This article is sponsored by PPL. As home-based care providers and state programs look for more sustainable ways to meet rising demand, self-directed care is gaining traction as a model built around choice, flexibility, and accountability. PPL is helping states modernize that approach by giving individuals the technology and support to remain at home with caregivers they know and trust, and do so in a fiscally responsible way that protects Medicaid dollars. In this Voices interview, Miki Kapoor, CEO of PPL, shares how mission-driven leadership shaped his perspective on care, why self-direction is becoming a central pillar of long-term care, and what it will take to scale the model in 2026 and beyond.
Home Health Care News: What core experiences have shaped the way you view home-based care today?
Miki Kapoor: Several core experiences have shaped how I view home-based care today, but the theme has always been a mission-first focus on the people we serve. Throughout my career in public health, I’ve been driven by a belief that access to quality care, and strong outcomes should go hand in hand—and that systems can be both person-centered and financially responsible stewards of taxpayer dollars.
Earlier in my career, I had the opportunity to work on global health initiatives across Africa and India, which were incredibly formative for me. I was doing work on the ground and leading a 1,000-person team for a large global nonprofit, all centered on expanding access for people facing serious, disabling and sometimes life-threatening diseases. My time in South Africa especially reinforced how much access to quality care shapes not just health outcomes, but a person’s ability to live with dignity.
That perspective has stayed with me ever since. It’s what drew me to PPL initially as a board member and ultimately into the CEO role. Home-based care, especially in a self-directed model, reflects those same principles: giving people more control, supporting them in their communities, and ensuring care is delivered in a way that’s both compassionate and accountable.
How do you define self-directed care? And what has held the model back from broader adoption across states and health systems?
Self-directed care challenges the traditional way we’ve thought about delivering care in this country. For years, the system has been built around costly institutions and large agencies, not individuals. Shifting that mindset takes time. Our healthcare system is still largely built around what I’d call large transactions for patients, while self-directed care centers on smaller but deeply meaningful home care interactions. That goes against the grain of how the broader system has traditionally operated.
Historically, one of the biggest barriers to broader adoption has been infrastructure. Earlier models often lacked the standardized systems, oversight, and technology needed to scale effectively, which made some states hesitant to expand. There was also a misconception that giving consumers more control would mean less accountability, when in reality, the opposite is true when the model is implemented correctly and with proper program controls overseen by a fiscal intermediary.
What’s changed is that we now have the necessary tools to support self-direction at scale and prevent fraud, waste and abuse. We have better technology, clearer program rules, stronger administrative support, and more real-time visibility into care delivery. That’s where PPL comes in. We provide technology, services, and support that help streamline every aspect of self-directed care. This allows people to live at home with dignity while hiring a family member or trusted loved one as a caregiver. That improves the participant experience, helps states manage these programs more effectively, and dramatically reduce expense for all constituents, especially taxpayers, in an accountable way. More states are starting to recognize that self-direction is not just a viable care model. It is essential to the future of fiscally sustainable and quality care and to the future of Medicaid.
With workforce shortages continuing to challenge traditional home care, how does the self-directed model change the dynamics of caregiver supply and retention?
The traditional agency and institutional model is struggling to keep up with demand. It relies on a very limited workforce, which has become harder and harder to sustain. Self-directed care changes that dynamic by expanding the workforce in a meaningful way. It recognizes and supports caregivers who are often already providing care, usually family members or close friends, and gives them compensation, structure, and access to benefits like healthcare coverage, sick leave and paid time off, while ensuring regulatory compliance to prevent fraud, waste and abuse.
That brings more people into the workforce while also improving retention. It creates the kind of flexibility many caregivers need but often cannot find in a traditional agency model. Just as importantly, it strengthens the relationship between the caregiver and the person receiving care. That consistency and trust lead to enhanced patient outcomes and a better experience on both sides, which is a major reason caregivers stay engaged over the long term. So in that sense, self-directed care is about more than just expanding workforce supply. It also improves outcomes, supports retention, and does so in an accountable way that prevents fraud, waste and abuse, and is more cost-efficient for states. That makes Medicaid stronger and more resilient over time.
One of the core features of self-direction is allowing consumers to hire family members or other trusted individuals. From your perspective, how does that reshape outcomes compared to agency-based care?
This is where care is going, because care is deeply personal. Outcomes improve when people feel comfortable, understood, and in control, and when they are cared for by a caregiver they know and trust. When individuals can remain in the place where they feel safest and choose caregivers they already know and trust, it fundamentally changes the dynamic.
You see stronger continuity of care, better communication, and support that is more aligned with a person’s cultural and personal preferences. It also reduces the friction that comes with rotating staff or unfamiliar providers, which is often part of the traditional agency-based model.
In many ways, self-direction formalizes what families have been doing all along, but adds structure, support, and fiscal] accountability. That combination leads to better well-being, a better care experience, reduced expense for the overburdened healthcare system and a higher quality of life for the person receiving care.
As more states look to scale self-directed programs, what are the key operational or policy guardrails needed to balance consumer choice with program integrity?
The key is recognizing that flexibility and accountability can coexist. It just takes the right foundation.
First, you need clear and consistent program rules that reinforce the consumer’s central role in directing and approving care. Second, strong oversight mechanisms such as electronic timekeeping, real-time data visibility, electronic caregiver visit verification, and standardized processes are critical for ensuring accuracy and preventing fraud, waste and abuse. Just as important are accessible training, multilingual resources and responsive customer service so both consumers and caregivers can navigate the program with confidence.
When those elements come together, self-direction can scale in a way that preserves choice while also strengthening transparency, compliance and long-term sustainability.
Looking ahead, do you see self-directed care remaining a complementary model? Or evolving into a central pillar of long-term care delivery in the United States? If it’s the latter, what will drive that shift?
There is no question in my mind, that self-directed care is evolving into a central pillar of long-term care. The demographic and workforce trends make that inevitable. We have a rapidly aging population and not nearly enough traditional caregivers to meet that demand. At the same time, people overwhelmingly want to receive care at home. They want to live with dignity and be supported by people they know and trust. Additionally, institutionalization will continue to drain our overburdened healthcare system.
Self-directed care directly addresses all of those realities. What will drive the shift is a combination of necessity and proof. As more states implement these programs successfully and demonstrate better outcomes, higher satisfaction and more efficient use of resources, it becomes clear that this is not just a quickly scaling model. It is a smarter way to deliver care. And we’re already seeing that recognition grow across the country.
In self-directed care, 2026 will be the year of…
Scale with accountability.
We’re moving beyond proving that self-directed care works. Now the focus is on showing that it can work at scale with the structure, transparency, and support needed to sustain it over the long term. That is when real transformation starts to happen, not just for individual programs, but for how care is delivered across the country.
What makes me optimistic is that we are already seeing that take shape. More people want to be cared for at home by people they know and trust, and states are increasingly recognizing the value of a model that can support dignity, choice, cost efficiency, outcomes and program integrity all at once. That is what 2026 is really going to be about.
Editor’s note: This interview has been edited for length and clarity.
To learn more about how self-directed care models are evolving and what it takes to implement them at scale, visit: https://hubs.ly/Q04cN9p-0.
The Voices Series is a sponsored content program featuring leading executives discussing trends, topics and more shaping their industry in a question-and-answer format. For more information on Voices, please contact [email protected].