Τ t has been said that, "Old age can become an expression of human experience.. .It can be rich, varied, colorful, and in turn enriching; or it can be impoverished, empty, and only serve to emphasize the futility of life and its meaning to many of the old." For many citizens, reality is most accurately described by the latter possibility. Many seniors face but two alternatives: the loneliness and difficulty of self-care or the expensive, sometimes unnecessary and dehumanizing experience of institutionalization. However, a growing awareness of the quandries of old age has produced a new option, that of the multipurpose day center.
The elderly population of the United States now numbers over 23 million people and by the year 2000 the aged will constitute 20% of the national population. Attaining the status of senior citizen involves confrontation with a multitude of emotional, financial, and physical problems unique to that stage of life. It is a period of change which frequently requires difficult adjustment. Feelings of uselessness and depression are experienced after the departure of children. Retirement and the excess of free time it provides, tries the patience of both husband and wife. Widowhood leaves many people suffering from isolation and low morale. Loneliness, which afflicts approximately 30% of older people, takes its toll.1 In addition, problems are created by society's perspective on the elderly.
To be sure, old age is viewed as the least satisfactory period of life. Most older people are seen by the generation they produced as having problems of insufficient income, declining health, fear of crime, loneliness, widowhood, and lack of meaning in their lives. There appears to be a rather general feeling that the preponderence of older people has suffered losses in alertness, activity, usefulness, mental flexibility, and sexual competence or interest. '
Thus, senior citizens must cope with attitudes toward the elderly which are unlike any they have yet encountered.
Monetary worries frequently confront elderly citizens. The majority experience sharp decreases in income during their retirement years. Two fifths of older couples lack the. income to sustain the intermediate standard of living set by the White House Conference on Aging, while the incomes of one fifth fall below the poverty level. In the case of widows, some 25% have income below the poverty level.1 Further, two studies document that this deficiency of funds denies the elderly even the most basic of necessities. A Chicago survey of people over 65 revealed that 26% did not have enough money for food and clothing.2 Another study by the Agency on Aging found that 48% of those who were in need of optical care did not seek such care due to financial difficulties.3 Though preventive health care is basic to the elderly, such financial restrictions are a major impediment.
The health problems of old age may lead to apprehension and pain. Hardening of the arteries, heart disease, mobility restrictions, etc, complicate the lives of these people, yet treatment is not always at their disposal. Outpatient clinics of hospitals offer services which frequently cause unnecessary inconvenience and possible harm through extra waiting and travel. In addition, the outclinic is but one example of bureaucratic treatment of the elderly. The treatment process is geared toward addressing large numbers as opposed to personalized treatment. "Bureaucratic systems seem to breed indifference in direct proportion to their size and fragmentation of work assignment. Nowhere is this truer than when clients are the poor, the aged, and the infirm."2
Legal problems faced by the elderly are significant. Senior citizens more than any other age group rely upon monolithic, complex public and private institutions for their day-to-day existence. Thus, the legal problems of the elderly frequently relate to the policies and actions of governmental agencies and private corporations. Among these kinds of problems are matters related to Social Security, Supplemental Security Income, Medicare, and Medicaid. Unfortunately, the aged are caught in a web of discrimination because of their inability to secure adequate representation.
The result of the problems mentioned above is the loss of independence. Many aged citizens find it difficult to accept assistance after a lifetime of selfsufficiency. Aid, viewed as a violation of the basic principles of society, is often desperately avoided. The Chicage study, already cited, stated that although 26% needed financial support, only 5% applied for welfare.2 Even family help is not always welcome; less than 5% of the total elderly income is in the form of direct transfer payments by children.1 A strong desire for independent living is the established pattern of life in our culture and is the principle behind the movement to encourage seniors to remain in the mainstream of the community.
The development of adult day care has added a new dimension to the elderly lifestyle. Due to its novelty, adult day care is subject to both varying definitions and applications. Its overall purpose is to provide services and programs for preventing, shortening, or delaying the need for institutionalization. It is important to note that maintaining people in the community for the sake of just keeping them in the community can be destructive and dehumanizing. In fact, some older persons have become virtual prisoners in their homes- out of sight and mind, lonely, isolated, and alienated. Outreach services may keep the body alive while the soul perishes. The ultimate goal of day care is to preserve human dignity while filling the gap between limited care and total institutionalization.
