Consumer direction, a model of long-term care service delivery where service recipients and their families/advocates have enhanced control and choice over the services that they receive, is a growing phenomenon in United States. As it becomes greater utilized, it is important to understand the model and study its impacts. This dissertation details the history of the consumer direction movement, describes the current landscape of consumer direction in the United States, and presents a comparison study of users of consumer-directed (CD) services in three of Virginia Home and Community Based Services (HCBS) Medicaid Waivers. Self-determination theory is provided as a theoretical framework for understanding consumer direction. The influences of liberty, empowerment, and paternalism are discussed in the context of self-determination theory as well as multidisciplinary influences. Results from the study indicate that overall, CD services facilitate self-determined decision making by enhancing recipients choice and control over services. When comparing differences between waiver groups, the survey domain of “access” was the only domain where statistically significant differences (p<.01) were found. Implications for users, advocates, and administrators of CD services are discussed.

Self-directed supports, as a method of service delivery, have grown from small pilot programs in a handful of states to at least one program in every state. For individuals with intellectual and developmental disabilities (IDD), self-direction presents unique opportunities to engage in self-determined behavior and shape the services upon which they rely. Although the evidence base for self-direction is relatively robust, there is a significant lack of information on how implementation of self-direction is faring on the national level. The purpose of this study is to understand how the political and economic factors within and across states have impacted the implementation of a self-directed service delivery system.