Adult Day Services: A Key Community Service for Older Adults

Publication Date

Jun 30, 2006

U.S. Department of Health and Human Services

Adult Day Services: A Key Community Service for Older Adults

Janet O'Keeffe and Kristin Siebenaler

RTI International

July 2006

This report was prepared under contract #HHS-100-03-0025 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Research Triangle Institute. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officers, Gavin Kennedy and Emily Rosenoff, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. The Project Officers can be reach through email at: Gavin.Kennedy@hhs.gov or Emily.Rosenoff@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services or the Research Triangle Institute.

EXECUTIVE SUMMARY

1. INTRODUCTION

Purpose of Study

Methodology

Organization of Report

2. OVERVIEW OF ADULT DAY SERVICES RESEARCH

3. OVERVIEW OF ADULT DAY SERVICES REGULATIONS

Regulatory Approaches

State Definitions of Adult Day Services

Provider Requirements

Monitoring

Medicaid Contracting Requirements

4. SITE VISIT FINDINGS

General Impression of Physical Structure

Organizational Affiliations

Population Served

Participants Functional Limitations

Health and Medical Conditions

Increase in Acuity

Limitations on Who Can Be Served

Services

Role of Adult Day Services in the Health and Long-Term Care Systems

Operational and Policy Issues

5. PROVIDER AND STAKEHOLDER VIEWS ON REGULATORY ISSUES

Georgia

Illinois

Maryland

North Carolina

Washington

6. CONCLUSIONS AND RESEARCH RECOMMENDATIONS

Recommendations for Future Research and Policy Analysis

ENDNOTES

APPENDICES

APPENDIX A: Methodology

APPENDIX B: Regulatory Summaries

Georgia [PDF, this state only]

Illinois [PDF, this state only]

Maryland [PDF, this state only]

North Carolina [PDF, this state only]

Washington [PDF, this state only]

APPENDIX C: Technical Advisory Group Members

NOTE: A Portable Document Format (PDF) file requires Acrobat Reader in order to view it.

EXECUTIVE SUMMARY

Over the past two decades, state and federal long-term care spending on home and community services has increased, primarily through Medicaid waiver programs. Most of the research and policy literature on home and community services for elderly persons has focused on home care and residential care, including adult foster care and assisted living. Little attention has been paid to adult day services (ADS)--a nonresidential community service provided outside the home. Three major adult day services models are generally recognized: a social model; a health or medical model, which is sometimes combined with the social model; and a specialized model. This report will refer to all models generically as ADS.

The first ADS program was a geriatric day hospital program established in 1960 in Greensboro, North Carolina. The program evolved to become a community service to meet caregivers need for respite in order to work, fulfill other obligations, and recover from the demands of continuous care. Many caregivers who use ADS are providing care to family members with dementia who need constant supervision to assure their safety.

The social model of ADS provides a secure environment, assistance with some activities of daily living (ADLs), and therapeutic activities aimed at helping participants to achieve optimal physical and mental functioning. In the health or medical model, ADS programs also provide skilled nursing and rehabilitation services and many programs combine both models. Specialized models are targeted to specific groups, such as individuals with HIV/AIDS, multiple sclerosis, acquired brain injuries, or mental illness. Most ADS programs serve a large proportion of participants with some degree of cognitive impairment, but some programs specialize in the care of individuals with dementia.

ADS programs are of interest to states because of their potential to delay or prevent nursing home placement, in large part by supporting informal caregiving. Informal caregivers are the backbone of the nations long-term care system. Over seven million Americans provide 120 million hours of care to about 4.2 million elderly persons with functional limitations each week. The estimated economic value of this care ranges from $45-$96 billion a year. Research has found that caregivers who experience stress and burden are more likely to institutionalize relatives suffering from dementia. Once the physical resources of caregivers decline and other home and community resources (paid or unpaid) are unavailable, nursing home placement is more likely.

States are also interested in the potential of ADS to reduce health care costs by providing health monitoring, preventive health care, and timely provision of primary care, particularly for individuals at risk for incurring high medical costs. These include elderly individuals who are dually eligible for Medicare and Medicaid--called dual eligibles--who comprised 18 percent of all Medicare beneficiaries in 2000 but accounted for 24 percent of total Medicare spending. Similarly, in 2002, they represented 16 percent of all Medicaid enrollees but 42 percent of program spending.

