Adult Day Care: An Important Long-Term Care Alternative & Potential Cost Saver

Abstract

As the number of elderly continues to increase dramatically, families are often faced with exploring how to secure needed care and assistance for a frail or functionally impaired relative. These decisions are often made in times of high stress and families frequently do not have the time needed to explore all potential care options. One important source of family support that is often overlooked or not even known to be a feasible option is adult day care. This article will help the reader gain better understanding of this important service and who might benefit from enrollment in such a program.

Introduction

Adult day care programs are an invaluable alternative to traditional long-term care placement, provide needed support to family caregivers and can often lessen health care expenses for consumers and the health care system.^{1, 2} Programs are staffed by a full range of interdisciplinary professionals who provide clients with health monitoring, leisure activities, socialization opportunities and assistance with activities of daily living (ADLs). For caregivers, adult day programs offer respite, support group opportunities and access to supplementary networks and resources. In addition, these centers can reduce out of pocket health care expenses, lessen use of high cost centers such as emergency departments and delay institutionalization.^{1, 2, 3}

Missouri has over 120 licensed programs, with a majority in the metropolitan St. Louis area. Adult day centers are regulated by the Missouri Department of Health and Senior Services and are subject to inspections similar to those for skilled nursing and residential care facilities. Care plans, current physician’s orders for each participant and standards for quality care ensure program participants receive individualized medical oversight while in attendance. Missouri programs are required to provide assistance in ADLs, up to four hours of planned group activities each day, meals, and arrangements for any special dietary needs, and observation of health, functional and psychosocial status of program participants. Additional health services vary, but typically include regular vital sign monitoring, counseling, supervision of diabetic needs, assistance with bathing, medication set-up and administration, connection to contracted therapy providers and transportation services.

According to the National Alliance for Caregivers and the AARP, there are an estimated 44 million Americans providing unpaid care to a family member or loved one. A substantial body of research shows that a majority of caregivers are unprepared for their role and generally have little to no support. ^4,5,6 Resources like the Adult Day Connection (ADC), at the University of Missouri School of Health Professions, provide respite and are an alternative to placement in an assisted living or long-term care facility.

Case One Presentation

Roger is 77-years-old. Roger is two years post-ischemic stroke. He attends ADC two days per week while Betty, Roger’s wife, runs errands and has time alone. Their children live in other states and Betty is his sole caregiver. Roger uses a wheelchair, has poor vision, impaired judgment, increased fall risk, is unable to verbally communicate effectively and requires medication several times each day. “Adult day care has been a lifesaver for us. I know I could not do this myself,” says Betty.

While at the ADC, the staff monitor Roger’s vital signs, observe for physical and cognitive changes, administer medications throughout the day and assist him with his toileting needs. In addition, Roger enjoys interaction with other participants, is served lunch, two snacks and benefits from physical therapy provided by the School of Health Professions’ physical therapy faculty and students.

Daily assessment and observation help promote early detection for urinary tract infections, dietary and nutritional problems and diabetic related concerns. Even small changes are communicated to caregivers at arrival and pick-up times in an effort to encourage prompt medical intervention through their primary care physician.

For families like Roger’s, the ADC provides a safe and engaging environment for him while Betty experiences much needed respite and enjoys a reprieve from her always watchful duties as a caregiver. Full-time caregivers like Betty are significantly more likely to experience depression, an increased risk of heart disease and less likely to engage in self preventive health behaviors.^{7, 8, 9} It is estimated that elderly spousal caregivers (aged 66–96) have a 63% higher mortality rate than noncaregivers the same age.¹⁰ One client’s caregiver called the ADC “an oasis for the cared-for and caregiver alike.” The ADC staff monitor client’s physical and cognitive status and promptly alert caregivers to any changes. Early detection of health status changes and good communication with caregivers can lead to a quick trip to a primary care physician versus an alarming and expensive visit to the emergency department. The ADC staff are ever watchful of the caregiver’s health and stress level. Constantly ready with additional resources and support, the center’s staff are equally quick to act when caregivers show signs of distress or declining health. Betty reports that utilization of adult day services has helped to maintain Roger’s general health and has enhanced quality of life for both.

A volunteer brings a puppy to the Adult Day Connection for socialization with participants.

