Use of Self-Directed Home Care Services Jumped 20% in 2020

Self-directed home care services are on the rise.

Last year, many states created even more Medicaid flexibilities to allow seniors to essentially hire their own family members as their caregivers, which was especially helpful amid stay-at-home orders and fears surrounding COVID-19.

On their end, states see this strategy as a win-win. Patients can be cared for in their own homes without exposing themselves to the virus, and more caregivers can be paid and effectively join a workforce that is always in need of more soldiers.


That’s why New York City-based home care technology platform HHAeXchange acquired Annkissam last October. Annkissam — now a subsidiary of HHAeXchange — is a provider of software that supports self-direction programs.

Acquiring Annkissam enabled HHAeXchange to embed the company’s capabilities into its network and hit the ground running.

“Some of the foundational technical elements and requirements in that space are just different than the home care agency, employed-caregiver model,” Greg Strobel, the CEO of HHAeXchange, told Home Health Care News. “I think about 44 states now are serving financial management services programs that are coordinating either at the community level or at the county level for self-directed programs.”


Founded in 2008, HHAeXchange is a technology platform for home care and self-direction program management. The platform is developed specifically for the Medicaid patient population, with the HHAeXchange platform connecting state agencies, managed care payers, providers and caregivers.

COVID-19 has been an accelerator for HHAeXchange’s business. Self-directing programs were an area of the home care business where it expected more growth. The acquisition of Annkissam gave HHAeXchange even greater insights into the trend.

Overall, there was a 20% growth in self-direction for the first nine months of 2020, data from Annkissam’s software shows. That is an increase of 7.5% compared to prior years.

“We felt that with the tightening of the caregiver employment pool, that there would just be a natural growth in this particular industry — and not only from the perspective of just the necessity of hiring friends and family members,” Strobel said. “But also the desire of individuals to move into that kind of arrangement. The advent of the COVID pandemic confirmed for us that more participants at least considered self-direction when making their choices in 2020, for all the obvious reasons that we know.”

HHAeXchange expects that self-directed programs will continue to grow and that their success will beget more growth down the line.

Self-directed programs differ from market-to-market. But in New York, for instance, there are even some home care agencies that act as normal providers but also facilitators of these programs. These entities are often referred to as fiscal intermediaries (FIs).

“You’ll have agencies that are operating both as traditional employed caregiver agencies, as well as a financial management services organization,” Strobel said. “And so they’re operating kind of both models.”

The momentum of self-directed — or consumer-directed — models is a change from 2019 when such programs faced budgetary constraints. FIs in New York, for example, had to navigate through harsh regulatory changes and agency closures two years ago.

“My understanding is that one agency has sent in notice to the department of health that they intend to close,” Bryan O’Malley, executive director of the Consumer-Directed Personal Assistance Association of New York State (CDPAANYS), previously told HHCN. “I know a number have the paperwork filled out and ready to go.”

Additionally, not all home-based care stakeholders have been pleased to see growth in self-directed and consumer-directed models. Some home care professionals believe certain states overuse such programs when they should instead be balancing reimbursement with traditional providers.

Others argue that consumer-directed programs are too susceptible to fraud, waste and abuse.

“The matter of self-directed care is a complicated one involving a broad array of well-intentioned constituents,” one home care veteran told HHCN in 2019. “As it’s currently set up, though, I think it’s a bigger threat to home care agencies than most people realize, just because of the siphoning of resources.”

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