All states fund some form of ADS through either their Medicaid state plan or a waiver program, and in fiscal year 2005, Congress funded a Medicare demonstration of the provision of home health benefits in ADS programs.

However, little is known about the provision, use, or outcomes of ADS, particularly the medical model, and the ADS industrys capacity to provide health services. Research has been hampered by the considerable variation in the characteristics of ADS programs both within and across states, and by a lack of data.

Purpose of Study

The purpose of this study is threefold: (1) to inform policymakers about the current and potential role of ADS in the health care and long-term care systems as determined by state regulation; (2) to identify operational and regulatory issues facing ADS providers under different ADS models and in different regulatory and financing environments; and (3) to provide information that can guide future research and policy analysis on ADS for elderly persons generally and on medically-oriented ADS specifically.

Methodology

The study used several qualitative research methods, including: (1) an in-depth review of state approaches to regulating ADS; (2) consultation with a Technical Advisory Group, subject experts, state regulatory and Medicaid staff, and state provider associations; and (3) site visits to ADS providers in five states: Georgia, Illinois, Maryland, North Carolina, and Washington. See Appendix A for detailed information about the methods employed.

Regulatory Findings

States vary in their regulatory approaches. Half of the states license ADS providers, ten states certify them, four states require licensure for one ADS model and certification for another, and 13 states use some other type of regulation, such as contractual requirements for providers receiving public funding. The majority of states require inspections that often coincide with initial or annual certification or license renewal, and several stipulate that unannounced visits can be performed at any time. Providers of Medicaid-funded ADS must meet applicable state licensing and regulatory requirements and in over half of the states, must meet additional Medicaid requirements.

Most states regulate ADS to allow the provision of medical services. They provide general parameters for who may or may not be served but do not specify admission and discharge criteria. For example, they lack specific provisions regarding the types or level of functional or health needs that should prevent admission or trigger discharge.

Required and Optional Services

In most states, parameters regarding who can be served are determined indirectly through provisions regarding mandatory and optional services that indicate the level-of-care participants may receive. ADS providers are generally required to furnish assistance with ADLs and health monitoring. States that regulate adult day health care as distinct from adult day care require the former to furnish additional services, including skilled nursing services, medication administration, and physical, occupational, or speech/language therapy.

The majority of states require licensed personnel to administer medications. Some states permit unlicensed staff to so under nurse delegation provisions. Most states require written policies for medication management and administration and many have requirements related to self-administration of medications.

Staffing Requirements

Most states specify minimum mandatory staff-to-participant ratios. Nearly two-thirds require one staff person to every six or eight participants. The highest ratio is one staff person for every four participants and the lowest ratio is one staff person for every ten participants. Some states require different ratios for different types of ADS programs and/or specific types of participants, for example, those with dementia and those with extensive needs. Required staffing ratios for persons with dementia are generally 1:4, but Michigan requires 1:3. Several states do not have minimum staff-to-participant ratios and allow providers to determine the number of staff based on their own assessment of the number necessary to meet participants needs.

Virtually all states require specific types of staff for ADS programs, for example, a program, director, activities director and a nurse. Requirements for nurses vary from part-time to full-time, and whether they must be available or on-site at all times. Because most states require staffing consistent with participants needs, licensed nurses are always required if ADS providers are mandated to furnish skilled nursing services.

Training Requirements

Nearly all states have orientation, initial, and ongoing training requirements, but they are minimal. Some states requirements are general, while others specify the content of training and the number of hours required. Most states require at least one staff trained in first aid and CPR to be on duty at all times. About half of the states have special training requirements for staff who serve individuals with dementia.

Site Visit Findings

The ADS providers we visited are providing both health and long-term care services to impaired older persons, a high proportion of whom are unable to live alone. Informal care supplemented by ADS is enabling them to remain in their homes. The age range in the programs is 21 through 90-plus, but with the exception of the program serving persons with HIV/AIDS, all served a primarily elderly population.

Whether an ADS program serves younger adults--including those with mental retardation and other developmental disabilities and those with acquired brain injuries--depends on a combination of regulatory requirements and funding streams for these population.

The majority of program participants have extensive functional limitations, due to physical or mental impairments or a combination of both. Providers estimate that about 50-80 percent of older participants have cognitive impairment--with or without a diagnosis of dementia. Many have chronic health conditions requiring daily health monitoring and skilled nursing services. The licensed nurses employed by these ADS providers provide preventive and primary health care and coordinate this care with participants primary care physicians.

