Community First Choice Option

  • Manual also available in Portable Document Format (PDF)

Voluntary Training Program
How to Select, Manage and Dismiss Attendants

New York State Department of Health
Division of Long Term Care

January 1, 2019



We wish to express our gratitude and appreciation to the individuals who assisted in the creation of the Community First Choice Option Voluntary Training Program, How to Select, Manage and Dismiss Attendants.

Staff from the New York State Department of Health:

  • Krista McNally, Division of Long Term Care
  • Sarah Atkinson, Division of Long Term Care

Representatives from Home Care Agencies, Provider Associations and Advocates:

  • Bryan O’Malley, CDPAANYS
  • CFCO Development & Implementation Council Members


Section 1: Introduction

  • 1A. Goal and Objectives of the Community First Choice Option (CFCO) Training Program
  • 1B. Choices in CFCO
  • 1C. Key Definitions for CFCO

Section 2: Responsibilities

  • 2A. Your Responsibilities
  • 2B. Fiscal Intermediary´s Responsibilities
  • 2C. LDSS, MMC Plan, or MLTC Plan Responsibilities

Section 3: My Services and My Preferences

  • 3A. My Really Good Day
  • 3B. My Planning List
  • 3C. My Preferences for a Direct Care Worker
  • 3D. Advantages and Disadvantages of Supervising DCWs by Yourself
  • 3E. Is It Right for Me?

Section 4: Recruiting A Direct Care Worker

  • 4A. Who Can Be a Direct Care Worker?
  • 4B. Ways to Find Direct Care Worker Candidates
  • 4C. What is Important to You in a Direct Care Worker

Section 5: Hiring

  • 5A. Seven Steps to Follow When You Hire a Direct Care Worker
  • 5B. Finding the Best Match
  • 5C. Talk to Candidates on the Phone First
  • 5D. Phone Pre–Screening: Sample Messages
  • 5E. Tips for Phone Calls
  • 5F. Interviewing in Person
  • 5G. Getting Ready for Your Interview with a Direct Care Worker Candidate

Section 6: Supervising

  • 6A. Comparing the Traditional and the Coaching Supervisor
  • 6B. Important Supervisory Skills
  • 6C. Giving Constructive Feedback


1A. Goal and Objectives of the Community First Choice Option (CFCO) Training Program


After completing this training, you will be better able to find, hire and supervise a direct care worker who will provide CFCO services and supports to you.


By the end of this training you will be able to:

  • Identify your specific service needs and preferences;
  • Identify qualities that your direct care worker must have and those qualities that would be good to have;
  • List the steps in the hiring process;
  • Find direct care worker candidates;
  • Pre–screen candidates over the telephone;
  • Interview candidates;
  • Identify the qualities of a good supervisor;
  • Understand your purpose, roles, and responsibilities as the supervisor of your direct care worker;
  • Identify four coaching skills that can be used in supervision;
  • Give constructive feedback to a direct care worker if there is a problem.

1B. Choices in CFCO

Under CFCO, services can be provided by a direct care worker who is supervised (hired, trained and, if needed, fired) by an agency such as a home care agency, or services can be provided by a direct care worker who you will supervise. You have chosen to recruit, hire, and supervise your own direct care worker (like the way services are provided within the Consumer Directed Personal Assistance Program (CDPAP), if you are familiar with that program). You will be responsible for identifying possible direct care workers, interviewing them, and checking references as you decide who to hire. Once hired, you will set the schedule for your personal assistant, determine how he or she performs authorized tasks, and ensure that payment is made for the correct number of hours worked by your personal assistant. A fiscal intermediary will help you with much of the paperwork, the medical clearances, and paying your direct care worker.

Your roles and responsibilities are explained in the next section.

1C. Key Definitions

Community First Choice Option (CFCO): This set of services provides help from an aide or direct care worker with everyday activities and health–related tasks that will help you to be independent and participate in your community.