Adult Day Care and Meeting Increased Demands Under ACA

The implementation of the Patient Protection and Affordable Care Act (ACA) has all providers searching for ways to efficiently and effectively control health care costs and maintain the highest quality care. Research suggests that adult day services can play a significant role in this discussion. According to the MetLife National Study of Adult Day Services, participants of adult day centers have higher incidents of chronic disease including hypertension (46%), physical disability (42%), cardiovascular disease (34%), diabetes (31%), mental illness (25%), and developmental disability (20%).¹ Programming and activities designed to address these pressing health issues are important to reducing health care costs. At the ADC, the center uses the evidence-based Arthritis Foundation exercise program on a daily basis for all participants and offers individualized workouts to address cardiovascular disease and diabetes. Medication management and nutrition counseling are provided by center staff and other rehabilitation services (physical, occupational, speech therapy and neuropsych services) are available through the MU School of Health Professions at no or reduced costs. In addition to maintaining or improving a client’s general health, adult day services can delay placement into a long-term care facility. Community based options are in demand and boomers are readily choosing aging in place alternatives for themselves and their aging parents.¹

Participants Diana and Leta enjoy a laugh during exercise program.

Case Two Presentation

The ADC provided the optimal choice for Edna. Edna was 84 and lived with her daughter and son-in-law Sue and Bob. Edna had been diagnosed two years earlier with dementia and was no longer able to stay home alone. Sue and Bob both worked full-time. Edna needed help with ADLs, requiring staff assistance in the restroom and set up for grooming and meals. Her cognitive decline and low income qualified Edna to receive adult day services through the Missouri Medicaid program. Edna attended the ADC for 14 years before being placed in a long-term care facility.

Fourteen years ago, Sue could have selected a skilled nursing facility to provide Edna’s care. The use of adult day services allowed Edna to remain at home and saved the state of Missouri considerable resources. The expense to Missouri’s Medicaid program was substantially less than the cost of entering a skilled nursing facility. Based on the average daily rate for Missouri today, her semi-private nursing home bed would have cost $139 per day, compared to $70.20 per day of adult day ser vices. This amounts to nearly $500,000 in savings to Missouri taxpayers. Unlike many caregivers, Sue and Bob reported they have not experienced negative financial setbacks due to lost wages or poor personal health or well being sometimes associated with being a full-time caregiver.^{6, 11, 12, 13} As demonstrated at the ADC, Edna’s delayed institutionalization yielded considerable cost savings. Adult day services are clearly at the intersection of cost effective care and the highest quality of life for these individuals.^{1, 14, 15}

An important factor in ensuring the long-term viability of this care option is increased utilization. Area Agencies on Aging, family and friends and self-referral were the top three referral sources reported by adult day centers.¹ Enhancing the dialogue between adult day service providers, physicians and other healthcare providers to promote greater awareness and utilization of services is essential. Nationwide, fewer than 50,000 individuals use adult day services.¹ Of the 4,601 adult day center in the U.S., less than one-third report having a waiting list. According to the MetLife National Study of Adult Day Services, the Patient Protection and Affordable Care Act “provides potential new avenues of federal support for adult day services. This includes the Community First Choice program which adds 6% additional funding to states for home and community based care. Pilot programs supporting Medicare funding for adult day services are also currently being evaluated.”¹ Utilization is key to demonstrating cost effectiveness.

Group activity and exercise at the Adult Day Connection.

Currently, adult day programs accept private pay, long-term care insurance and Medicaid. There exists a substantial body of research highlighting adult day services benefits to individuals and their caregivers. Less is known about actual cost savings. The experience at the MU ADC suggests that utilization of the center does enhance quality of life as well as reduce use of high cost centers within the health care system, thereby, reducing health care costs.

How To Refer a Patient for Adult Day Care

Physicians interested in learning more about adult day services can find an up-to-date list of licensed providers at the Missouri Department of Health and Senior Services website, http://health.mo.gov/seniors/nursinghomes/pdf/ADC-licensed.pdf. The Missouri Adult Day Services Association (MoADSA) can also provide information about programs in your area; see http://www.moadsa.org/ for more information. State regulations require current physician’s orders, including medications, diagnoses, activity limitations and restrictions, dietary modifications, and indicated therapies. Programs work with discharge planners and social workers to ensure a smooth transition into the day program, work out transportation arrangements, and secure assistance with funding if needed.

Ideally, as more citizens gain increased awareness of long-term options, the role of adult day health services on the continuum of care will be better understood and utilized in Missouri.

Biography

Richard E. Oliver, PhD, is Dean, School of Health Professions, and Meichele A. Foster, MPA, is Assistant to the Dean for Strategic Opportunities, School of Health Professions. Both are at the University of Missouri.

Contact: Oliverr@health.missouri.edu