Self-directed support: impact of hiring practices on adults with intellectual and developmental disabilities and families.

Heller et al. (2012) looked at adults with intellectual or developmental disabilities who run their own Medicaid budget.

Each adult could pick and pay their own support worker. The team asked: does it matter if the worker is an agency staff, a friend, a parent, or a brother or sister?

They tracked caregiver stress, confidence, and happiness, plus the adult’s daily choices and health.

Caregivers felt better when the paid helper was an agency worker or a friend.

Adults with disabilities also had more daily choices and better physical health with these helpers.

Bringing in Mom, Dad, or a sibling as the paid worker gave the worst scores for both sides.

Bigby et al. (2009) showed family support budgets were already rising, so Tamar’s work tells us how to spend that money wisely.

Curryer et al. (2018) heard adults say family control can feel tight; Tamar’s numbers back that story—non-relatives give more room to choose.

Watanabe et al. (2003) proved that even tiny choice bumps in work tasks double engagement; Tamar widens the lens to life-wide choice and health.

Nord et al. (2024) found public insurance links to higher caregiver job loss; Tamar adds that who you hire with those funds can ease or add to that strain.

If you write waiver plans, steer families toward hiring agency staff or trusted friends first. Keep parents and siblings in the circle of unpaid support, not on the payroll. This one shift can lift caregiver mood, boost adult autonomy, and still stay inside the same budget.