Designated representative: The person to whom you have given permission to make decisions for you and who agrees to make those decisions, including managing your direct care worker. The designated representative can be:

  • Your parent
  • Your legal guardian
  • A responsible adult who can and will make decisions for you.

The designated representative CANNOT be:

  • Your direct care worker
  • Anyone who works for the fiscal intermediary

Direct Care Worker (DCW): The person who is hired to help you. You may have more than one DCW, depending on your needs. You may refer to your DCW as your "attendant."

Fiscal Intermediary (FI): An agency/organization that is allowed by the State to take care of CFCO paperwork for you and to pay your DCW.

Individual: The person who is eligible to receive a CFCO service (you).

Local Department of Social Services (LDSS): The county agency that approves CFCO services, decides what services are covered, and authorizes the number of hours for a service if you are participating in Fee–For–Service Medicaid.

Mainstream Managed Care (MMC) Plan: A health insurance plan for Medicaid recipients who are not also receiving Medicare. The MMC plan approves CFCO services, decides what services can be covered, and authorizes the number of hours for a service if you are enrolled in that plan.

Managed Long Term Care (MLTC) Plan: A health insurance plan for Medicaid recipients who also receive Medicare and who need long–term supports and services. The MLTC plan approves CFCO services, decides what services can be covered, and authorizes the number of hours for a service if you are enrolled in that plan.

Self–directing individual: An individual who can make his/her own decisions and take responsibility for the decisions without help from a designated representative.


2A. Your Responsibilities

Find and Hire Direct Care Workers Who does this?
Determine how many DCWs you will need based on your plan of care You
Advertise for DCWs and pay the costs of advertising You
Screen and interview candidates You
Check DCWs´ references You
Hire DCWs You
Complete paperwork for hiring DCWs and submit to FI FI and DCW

Supervise DCWs Who does this?
Schedule DCWs according to allowed number of hours You
Review timesheets for correctness and submit to FI You
Set up back–up plans for when DCWs are sick, on vacation, or unable to come to work You
Keep accurate records
Decide which duties DCWs will do based on your plan of care You and DCW
Train DCWs You
Meet with DCWs regularly to tell them how they are doing in the job and if they need to do anything differently You
Fire DCWs when necessary You
Make sure that DCWs are providing only the care that is approved by the LDSS, MMC, or MLTC You
Make sure the DCWs are doing their jobs safely and correctly You

Other Matters Who does this?
Tell LDSS, MMC, or MLTC if there are changes in your medical or mental condition, or in your living arrangements You
Tell fiscal intermediary (FI) if one of the DCWs stops working for you or if you are hospitalized You
Review timesheets and pay DCWs FI
Calculate yearly salaries, weekly pay, and benefits FI
Oversee DCW taxes and benefits FI
Pay for work–related accidents and injuries following the state´s Worker´s Compensation Policy FI
Make sure that DCWs have annual physical exams and TB tests You and FI

2B. Fiscal Intermediary´s Responsibilities

Here are some things the FI must do to help you manage your services:

  1. Prepare paychecks for each DCW:
    • Determine each DCW´s pay and benefits in accordance with all federal and state wage laws.
    • Take out income tax and other withholdings from each paycheck and pay that amount to the government.
    • Follow the rules for worker´s compensation, disability, and unemployment insurance for each DCW.
  2. Make sure each DCW completes the required physical exam and TB test before they start work.
  3. Keep records for each DCW, including time sheets and a copy of the required medical documents.
  4. Keep records for you, including the LDSS, MMC plan or MLTC plan authorization for your services. This does NOT include the plan of care.
  5. Make sure you or your designated representative keep up with your responsibilities (section 2A).
  6. Tell the LDSS, MMC plan, or MLTC plan right away if the FI believes that you or your designated representative are no longer able to manage your responsibilities.

