Mental Health Self-Directed Care

Citation: Cook, J. A., Shore, S., Burke-Miller, J. K., Jonikas, J. A., Hamilton, M., Ruckdeschel, B., Norris, W., Markowitz, A. F., Ferrara, M., & Bhaumik, D. (2019). Mental Health Self-Directed Care Financing: Efficacy in Improving Outcomes and Controlling Costs for Adults With Serious Mental Illness. Psychiatric services (Washington, D.C.), 70(3), 191–201.

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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. Mixed-effects random-regression analysis tested for longitudinal changes in outcomes between the two conditions. Differences in service costs were analyzed with negative binomial and zero-inflated negative binomial regression models.


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.