Table 2.

Themes by Category/Concept and Representative Quotes

Concept	Themes	Representative Participant Quotes/Field Notes/Theoretical Notes
Programmatic Philosophy, Positioning, and Environment of ADS	-In the shadow of the nursing home -The business and marketing of ADS -Budget cuts/Economic stress -Environmental positioning/Physical constraints of ADS -Community and personal integration	Family member, CADS: [After mentioning to the interviewer, Dr. Gaugler, that the family member’s relative was once in a nursing home]: “And it was so depressing that uh, you walk out really sad feeling. But down at CADS you don’t walk out that way. You walk out happy and you know knowing that it was, she was taken care, good care of, you know…I don’t say nursing homes are bad. I don’t mean to infer that at all, but my mother was in rehab for a month when she fell. And I was there every single day, and I observed that there was less socialization than there is in a daycare program.” Family member, BLADS: “You know, honestly, I wish more people knew about it, because we probably have a large population of elderly people who are sitting in their homes…it kind of makes me sad that we don’t go out as a society and try and do a better job of canvassing those people and figuring out a way to get them there.”Staff member, BLADS: “There was this idea or notion that once you build an adult day program, people would flock to use it. And this happened at a number of different places. And there was a real explosion of adult day programs, but in the time since, many of those programs have closed. In part because it took a lot of time and a lot of marketing savvy to get these programs up and running, and to get an appropriate number of clients using those programs…many executive directors, even now, many of them don’t have marketing background. So the knowledge to actually market, to try to identify people to use these programs, took a lot more time than some of the sponsoring nursing homes or other organizations were comfortable with, and many of these programs ended up closing.” Theoretical note: Or perhaps an example of this idea of permeability or the ability of a program to really be able to reach out and touch the lives of the people that are in it. The other examples—which really emerge a little bit during my observation at BLADS, but came out afterwards. As I noted in my field notes, I had heard (the director of BLADS) had gotten on the phone to talk about a tractor, and in particular a tractor in a parade in town that actually, BLADS was going to participate in. They were actually going to have a tractor for this parade. And after I had finished my observation I had gotten a haircut in a barbershop very near by the BLADS adult day program in town I had overheard a woman who was in the barbershop with her children talking about this parade and how popular it was and how there were going to be something like 70 tractors and what a big deal it was. I think that shows another potential concept here, which is this idea of community integration. Staff interview, CADS: “He had dyslexia. He was relatively calm and passive when he first started using the adult day program. But then (executive director of CADS) started giving him various projects to do, projects related to, maybe, projects focused on his past interests. In particular, work-related projects, etcetera. And that really seemed to get him out of his shell. (Executive director of CADS) also told me a little bit about his wife. And apparently his wife was also a client at the adult day program. She was very much more in charge of things, but she had dementia. She eventually died, but (executive director of CADS) told me a little bit about how she created a story book with this woman, and how she shared that storybook with other family members.”
Reasons ADS Use	-Dissatisfaction with other care -Relative required supervision -Caregiver need for respite -Health professional recommendation -From nursing home to community -Affordability	Family member, CADS: “Here (CADS) I think there’s enough if you want to say staff to client ratio, where there (the nursing home), like I said, I couldn’t even consistently get my mom up for something that was important to here, like church, cause no one—unless she could self propeller up there, no one would do that. And when my mom was up to the floor like for church, she was anxious on that floor. And there was nobody there to kind of—they didn’t pair her up with somebody that she might be able to feel more comfortable with, even if it was another nursing home patient. You know, where here, at least, she’s an active participant. And she was not always an active—that’s the big one. She was not always an active participant.” Family member, BLADS: “Because I know that she’s very independent, and I knew she kept talking a lot of like her husband had passed away, and she just needed that peace of being around other people her age. And I couldn’t supply that for her. And having her just in an apartment by herself, she just wasn’t getting the interaction that she needed…she just kind of secluded herself to her apartment…I just knew that that wasn’t right for her and I needed to bring her where she was around other people her age.”