2C. LDSS, MMC Plan, or MLTC Plan Responsibilities

Here are the things the LDSS, MMC plan, or MLTC plan must do:

  1. Follow the Department of Health rules to assess, authorize, reassess, and reauthorize you for CFCO services.
  2. Review reports from the FI about your ability or the ability of your designated representative to do what you are responsible for.
  3. Change your authorization if you or your designated representative cannot carry out your responsibilities, if you require more hours, or if you no longer qualify for the service.
  4. Let you know if you are no longer eligible to receive CFCO services. Make referrals to other services, if needed.
  5. Let you know about any LDSS, MMC plan, or MLTC plan decisions, including decisions to authorize, reauthorize, increase services, decrease services, stop services, or not allow specific tasks.
  6. Send you a notice about any change to your services before the change will take effect. If you think the change is wrong, the notice will tell you how to ask for an appeal or State Fair Hearing to look at your services again. For more information about the State´s Fair Hearing process, you can go to this website: The notice will also tell you how to continue your services while your appeal or State Fair Hearing is under review
  7. Keep records about your participation in CFCO.


3A. My Really Good Day

Imagine what would be a really good day for you by thinking about the following questions. If it helps, you can make notes on this page. Remember to keep it realistic—this is a day in your life NOW, a day that is possible.

  1. Where are you?
  2. Who is with you?
  3. When and how did your day start?
  4. What will you do today?
  5. When and how will your day end?

CFCO services are meant to help you live your really good day in the community. As you complete this exercise, think about the services you would need to make this day a reality. What skills might your DCW need to have to assist you? Would your DCW need to possess a car or a driver´s license? What other services would you require to make your really good day a reality?

3B. My Planning List

As you schedule your DCWs, it is important to have a realistic idea about what they will be doing during their shift, how long each task should take, and when you want those tasks performed. This will allow you to properly schedule your staff based on the specialties of each and which tasks you want them to perform.

As you complete this list, it is important to remember that your LDSS, MMC plan, or MLTC plan will determine what tasks may be performed by your DCW and how long, during the course of a week, the workers have to complete all of those tasks.

To figure out how to schedule your DCW, look at the activities in the left column. Then fill in the columns on the right to indicate:

  • How many times a day or week you need assistance with the activities.
  • How long each activity should take.
  • Whether you need the assistance during the day or at night, or both.

Activities of Daily Living (ADLs)

Activity How often? For how long? Day/Night
Bathing or showering      
Bowel care      
Bladder care      
Dressing (morning)      
Dressing (bedtime)      
Grooming (hair care, shaving, make up, oral care)      
Making breakfast      
Eating breakfast      
Making lunch      
Eating lunch      
Making dinner      
Eating dinner      
Turning in bed      
Transferring to/from chair, couch, toilet, etc.      

Instrumental Activities of Daily Living (IADLs)

Activity How often? For how long? Day/Night
Shopping for groceries      
Doing errands      
Making the bed      
Doing laundry/ironing      
Driving or using public transportation      
Using the phone and looking up numbers      
Managing finances      

Health–Related Tasks

Activity How often? For how long? Day/Night
Preparing meals following modified diets or complex modified diets      
Taking medications      
Using medical equipment, supplies and devices      
Positioning/giving body pressure relief      
Providing range of motion      
Caring for my skin      
Suctioning/respiratory care      
Caring for wounds      

3C. My Preferences for a Direct Care Worker

Indicate how important each of these items is when you choose a direct care worker.

DCW Characteristics Very Important A little important Not important
Male Female      
Younger Older My age      
Talkative Quiet      
Physically strong      
Able to drive      

DCW Skills Very important A little important Not important
Can read      
Can write      
Can manage money      
Is a good cook, particularly for my tastes      
Can use computers      
Is a good cleaner and housekeeper, particularly for my standards      
Can speak my language well      
Can use American Sign Language (ASL)      

Other Considerations for a DCW Very important A little important Not important
Eats meals with me      
Goes to religious services with me      
Enjoys my pets      
Shares my interests such as TV, music, shopping, theatre, film, art, cooking      
Goes with me to socialize      
Goes with me as I participate in activities such as volunteering, my job, and school      
Gets along with my children/family      

3D. Advantages and Disadvantages of Supervising DCWs by Yourself

Recruitment, Availability, and Assignment of DCWs

  • You can choose your own DCW and design a schedule for your care based on the approved service plan.
  • You can make sure that your DCW has the skills and characteristics that are most important to you.
  • You can eliminate problems related to an inability to understand or work with your DCW because of language or cultural differences.

