[NYAPRS Enews] Study: Self-Directed Care Shown to Improve Outcomes and Controlling Costs in Comparison to Traditional Services

Mental Health Self-Directed Care Financing: Efficacy in Improving Outcomes and Controlling Costs for Adults With Serious Mental Illness by Judith A. Cook, Ph.D., Samuel Shore, L.M.S.W., Jane K. Burke-Miller, Ph.D., Jessica A. Jonikas, M.A., Marie Hamilton, L.C.S.W., M.P.H., Brandy Ruckdeschel, M.Ed., L.P.C., Walter Norris, M.A., Anna Frost Markowitz, M.P.H., Matthew Ferrara, B.A., Dulal Bhaumik, Ph.D.

Over the past two decades, the federal Centers for Medicare and Medicaid Services (CMS) has promoted use of a consumer-directed, “money follows the person,” health care financing approach for use by individuals with a broad range of disabilities. Called self-directed care, this model gives individuals direct control over public funds to purchase health care services, supports, and material goods necessary for them to reside in the community rather than in inpatient or nursing facilities.

Although use of this model to promote the recovery of people with serious mental illness is less common, multiple states are now developing mental health self-directed care initiatives, and interest in this approach is growing. Recently, consumer, advocacy, and service provider communities have called for greater use of self-directed care in mental health, as have federal agencies, including CMS (1), the Substance Abuse and Mental Health Services Administration (2), and the U.S. Department of Health and Human Services’ Office of Disability, Aging and Long-TermCare Policy (3). The purpose of this study was to conduct a randomized controlled trial of a mental health self-directed care program, assessing its effects on participant outcomes, service satisfaction, and service costs.


Self-directed care allows individuals with disabilities and elderly persons to control public funds to purchase goods and services that help them remain outside institutional settings. This study examined effects on outcomes, service costs, and user satisfaction among adults with serious mental illness.


Public mental health system clients were randomly assigned to self-directed care (N=114) versus services as usual (N=102) and assessed at baseline and 12 and 24 months. The primary outcome was self-perceived recovery. Secondary outcomes included psychosocial status, psychiatric symptom severity, and behavioral rehabilitation indicators.


  • Compared with the control group, self-directed care participants had significantly greater improvement over time in recovery, self-esteem, coping mastery, autonomy support, somatic symptoms, employment, and education. No between group differences were found in total per-person service costs in years 1 and 2 or both years combined.
  • However, self-directed care participants were more likely than control group participants to have zero costs for six of 12 individual services and to have lower costs for four.
  • The most frequent nontraditional purchases were for transportation (21%), communication (17%), medical care (15%), residential (14%), and health and wellness needs (11%).
  • Client satisfaction with mental health services was significantly higher among intervention participants, compared with control participants, at both follow-ups.


The budget-neutral self-directed care model achieved superior client outcomes and greater satisfaction with mental health care, compared with services as usual.

Psychiatric Services in Advance (doi: 10.1176/appi.ps.201800337)


California Association of Mental Health Peer-Run Organizations (CAMHPRO) is an incorporated non-profit consumer-run statewide organization consisting of member entities which are consumer-run organizations and programs, and individuals.

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