I. Consumer Choice and Control
II. Universality
III. Provision of Health Related Tasks
IV. Personnel
V. Liability
VI. Funding

States should get consumer input in the design, implementation and evaluation of attendant services program.

This attendant services program should be based on an independent living not a medical model of service delivery. There are two basic models for the delivery of attendant services: the individual provider (sometimes called voucher or direct pay) model, and the agency delivered model. One service delivery model will not meet the varied needs and skills of the diverse disability community in the United States.

Whatever delivery system is designed, individual provider or agency model, it is essential that recipients of attendant services have the greatest possible choice and control of who provides his/her attendant services. This means people with disabilities should have the option to select, manage and dismiss their attendants.

Other consumer choice and control issues include: services provided in a community setting, back up and emergency services, availability in locations other than the home (like school or work), and on flexible hours, 24-hrs. a day, seven days a week. These services must be based on functional needs, not on the person's mental and/or physical diagnosis/status. The services must be available regardless of age. Federal minimum standards must be set that all states must comply, to guarantee equity of services throughout the country.

These minimum standards should include but not be limited to:

1. services that are community based,
2. availability for people of all ages,
3. allowing maximum control of the service both in an agency administered as well as an individual provider situation,
4. availability 24 hours a day, 7 days a week,
5. provisions for back-up and emergency services
6. allowing for cost sharing (co-pay) for people with higher incomes,
7. allowing for health-related tasks to be performed by unlicensed persons in certain instances.

The current fragmented system is too medically oriented. Many tasks currently defined as medical, must now be done by a licensed health professional, but could be done by a qualified unlicensed attendant. Current Medicaid Home Health rules prohibit this in most instances, or require lengthy training for the attendant. The Medicaid Personal Care option currently does not allow any health related tasks to be performed. What is needed is a modified hybrid of the two, allowing delegation of health related tasks in conjunction with personal care. Any national program must direct states to review and change their Nurse Practices Acts to allow delegation of health related tasks to qualified unlicensed attendants.

The most important component of an attendant services delivery system, whether individual provider or agency-based, is the attendants. Three issues concerning attendants must be addressed: first, increasing the number of qualified attendants; second, assuring attendants a livable wage with benefits; and third, deciding if and how much training attendants need. Any national program must also clarify who the actual employer is. Who pays the taxes? Workmen's Compensation? Health insurance? These questions are also tied to the direct payment versus agency model debate.

We live in a litigious society where the FEAR of lawsuits, rather than data on actual occurrences of lawsuits, drives the delivery system we have today. We require licenses of the agencies and/or professionals which provide attendant services. State agencies promulgate pages of rules to protect themselves from potential lawsuits. A balance must be struck between protecting the individual and allowing people to take reasonable risks. This issue is particularly intense when health-related tasks are provided. State or federal funded liability pools may be one solution to this problem. At a minimum a study must be conducted to come up with possible solutions.

Currently billions of dollars are spent on institutional care in this country. This is six times as much money as we spend on community based services. Even if no new dollars were allocated in the federal budget, 25% of the current Medicaid institutional dollars could be redirected to fund a national attendant program. Any new funding must be directed towards community based attendant services. A co-pay option or sliding fee schedule must be established for those individuals with higher incomes who currently do not qualify for Medicaid but also need assistance to access attendant services.