The Center for An Accessible Society Disability Issues Information









Safety and Personal Assistance Services

A large 1999 study in California found that there is no higher incidence of abuse or safety problems when people are in charge of their own services.

The study, said the researchers, "should lay to rest the notion that the consumer-directed model ofservice provision " should be restricted.

Researchers A.E. Benjamin, R.E. Matthias, and T.M. Franke found that "when consumer input is used in programming, the quality of services is improved, and there is often an increase in health, safety, well being, and satisfaction for all consumers."

From the study:
Advocates for the elderly, including the organizations which make up the "aging network" have long favored formally organized professional supervision and accountability under the aegis of government-regulated home care agencies. . . . Professional home care agencies and their trade associations, not surprisingly, assert the superiority of the "professionally managed" model. Trade unions representing or seeking to organize home care aides express concern that states may choose to implement consumer direction in ways that go counter to workers' interests.

Critics of consumer-directed models of service delivery have expressed concerns about client safety under this model and have generally taken the view that consumerdirection should be restricted to a minority of clients (primarily younger adults) who social workers judge to be capable of hiring, firing and giving direction to their workers. This study provides no evidence in support of restricting availability of the consumer-directed model. . . .

When consumers were asked whether they had ever thought that their provider was responsible for money or other items disappearing from their homes, 89.1 percent of people who received services from "professionally-managed" agencies said "never" as compared to 93.5 percent of the people who hired their own workers--a statistically significant difference favoring the "consumer-directed model." Although instances of abuse, neglect, and mistreatment were occasionally reported, said the reserachers, "consumers in the consumer-directed model reported such occurrences either less frequently -- or no more frequently -- than consumers in the professional management model."

We believe that the results of this study with respect to client safety measures should lay to rest the notion that the consumer-directed model of service provision is best restricted to a minority of exceptional, "high-functioning" elderly and disabled individuals, whom professionals have assessed and found to be capable of managing their own services. In California, the overwhelming majority of elderly and disabled IHSS clients receive services through the consumer-directed model, with few untoward results. Although instances of abuse, neglect, and mistreatment were occasionally reported, consumers in the consumer-directed model reported such occurrences either less frequently or no more frequently than consumers in the professional management model. . . .

Client Safety

The client safety area has two dimensions--client-perceived physical and psychological risk and client sense of security. The "perceived risk" dimension summarizes client reports of having experienced abusive, frightening, or harmful behaviors by their providers (i.e, yelling, threatening, possible stealing, pushing or shoving, neglect, injury, alcohol use, unwanted sexual advances). The "sense of security" measure reflects client's feelings of being safe or unsafe with their aides and their perceptions of how well they get along with their aides. Neither of these safety measures was significantly influenced by service model type.

That model type does not predict client safety is an important finding because proponents of the PMM argue that clients are safer under this model of service delivery.Indeed, the presumed superiority of professional management in safeguarding client safety is so taken-forgranted that even some advocates of client direction believe that a CDM requires clients to make trade-offs between independence and risk and often base their advocacy of the CDM on a defense of clients' "right to risk." However, at least in California's IHSS, the client-reported incidence of abuse, neglect, and mistreatment is equally low in both service delivery models. Within the CDM, however, type of worker is a significant predictor of clients' sense of security with clients who have family providers experiencing a significantly greater sense of security.

Several non-model factors emerged as significant predictors of client reports of having experienced various forms of provider abuse. Clients who needed less paramedical help, those who had fewer workers in the past year, those who were more confident of backup help from family and friends, and those who used fewer formal services (other than IHSS) reported fewer incidents. Paradoxically, clients who said that they did not have someone to turn to for advice also reported fewer incidents of provider abuse. These findings suggest that, as might be expected, clients with the highest level of dependency are most at risk for provider abuse, regardless of which service model they are in. On the other hand, greater access to and reliance on informal as opposed to formal supports appear to protect clients from incidents of provider abuse. The one predictor that is counter-intuitive and difficult to interpret is that not having anyone to turn to for advice is associated with fewer reported incidents of provider abuse. It may be that some clients who are able to remain in the community despite lack of informal supports are unusually self-reliant and capable of looking after their own safety--but these are only hypotheses that would require testing in further research.

With respect to sense of security, clients who felt significantly more secure were more likely to be White (rather than Latino or Asian), believe they were not receiving enough IHSS service hours, live alone, are more confident of having backup help, have known their workers before hiring them, and have no language problems with their workers. Several of these relationships suggest that ease of communication with the worker and trust in the worker based on a prior relationship positively influence clients' sense of safety.

