The frail, disabled, or dysfunctional elderly are a peculiarly powerless and voiceless constituency and if professionals do not speak up for them, no one else will. The nurse is in a unique position to recognize the needs of this group and not only perform advocacy functions on their behalf but also assist families in assuming and performing their advocacy functions. However, because of the diverse needs of these frail elderly, nurses must work with other disciplines and groups to be effective in this type of advocacy. I would like to share my experiences in developing the Day Care Network that we presently have operating in San Diego County.
Back in 1967, the local Community Welfare Council, which has since been dissolved, was awarded a grant from the Administration on Aging to develop and provide protective services for older persons in their own homes. I was fortunate to be appointed to the original Board of Directors of this project. The Director of the Visiting Nurse Association also was appointed together with 1 2 other persons represen ting a cross section of community agencies and disciplines. At the conclusion of this grant, a non-profit organization called "Adult Protective Services" was formed and after much politicking and effort, we were able to receive funding from the local Community Mental Health Program on a contract basis to continue these home services.
At about this same time, 1969 tobe exact, I also was appointed to the Citizens' Advisory Council on Mental Health at the State Level. This was the time the New Mental Health Act for the State was being implemented under Governor Reagan. This appointment placed me in a unique position to politic with our local mental health director, since I also was appointed toacommitteeof the conference of local mental health directors and helped them develop a position paper on mental health needs of the aged.
With the implementation and growth of the home care program, it rapidly became apparent that there was a great need for day care services to provide some relief for families caring for disabled elderly at home, and also to provide additional therapy and stimulation for the clients. The period from 1973 to 1975 might be considered a period of politicking during which many grant proposals were written, submitted, turned down, rewritten, and resubmitted to numerous sources. Presentations were made by both staff and board members at hearings, etc. One of our county supervisors became a supporter. In 1973 he made a speech on television calling for a "Blueprint for Action" describing new services needed by the elderly and focusing on the need for adult daycare. We quickly gai ned support from other supervisors as well aseity councilmen and the Office of Senior Citizens' Affairs. However, there was also opposition from other service providers who claimed they were offering such care.
It is important that thedistinction between day care and the multipurpose senior center be clear. Day care is for seniors who could not participate in the typical senior center; that is for the senior described as neither "go-go" or "no-go" but rather as "slow-go." Pacing of activities to client's abilities is a major factor in both the preventive and rehabilitative aspects of senior day care, as is individual planning. Each member has his or her own health improvement plan and a social plan based on their physician's recommendations. It is also important to include family members in planning and implementation so there will be follow-through at home. Both individual sessions and groups sessions are held with family members, or whoever the home caretaker is.
In 1975 we finally had four Adult Day Houses established with city and county revenue sharing funds. Community Care licenses were issued by the State. In 1976 another center was started in East County and the State enacted legislation under AB 1611 and 1612 called the "California Adult Day Health Care Act." This law defined adult day health care as "an organized day program of therapeutic, social, and health activities and services provided pursuant to this chapter to elderly persons with functional impairments, either physical or mental, for the purpose of restoring or maintaining optimal capacity for self-care." The law further states that this care is provided on a shortterm basis: adult day health care serves as a transition from a health facility or home health program to personal independence. Provided on a long-term basis, it serves as an Option to institutionalization, when 24-hour skilled nursing care is not medically indicated or viewed as desirable by the recipient or family.
Prior to enactment of this law by the State, San thego had been selected as a demonstration site to make comparisons between day health care participants and matched controls, of which 96% were in SNF's as to costs and effectiveness of service systems with Medi-Cal reimbursement for MediCai eligible Day Health care participants. To sum up the results of that 18-month demonstration:
The total public health cost for Day Health participants was one half that for the matched controls.
The scores on life satisfaction for Day Health participants were at or above the 90th percentile, while those for matched controls were below the 50th percentile (based on several scores for each person).
The effectiveness objectives set for restorative care were all met by the San thego network (the only demonstration project that established such objectives).
As a result of this demonstration and the interest of the State Assembly Committee on Aging, Adult Day Health Care was established as a Medi-Cal benefit in the State of California and licensing passed to the Department of Health Services. Next followed a period of establishing state regulations and numerous appearances at hearings to correct some of the undesirable aspects of the regulations. The states wished to establish centers larger than we felt were desirable. Our feeling was that a network of centers was much more desirable in an area of scattered, heterogeneous population because a network combines the best features of decentralization with small, home-like or club-like groups, shorter transportation runs, local neighborhood support, and local advisory councils and an ability to cater to cultural differences in taste and style. Overall administration can result in lower administrative and fiscal management costs with centralized intake and a traveling team of restorative specialists.
Regardless of type of license, a full range of health and social services needs to be offered. We are constantly asked by visitors, "What model do you use?" The concept of specific models does not grow out of the felt need of disabled seniors, but is a conceptual crutch for professional planners. The felt need and the real reason disabled seniors are institutionalized usually is that they are not safe left alone and there is nobody to care for them on a 24hour basis or the caretaker is too burdened to provide 24-hour supervision. Most older persons do not got to institutions because they have diabetes or hypertension or are poststroke or incontinent or senile. These are labels put on after the decision for institutionalization is made.
In a study conducted by Dr. W.G. Weissen1 of the U.S.P.H.S. National Center for Health Services' Research, a savings of from 37 to 60% was demonstrated, which can be realized by using day care centers rather than nursing homes to meet the needs of the aged. This study is particularly significant because previous research has indicated that government reimbursement policies encourage institutionalizing many elderly who could receive appropriate care on an ambulatory basis. Stuthes cited by Dr. Weissen showed that at least one out of every four nursing home residents really did not require institutionalization. Because of the success of the day care programs in deterring the necessity of institutionalization and the resultant cost savings, it is difficult to understand why Medicare has not yet expanded coverage for Day Care services.
Our San thego network of five centers presently serves 188 participants and their families and an average of 45 other families each month who are planning for relatives with us but for whom day health care may be inappropriate. The budget for 1979-80 was $495,085, of which 54% was Revenue Sharing and 46% Medi-Cal and other fees paid by families. The health care offered includes a full range of services - restorative and maintenance as well as physical, mental, and social. The intensity of the program is mild and cumulative with pacing the major consideration. Disabilities are overwhelmingly chronic rather than acute. The health care is holistic because the whole person is involved and the environment provides for social interaction, mutual affection, concern, and love.
In the original setting up of the centers, much money was saved by soliciting donations of furniture and equipment and by purchasing government surplus equipment. Students in nursing, social work, and psychology have been included from the beginning, as well as volunteers. Four senior aides also are employed at each center in addition to the professional staff. The experience for nursing students is most gratifying as we observe them "turn on" to wanting to work with the elderly. The first class of students assigned to these centers wrote up a "job description" of their own duties and responsibilities in day care. All of the registered nurses employed by the program have come from the student affiliation program and some of them have pursued graduate work in order to become gerontological nurse practitioners.
My own tenure on the Board of Directors had to be interrupted after six years since that was the limit imposed by the by-laws, but after a two year absence, I was reappointed to the board and am currently serving as President of the Board of Directors. This has been one of the most gratifying experiences of my own professional career.
- 1. Weissen WG: Cost of adult day care; A comparison to nursing homes. Inquiry 15:10-19, 1978.