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Change and Inertia in the New York State Medicaid Personal Care Services Program: An Institutional Case Study


ABSTRACT CHANGE AND INERTIA IN THE NEW YORK STATE MEDICAID PERSONAL CARE SERVICES PROGRAM: AN INSTITUTIONAL CASE STUDY Toby Adelman RN, PhD c. University of California, San Francisco, 2007 This study draws from institutional theory to analyze how the competing logics (belief systems) of stakeholders have influenced patterns of change and inertia in the development of the New York State Medicaid Personal Care Services Program. A case study methodology was used to conduct face-to-face and telephone interviews with four key stakeholder groups: state and city officials; agencies providing personal care services; labor unions; and consumer advocacy organizations. Interview data, documents, and statistical trend data were collected on the program from 1999-2005. Results of the inquiry confirmed the importance of competing logics in a number of ways. First, the development of the program was strongly influenced by founding (imprinted) conditions, especially the early unionization of workers that resulted in relatively generous wages and a stable, agency-based program. Second, public support and pressure, from both individuals and collective disability groups, to expand a consumer-directed delivery model of personal care services is challenging the status quo. However, while the optional consumer-directed model of care is expanding slowly, there is considerable resistance from stakeholders whose logics legitimate agency-based models. Expressed logics elaborated by study participants help explain how belief systems have influenced patterns of change and inertia in the program, especially concerning the growing demands for consumer-direction.

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