You may:

  • not know how to advertise for and find DCWs.
  • have a hard time finding DCWs that can work the schedule that you need.



You can train DCWs to provide services and support in the way you want.


You may:

  • not know how to train DCWs.
  • be uncomfortable training DCWs.
  • want to have someone else train the DCW.

Meeting Personal Assistance Needs


You can:

  • get the services and supports you want and need in ways that you like.
  • decide how to deal with your ADLs, IADLs, and health–related tasks, as well as changes in routine.

You may:

  • not be able to develop a schedule that makes sure you get services in the ways that you like.
  • feel like it´s too much when you forget something or when changes occur.
  • hire DCWs who are unwilling or unable to be flexible and not have coverage at times.
  • have problems setting up a back–up system.
  • have problems getting emergency or last–minute coverage.

Supervision and Administration


You can:

  • feel good about taking care of your services by yourself.
  • learn how to talk to people and how to deal with people in ways that can help you in all parts of your life.

You may:

  • not know how to supervise someone or not be comfortable doing it.
  • have difficulty understanding DCWs because of language or other differences.

3E. Is It Right for Me?

After reading about some of the advantages and disadvantages above, think about your own needs. What are the good things and the not–so–good things about supervising DCWs by yourself? List them here:

Good Things Not–So–Good Things


4A. Who Can Be a Direct Care Worker?

According to New York State law, a DCW providing CFCO services that you supervise can be:

  • A friend;
  • An adult member of your family who IS NOT your spouse, parent, or designated representative; or
  • A qualified person you find through the hiring process.

4B. Ways to Find Direct Care Worker Candidates

Search in Your Community

  • Ask your family, friends, current DCWs and other people you know if they know of anyone who might be interested or if they can help you spread the word.
  • Check registries at Centers for Independent Living, Agencies on Aging, or advocacy organizations for lists of possible candidates.
  • Post ads on bulletin boards in:
    • shopping centers, supermarkets, or food co–ops
    • laundromats or laundry rooms in your apartment building
    • coffee shops or cafés
    • high schools or colleges
    • gyms or community centers
    • churches, synagogues, mosques, or temples

Target Community and Local Colleges and Training Centers

  • Place ads in career centers at colleges and other places that offer training in health–related programs.
  • Call colleges that offer a Home Health Care or Certified Nurse Aide/Assistant (CNA) program and speak with people that run those programs.

Advertise in Newspapers and Online

  • Advertise in town or community newspapers.
  • Post ads on websites that offer support for people with disabilities.
  • Utilize Facebook and other social media that sometimes offer groups for those seeking to hire DCWs.

Contact Community Health Centers or Clinics, Day Cares, Nursing Homes, and Hospitals

  • Post ads on bulletin boards to attract staff members looking for extra hours.
  • Call to ask about students in work placements who might want extra work.

4C. What is Important to You in a Direct Care Worker

My Best DCW

Think about the following questions and write your answers or share them with a partner.

  • What was your best DCW experience?
  • Who was the person?
  • How did this person come into your life?
  • Why was this experience the best?

Based on that experience, what things would you like to see in your DCW?











