Self-direction is a model of long-term care service delivery that helps people of all ages, with all types of disabilities, maintain their independence at home. When a person self-directs, they decide how, when, and from whom their services and supports will be delivered. As a model, self-direction prioritizes participant choice, control, and flexibility. This contrasts with "traditional" services received from an agency, where the agency controls most aspects of service delivery, including who will provide the service. In self-direction, the participant selects and trains their own staff, develops their staff's schedules, and sets their own standards for how their services will be delivered. Today, over 1 million Americans self-direct, and most self-directed services are funded by Medicaid. More information on self-direction programs in the United States is available here. Self-directed services are a flexible, person-centered, and cost-effective alternative to nursing homes and other institutional settings.
Self-direction is based on the principle that people with disabilities know their needs best and are in the best position to plan and manage their own services. Nationally, services that are most often self-directed include personal care, transportation, and respite. Participants often choose to hire family members and friends to provide these and other services. In Medicaid programs, the specific services and supports that can be self-directed depend on the state in which the participant lives. Often, states also include options to use Medicaid dollars to purchase goods and non-employee services that can reduce the individual's need for other Medicaid services. For example, a participant who uses a wheelchair might choose to purchase a front-facing washing machine and dryer, which would reduce their ongoing need for a worker to assist with laundry.
When it comes to being an employer, people who self-direct are not required to figure everything out on their own. Instead, support is available every step of the way. In fact, federal Medicaid rules require certain supports to be in place in Medicaid-funded self-direction. These supports include Financial Management Services, which helps participants manage payroll and other administrative responsibilities, and Information and Assistance, which helps people develop spending plans based on their budget allocation and learn how to be an effective employer. More information about these supports is available at Medicaid.gov. Also, an individual who wants to self-direct but is unable or unwilling to perform employer duties themselves may appoint a representative to serve as the employer on their behalf. For example, children who self-direct typically have a parent or guardian serve as the employer. These supports help ensure self-direction is accessible to everyone, regardless of their age or disability.