly and disabled

Boston College's Graduate School of Social Work has been awarded a $7 million grant from the Robert Wood Johnson Foundation to expand the Cash and Counseling program piloted by associate professor Kevin Mahoney. The program gives disabled and elderly Americans who qualify for Medicaid more of the discretion that other health care consumers have when they hire aides or purchase items to make their lives easier.

Under traditional Medicaid, individuals who need help with daily activities such as bathing or housework must rely on state-contracted home care. In Cash and Counseling, participants are given funds based on what Medicaid would expect to pay out on their behalf. They can engage the services of relatives or friends; they can buy their own equipment; they can even let the money accumulate in a special account in order to save for a large purchase or to create an emergency fund. Mahoney cites the example of one recipient, a woman with multiple sclerosis: Under traditional Medicaid, he says, "the home care worker could come and help her do her laundry, but she couldn't help her do her children's laundry, because the Medicaid benefit was just for the mother." Through Cash and Counseling, the woman could use funds in ways traditional Medicaid does not allow—buying a washing machine, for example. A consultant would work with her closely to develop an individualized budget, handle paperwork, even recruit, train, and pay the caregivers of her choosing. Mahoney says one man whose adult son had spina bifida was able to retire early and provide full-time care for his son himself with the wage obtained through the program, rather than see him enter a nursing home.

The Cash and Counseling model has been tested in three states since 1995—Arkansas, Florida, and New Jersey. The longest-running program, Arkansas's IndependentChoices, was evaluated last year by a public policy research firm, and the results were published in the journal Health Affairs. Among the findings: Only 6 percent of non-elderly consumers enrolled in IndependentChoices were dissatisfied with their care, compared to one-third of those receiving traditional Medicaid. Roughly 75 percent of participants surveyed hired friends or relatives, for everything from constant personal care to odd jobs. And within two years of the program's launch, spending on nursing homes and hospitals declined in comparison with results from a control group. IndependentChoices "fits the rhythm of my life," one participant said.

With the GSSW's new grant, supported also by the U.S. Department of Health and Human Services, 10 more states will receive $250,000 each over three years to implement Cash and Counseling, with an additional $100,000 going to up to three of those states to extend the approach to other facets of public assistance. Cash and Counseling is not for everyone, says Mahoney. Consumers unable or unwilling to make decisions about their care, and who choose not to name a representative to do so on their behalf, may still rely on the state to arrange services. The program won't replace the current system, says Mahoney, but it can be a valuable addition to the Medicaid menu.

Nicole Estvanik

 

Photo: Associate professor Kevin Mahoney, of Cash and Counseling. By Lee Pellegrini

 

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