One very promising format for extending the services of adult day care is the multipurpose senior center which provides an unduplicated variety of services. Realizing that the various problems of the elderly overlap, senior centers attempt to treat a patient's individual ailment or complaint in the context of their complete lifestyle. For example, the immediate symptoms of depression may be caused by legal entanglements. But, unless the social worker has contact with the lawyer, this connection may not be recognized. Senior centers can arrange such connections and thus simultanelously furnish treatment in several areas. A center's staff collaborates on diagnosis and cure, thereby reducing work effort while improving treatment.
Multipurpose senior centers are designed in the belief that the elderly should remain in the mainstream of the community. While home care alone may result in isolation and institutionalization segregates the elderly population, senior centers emphasize involvement. Centers do not wish to simply sustain life, but also to give it new meaning. Such meaning can be demonstrated through association with other community projects. The Adult Day Center of West Haven, Connecticut is connected with a vocational program, a cultural organization, and a child day-care program. Through Foster Grandparents and the discovery of new talents and interests, new horizons are opened for the elderly.
From an economic viewpoint, the development of multipurpose day-care facilities is essential. Limited resources and present economic conditions demand that measures be taken to curtail the widespread pattern of duplicative and overlapping services and unneces- sary costs. Due to spiraling costs of hospital stays, the increased cost of operating new facilities, and the recognition that the room and function of the hospital or institution represents a significant portion of the total inpatient operating cost, centers have emerged as a viable solution.
The West Haven Adult Day Center, is one example. Working in the belief that health is a product of all aspects of life, it offers meals, employment opportunities, legal services, speech, physical and occupational therapy, home care, and other services. Since its implementation, the cost per client-day amounts to $14.96. This figure is comparable to other high quality day-care programs in the State of Connecticut. Elderhouse, in the city of Norwalk, is projecting a second year cost of $14.19 per client-day based on a total of 5,557 total days. The oldest free-standing adult day center in New England (Warwick Geriatric Center, Warwick, Rhode Island, begun in 1973) has been able to lower its costs to $14.50 for their budget year beginning January 1, 1978.
A federally-funded study of 10 adult day centers in 1975 found that most cost between $17 and $22 per day, which is comparable with the costs listed above when in-kind costs like CETA staff positions are taken into consideration.
The regional Health Systems Agency for South Central Connecticut, in its recent plan for the area, has recommended adult day care as the primary solution for health problems among the outpatient/ambulatory population needing long-term care. Their arguments are based on the large potential annual cost savings of day care over institutional care, especially when day care is utilized two or three days per week instead of the continuous, seven-day week in average nursing homes and rest homes with nursing supervision. Based on average nursing home costs of $26/day and the rest home costs of $17/day, the HSA plan demonstrates potential annual savings ranging from $4-$6 million over skilled care and $1.5-$3.7 million over rest home care. Of course, savings over costs of inappropriate institutionalization in medical hospitals would be even greater, given the costs of area hospitals, which begin at $120-$130/day.
The principle source of cost saving of day care over institutional care, therefore, derives from the intermittent or episodic versus continuous pattern of utilization. Table I and Table II illustrate a range of potential cost-savings for three levels of cost for day care as compared to nursing home and rest home care at current Connecticut Medicaid rates based on a projected 340 places for day care at 90% occupancy with a utilization rate of two days per week for 23 weeks.
Although it may he argued that comparable institutional stays may be considerably shorter due to the intensity of daily, rather than twice weekly care, the number of days per case would have to be reduced by 90 to 140 days for nursing home and 50 to 130 days for rest home to equal the cost of day care. Table I and Table II are intended to be illustrative only, not definitive. While it is valid to conclude that increased availability can result in cost-savings, the amount of savings may vary over a wide range.
Maintenance of physical health is an important aspect of multipurpose centers. Less than 20% of the respondents in the Chicago study were in good health, but 66% had not seen a doctor in the previous three months. Adult day centers can make dental, optical, podiatric, and physical treatment available to participants. The services are administered by people trained in the special problems of aging and, therefore, provide complete and adequate medical treatment. In addition, a center's home care program can make medical treatment financially feasible for most elderly; the National Association of Home Health Agencies had estimated that home care can run one third the cost of hospitalization.2
Along with medical treatment, the day-care programs would provide health maintenance services. The most vital activity in this area is nutrition. Congress has established separate funds under Title VII of the Older Americans Act which, among other things, establishes projects which for five or more days per week will provide at least one hot meal per day.
Each meal assures a minimum of one third of the daily recommended dietary allowances. For many recipients, financial or mobility restrictions make the meals their only source of nourishment.
