The steady increase in the numbers of elderly in our population is particularly significant in view of the fact that chronic disease, long-term illness and disability comprise the bulk of the health problems of adults in their later years.1 Statistics show that there are more than one million elderly in long-term care facilities.2 They are there because there are no alternatives open to them.
A study done in 1975 by the Department of Health, Education, and Welfare2 cited figures that indicate that between 14 percent and 25 percent of these elderly are in facilities that are excessive to their needs. In addition to this, the high costs of providing these services often makes them inaccessible.
These facts have stimulated our legislators and health professionals to look at alternatives which are less costly and enable persons to live in their own homes, rather than become institutionalized.
Since one out of every six persons who are not institutionalized is in need of some type of health care and social services, intensive efforts are being generated by both the legislators and health care providers in the development of day care programs for these elderly persons.® Day care is essentially a program designed to serve the elderly, infirmed and disabled who do not require 24-hour institutional care, but who would benefit by a therapeutic program of social, physical rehabilitation, dietary services, counseling and recreation.4
Day care is one area of health care for the elderly which provides more than a safe, protected environment. It utilizes a framework of health as a state of complete physical, mental, and social well-being within one's limitations and abilities (irrespective of the presence or absence of disease or infirmity). Moreover, day care is an intervention which can be primary, secondary, or tertiary in nature. Results of such intervention will prevent or slow down physical, mental, emotional, and social deterioration. So, the focus is on individual strengths, with emphasis on independence.
With such a philosophy, today's geriatric nurses and allied health professionals can no longer look upon the elderly as too old or too feeble to help him/herself. Instead, they must accept them as they are and build on their strengths. Furthermore, this philosophy of care will improve the kind and quality of care as well as encourage a more positive response by the community in favor of the elderly population.
Review of the literature shows that three models of day care have emerged. The programs are differentiated largely by the kinds of services provided, the existing staffing patterns, and participant characteristics. The three models included are :
1. A time-limited restorative model in which there is a high ratio of professionals to participants-a heavy emphasis on health services and participants who have suffered serious illnesses and need much rehabilitative care.
2. A long-term maintenance model in which there is a smaller proportion of professionals to participants- less emphasis on health services and participants who suffer from the infirmities of old age.
3. A psychosocial model in which there is a small proportion of professionals to participants-less emphasis on health services, more emphasis on social services and participants who suffer from isolation, depression, and loneliness.
Participants in day care programs must comply with admission criteria before they are accepted into the program.
Three critiçal criteria used by the three day care programs which were surveyed in a recent study5 are (1) that participants are able to return home at night; (2) that participants are not incontinent; (3) that participants are not abusive or harmful to other participants even though they are confused.
Once they are accepted, participants must have a preadmission physical. This is usually done by their personal physician since there is no medical care componeni "in most day care programs. The other contribution of the personal physician is in the periodic renewal of all orders. In addition, emergency services are provided for all participants by a transfer agreement with the local hospital.
Other comprehensive health care components are offered in day care. These are coordinated by the program director who is often a registered nurse. The nurse directors are responsible for the coordination of all services. Her functions range from administrative to community relations. Consistently, these nurses are involved in screening, diagnosis, distribution of medications, charting, and providing health records systems, giving treatments, providing therapies, arranging physician contacts, providing personal hygiene, nutrition education, counseling, guidance, assistance with housing relocation, and referral to other medical, social, financial, and legal agencies. Since there are no physicians on the day care staff, the nurse must assume the major medical responsibility. When the director is not a nurse, a registered nurse must be available. In this case, she would provide supervision of nursing services and recognize as well as deal with the symptoms of physical or psychological distress. Moreover, she would institute preventive health measures when possible.6
Provision is made for a minimum of one meal per day which would supply at least one-third of the daily nutritional requirement. Along with this provision, two daily snacks are given: one mid-morning, the other mid-afternoon. If the day care center is located in a long-term care facility such as a nursing home, the participants can eat their noon meal with the nursing home residents. The success of this concept is noted in a recent survey of three geriatric day care centers.5
A planned recreation and activities program suited to the needs and wishes of the participants is provided. Emphasis is placed on physical exercise-this promotes social interaction and prevents physical deteriation. It is estimated that between four and five hours of an eight-hour day program are devoted to the activities and recreation component.6
Rehabilitative services, including physical therapy, occupational therapy, and speech therapy, are provided through qualified consultants. These programs are designed to improve or maintain independent functioning.
