ADULT DAY CARE

The National Adult Day Services Association (NADSA) defines an adult day center in its Standards and Guidelines for Adult Day Services (revised 1997) thus:

An adult day center is a community-based group program designed to meet the needs of adults with functional impairments through an individual plan of care. This is a structured, comprehensive program that provides a variety of health, social and related support services in a protective setting during any part of a day, but less than 24-hour care.

Individuals participating in adult day centers attend on a planned basis during specified hours. Adult day centers assist. . .participants to remain in the community, and this enables families and other caregivers to continue caring at home for a family member with an impairment.

This community-based program meets the needs of participants and their caregivers in a congregate setting. Participants generally provide their own transportation, though many adult day care centers provide or arrange for transportation.

Though each adult day center is staffed according to the needs of its participants, most programs operate with an interdisciplinary team that consists of activity staff, usually an activity director and assistants; program assistants who aid with personal care; a social worker; a registered nurse or licensed practical nurse; and a center director. In small programs the center director often functions as both the director and the social worker or the director and the nurse. Centers that serve a large number of participants may also employ a driver, secretary, and accountant. The average adult day center has a daily census of twenty-five to thirty participants. NADSA recommends a minimum staff-to-participant ratio of one to six. This ratio can be even smaller, depending upon the level of participant impairment. For example, if a program serves a large proportion of participants with dementia, the ratio of staff to participants should be closer to one to four.

The typical adult day center operates for eight to twelve hours each day. Because of the changing needs of caregivers, many centers are open five to seven days per week. Participants experience a structured day that includes meals, activities, exercise, and opportunities for informal socialization, as well as assistance with personal care when needed.

Benefits of the center setting

Adult day centers offer a variety of health and social services for one-third to one-half the cost of home health or nursing home care. Home health care agencies and nursing homes nationwide are facing shortages in the paraprofessional work force. Adult day centers are able to provide services with adequate staffing because their staffs, by and large, are not required to work evening and weekend shifts. Desirable hours and the congregate setting contribute to the efficacy and cost-effectiveness of adult day programs.

Adult day services are commonly referred to as "the best kept secret in long-term care." This community-based group program offers participants and their caregivers a viable alternative to nursing home care. Experts agree that despite the efficacy and cost-effectiveness of adult day services, they remain underutilized due to consumers' lack of awareness and inadequate reimbursement.

The facility

Adult day programs are offered in a variety of settings: in a freestanding building; on the campus of a hospital, nursing home, or assisted living facility; or in conjunction with another program, such as a home health agency. Participants can expect centers to offer services in a building that is handicapped accessible. Every center, regardless of the setting, must have bathrooms (one toilet for every ten participants at minimum, according to NADSA), staff offices, and activity space. Additional space may include therapy rooms or offices, a bathtub and/or shower room, laundry area with washer and dryer, nursing clinic, large and small activity spaces, and a kitchen area (for snack preparation). NADSA recommends a minimum of sixty square feet of space per participant. This figure excludes staff offices, corridors, bathrooms, closets, and similar space that is not solely for participants' activities.

Goals of the adult day program

The adult day center setting offers stimulation and growth for participants with impairments while providing respite for families and caregivers. Based on these premises, the NADSA Standards (revised 1997) establish the following goals for adult day centers:

• • Promote the individual's maximum level of independence.
• • Maintain the individual's present level of functioning as long as possible, preventing or delaying further deterioration.
• • Restore and rehabilitate the individual to the highest possible level of functioning.
• • Provide support, respite, and education for families and other caregivers.
• • Foster socialization and peer interaction.
• • Serve as an integral part of the community service network and the long-term care continuum.

These overall goals are coupled with each participant's individual plan of care to maintain an optimal level of physical and mental health.

Care models

Adult day services are delivered, most generally, in one of two program types: the social model or the medical model. The primary focus of the social model is opportunities for socialization and recreation. Such programs typically offer limited health care and rehabilitative services. Participants who attend social model programs usually enjoy fair physical health, but would otherwise lack opportunities to socialize with peers. If participants require medication during their time at the center, it is usually self-administered.

The medical model program has intensive nursing and rehabilitative services as the primary focus. Participants who attend such programs usually have multiple chronic conditions that require monitoring and/or a nursing intervention, and medication administration at least once during the day.

Approximately thirty-five states license or accredit adult day programs. For example, a center may be licensed as a social and/or a medical model. Each program determines which level of licensure is most appropriate.

Services offered

The types of services offered in an adult day care center vary according to whether the program is medical or social. Medical model programs offer nursing care provided by a registered nurse or a licensed practical nurse under a registered nurse's supervision. The nursing care can include medication administration, wound dressing changes, injections, and overall health monitoring. Medical programs also provide or arrange for physical, speech, and occupational therapy. Social model programs tend to be more limited in their scope of services. They emphasize opportunities for socialization, activities, and outings. Medical model programs offer similar social programming in addition to nursing care. Additional services that are offered in both types of programs are therapeutic activities; meals and snacks with special dietary accommodations (for example, diabetic or renal diet); door-to-door transportation; social services provided by a licensed social worker; shower or bath; toileting assistance; grooming; and caregiver support.

