You were barely making ends meet when your grandmother had a stroke. Nana was the pillar of the family, always there loving and supporting, no matter the circumstances. Now she needs some help caring for herself. And she loves her home, where three generations gathered every holiday, and most Sundays. It would break her heart to leave. Mementos fill every room, and she has a family story to share about every inch of the homestead she and your grandfather built from scratch.

Over time, family members had passed away or moved, and now it’s just you and Nana. Nana refused placement from the hospital, and you stood up for her choice, pledging to see to her care. Problem was, you had no idea what you were getting into. The hospital social worker knew and arranged for Nana to receive home care. You thought that would take care of matters and you could continue to visit and love her as before.

Medicare picked up the tab while she remained in an “acute” stage of rehabilitation. But the aide came by only for a few hours a day. That is, when she showed up. Physical and occupational therapists were a tremendous help, and Nana gradually learned how to manage most of her own care. But she was not totally independent and still needed some help during the day. After Medicare coverage ended, that $40/hour aide service would burn through her savings. It looked like you needed to drop your work hours to part-time to help Nana.


The Consumer Directed Personal Assistance Program (CDPAP) allows people like you to give that loving care you want, and be paid to do it. It is a program of Medicaid, but if you don’t qualify for Medicaid, keep reading to the end of this blog.

The patient, or responsible family member must be “self-directing”—that is, to be able to direct or instruct the caregiver in his/her tasks. The patient must need hands-on care, such as help with activities of daily living like bathing, dressing, meal preparation, or walking.

The family (read patient or primary caregiver) interviews, hires, trains, schedules, and fires (if need be) their caregivers. They assign and supervise the tasks to be done.

Most patients I encountered on this program when I was working in home care for Monroe County, blossomed under CDPAP. Loss of control over one’s life can be devastating, and this program returned that control to the patient, with amazing outcomes. The family-selected caregivers were deeply invested in the patient’s well-being and often exceeded expectations.

As Supervisor of the Home Care Unit, I loved that the program saved the State money. Although Medicaid paid the care attendant’s wage, it freed up would- be family caregivers to remain at work and continue paying taxes. They no longer faced losing income to care for a loved one. Or they could, with a few exceptions, provide the care themselves and be paid to do it. Because they continued to work, either at their jobs or as caregivers, their eventual Social Security payments would  not take a nose-dive.

In one case, two sisters each had a child with special needs, so were stay-at home moms. With CDPAP, the sisters traded roles, each aunt caring for her nephew and getting paid to do it. I think that was absolutely elegant! Here’s a link for those with developmental disabilities needing personal care.

Because the caregivers are paid by Medicaid, there must be a fiscal intermediary to handle payments , such as:


This is an excellent link for more information about the program.

Don’t Qualify for Medicaid?

I fought tears in the grocery store. My husband and I had just come from his PCP’s office where the good doctor assured us he had many more years to live. I thought we would stop in the store’s café to celebrate while I picked up a few items. I guided Gene in his scootie to a table and told him to stay there for a few minutes until I got back. When it was clear he was not computing what I’d said, I realized we had finally reached the dreadful moment.

We needed help, but it would be on my terms.

I adopted the concept of CDPAP. I would direct Gene’s care according to what he needed, not according to what would be allowed by state regulations under Medicare. And we did not qualify for Medicaid, the payor for CDPAP.

Since it was the agencies that got the big bucks per hour, not the caregivers, I knew $15 per hour was more than any aide was currently receiving anywhere at that time. I would interview, hire and train our own team and give them a better hourly wage!

I had difficulty finding experienced, or even willing-to-learn, employees. Gene and I were both only children, and we had no extended family network, like most people. But I was blessed with dear friends, some who had worked with me. When I called two of them and said, “I want to do CDPAP with Gene. Would you be interested in filling some hours?” both responded with a resounding “Yes!”

Professional Approach

Sometimes it can be dicey, employing friends and relatives. Some people are comfortable with “under the table” monies, others are not. So I called in the big guns, a company called Paychex. It handles all that employee personnel stuff, including direct payments into people’s accounts, taxes and W2s.

In effect, my husband became an employer. Now taking that legal/tax responsibility would be enough to make me twitch, but Paychex had about 30 people doing the same thing as I wanted to do. They knew the drill. Their representative, my contact throughout, came to my home and sat next to me while I set everything up online. And they handled or guided me with any government correspondence. All I had to do, once I provided all the data, was input the hours each friend worked each week, and their check appeared in their bank accounts.

My own CDPAP version provided my husband the best care possible. The money I paid the caregivers was so much lower than home care agency fees, the fees I paid Paychex were well worth it. I still saved money.

Eventually, Gene did so well, I discontinued my version of CDPAP. Years later, I used an agency, but it was short term and resurrecting CDPAP was unnecessary.

I’m a fan of CDPAP. In the end, friends and family make the best caregivers and it would surprise you how willing many of them are. Patients can control the quality of their lives, while caregivers can stay financially secure. I just love a government program that works well for all involved, including the taxpayer!