During the late 1980s, when New Hampshire's regional area agency system was in the early stages of its development, individuals with developmental disabilities and their families, who were typically being offered services in group homes and congregate day programs, began to pose a fundamental question: "Who gets to decide where, when and how services are going to be delivered?"

Although individuals and families had always had the opportunity to participate in service planning and the right to sign off on agency decisions, they were now expressing interest in more direct and influential opportunities to choose and control the nature and particulars of their service arrangements. The above critical question from individuals and families prompted substantial changes in the way the service system offered and provided supports, ultimately culminating in revisions in state rules, which empowered individuals and families to `decide when, where and how their services are going to be delivered.'

Since 1999, when the regulatory changes were made, New Hampshire's area agency system has offered a unique service option, called Consumer-Directed Services (CDS), to those individuals and families who prefer to have extensive involvement in all aspects of their services and related decisions. Typically in CDS arrangements, individuals and their families design their services, select providers and staff, and — most significantly — make decisions regarding how the authorized funds are to be spent. Under CDS individuals and families also have the flexibility to move funds within an individual budget to address their changing needs. In all of these activities, the area agency's role is to provide supports and to help individuals and families make informed choices and decisions. In addition, the agencies have the responsibility to oversee the CDS arrangement to insure that services and expenditures are in compliance with state and federal regulations.

Currently there are over 600 individuals and families across the state that have opted to use the CDS model. The feedback from the great majority of these folks has been quite positive. [In my position as the Administrator of the Bureau, I tend to hear more from people who are unhappy; but this has not been the case for those who use CDS. During our annual Family Support Conferences and other statewide or regional events it is not unusual for parents and family members to spontaneously tell me how much they appreciate the opportunity to make decisions and direct their services under the CDS model.] Although CDS requires the investment of a significant amount of time and energy, it is clear that, overall, a considerable number of the new generation of individuals and their families are showing a clear liking for this distinct approach.

Individuals' and families' satisfaction with services is obviously an important consideration in the decisions that the agencies and the Bureau make regarding how to make best use of the system's resources. In the case of CDS, there seems to be a yet another potential advantage: cost effectiveness. A preliminary comparison of the expenses related to the CDS model versus the traditional service arrangements, where the agency is "in charge" and designing the services, indicates that the system is not only achieving higher consumer satisfaction in CDS arrangements but is also accomplishing that outcome in a more cost effective manner.

Given the above results regarding consumer satisfaction and cost effectiveness, New Hampshire's Developmental Services system has begun to increase its capacity to serve more people under the CDS model through a variety of strategies, such as:

= Creation of a guidebook to provide information to individuals, families and agencies regarding how to implement CDS arrangements;

= Establishment of regional and statewide "CDS list serves" for families, individuals, and agencies to share information (answer questions, facilitate staff and provider recruitment and send out notices for quality improvement surveys)

= Offering of on-line access to individuals and families to review their up-to-date budgets (i.e., web-based access to CDS accounts) and to make funding decisions.

By increasing awareness and system capacity regarding CDS, New Hampshire is attempting to enable a larger number of individuals and families to take advantage of this valuable service option, which seems to offer greater potential for achieving desired outcomes, consumer satisfaction, and cost effectiveness.

The State of New Hampshire has a pioneering history of improving its system of supports for people with disabilities: becoming the first state in the nation to provide completely community-based services to its citizens with developmental disabilities; ground-breaking formal explorations of self-advocacy; and establishing the first in the nation consumer-directed Medicaid Waiver Program. The efforts regarding the expansion of CDS arrangements is another example of this rich tradition, where the agencies and the Bureau continue to seek improvements to create a more responsive service system and to meet the needs of the individuals with disabilities and their families