Process of ADS Use	-Staff as serving -Flexibility of ADS care provision -Client segregation vs. client integration -Intensive care provision -Staff working together -Lack of engagement -Client preference vs. client need -Integrating multiple services -Lack of family knowledge -Family involvement in ADS -Getting the relative ready to go to ADS -Person-centered care -Stability and retention in ADS	Family member, BLADS: “Like I said, using his mind, you have to think, have to be, you know, get up and do something. Or go walking when he doesn’t even feel like it. Sometimes that does you some good, it’s just like when we do his exercises here. He don’t sometimes like to do them, but doing them has kept him from falling now and he’ll do them.” Family member, CADS: “They had a table here that people who need a little more help. And they mixed the people up. It wasn’t always—as Mother needed more help she sat at a table where the feeding could be easier, but during the activities there wasn’t any division. Everybody sat together and played together. So. They did a great job.” “(Interviewer): It seems hard. I mean, like for example, when you’re playing cards in the game at the one table, you tend to have—usually it seems like the people with dementia are at their own table, and you have to keep them engaged. (BLADS staff person): Yes. Now, this is just a good example of being creative. And (BLADS staff person) loves cards and bingo, but in between she can be really creative. And yesterday she found a bunch of scraps of material, in the garbage. She took them out of the garbage, she plopped them on the table here. She took the dementia people around the table. And they were folding them. We’ve done that too. Fold towels is great for the dementia people. And she was cutting out snowflakes, Christmas trees, you know, with them. It was great.” Staff interview, CADS: “And adding in the home services. I mean it all kind of weaves in together, kind of like just a support system. And it’s different for each of the caregivers. What we do is a little different for each of them.”
Pathways to Negative Client and Family Psychosocial, Client Function Outcomes	-Client resistance -Lack of use -“Bingo” -Family interaction- involvement issues -Food -Lack of cohesion -Need to offer more comprehensive services	Staff member, BLADS: “Yeah. But one of my least favorite is, they are elderly, and when they get sick, or pass, that is hard. Because they become—you can become connected in your heart with them. And that is hard. I mean, you know you’ve given them good times here, but you know that their time is limited.” Family member, CADS: “Every month I try to get her schedule. My mom has lots of word finding problems, and a lot of times we like to—I talk to her on the telephone everyday, and I just like to be able to talk to her about what the activities were. So I just try to get them to send two copies of this home at the beginning of the month. And they said, for whatever reason, they have a hard time remembering to do that. So I have to remind them every month, or come in and—like today, I’m picking it up.” Staff member, CADS: “What doesn’t work for families is for families who’ve waited way too long. And especially if there’s major behavioral problems and issues, that some of these things could have been taken care of maybe a year ago. Maybe a couple months ago.”
Pathways to Positive Client and Family Psychosocial, Client Function Outcomes	Activities lead to independence Care planning and coordination with families Socialization Outings Security Quality of care/Benefits of attendance Stimulation Increasing client participation at home Allows client to stay at home	Family member, BLADS: “Well he hadn’t been playing cards here when my sister and brother would come up. But now after BLADS now when they come up, on Wednesdays they’ve been playing and he’s been pretty good at it. My brother and my sister comment that he was doing a really good job on playing and stuff. And he was even playing cribbage with my brother, took him a little longer, but he was even doing the moves and knew how to hold his hand and everything.” Family member, CADS: “And if she’s, the doctors told her she’s supposed to keep up the therapy and stuff. But when my mom’s home here by herself, she doesn’t do it. She doesn’t, she can’t get motivated. She sits on the, lays on the couch and watches t.v. I think if it wasn’t for CADS that she would be a vegetable right now.” Staff member, CADS: “I love that. I love that flexibility. And the staff is so great. I mean, (CADS staff person)—oh sure we can work this out…Oh right, right. No problem. I’m always here, or I’m usually here when he—if anything goes with the tubes. I know how to handle that. Who wouldn’t want to work in a place like that? Or put time in doing that kind of thing? If this is what you’re interested in. The flexibility is phenomenal. And that makes it fun. I like that.” Family member, BLADS: “(Family member): Yes. Yup. I could have put her in a nursing home, probably a year and a half, two years ago. Her physician said when things get kind of rough, just let me know and we can make other arrangements. But my desire was to keep her home.
		(Interviewer): That’s right.
		(Family member): And I realized the care that would be needed, but realizing it and doing it are two different things. But, it wasn’t bad at all, because we had the daytime hours to do our chores or whatever we wanted, morning was kind of, you know, it’s social time. It wasn’t a big deal to get Mother ready and take her and visit with her in the car. And then in the evening it was the same. So she had a fulfilling life, like going to school or going to work. I could do my thing, <husband> could do his thing, and then we were together in the evening.”
		Staff member, BLADS: “And the outings. Just in general, just having them have an outlet just seems to really be the best part.”

NOTE: ADS = adult day services