Given the independent senior f adult who is capable of maintaining his or her own hierarchy of needs, when physiological or psychological decline accelerates, some degree of intervention may be necessary. If family are not available or are incapable of restoring independence, introduction to the long-term care continuum can assist the individual's return to independence or help maintain homeostasis at the point of introduction.
Adult day care has become a recognized service in the community long-term care continuum. Having originated in England in the early 1940s, it has evolved in the United States to programs designed to provide a combination of health and social services to the chronically ill and disabled. Programs can range from the provision of pleasant daytime environments with emphasis on supervised recreation, to more comprehensive programs of health care and rehabilitation.
Day care programs should not be confused with drop-in centers for seniors who seek companionship, take in lectures, learn crafts, play cards, etc. Day care is for individuals who. for various reasons, are not motivated to leave their homes because of fear, inhibition, or who physically or emotionally do not seem to have the stamia to travel on their own to these centers.
In concept, day care places emphasis on health maintenance, promotion, and restoration. This is accomplished by nursing personnel, pharmacists, physicians, physiotherapists, occupational therapists, social workers, lay persons, and volunteers. The amount of nursing care would depend on the extent of the services provided. Results from such care can prevent or slow down mental, physical, or social deterioration. The objective is to maximize individual potential irrespective of disease or infirmity.
One study of ten adult day care programs has led to the identification of two models of adult day care."'12 Model I programs are often associated with health care institutions or ambulatory settings and draw participants from them. These programs have a strong health care orientation and seek physical rehabilitation as a treatment goal. Participants in this group typically have suffered a stroke or have other chronic disabling problems. They may have been previously institutionalized, but have become sufficiently recovered to be released from inpatient status provided that follow-up rehabilitative treatments are available on an ambulatory basis. The program provides such services as meals and diet counseling, social work services, physical and occupational therapy, and periodic medical evaluation.
Model II or "multi-purpose" program participants, in contrast, show few or no dependencies and few diagnosed medical problems. They are served in programs that usually do not provide rehabilitative care, focusing instead on these less infirm participants' needs for social interaction and activities.
In the state of Washington, adult day care exists primarily under the title of "Day Health." It follows the Model I classification. The programs provide services offered during the day, at a center, to individuals who do not require 24-hour institutional care, but who, due to physical, social, and/or mental impairment, are not capable of full-time independent living.10
Day health is designed to serve persons who are at risk of acute or long-term care if they do not receive the specialized services provided by a day health program. The primary target population of the day health program is persons who are mentally, physically, socially, and/or emotionally impaired and need day health services to maintain or improve their level of functioning, so that they can remain in, or return to, their own homes. A secondary target population is persons who cannot be left unsupervised and are living with friends or relatives who provide the supervision they need to remain in the community but need some relief from 24-hour care.
The following priorities have been established by the Bureau of Aging for the provisions of day health services in the state of Washington:
First priority. People residing in the community in an unsupervised living situation, either independently, or with family or friends, who are likely to require supervised living in a foster home, congregate care facility or nursing home if they do not receive day health services. A nursing home is defined as an intermediate care facility or a skilled nursing facility.
Second priority. People living in a supervised living situation who are likely to require a higher level of care if they do not receive day health services. For example, people living in foster care or congregate care who can be expected to need nursing home care without the help of the day health program. A statement of the reasons why the applicant is considered to be at risk of a higher level of care must be written by day health staff and placed in the applicant's care record.
Third priority. People living in a supervised living situation who can be expected to move to a lesser level of care through the provision of day health services. For example, people who can use the day health program to make the transition from a foster home or congregate care facility to unsupervised living, or from a nursing home to congregate care or foster care. A statement of the reasons why the applicant has potential for moving to a lesser level of care must be written by day health staff and placed in the applicant's care record.2
The programs that currently exist are located in urban areas of the state. Many are sponsored by a parent health institution. According to a report done by the Bureau of Aging,7 "if Adult Day Care was available in all areas of the state and accompanied by adequate support services (primarily outreach and transportation)," their survey substantiates that there are thousands of potential users among the elderly population.
Senior citizens with chronic illnesses use more of the social services available to the state's elderly than do their more healthy fellow citizens. They also use the services more frequently. Yet, somewhat ironically, they are less aware than other members of the elderly population of the array of services available. Table I illustrates this point and shows the lack of awareness regarding social services is higher among those with three or more chronic illnesses than it is among the general survey sample used for the study.
There are a number of issues that have been raised in the delivery of adult day care services. The following list contains some of the areas that are a concern to those who provide, monitor, or receive this service:
1. Because of the nature of these programs, the skill level of certain staff, and the transportation difficulties, the establishment of rural day care centers does not seem feasible at this time. Day care services are unique in the facilities that are required and the special mix of staff that must be available. Modification must be made to a building and special equipment acquired for various forms of therapy. In the urban setting these facilities may be readily available, but in less populated areas, nonexistent. Where many programs now are housed in a hospital or nursing home, this often becomes difficult in a rural setting. Transportation represents a major problem in providing day care to individuals. It also results in one of the major expenditures for the service providers.
Reasons for the problem are low income, little access to a car, and poorly designed physical and service features of the present transportation system. Impairment and disability of the aged population compound the problem. It is evident that day care must provide some means of transportation. However, solutions to the problem are different in all situations depending on local conditions. In some centers the most efficient and effective manner of providing this service is through a program owned van. In other centers it might be through a contract with a commercial provider.
2. Utilization of adult day care by young people with debilitating diseases or injuries is often difficult to achieve. Existing programs receive funding primarily from Title XXof the Social Security Act, Title XIX of Medicaid, and from state senior services money. Only the Title XIX money can be used to purchase day care for persons under age 60.