5A. Seven Steps to Follow When You Hire a Direct Care Worker

Step Task Done
1 Advertise
  • Have you used your answers about your best experience to help you write an ad that describes what you are looking for?
  • Have you also talked to people and asked them to let others know you are looking for a DCW?
2 Pre–screen the candidate on the phone
  • What are your first thoughts about the candidate?
  • Did they talk to you in a way that you could understand and felt comfortable with?
3 Interview the candidate in person
  • What do you think now?
  • Are you comfortable spending time with the candidate?
  • Do you have a place other than your home to interview the candidate?
4 Think about the candidate after the interview
  • Is the candidate like your best DCW?
  • What do you like best about the candidate? Least?
5 Check references (people the candidate used to work for or with)
  • What do they think about the candidate?
  • Would they work with the candidate again?
6 Offer the job to the candidate
  • Ask the candidate, "Would you like to work for me?"
  • (If the candidate accepts, ask, "When could you begin?")
7 Call the candidates whom you did not choose
  • Tell them, "I´m sorry, but I can't offer you the job. Thank you for taking the time to meet with me."

5B. Finding the Best Match

To find the best match, you need to:

  • Know your needs and what you like and don´t like.
  • Know what personality traits in your DCW you like and don´t like.
  • Tell each candidate clearly what your needs are and what you like and don´t like.
  • Know what you are willing to give up (if you must) to meet your staffing needs.

5C. Talk to Candidates on the Phone First


Talking to candidates on the phone before meeting them gives you an opportunity to:

  • Not take the time to interview someone if you are uncomfortable with them on the telephone.
  • Ask questions about your most important needs and preferences.


When you talk on the phone, you may decide not to interview:

  • A good candidate because you didn´t like how they were on the phone (some people seem different on the telephone than in person).
  • Someone who cannot work the hours you need now, but who might be a good back up or who might be able to work for you in the future.

5D. Phone Pre–Screening: Sample Messages

Instructions: A consumer named Anita placed the following ad in the newspaper.

$10/hr. to help a person with a disability
Get experience working with a person in a wheelchair. Active person needs help with daily activities, 6–8 hrs. weekly. Only 10 minutes from campus. Car required. Routine is easy to learn. Help needed now. Call Anita to leave message at 212–999–9999.

She received four telephone messages in the first day. As you read these messages, think about which candidates you would call back if you were Anita. Circle either "yes," "no," or "maybe" for each message. After you have read all four, go back and put a number next to who you would call back and in what order (rank).

The Messages

1. I´m calling about the ad for your live–in position. My name is Jenn, but I´m really calling for my best friend Mikey. He´s a nice, gentle guy who is interested in this job. Can you call me back at 907–222–2222 and I´ll be happy to tell you more about him.

Rank ______

2. (Happy, warm voice) Hi, Anita. My name is Christy and I saw your ad in the paper. I am 28 and a first–year graduate student in occupational therapy at New College. I´d really like to get experience working with a person with a disability. I think I could learn a lot from you. Please call me at 212–000–0000. Again, it´s Christy and I hope to hear from you.

Rank ______

3. (High pitched voice) My name is Nora Joseph and I´d like to know more about the disabled woman who needs help. I think these people are so brave and inspiring. I have helped out several before. I have access to a real good car since my current boyfriend says I can use his. Please call me at 646–292–4646. Catch you later.

Rank ______

4. (Quiet, pleasant voice) Hello, Anita, my name is Martin. I´m a 42–year–old single dad with two teenage daughters. I´ve done some health care aide work before. Could you return my call so that we could discuss your needs? You can call me at 907–448–2221 between 8 and 11 pm. I look forward to your call. Bye for now.

Rank ______

5E. Tips for Phone Calls

  • You don´t have to call back everyone who leaves a message.
  • Plan what you want to say before you call.
  • Let candidates know that you are talking to several candidates, and you will call them back if you are interested in meeting them in person.
  • If something is not clear or does not sound right, ask, "Can you tell me more about that?"
  • If you don´t feel right when talking to someone, trust yourself and end the conversation.

