Academic journal article Care Management Journals

Dodecaphony: Enacting Support Brokerage in the Twelve Cash & Counseling Expansion States

Academic journal article Care Management Journals

Dodecaphony: Enacting Support Brokerage in the Twelve Cash & Counseling Expansion States

Article excerpt

Support brokers are entities that provide information and assistance to self-directed clients in Medicaid waiver programs. Although all Cash & Counseling programs have support brokerage, each state has a great deal of liberty in determining how those functions are carried out, who provides those activities, which functions are emphasized, and how responsibility for support broker tasks coordinates with other support activities. In this article, we map out the various ways in which states have operationalized the support brokerage concept. Differences in title, qualifications, training, hiring preferences, and caseload are described, and further directions for research are suggested.

Defining the concept of support brokerage is difficult. Generally, support brokers fall under the category of "Information and Assistance" in Medicaid waiver programs. Centers for Medicare & Medicaid Services (CMS) defines support brokerage as a

service/function that assists the participant (or the participant's family or representative, as appropriate) in arranging for, directing, and managing services. Serving as the agent of the participant or family, the service is available to assist in identifying immediate and long-term needs, developing options to meet those needs, and accessing identified supports and services.

Literature on the Cash & Counseling (C&C) program often uses the term interchangeably with the terms "counselor" and "consultant" because support brokerage constitutes the counseling part of the C&C program. This literature also acknowledges that in some circumstances, mixing responsibilities of case management and support brokerage is inevitable. For example, several states use case managers to perform some or all of the support broker tasks as defined by the C&C vision statement.

Phillips et al. (2003) and literature outside of C&C warn against mixing support brokerage with case management. Phillips et al.'s work suggests that although case managers cannot be independent because they serve gatekeeping functions, and unlike support brokers who are defined for versus by people receiving support, support brokers can and perhaps should remain independent from all other stakeholders (i.e., organizations that provide funding, provide services, or have other responsibilities). Furthermore, Smith (2003) stresses that support brokers must avoid conflict of interest: "(they) simply can't serve two masters at the same time." Their primary loyalty should remain to the consumer.

Phillips, Mahoney, and Foster (2006) also found that support brokers are most efficient and efficacious when they work in consumer direction full time-a finding that has been repeated in several different studies. The original states found that in later stages of the program, once solid base of participants was established and enrollment decreased to maintenance levels, charging support brokers with outreach and enrollment dovetailed with their mandate to educate participants about consumer direction and assist them in developing spending plans and made the program more efficient. The same did not hold true when a program was just beginning because specialized staffwere needed to deal with a large influx of admissions (Phillips et al., 2006).

The concept of support brokerage has been used in international settings; however, although U.S. systems struggle to separate the support brokerage role from case management, support brokers in the United Kingdom have been recognized as separate entities from the beginning. These staffmembers are independent from the government's social services and charged with responsibilities such as accessing and assessing the needs of the clients; developing service plans that match these needs; obtaining, negotiating, and managing clients' funding that meet their needs; monitoring and evaluating services; and building personal networks among others. Support brokers also provide help and advice as long as the person uses care services. …

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