Although some funding can be provided for younger persons, the programs themselves tend to be oriented more to the senior adult. The current legislative mood also appears to be more sensitive to supporting this service mainly for the elderly. The study done in Washington by the Bureau of Aging indicated that if more day care was available, a greater proportion of the elderly would use it. If day care is to be made available for younger people, alternative programs may need to be established. In addition, different funding sources may need to be considered. Third parly reimbursement for day care to individuals injured or who have contracted a debilitating disease could provide one source. Various employment compensation programs might also be encouraged to support day care for rehabilitating employees.
3. Adult Day Care expenditures are generated by capital investment in facilities, ongoing transportation, and the utilization of professional staff. Facilities and transportation appear to be major items, with staff costs varying depending on the type of program and the goals of the provider.
Studies that have examined the cost of day care indicate that, on a per day basis, day care is more costly than nursing home care.! 1 However, others have shown that if an individual only requires six to eight hours of day care, three or four days a week, substantial savings would result because of the unnecessary seven days a week, 24-hour maintenance expense of a nursing home.5 The literature only compares day care to nursing homes. As yet, little has been done to compare costs with the other forms of long-term care. If adult day care can successfully keep individuals from institutionalization, or assist early discharge, some degree of positive economic impact should be obtained. If, however, it merely becomes another service alternative on the long-term care continuum, no matter the benefits, it will increase our social financial expenditures.
4. Currently the Bureau of Aging in the state of Washington recommends at least 14 clients be serviced each day. Should smaller groups be encouraged? Should state developed criteria and standards apply to smaller "in home" programs? As more states adopt specific criteria and standards to govern the operation of day care services, they may need to guard against eliminating useful programs that are smaller or less sophisticated. Private religious programs or other supported services that do not depend on major federal or state monies may require an exempt status or less stringent regulation. The upper range of the client population/efficiency ratio should also be examined. Too many persons may be kept in the center and receive no attention because of the size of the group being maintained.
5. Licensing of adult day care programs is not now required in all states. The state of Washington currently regulates the programs receiving state money through the contracts established with the local Area Agency on Aging. If new programs begin operation and do not require such funding, quality control could become a problem. In those states that have licensure, a smaller, well-meaning program may be kept from operation if, as with the criteria and standards, the requirements are too difficult to meet. If licensing is established, the process itself can become costly if mechanisms are not properly set up. With either licensure or contracts, monitoring for quality should be a major objective.
6. There is some confusion about the interface between adult day care and psvchogeriatric day care. Should outpatient mental health clients be included in adult day care services? As awareness of the needs individuals have in the area of menial health becomes greater, adult day care may provide a good source for outpatient treatment. Arguments have been made that disturbed elderly can be better maintained when surrounded with normal activity and "healthy" peers. DAY CARE PROGRAMS
Many programs currently screen out such individuals because of the physical rehabilitation focus. However, with better community understanding and acceptance, the blending of these services may become more natural.
7. The more recreation- or social-oriented programs are often not a part of adult day care services in a state. Should more programs of respite care be established? Should they become a part of the adult day care programs funded by state and federal monies?
The Model II programs that place primary emphasis on social and recreational activities have not received a great deal of federal and state support to date. These so called "senior centers," that often create confusion among consumers when compared with day care, provide an environment that may be a great help in avoiding the need for more community intervention. In addition, the staff and transportation requirements are less costly. The state of Washington has begun to explore the preventative value of respite care, and the expanded funding of such services. Again, seeking to intervene sooner and at less cost in order to maintain the individual at the highest level of independence.
The smooth flow of individuals along the continuum of long-term care services is difficult. Many programs and services are new, others are changing. Washington is unique in that it has developed standards for a comprehensive day health program that offers a broad range of services and affords each client the opportunity to use each service to the degree necessary for his/her particular situation. There was a deliberate attempt to develop standards* that would meet the requirements for various sources of funding because the Bureau of Aging believes it is administratively wasteful and a disservice to clients to establish a one-day health program for clients who are physically impaired, another for clients who are socially isolated or confused, and a third for clients who are emotionally or psychiatrically disturbed.
In order to be effective in assisting the many persons who enter the long-term continuum, adult day care services should be clearly defined to allow for the most appropriate referral. In addition, accurate information should be made available to those with the greatest potential for its use.
- 1. Department of Health, Education and Welfare: Directory of Adult Day Care Centers. Department of Health, Education and Welfare, Health Care Financing Administration, Health Standards and Quality Bureau, May 1978.
- 2. Department of Soc ial and Health Services for the State of Washington, Office on Aging: Day Health Payment Standards 1978.
- 3. Elliott M, McCuan E: Geriatric day care in theory and practice. Sex Work Health Care Winter 1976-1977.
- 4. Morgan D: Day care as an alternative to nursing homes. Dimen Health Serv March 1978.
- 5. O'Brien C: Exploring geriatric day c are: An alternative to institutionalization? J Gerontol Nurs 3(5):Septembcr/Ociober 1977.
- 6. Pierotte DL: Day health care for the elderly. Nurs Outlook August 1977.
- 7. State of Washington Department of Social and Health Services: Report: The Needs of the Elderly 1978. Department of Social and Health Servic es, Offic e on Aging, February 1978.
- 8. Thodes 1.: Alternative care for the elderly. Pub Welfare Winter 1978.
- 9. US Department of Health, Education and Welfare: Health*Unitecl States. DHEW Pub No 78-1232.
- 10. University of Washington, Health Policy Analysis Program, Department of Health Services: Long-Term Ciare for the Elderly in Washington, April 1978.
- 11. Weissen WG: Adult day care programs in the United States: Current research projects and a survey of 10 centers. Public Health Reports January-February 1977.
- 12. Weissen WG: Costs of adult day care: A comparison to nursing homes. Inquiry March 1978.