By Carli Friedman, CQL Director of Research
In contrast to how services and supports have been traditionally provided and run by agencies, self-direction allows the people receiving those services and supports to have control over the services they receive, including budgeting for those services, and controlling who provides services to them. People who self-direct their services not only have more choice and control, they often also have better outcomes because they’re more likely to receive the services and supports they want and need. That’s why the aim of this study conducted by Natalie Turner, a PhD candidate in the School of Social Work at the University of Washington, and me was to examine how states across the United States allocate self-direction in their Home- and Community-Based Services (HCBS) programs for older adults. To do so, the study analyzed 1915(c) waivers from 2023.
We found slightly more than half (58%) of HCBS waivers for older adults allowed older adults to self-direct. However, not only did the authorities granted to older adults who self-direct vary widely, so too did states’ goals for the number of older adults that will self-direct. Across the United States the goal was only to have 12% of older adults self-direct their services. However, this ranged from a goal of 0.7% of people receiving HCBS in Georgia to 100% in Florida.
State Goals for Self-Direction in HCBS Programs for Older-Adults
There were also large differences in the types of services older adults were allowed to self-direct. For example, 97% of waivers allowed personal care services to be self-directed. In contrast, only 9% of waivers allowed community transition and integration supports to be be self-directed.
% of Waivers That Allowed Self-Direction Per Service Type
“This study provides insight into important nuances of 1915(c) waiver Self-Direction design and availability among older adults. Older adults’ access to and experience with Self-Direction is likely significantly influenced by their state of residence. As the use of Self-Direction continues to increase nationally across populations, program design and investment decisions may affect access to its use and ultimately influence health outcomes among older adults” (Turner & Friedman, 2025).
This article is a summary of the following journal manuscript: Turner, N. R., & Friedman, C. (2025). Examining cross-state differences in self directed services provided through 1915(c) waivers for older adults. Journal of Aging & Social Policy, advanced online publication. https://doi.org/10.1080/08959420.2025.2568441
Self-Direction in HCBS for Older Adults