Most providers felt that participants functional and nursing needs have increased over the past few years and several providers felt that it was due to the increasing recognition of ADS as a viable alternative to nursing home and assisted living placement. Providers reported that they try to serve everyone who needs assistance, but the number of people with severe needs who can be served (e.g., individuals who need two persons to assist with toileting) is limited by the number of staff available.

Services Provided

Providers identified ADL assistance and medication administration as the most frequently provided services. Programs operating as combined or health/medical models also provided health monitoring, health education, and skilled nursing services.

Providers believe that their goals are to enable participants to remain in their homes as long as possible, and to maximize participants cognitive and physical functioning, both maintaining function and restoring function lost due to social isolation and lack of stimulation. Many providers said that the ability to simultaneously offer different types of programming according to functional level was essential to ensuring optimal functioning.

Operational and Policy Issues

None of the ADS providers could meet their costs solely through private payments and public program reimbursement. Nearly all of the providers receive a significant percentage of their operating revenue from Medicaid and other public funding sources and all said that the reimbursement rate did not cover their costs. Several programs use part-time, flex-time, and on-call staff so they do not have to carry staff overhead when the census is low.

Some providers set their private pay rate higher than cost to subsidize the lower than cost reimbursement from public programs. Several programs depend on a significant amount of in-kind contributions and volunteers, and many programs rely on subsidies from parent organizations and charitable organizations during budget shortfalls. To assure a daily census that will meet operating costs, providers have to continually market their services, and some have had to allocate a substantial amount of their budget to do so.

Because some states require ADS providers to furnish transportation and others do not, transportation issues varied among the states. Whether or not they were required to provide transportation, and apart from funding concerns, virtually all providers said that participants transportation needs posed a major logistical challenge and took up a great deal of staff time.

Several programs reported high retention rates for certified nursing assistants and other staff such as activity directors; others reported high turnover. Those that reported difficulty recruiting did so for professional staff--registered nurses (RNs) and rehabilitation therapists--noting that professional staff can earn more in other health care and long-term care settings.

For staff members who stay, providers attribute their retention to: (1) the work environment, which is less demanding than other long-term care settings; (2) higher staff-to-participant ratios than are found in assisted living and nursing facilities; (3) staff who value their role in a program that has a mission to serve the community; and (4) longstanding relationships with participants.

Regulatory Issues

Providers said that compared to other long-term care settings, ADS regulations set ideal rather than minimum standards. Providers felt that most state requirements regarding staffing and training were necessary to provide good care. They objected to requirements that they believed increased costs without increasing the quality of care, such as having to document staff arrival and departure times and some physical plant requirements. Providers noted other regulatory issues unique to their states.

Conclusions and Research Recommendations

Based on our study findings, we have drawn several conclusions.

Regulation

The method states use to regulate ADS varies considerably, as does the content of the regulations. However, states generally distinguish between ADS and adult day health services, and have more extensive requirements for the health model. In general, staffing requirements are more stringent than those for residential care settings, particularly requirements for licensed nurse staffing in adult day health programs and programs that combine a social and medical model of care.
In some states, regulations appear to limit providers flexibility to provide services that meet caregivers needs, such as arbitrary restrictions on the number of service hours that may be provided on weekends.
It is likely that the considerable state variation in regulatory approaches will continue in the near future. In states without licensure, providers disagree about whether the industry should be licensed. One argument for doing so is that long-term care insurers will not reimburse ADS unless they are furnished by licensed entities. Providers in Washington noted this difficulty but those in Illinois did not.

Some providers would support licensure if it led to an increase in reimbursement rates and others believe it would aid in their marketing efforts to recruit private pay participants. However, in states that do not license ADS providers, some fear that licensing would be added to Medicaid requirements rather than replacing them.
Adult day health services are part of the continuum of both health and long-term care services. In the states we visited, ADS providers are furnishing preventive care, health monitoring, and skilled nursing services to individuals with chronic illnesses and physical and cognitive impairments. Some providers are also serving adults under age 65, depending on regulatory requirements and the funding streams for this population.

Because ADS providers must meet Medicaid state plan or waiver contracting requirements to furnish services to Medicaid beneficiaries--either in addition to or in lieu of state licensing or certification requirements--they are regulated at a level which allows them to furnish health-related and medical services as well as long-term care services to elderly persons with a high level of nursing and medical needs.