Questions About Issues That You Will Not Change Your Mind On

In a phone conversation, three to five questions about issues that you are set on can help to decide if the candidate is a good fit for your needs and preferences. List at least three questions that you would ask about an issue that you will not change your mind on:





5F. Interviewing in Person

  1. Get a sense of the candidate as a person and as a DCW.
  2. Tell the candidate a little bit about the DCW position.
  3. Show respect for and interest in the candidate.
  4. Learn what skills and knowledge the candidate brings to the job of DCW.
  5. Give the candidate a chance to ask questions.

5G. Getting Ready for Your Interview with a Direct Care Worker Candidate

  • Who will participate in the interview?
    •     Only you
    •     A family member
    •     Your current DCW
    •     Others
  • Where will you have the interview?
    •     Your home
    •     Another location
  • What do you want to learn about the candidate?
    •     DCW skills
    •     Other skills
    •     Work experience
    •     Training
    •     Personal qualities, including attitude
  • What do you want to tell the candidate about the job?
    •     Pay and benefits
    •     Schedule
    •     Your flexibility
    •     Your needs and preferences
  • What materials do you want to have with you?
    •     Job duties and application form
    •     List of interview questions; paper and pen
    •     Equipment to show them what you will need done with it


6A. Comparing the Traditional and the Coaching Supervisor

Traditional Coaching
  • Identifies the main issues to address
  • Creates a positive relationship with the DCW
  • Explains the rules clearly
  • Presents problems clearly
  • Explains the consequences of breaking the rules
  • Gathers information about the DCW´s point of view
  • Offers possible solutions to problems or challenges
  • Explores options to solving problems with the DCW
  • Requests or directs the DCW to follow the rules
  • Helps the DCW commit to action steps

Acting as a coaching supervisor is the best choice.

6B. Important Supervisory Skills

  1. Communicating Clearly
    • Speak clearly, and every so often, ask if the other person understands what you are asking or saying (for instance, "does that make sense to you," "do you understand what I am asking").
    • Be aware of body language (the speaker´s and your own).
    • Repeat what the candidate said in your own words to make sure you understood them (for instance, "so what I am hearing is that you feel).
    • Ask questions that can´t be answered yes or no. For instance, ask the candidate how they did something or to explain or describe their experience. This will let you gather more information from them.
  2. Being Self–Aware
    Know your assumptions, biases, and negative judgments. They can get in the way of hearing a DCW´s perspective. They can also make it harder for you to deal with issues in an effective way. For instance, you may have had a negative experience with a DCW who used their cell phone while working. This will impact how you react if your current DCW is on his/her cell phone. Rather than assuming why he/she was on the phone, use communication skills listed above to find out why s/he was on the phone; there may be a good reason for him/her using the cell phone.
  3. Managing Emotions
    Try not to react emotionally and don´t jump in with answers. If you have a problem with a DCW, present it calmly. Explain the problem and use the communication skills listed above.
  4. Giving Constructive Feedback
    Tell the DCWs when they do jobs well. When DCWs have not met your needs and likes, tell them directly what was or wasn´t done (and what needs to or doesn´t need to be done to meet your needs and likes), but do not blame them.

6C. Giving Constructive Feedback

Your goals in giving DCWs constructive feedback are to:

  • Tell them you appreciate what they did (or are doing) when he or she meets your needs and likes.
  • Let the DCW know when your needs and likes are not being met.
  • Give the DCW information so you can know what the problems are and fix them together.

General Guidelines for Giving Constructive Feedback

  • Give positive feedback often to reinforce good performance.
  • Give feedback as close as possible to the time of the behavior that you want to reinforce or change.
  • Be clear and direct about the behavior you are addressing.
  • Tell DCWs how this behavior affects you.
  • Don´t blame or judge.
  • Show your belief in the DCW and in his or her ability to work with you to deal with the problem.
  • Set up a regular time each month to discuss how things are going for you and your DCW. Regular meetings will help make sure that you are giving and receiving the feedback necessary for a strong and constructive relationship.