Meet Elizabeth, an 80-year-old widow with multiple chronic health conditions for years. Previously, she relied solely on her daughter Angela for unpaid assistance with personal care and household tasks. Angela lives close by and cares for Elizabeth before or after going to her job at a local supermarket and on her days off. Unfortunately, Elizabeth’s needs for assistance became too much for Angela to handle alongside her job and supporting her own family. Elizabeth now qualifies for publicly financed nursing home care, but she has always been fiercely independent and wants to continue to live in her own home. Luckily, the public program also offers home and community-based services alternatives to nursing home care. Elizabeth discovered the “Cash and Counseling Program,” which provides her with a monthly allowance for services and supports of her choice. She has decided to enroll and regain her independence.
The Cash and Counseling Program provides individuals with long-term care needs, such as older persons and people with disability, the option to manage their own care and choose the services they receive. This program has been implemented in numerous states in the United States and has been shown to improve participants’ satisfaction with their care, as well as reduce the use of institutional care and hospitalizations. Participants receive a cash allowance, whose amount varies depending on the state and individuals’ needs, and work with a counselor to develop a care plan to determine how they will use this budget. One feature of this program is that a friend or a relative may be hired as a caregiver, including even spouses and parents of developmentally disabled children in some states.
With the help of her counselor, Elizabeth developed a care plan that included hiring a caregiver to assist with her daily activities, such as bathing, dressing, and preparing meals. She also used her cash allowance to purchase a wheelchair ramp for her home and to pay for wheelchair accessible transportation to her medical appointments. Elizabeth was thrilled with her level of control and flexibility with the program. The program allows Elizabeth to employ Angela as her caregiver and the hourly wage, while low, is equivalent to what Angela previously earned as a supermarket cashier. Because Elizabeth is not cognitively impaired, she can sign Angela’s timesheets without designating a representative. Still, she chose to designate her son Michael as her representative. To ensure that she has the help she needs if Angela cannot work because of sickness or otherwise requires time off, Elizabeth has signed up her retired next-door neighbor to be paid as a “backup” caregiver if necessary. An accounting service paid for by the public program acts as Elizabeth’s payroll agent and purchases other goods and services that Elizabeth included in her care plan. Thus, the accounting service can document that Elizabeth spent her publicly funded allowance appropriately.
Thanks to the Cash and Counseling Program, Elizabeth continued to live safely and independently in her home and receive care from her daughter who knows her needs and preferences and whose company she enjoys. She did not want to rely on agency-employed aides who she might or might not get along so well with and who might be reassigned at a moment’s notice for agency convenience. Also, agency aides would not have been permitted to help her with taking her medications. Angela is still able to earn the income her family needs, and she likes being her mother’s paid caregiver more than she ever liked her job as a supermarket cashier.
Elizabeth and Angela’s history is just one example of how the Cash and Counseling Program can make a positive difference in the lives of individuals and families who require long-term care. The Cash and Counselling Program could be a valuable reference to develop similar programs in Latin America and the Caribbean. This program, which originated in the United States, also developed in other high-income countries. For example, in the United Kingdom, the program Direct Payments allows individuals to receive cash payment from a local authority to buy their own care services, rather than having the services provided by the authority directly. In Australia, the program National Disability Insurance Scheme (NDIS) provides funding to people with disability to purchase the services and support they need. In Canada, some provinces offer the Self-Managed Care, a program that allows individuals to manage their own care services and choose their own caregivers.
So, what are the main benefits of cash and counseling?
- More control and empowerment for users. The Cash and Counseling Program gives more choice to service users and their families, especially when they not only recruit individual paid caregivers but also manage a budget. It also allows hiring a friend or a relative as a caregiver, giving the possibility to choose individuals they know and trust.
- Higher quality and continuity of care. Participants in the Cash and Counseling Program often report higher levels of satisfaction with their care compared to those in traditional long-term care programs. They can receive a more tailored care to meet their individual needs and preferences and avoid turnover, especially if a family caregiver is hired – annual turnover among agency workers in the U.S. averages 60%.
- Formalization of family caregiving. Family caregivers can be formally employed, which implies enrollment in social security and the accumulation of professional experience in the care sector.
- Cost effectiveness. Administrative costs are lower when beneficiaries recruit and supervise individual aides. Home care agency overhead typically accounts for 40–60% of hourly rates, whereas the accounting service and counseling cost 10–20%. The savings can be used by the government to serve more individuals and allow for more generous benefits.
- Immediately having enough providers to meet demand. It can take several years for a robust network of formal service providers to emerge and there may be long waiting lists to get services from home care agencies. Meanwhile, unpaid, experienced family caregivers already exist and likely could use the income from paid employment.
In sum, the cash and counseling program has several advantages and can lead to improved outcomes for beneficiaries, including increased autonomy, better quality of care, and cost savings.
Latin America would benefit implementing programs like Cash and Counseling, where most women continue to bear the burden of care within the private dimension of life. A study based on time-use surveys in Chile, Colombia, Costa Rica and Mexico shows that between 63% and 84% of long-term family unpaid caregivers are women and that their work accounts for 72% to 88% of total hours of care provided by families. Data from UN-ECLAC show that the economic value of unpaid work within the household in eight countries of the region ranges from 15.2% of the GDP in Ecuador to 22.9% of GDP in Uruguay, where women account for more than 70% of this production that is not accounted in national account systems.
Therefore, this type of Program can help recognize and remunerate family care work in Latin America and the Caribbean, while also recognizing it as a skilled labor essential for our societies.
If you wish to learn more about the cash and counseling program, watch the webinar “Cash & Counseling: Family directed long-term care plans”:
You can also read the learning material here:
You can watch the series “The Voice of Experience” about “Cash & Counseling” here: