Consumer Directed Care Explained: CDPAP, Self-Directed Services & Participant Control

What Is Consumer Directed Care?#

Consumer directed care puts you in charge of your home care services. Instead of an agency sending caregivers they select, you:

• Choose who provides your care (including family members)
• Set schedules that work for you
• Train caregivers the way you want
• Manage the care relationship directly

It's called different things in different states:

• CDPAP (Consumer Directed Personal Assistance Program) — New York
• Participant Direction — Federal Medicaid term
• Self-Directed Services — Many states
• Individual Provider Program — Washington
• IHSS (In-Home Supportive Services) — California

How It Works#

The Basic Model#

Traditional Agency Model:
State → Agency → Caregiver → You

Consumer-Directed Model:
State → Fiscal Intermediary → You → Caregiver
         (handles payroll)      (you direct care)

Key Players#

You (or your representative):

• Recruit and hire caregivers
• Train them on your specific needs
• Create schedules
• Supervise care
• Can fire caregivers who don't work out

Fiscal Intermediary (FI):

• Handles payroll and taxes
• Processes timesheets
• Manages workers' comp insurance
• Ensures compliance
• You don't have to be the legal employer

The State (Medicaid):

• Authorizes your hours/budget
• Sets wage ranges
• Defines eligible services
• Monitors program compliance

Who Can Be Your Caregiver?#

This is the big advantage—your caregiver pool expands dramatically:

Typically Allowed#

Relationship	Most States	Notes
Friends	Yes	Must meet program requirements
Neighbors	Yes	Background check required
Adult children	Yes	Cannot live with you in some states
Siblings	Yes	Same household rules apply
Nieces/nephews	Yes
Grandchildren (18+)	Yes
In-laws	Yes

Varies by State#

Relationship	Depends on State
Spouse	Some states allow, some don't
Parent (you're the client)	Often allowed with limits
Legal guardian	Rarely
Anyone living with you	Varies significantly

Usually NOT Allowed#

• Your legal guardian
• Your representative/power of attorney (in some states)
• Anyone who would receive your inheritance

State-by-State Overview#

New York CDPAP#

The largest consumer-directed program in the nation:

• Eligibility: Medicaid + need for home care
• Can hire: Almost anyone except spouse (pending 2026 changes)
• Hours: Based on assessment, no arbitrary cap
• Wage: $18-20/hr+ (highest in nation for family caregivers)
• Big news: 2026 restructuring consolidating fiscal intermediaries

California IHSS#

The largest in participation:

• Eligibility: Medi-Cal + meets functional criteria
• Can hire: Including parents and spouses in some cases
• Hours: Based on assessment (typically 20-283 hrs/month)
• Wage: Varies by county ($17-22/hr typically)
• Note: Paid family caregivers are common

Washington Individual Provider (IP) Program#

• Eligibility: DSHS long-term care clients
• Can hire: Friends, family, neighbors
• Hours: Based on CARE assessment
• Wage: $17.25-19.50/hr (2026)
• Training: 75 hours required for new IPs
• Union: Yes (SEIU 775)

Texas Consumer Directed Services (CDS)#

• Eligibility: Various Medicaid waiver programs
• Can hire: Family (including spouses in some programs)
• Structure: Employer of Record model
• Budget: Monthly budget you manage

Consumer Directed vs. Agency Care#

Factor	Consumer Directed	Agency
Choice of caregiver	You choose	Agency assigns
Family as caregivers	Usually yes	Usually no
Scheduling flexibility	Total control	Agency policies
Supervision	You supervise	Agency supervises
Backup care	You arrange	Agency provides
Administrative burden	Moderate (FI helps)	None
Rate paid to caregiver	Often higher	Lower
Training	You provide	Agency provides

Benefits of Consumer Direction#

1. Hire People You Trust#

Family members and friends who know you provide care that's:

• More personalized
• More consistent (lower turnover)
• More comfortable for you
• Culturally appropriate

2. Family Gets Paid#

Without consumer direction, family caregivers often provide care for free—while struggling financially. With participant direction:

• Average family caregiver hours: 20-40/week
• Average pay: $15-22/hr depending on state
• Annual income potential: $15,000-40,000

3. Better Care Quality#

Research consistently shows consumer-directed care leads to:

• Higher satisfaction rates
• Fewer unmet needs
• Better health outcomes
• Fewer hospitalizations

4. Cost Effective for States#

Consumer-directed programs typically cost 10-20% less than agency care while delivering equal or better outcomes.

Challenges and Considerations#

1. You're the Boss#

This means:

• Finding caregivers is on you
• Training is on you
• Managing schedules is on you
• Handling problems is on you

Not everyone wants this responsibility.

2. No Built-In Backup#

If your caregiver is sick, you need a plan. Options:

• Secondary caregiver on standby
• Family/friend backup
• Short-term agency care (if allowed)

3. Family Dynamics#

Paying family to provide care can complicate relationships:

• Are they doing it for the money or for you?
• What happens if care quality slips?
• How do other family members feel?

4. Administrative Requirements#

Even with a fiscal intermediary, you'll need to:

• Approve timesheets
• Report changes
• Respond to state inquiries
• Handle paperwork

How to Enroll#

General Steps#

1. Determine eligibility: Contact your state Medicaid office or aging and disability resource center

2. Request assessment: A case manager evaluates your care needs

3. Choose self-direction: Opt into the consumer-directed option (not automatic)

4. Select a fiscal intermediary: In states with multiple FIs

5. Recruit caregivers: Find and hire your care team

6. Complete training: Both you and caregivers may need training

7. Begin services: Start receiving care and submitting timesheets

Washington-Specific Steps#

1. Contact DSHS Home and Community Services: 1-800-422-3263
2. Request a CARE assessment
3. Choose Individual Provider option
4. Your IP completes 75-hour training
5. Services begin after training completion

Making It Work: Tips from Participants#

On Hiring Family#

"Set clear expectations from day one. Just because she's my daughter doesn't mean she can show up late. We have a schedule, and she follows it." — CDPAP participant, NY

On Managing Care#

"I keep a notebook. Every day, I write what we did, any issues, anything I need. It keeps us both accountable." — Self-direction participant, WA

On Backup Plans#

"I have three people trained—my main caregiver, my neighbor, and my cousin. If one can't make it, I'm not stuck." — IHSS recipient, CA

On Boundaries#

"Hardest part was telling my son his care wasn't good enough. But that's my right as the consumer. I directed him to more training, and now he's excellent." — Participant, TX

Is Consumer Direction Right for You?#

Good Fit If:#

• You want to hire a specific person (family/friend)
• You value control over your care
• You can manage or have someone to manage for you
• You have reliable backup options
• You're comfortable giving direction and feedback

May Not Be Right If:#

• You prefer someone else handling everything
• You don't have candidates to hire
• Managing people stresses you out
• You need guaranteed backup coverage
• Cognitive limitations make direction difficult (though representatives can help)

The Future of Consumer Direction#

Consumer-directed care is growing rapidly:

• 2015: ~1 million participants nationally
• 2020: ~1.5 million participants
• 2026: ~2.2 million participants (estimated)

States are expanding these programs because they work—better outcomes, lower costs, happier participants.

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CareCade helps Washington families navigate home care options. Find providers in your area or learn about Washington DDA waivers that offer self-directed services.