Finding the Right People: Provider Agency vs. Family Management

Families often struggle with the issue of whether to hire assistants directly or to use a provider agency. Each choice has pros and cons, and the final choice depends on the needs of your child.

Family Management

Agency Management

Provider Agency vs. Family Management

Is it better to contract with an agency or hire and manage a staff on one’s own? The answer may depend on the funding source.  Some funding requires the use of an agency. Other sources may give you an option to hire individuals directly.
For example, the State of Ohio is still developing rules for Medicaid Home and Community Based Waivers. Although the proposed rules are stricter in terms of who can provide services, they do not eliminate the option for direct management by families.

Choosing a Provider

You may already have an established relationship with a provider or may know whom you want to hire.  If not, the county board will furnish a list of certified providers.

However, the county board cannot recommend a provider. The board is required to provide “uniform and consistent information pertaining to each provider.”

The ultimate decision as to what provider to use is up to you and your family.

How to Choose a Provider

1. Narrow the Pool: It is too time-consuming to investigate every provider in an area. Before scheduling interviews or visiting any homes, narrow the field by calling providers on the list. Ask each provider:
   • Are you currently accepting new clients?
   • Can you provide supports in the desired area?
   • Can you provide the specific supports needed, including medical and behavioral services and transportation?
2. Prioritize: Use the Letter of Intent to choose the most important issues your child will need from a provider. This could include such things as attending weekly worship services, planning meals, having a pet, staff members trained in lifting and repositioning or in positive behavioral supports. Note what’s negotiable and non-negotiable.
3. Have Realistic Expectations: Read Appendix C about what to expect from a provider, or talk to someone whose family member is currently receiving residential services to reevaluate your expectations. This can help you evaluate interviews and save time.
4. Make a List of Questions: These can derive from you priority list (#2.), or from sample questions in Appendix F.
5. Interview Top Three: Interview your top 3 choices. (Use these Interviewing Tips.) Contact the next 3 on your list only if none of the top 3 work out.
6. Interview Again: Interview your top choice(s) a second time.
   • Ask more specific questions and to talk with the provider in more detail about your child’s needs.
   • Talk to the “house manager” or direct support staff.
   • Pose similar questions to several staff members for comparison’s sake.
   • You should enough information to make a choice on the provider, and the provider should also gain a realistic, honest impression of your child. Without this information, a provider may agree to provide services only to find out later that they are unable to meet your child’s needs or expectations.
7. Request Services: Once a final choice is made, request services from the provider. Agencies each have a slightly different process for this step, but they will communicate their requirements.

Interviewing Tips

• If possible, your child should be present for the interviewing process. The first interview will likely be with managers or administrators who will not provide daily care for the child, but the child’s impressions during the process could influence the final decision.
• Use the same list of questions for each interview for a comparison of agencies.
• The meeting should less than two hours. The longer the meeting, the easier it is to forget, even if taking notes.
• Use the second interview for follow-up questions.
• The provider should ask questions about your child. The agency needs to learn some basic information about your child’s abilities, needs, and preferences to know if the agency will be able to provide the necessary services.
• Interview multiple staff members. For example, the director may have more information about policies and regulations However, staff members are better able to talk about daily routines.
• Take good notes to make comparisons later. Use this worksheet. Review the notes with the interviewee to be sure information is correct.
• A friend or family member should attend the interview along with you. You can then compare notes on what was heard, because people often interpret what they have heard differently.

Investigating Prospective Agencies

During an interview, providers will naturally want to make a good impression and paint the best picture of the agency. This picture may not always be realistic. You may want to investigate a prospective agency further.

The best information will come from several sources, as well as through direct observation.

Other Ways to Investigate a Provider

Get References:

• From individuals and families who currently receive support services from the provider
• Most agencies will give the names and phone numbers of families or ask families to contact prospective clients
• Friends, other service providers, or advocacy groups may be able to provide the names of individuals who have received services from the agency

Ask Around:

• Ask other professionals (physical therapists, teachers, vocational counselors) if they know anything about the agency.
• There may be a conflict of interest if county employees or other professionals make a recommendation concerning a provider. Many other people, however, will be able to share what they have observed.

Meet Agency Clients:

• Schedule a visit with individuals who receive services from the prospective provider. These individuals, of course, would need to be willing to have visitors in their homes and answer questions.
• Example: One family took dessert to a home and visited with a group of four adults supported by a prospective provider. In addition to an enjoyable visit with some new people, they and their son were able to observe how the staff and manager interacted with the people they were supporting, as well as how they cared for the home.

Advocacy Agencies:

• Check with local advocacy agencies, such as the Association for Retarded Citizens.

Review Licensure and Medicaid Surveys:

• These are all public records which can be requested from the provider.
• Caution: Such reports can be misleading. For example, a statement that an agency failed to prevent insect infestation in a home does not explain that the actual problem was a small hole in a window screen. Reports also may not give a complete picture of what is happening in an agency since inspectors are in the home only for a few days.

Directly Observe the Staff:

• Don’t spy
• Observe at a social activity, a doctor’s office, or a meeting at the day program, agency staff members assisting individuals and feel free to ask the staff person what agency he or she is from.

Small vs. Large Agencies

In the past, most community-based service providers were small agencies, often started by a caring individual or group of families.  As the field has grown, more agencies have increased their services to be competitive and operate economically.

Many administrators and boards of directors believe that this is the only way for an agency to remain viable. However, families sometimes feel that as size has increased, the quality of support services has decreased.

So, how much does the size of an agency matter?

Does an Agency Strive for Quality?

How do you know if any agency — small, growing, or large — still strives for quality?

1. Ask those who have received services from the agency as it grew whether the quality of their supports changed during the process.
2. Listen to the focus of administrators and managers when they speak about the organization. Consider what reasons they give for growing or remaining small.

• If the reasons relate to profit margins or staff convenience, there may be cause for concern.
• If their reasons relate directly to the ability to provide quality supports — such as using administrative cost savings to increase support services — then it may be safe to assume that the agency will strive to maintain quality.

Advantages of Larger Agencies

• Larger agencies can spread out administrative costs. Funding can be used more efficiently, such as paying more to direct support staff.
• Larger agencies attract more experienced staff because of room for advancement.
• With a larger pool of staff, it is easier to replace employees that quit or are unable to come to work.
• With more people, some staff can specialize in one particular area, rather than being a being spread thin or have only some skills in all areas.

Advantages of Smaller Agencies

• In a small agency, even the top manager will have direct involvement with individuals receiving support.
• Administration and professional staff are not spread as thin, because they have fewer clients and sites to oversee.
• A small, “family-like” atmosphere may make families more comfortable and attract high-quality staff.
• It is easier for staff at all levels to get to know all clients and step in during an absence or emergency situation.

For more information on choosing the right support service providers, check out:

Taking Charge: A HandsOn Guide to Personal Assistance Services, published by the Ohio Personal Assistance Services Coalition, part of the Ohio Developmental Disabilities Alliance. http://ddc.ohio.gov/Pub/TC-05.PDF