That those who live alone should feel more secure seems more surprising because other findings generally point to the importance of informal supports in making it less likely that clients will actually experience threats to their safety. Perhaps those who live alone are a self-selected group who are unusually self-reliant and "fiercely independent." In other words, clients who live alone may feel more secure because they are more comfortable taking risks and are more confident in their own abilities to take care of themselves. Alternatively, those who live alone may perceive themselves to be more dependent on their workers, choose their workers more carefully, and, for that reason, feel safer with workers whom they trust. More research is necessary to understand the dynamics at work here. The issue is of interest because the disability rights movement has tended to equate independence and autonomy with being able to live alone and not relying on informal supports.

Client Empowerment

The client empowerment outcome area has three measurement dimensions within it: service choice and satisfaction, preferred role, and client assertiveness. "Service choice and satisfaction" measures client satisfaction with the amount of choice they had in four service areas (which provider, which tasks, how tasks were done, and when they were done) and the amount of choice clients had, particularly with respect to which tasks are done and how tasks are done. "Preferred role" measures client preferences for training and supervising their own workers. "Client assertiveness" reflects clients' desire to have a major say and feeling comfortable giving directions.

Service model is a strong predictor on two of these measurement dimensions: service choice and satisfaction and preferred role. Clients in the CDM as compared to the PMM and, within the CDM clients with family as compared to non-family providers, reported significantly more satisfaction with respect to amount of choice as well as more actual choice and greater preference for taking charge of training and supervision.

It is particularly striking, for example, that, in this study, the professional management model was not found to have better outcomes with respect to client safety. The professional management model has long been regarded by both its own advocates and advocates of consumer-direction as the "safer" approach. Indeed, advocates of consumer direction typically argue for their approach by defending consumers' "right to risk." In view of the widespread belief that the professional management model is the approach that minimizes client risk--albeit at the expense of restricting consumer choice and control--it was unexpected and surprising that the study provided so little evidence in support of this conventional wisdom. Indeed, in the bivariate analyses, with respect to reported instances of neglect and suspected theft by providers, consumers in the consumer-directed model reported significantly fewer negative experiences. . . .

About the study

California's In-Home Supportive Services (IHSS) Program was chosen as the locus of the study primarily because the program serves a large number of clients (approximately 200,000 at any point in time) and also serves a broad range of clients in terms of age, severity of disability, and the nature of the diseases or conditions responsible for their functional disabilities. . . .

The research design called for sampling by dividing (stratifying) the population into different groups and then selecting a certain number of cases at random from each group for the study sample. Stratifying in this way increases the precision of the estimates. The target sample for this study was first divided into the two service delivery models. Within each, the target sample was further divided by age (over and under 65) and severity of impairment (severe and not severe). The plan called for a sub-sample of 500 clients to be randomly selected (within stratum) for each service delivery model, yielding a total client target sample of 1,000. The plan for the worker target sample, totaling 500, was to select a sub-sample of 250 for each model from the pool of workers serving the clients in the study sample. . . .

From A.E. Benjamin, R.E. Matthias, and T.M. Franke, Comparing Client-Directed and Agency Models for Providing Supportive Services at Home, report for the Assistant Secretary for Planning and Evaluation, HHS (April, 1999)






The following sites contain information that may be of interest. Please bear in mind that the information at these sites is not controlled by the Center for An Accessible society. Links to these sites do not imply that the Center supports either the organizations or the views presented.
Freedom Clearinghouse, a grassroots website designed to help disability activists enforce the Olmstead decision in states

Consumer Choice and Control:
Personal Attendant Services and Supports in
Report of the National Blue Ribbon Panel on
Personal Assistance Services, August, 1999

Directory of Publicly Funded Personal Assistance Programs from the World Institute on Disability

"Understanding Medicaid Home and Community-Based Services: A Primer" -- from the U.S. Dept. of Health and Human Services, available at

Information on Home & Community-Based, Consumer-Directed, and Personal Assistance Services from the Office of Disability, Aging and Long-Term Care Policy at the U.S. Dept of Health and Human Services


How States' "Nurse Practice" Acts work against consumer direction -- from the January, 1999 Ragged Edge magazine






Expert sources

Nursing home data

Abuse of seniors under-reported, says study

The Institutional Bias of Public Policy

Consumer Direction in Personal Assistance

Study Validates Consumer Control's Superiority

In-home services: Implementing the Olmstead decision

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