Abstract
Home- and Community-Based Services (HCBS) offer person-centered care in home or community settings as an alternative to institutional care. In the United States, the Self-Directed Waiver program is a Medicaid-funded HCBS option that allows older adults and individuals with disabilities to select services and providers that best suit their needs. Under the program’s Budget-Authority model, support brokers guide participants in planning expenditures, coordinating services, and managing resources. While existing research demonstrates that brokers are instrumental in helping waiver participants maximize program benefits, the well-being of brokers themselves and the relational support available to them is underexamined. This dissertation addresses that gap by analyzing survey data from 95 support brokers who assist Budget-Authority participants in a single New England State.In this three-paper dissertation, the first paper provides a novel analysis of the concept of job crafting—realigning job tasks to optimize resources and reduce demands— in the context of support brokers. The paper investigates job crafting’s impact on brokers’ burnout and work engagement levels and examines how career orientation enhances wellbeing through the mediating effect of job crafting. Findings show that brokers who engage more in job crafting report significantly lower burnout and higher work engagement. Notably, those in managerial or leadership roles are more likely to engage in job crafting, presumably due to greater responsibilities and autonomy.
The second paper applies the relational coordination (RC) theory to assess the quality of communication and relationships within brokers’ professional networks. It examines the influence of sociodemographic factors on brokers' overall RC and its dimensions. It also evaluates how job crafting strengthens these relationships, especially for those in leadership roles who navigate complex relational networks. Findings suggest that job crafting correlates with higher RC, particularly in timeliness, accuracy, shared goals, and mutual respect dimensions
The third paper utilizes the public services co-production model and RC theory to investigate brokers’ relational ties at two levels: RC with peers in internal teams -organizational structures that provide a relational space for peer-based guidance- and RC co-production ties with newly enrolled (for a year or less) and established participants. The paper also analyzes the impact of brokers’ sociodemographic characteristics on broker-participant relationships. Results indicate that, overall, brokers report stronger ties with established participants. Additionally, brokers with financial expertise have stronger ties with newly enrolled participants, underscoring the value of financial skills in supporting participants in the early stages of enrollment. Brokers who report higher RC with peers also experience stronger broker-participant ties, highlighting the importance of relational support structures in strengthening relationships within the Self-Direction Waiver program.
Taken together, findings from the three papers suggest several practical steps to strengthen the support broker’s role in Budget Authority Self-Direction programs. They highlight the importance of improving communication and relationships with other stakeholders in the support network, offering job crafting training to empower brokers, recognizing the distinct needs of participants at different enrollment stages, leveraging brokers’ financial expertise, and scaling the benefits of relational support structures—as exemplified in the case of internal teams - in similar HCBS programs.