Another important facet of multipurpose day care is the treatment of emotional health. Treatment can be delivered indirectly of thorough more direct methods, such as counseling and therapy. Frequently an elderly person cannot cope with the problems and adjustments as previously indicated. Group or individual counseling may be needed to prepare for and deal with these aspects of old age. One program which helps the aging person ready himself for the approaching changes is Preretirement Education. "Preretirement Education may be defined as the acquistion of information, understandings and appreciations which serve to facilitate personal adjustment after retirement from the labor force."4 Designed as an eight-week course, PRE discusses physical and mental health, social and emotional change, housing finance, legal matters budgeting, and recreation.
An additional component of a program is the presence of the occupational therapist. The therapist can assist the individual in preparation for future needs and demands in a realistic manner. Teaching crafts suited to the individual's vision and hand movement capabilities is one primary method.
Further services which should be included in a multipurpose senior center are legal and financial advice. The problems already described may frequently be avoided with legal counsel. Upon consultation with co-workers, a center's lawyer can search out laws, public funds, and social services which will address the needs of the individual case. In this way, an elderly person can take full advantage of the law's provisions. Home aid may also be provided for members of a senior center. Heavy cleaning, errands, and simple companionship can be offered by volunteers and employees of the center.
POTENTIAL ANNUAL COST SAVING OF DAY CARE OVER INSTITUTIONAL CARE
To secure the multifaceted services of day care requires traveling certain distances. Transportation is frequently added to the list of services offered by such programs. Purchase or rental of specially equipped vans allows disabled and/or handicapped individuals to participate.
One obstacle which senior centers and all areas of gerontology face is a dearth of properly trained personnel. This is largely due to a shortage of training opportunities. As outlined above, society now appreciates the level of sophistication and interrelation of the problems of old age. Thus, new training programs must be established to retrain personnel.
In order to relate and emphasize with the older person's [rame of reference, we must bear in mind the experiences and problems which are almost universally shared by this group. An unskilled, untrained, human service worker can hardly be expected to find his way through the maze of a cultural gap, generation gap, common medical problems not to mention the psychosocial pressures of aging.5
These expected and needed training programs have not emerged. A survey of employees working with the elderly in the Washington, D.C. area indicates the need for more training. Over 50% had received no training prior to employment and 70% felt they could improve their performance with training.6 In a related article, John B. Martin,7 former Commissioner on Aging, indicates that, . .a third of a million professional and technical workers are employed in programs designed primarily or solely for older persons and fewer than 10 to 20% of these people have had formal training in their work." Furthermore, training is needed for a multitude of new positions. In 1973, it was estimated that some 139,125 newly trained personnel would be needed in the following five years.
Although senior centers are highly beneficial, there are not nearly enough in existence. Title V of the Older Americans Act authorizes funds for the acquisition, alteration, and renovation of multipurpose senior centers in the form of grants, mortgage insurance, and interest subsidies. It also authorizes grants for initial staffing. The National Council on the Aging has estimated that some 200,000 centers could be utilized, yet only 1% of this number are in operation.2
Can adult day care, and especially senior centers, continue to provide their essential services? Will they be able to reach the scores of aged who need them? If municipalities are interested, if training programs are established, if funding continues-the qualifying answers to these questions seem endless. But adult day care is a productive, beneficial, and worthwhile concept; senior centers are an auspicious format. With the support of educational institutions, private organizations, and all levels of government, the many ifs will become certainties. Older Americans should remain in the mainstream of the community, continuing to offer the experience of their long lives; multipurpose adult day centers can make this possible.
- 1. Tibbitts C: Older Americans in the family context. Aging 270271:10. (April-May) 1977.
- 2. Percy CH: Growing Old in the Country of the Young. New York. McGraw Hill, Co. 1974, ρ 101.
- 3. American optometric association issues survey findings on eye care. Aging 261-262: 4, (July-August) 1976.
- 4. Rosencranz HA (ed): Pre-Retirement Education. Connecticut, University of Connecticut Publications, 1975. ρ 11.
- 5. Elba G: Training needs in gerontology. Hearings before the Special Committee on Aging, USS, US Government Printing Office. Washington, DC, 1973 June 19, 1975, ρ 40.
- 6. Fields C: Training needs in gerontology. Hearings before the Special Committee on Aging. USS. US Government Printing Office, Washington, DC, 1973 Juhe 19, 1975, ρ 40.
- 7. Martin JB: In Butler RN: Why Survive? Being Old in America. New York, Harper & Row, Pub, 1975 ρ 171.
- The photographs for this article were the courtesy of the West Haven Adult Day Center.
POTENTIAL ANNUAL COST SAVING OF DAY CARE OVER INSTITUTIONAL CARE