The Cash and Counseling model of self-directed long-term care: Effectiveness with young adults with disabilities

Melissa L. Harry, Ph.D., M.S.W, Kevin J. Mahoney, Ph.D., M.S.W., Ellen K. Mahoney, Ph.D., Ce Shen, Ph.D.

Disability and Health JournalVol. 10Issue 4p492–501



Young adults with disabilities face numerous barriers to independence and achieving markers of adulthood. Qualitative evidence suggests that flexible, self-directed budgets for purchasing home and community-based services might help fill an identified service gap and help improve the transition to adulthood for this group.


Our aim was to evaluate the effectiveness of the Cash and Counseling model of self-directed budgets for young adults with long-term care disabilities by analyzing secondary data from the Cash and Counseling Demonstration and Evaluation randomized control trial.


We compared nine-month community involvement, satisfaction rating, health status rating compared to peers, and unmet needs outcomes using bivariate and multivariate logistic regression. Our sample included 456 participants aged 18 to 30 randomized to treatment groups with the opportunity to receive Cash and Counseling (n = 207) or control groups eligible for agency-based care (n = 249), whether self-reported (n = 128) or by proxy (n = 328).


Multivariate logistic regression models showed that compared to controls at nine-month follow-up, treatment group members had significantly greater odds of being very satisfied with life, when care was received, the care arrangement, transportation, help around the house and community, personal care, and getting along with paid attendants, and significantly lower odds of unmet needs with medication and routine health care at home and with transportation.


Cash and Counseling performed better than or comparable with agency-based care for young adults with long-term care disabilities, suggesting its viability as a service option for this population.