Defense Date


Document Type


Degree Name

Doctor of Philosophy


Public Policy & Administration

First Advisor

Susan Gooden


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.


© The Author

Is Part Of

VCU University Archives

Is Part Of

VCU Theses and Dissertations

Date of Submission

December 2008