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116 UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMERPersonal Assistance Service Delivery Models: Two Ends of a ContinuumTwo examples of state personal assistance service delivery models illustrate the ends of a continuum, with manydifferent models falling between them.Consumer-Directed Personal Assistance Service Delivery ModelsConsumer-directed (CD) models enable individuals to hire and fire, schedule, train, and supervise their own personalassistance providers (usually termed aides, attendants, or workers), with few restrictions on who can behired. A CD model typically puts all responsibility for recruiting and selecting an aide on the individual (or family)and usually assigns the individual responsibility for ensuring that the aide(s) know how to do the work andfor training the worker(s) if necessary. Public programs occasionally assist in identifying potential candidates, byproviding a worker registry or helping the consumer perform a criminal background check. A CD model mayalso make publicly funded consumer and worker training available. Although the number of hours of personalassistance authorized for the individual in any particular month might be limited, individuals have the authorityto schedule when the assistance will be provided, and both consumer and worker are free to negotiate schedulechanges. A full-fledged CD model also involves individuals in the process of paying their workers (e.g., bysigning timesheets), even though the actual wages are paid from public funds.Professionally Managed Service Delivery ModelsProfessionally managed models require that aides be employees of authorized home health or home care agencies.Agencies hire workers according to agency criteria and assign employees to serve particular consumers.Choice among agencies is limited by the number of authorized providers in the area where the consumer lives.Frequently, there is only one such agency. Consumer choice of agency aides is generally restricted to “veto”power—although dissatisfied consumers may ask to have a worker replaced, and the agency will generallyhonor such a request as long as another worker is available. Agencies may shift employees from one individualto another—although they typically try to honor individuals’ requests to have the same workers on a regularbasis. Agencies also schedule the aides’ work hours and may determine whether or to what extent they willaccommodate consumer scheduling preferences. Agencies also conduct aide training and supervision. Somepublic programs mandate minimum training and supervision requirements. Others leave it up to the agencies orstate licensing laws to set such requirements. Since training, certification, and professional supervision requirementscan affect service costs, the added value of such requirements needs to be carefully assessed.This evolving concept, referred to alternatively asself-determination, consumer-directed services,and participant-driven supports, is having a significantimpact on the development and implementationof home and community services andsupports for people with developmental disabilities,physical disabilities, and serious mental illness,as well as elderly individuals who have alltypes of disabilities. Regardless of the nomenclatureused, implementing the concepts of consumerdirection or self determination enables states tooffer individuals the opportunity, support, andauthority to direct the services they receive.The principles of consumer direction encompassthe goal of affording consumers the authority andtools to craft their own services plans, with thefreedom to use both traditional and nontraditionalproviders and to direct and manage their servicesand supports. In the CD model, the Medicaidbeneficiary is his or her own “care/service manager”(with the assistance, at the discretion of theindividual, of friends and family members).Individuals still have access to advice and professionalexpertise. However, this assistance takesthe form of educating and supporting consumersto do their own care planning and service coordination,rather than doing such tasks for them. 4Assistance for individuals in managing anddirecting their home and community services andsupports can be provided by paid professionalswho are variously termed service coordinators, supportbrokers, personal agents, counselors, or consultants.This new terminology underscores the philosophicaldifferences between professional case/