Jack Dunn
Director of Public Affairs
(617) 552-3350


$7 million grant from Robert Wood Johnson Foundation to support innovative consumer-directed care program led by Boston College Graduate School of Social Work

CHESTNUT HILL, MA (1-7-04) -- A ground-breaking program directed by the Boston College Graduate School of Social Work could dramatically change the nature of care for the nation's elderly and persons with disabilities.

The Robert Wood Johnson Foundation (RWJF) today announced a $7 million grant for the expansion of Cash & Counseling, a successful model program led by BC in which disabled Medicaid consumers decide for themselves how their personal assistance needs will be met.

In its demonstration period, Cash & Counseling showed that when Medicaid beneficiaries of various ages and disabilities have the option to direct their own supportive services, their quality of life is improved, satisfaction with services is increased, unmet needs for care are reduced, access to home care is increased and nursing home usage is reduced -- without compromising the beneficiaries' health or safety. Further, the option costs Medicaid no more than traditional agency services.

The Cash & Counseling program provides self-directed, individualized budgets to recipients of Medicaid personal care services or home and community-based services. Each person's allocation is comparable to the value of services that he or she would have received through a traditional agency. Program participants use the allocation to purchase their own care -- with the option of hiring friends, family members, or others -- instead of receiving it from an agency. They can also use their budgets to modify their homes or vehicles or to purchase a range of items -- from chair lifts to touch lamps -- that will help them live independently. Consulting and bookkeeping services are available to help participants weigh their options and keep up with required paperwork.

Under the new, expanded Cash & Counseling program, as many as 10 states will receive up to $250,000 each over three years to replicate the consumer-directed model. Three of these states may receive up to $100,000 each in additional funds to expand the model.

"The Cash & Counseling model is an idea whose time has come," said Boston College Graduate School of Social Work Associate Professor Kevin Mahoney, program director of Cash & Counseling and director of a new national social work research center at BC dedicated to improving the quality of support and services for the elderly and disabled. "The demonstration program showed this idea works. Now we want to take it to a national level."

The BC Graduate School of Social Work will serve as the National Program Office for the new program. In launching this effort, RWJF is joined by two funding partners: the Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the Administration on Aging (AOA) within the U.S. Department of Health and Human Services. ASPE was also a partner in the original Cash & Counseling demonstration project. In addition, the Centers for Medicare & Medicaid Services will help provide oversight and technical assistance to states.

Traditionally, state Medicaid programs have contracted with home care agencies to provide personal assistance services -- such as bathing, dressing, grooming, preparing meals, and housekeeping -- to the elderly and younger persons with disabilities. Although those who are eligible for services may be able to choose among available agencies, frequently their decision-making power ends there. They often have little say in who provides the services or even when or how they are provided.

"For example, most home care aides come only during the day, and only during the week," Mahoney said. "Those who receive the care, therefore, only get it when it's available, not when they actually need it. That means someone requiring assistance to get out of bed and prepare meals, for example, may have to wait until later in the day to rise and eat. And what happens on weekends, if the aide doesn't work then?

"The 'one-size-fits-all' philosophy in elderly and disabled care services just doesn't work," he said. "People with age-related or other disabilities face enough of a challenge every day. At the very least, they should be able to choose the help they want and need to perform the tasks of everyday life."

In 1995, RWJF and ASPE launched Cash & Counseling, a demonstration program in three states -- Arkansas, Florida, and New Jersey -- to stimulate and strengthen consumer direction and choice in long-term care.

An evaluation showed that, in Arkansas, the first state to implement Cash & Counseling, Medicaid beneficiaries who had the opportunity to direct their personal assistance services received better care than a control group. They reported higher satisfaction, better quality of life, fewer unmet care needs, better access to home care services, and less nursing home usage -- all without compromising health or safety or significantly increasing costs to Medicaid. In addition, no major instances of fraud or abuse were found. That evaluation was published online in two parts by the journal Health Affairs. The first part is available online at and the second at

"Providing more choice and control in managing these fundamental services makes a tremendous difference in improving the quality of life for consumers," said James R. Knickman, PhD, RWJF vice president of research and evaluation. "We envision a day when every state will permit -- and maybe even promote -- this model as an option for Medicaid beneficiaries who have disabilities."

Unlike the prior demonstration, the new round of Cash & Counseling will not include control groups. Grantee states will need to secure a section 1915c or an 1115 waiver in order to implement a participant-directed individual budget model for Medicaid.

For more information about the program, including details on how to apply, visit the Cash & Counseling web site at or the RWJF web site at