A major problem in implementing day eare is transportation. Reasons for this problem are: low incomes, little access to a car, and poorly designed physical and service features of the present transportation system.7 Impairment and disability of the aged population compound this problem. It is evident that day care must provide some means of transportation. Solutions to this problem are different in all situations depending on the local conditions. In some centers the most efficient and effective manner of providing this service is through a program owned and operated van; in other centers it might be through a contract with a commercial provider. However, whatever the mechanism, it remains an important consideration and a vital component of day care services.
One of the major arguments for day care is economic. This alternative can be less expensive than traditional institutional care. Without 24-hqur round-the-clock care, maintaining an individual in day care appears to have merit and obvious cost advantages. The current national trend is to encourage Title XVIII and XIX of the Social Security Act to reimburse the cost of day care services. To date, this effort has had only limited success. However, legislators seem to be moving in this direction since long-term institutional placement has been shown to be inappropriate for a large number of the elderly population.
In an attempt to assess the perceived need of day rare services in a suburban town of Massachusetts, a survey of ten community health leaders was done.5 The findings were favorable in response to day care services. All ten leaders agreed that day care was a perceived need in this community. First, they felt that this service would assist the aged person and his family by giving the necessary support services to maintain the individual and keep him/her in their home. Second, they felt that it would lessen the isolation and loneliness often associated with aging. Third, they felt that day care would encourage independence and responsibility on the part of the elderly person.
Sixty percent of community leaders who worked with the less-well elderly saw a need for this service at the present time and could refer between one and five persons to this service.
Findings such as these show that the development of such an alternative is necessary for our elderly population. Therefore, the study suggests the following recommendations:
1. Further research in day care to enable a comparison of tangible and intangible outcomes by cost effective and cost benefit analysis.
2. The establishment of a comprehensiveassessment tool which would measure the participant's need for such services before acceptance into the program is made.
3. The establishment of specific measureable admission criteria which would work in conjunction with the goals of the program.
4. The establishment of an on-going evaluation of all participants to measure outcomes and the appropriateness of these in relation to the objectives of the program.
5. The establishment of a coordinated referral system from day care or to day care within a continuum of health care services offered to the elderly.
It appears that day care, through the selected use of an appropriate model or combination of models, would offer one alternative to institutionalization. In fact, day care will be an outcome if the present trends continue. Current research shows that it is a feasible alternative to institutionalization, is cost effective, and is a national priority of the federal government.
- 1. US Department of Health. Education, and Welfare: Health Services and Mental Health Administration: Washington, DC Government Printing Office. Biological, Psychological and Sociological Aspects of Aging. 1972, ρ 1.
- 2. Pepper C: New Perspectives in Health Care for Older Americans: Recommendations and Policy Directions of the Subcommittee on Long-Term Care. Washington, DC, Government Printing Office, 1976, ρ 23.
- 3. Department of Health and Social Development: Day Care Centers in Manitoba, Canada. Winnepeg, Manitoba, September, 1973, ρ 2.
- 4. Lampe M: Adult DayCare For Manitoba. Department of Health and Social Development, Winnepeg, Manitoba. September, 1973, ρ 2.
- 5. O'Brien C: Survey of three geriatric day care centers: the relationship of their services to the perceived needs of the elderly population of Newton, Massachusetts. Unpublished Manuscript, Boston College, 1976.
- 6. US Department of Health, Education and Welfare: Guidelines and Definitions for Day Care Services to be Carried Out in Experiments and Demonstrations, (PL 92-603), Section 222(b), June 6, 1974.
- 7. Trancentury Corporation: Adult Day Care in the US, Prepared for the National Center for Health Services. Research Division of Health Services, Washington, DC, June 30, 1975.