Participant profile

Each center's organizational leadership determines what level of participant impairment it can accommodate. This decision is based on the center's design, staffing complement, community demand, and, in some cases, available reimbursement. According to the NADSA, the average age of adult day participants is seventy-four years. Although the adult day center population is largely comprised of older adults, many centers across the country have developed programs to meet the needs of young, disabled adults. The majority of adult day participants are women. Common participant diagnoses include Alzheimer's disease or a related dementia, diabetes, stroke, Parkinson's disease, and cardiovascular disease. The primary reasons for attending an adult day center are the need for socialization, the need for caregiver respite, and the need for supervision or assistance with activities of daily living. Individuals attend adult day centers an average of three to four days per week.

Operating costs of adult day centers

The major costs of operating an adult day center are staffing, rent/mortgage, transportation (vehicle purchase, lease, or fee for service), food, and supplies (medical, activities, office). These costs help center directors determine the daily fee for participants. Though there are wide regional variations in the costs of operating an adult day program, the cost of hiring and maintaining a well-trained staff is frequently the single largest organizational expense.

Funding sources

Adult day services is one of the few industries that lacks uniform reimbursement. Every state has a different reimbursement mix, and within a state, funding can vary widely from county to county. Medicare does not reimburse for the cost of adult day services. Medicaid does reimburse the cost of such services, but not in every state. The states that have Medicaid reimbursement offer it through Medicaid waivers by reallocating funds that had previously been used for institutional long-term care to pay for communitybased programs, such as adult day services, intended to help adults remain independent in their own homes and communities.

Long-term care insurance policies that are purchased by individuals sometimes cover the costs associated with adult day but because policies differ greatly, individual policies must be inspected to determine if adult day care reimbursement is a benefit, and if it is, at what level.

The Veterans Administration funds adult day services with money that previously was earmarked solely for nursing home care. Veterans with a service-connected disability may qualify for funding. The local or regional veterans hospital determines the level of available funding, and should be contacted for further information regarding adult day funding.

Selecting an adult day center

According to the NADSA's publication Your Guide to Selecting an Adult Day Services Center, the first step in selecting a high-quality adult day center is to determine the needs of the program participant and the caregiver. The program participant may have the following needs: a safe, secure environment; social activities; assistance with eating, walking, toileting, and medicines; physical, speech, or occupational therapy; health monitoring; accommodations for special dietary requirements; personal care; and exercise. A caregiver's needs may differ considerably. The caregiver may require reliable coverage in order to work outside of the home; occasional respite; assistance with transportation; support and education; or assistance in planning for care. After the most critical needs are identified, the local Area Agency on Aging is an excellent resource in locating programs in the community that meet those needs.

Potential program participants or caregivers should telephone several adult day centers and inquire about eligibility criteria and application procedures, and request printed information about the program, such as newsletters, brochures, and activity calendars. The program materials should contain information regarding ownership, years of operation, license or certification, hours and days of operation; availability of transportation; fees; conditions accepted, such as memory impairment, limited mobility, or incontinence; staff credentials and training; staffing ratios; health services and activities provided; and menus.

A visit to the adult day center is one of the most reliable means to judge a program's level of quality. According to the NADSA, the following questions are important: Do visitors feel welcome at the center? Do staff members spend time finding out what a prospective participant wants and needs? Do staff members clearly explain the center's activities and services? Do staff members give information about staffing ratios and qualifications, program procedures, costs, and care-giver expectations? Is the center clean, pleasant, and odor-free? Is the center wheelchair accessible? Is the furniture sturdy, clean, and comfortable? Do staff, volunteers, and participants appear cheerful? Are participants encouraged to help plan activities or make suggestions for program improvement? Current and past caregivers and participants may provide valuable information regarding a center's level of quality.

Adult day centers are an integral part of the long-term care continuum. Caregivers and participants benefit from the health and social services that are provided in a group setting for costs that are significantly lower than those typical in nursing home and home health care. And perhaps most important to caregivers and participants, adult day participants are able to continue living in the community while delaying or preventing inappropriate institutionalization.

DAYNA MCCRARY

See also DAY HOSPITALS; HOME CARE AND HOME SERVICES; LONG-TERM CARE; SOCIAL SERVICES.

BIBLIOGRAPHY

NATIONAL ADULT DAY SERVICES ASSOCIATION. Your Guide to Selecting an Adult Day Services Center. Washington, D.C.: NADSA, 1995.

NATIONAL ADULT DAY SERVICES ASSOCIATION. Standards and Guidelines for Adult Day Services. Washington, D.C.: NADSA, 1997.