Who chooses consumer-directed personal care? Characterizing users and switchers under New York Medicaid.

Introduction: Medicaid-funded personal care can be managed by an agency (agency-directed) or by the enrollee/their representative (consumer-directed). Despite its dramatic growth in New York, little is known about who chooses consumer-directed care. Methods: We compared characteristics of agency- vs consumer-directed care users and predicted likelihood of switching personal care source (from agency- to consumer-directed care or vice versa) using clinical assessment and claims data for 15 395 older, dually enrolled members of a large Managed Long-Term Care (MLTC) plan between 2018 and 2023. Results: Consumer-directed care users were younger and had more family support, with less functional and clinical care needs but greater cognitive impairment. Greater cognitive impairment, greater family caregiver availability, and attending college were significantly associated with switching to consumer-directed care, while fewer hours/week of personal care services predicted any switch in care model. Conclusion: Findings reveal differences in who uses consumer-directed vs agency-directed care and highlight the importance of cognitive, sociodemographic, and social/family contextual factors in influencing enrollees' choice to switch to consumer-directed care. Policies should ensure ongoing access to consumer-directed care for the diverse Medicaid enrollees who rely on this care model.