Program Models

The number of purely social ADS programs may decrease as more providers offer combined or health/medical models. Social programs appear to be at a disadvantage because many participants disenroll as they age and their health and functional needs increase. A combined program offering both a social and medical model appears to be the most financially viable.

The literature on caregiver stress has pointed out the need to use a social model of ADS when people are not so impaired, to help prevent burnout, and many providers noted a need for this model. Others point out that specialized social programs are essential for individuals with dementia who do not have ADL impairments and medical needs. However, these programs may not survive due to: (1) the pressure to serve large numbers in order to meet fixed overhead costs and regulatory requirements, and (2) the need to meet the health and functional needs of increasingly older and more impaired participants, particularly if they want to be Medicaid providers.

Funding and Reimbursement

A unique feature of ADS relative to nursing homes and residential care settings is their reliance on multiple funding sources to cover operating costs. While Medicaid is the primary public funding source for ADS providers through either a waiver program or the state plan, in the five states we visited reimbursement rates were not sufficient to meet costs. To remain financially viable and serve nonMedicaid eligibles who cannot afford to pay for some or all of the services they need, ADS programs must find other sources of funding.

Other funding sources include state and local program funds, Veterans Administration funds, the Social Services Block Grant, Older Americans Act funds, private payments--both out-of-pocket and from long-term care insurance, contributions from local service agencies such as United Way, and charitable contributions obtained through significant and ongoing fundraising efforts. Every ADS program we visited also relied extensively on in-kind contributions and numerous volunteers. The combination of funding sources, each with its own rules, greatly complicates the administration of ADS and can limit providers flexibility to meet consumers needs.
States that pay flat rates create a disincentive for providers to admit participants with severe impairments. Some states pay either hourly rates or have tiered rates for different levels of care.
The cost of ADS is relatively inexpensive compared to home care. Agencies charge as much as $20-$25 for an hours visit by a home health aide and $85 or more for a half-hour visit by an RN. The national average daily cost for the social model of ADS is about $54, for the medical model about $59, and for the combined model about $57.

In the five states we visited, some providers furnished only the minimum number of hours required by public programs to receive the daily rate--never fewer than four. In other states, providers furnished up to 11 hours a day on the daily rate. Despite the relatively low cost of ADS, the five states we visited do not appear to be interested in expanding the availability of ADS generally--or medically-oriented ADS specifically.

Operational Issues

Lack of transportation and the high cost of transportation are major impediments to the use of ADS.
Without greater public recognition of the role ADS can play in maintaining adults of all ages with disabilities in home and community settings, it is unlikely that ADS programs will see an increase in private pay participants.

Although some providers and experts feel that public knowledge about ADS has improved, all acknowledge that it lags far behind public knowledge and understanding of other long-term care options. Even though ADS allow significantly impaired nursing home-eligible participants to remain at home or living with family, providers believe that the public still thinks that ADS are the adult equivalent of child care. This perception would appear to be widespread, as evidenced by a 2002 article in the Wall Street Journal titled When Your Parents Need a Baby-Sitter: Adult Day Care Centers in Short Supply.

Other erroneous perceptions are that ADS are only for the poor, only for the rich, only for old people, or only for people with dementia. To alter these perceptions, the industry may need to engage in public education efforts. While the national ADS association supports a change in the name from adult day care to ADS, providers need to use the terms that public programs use in order to qualify for funding.

Recommendations for Future Research and Policy Analysis

Based on anecdotal evidence from providers and families, ADS enable informal caregivers to continue providing care in the home, thereby delaying or preventing institutionalization. More research is needed to document the long-term care cost-savings of these programs. Such research could guide state policymakers who have to carefully target expansions of home and community services to assure the cost-effectiveness of limited resources.

ADS also appear to offer a means to reduce health expenditures. Washingtons Medicaid agency is conducting a study examining clinical outcomes and medical expenditures for adult day health participants who reside in adult family homes. While the final results of this two-year study are not yet available, preliminary analysis has demonstrated overall cost-savings. Given the potential for health care cost-savings, particularly as the population ages, other states may want to consider analyzing Medicaid data to determine the cost-effectiveness of ADS.

Such research would provide much-needed documentation to determine whether an expansion of ADS that provide health services is warranted.

1. INTRODUCTION

Over the past two decades, state and federal long-term care spending on home and community services has increased, primarily through Medicaid waiver programs. Most of the research and policy literature on home and community services for elderly persons has focused on home care and residential care, including adult foster care and assisted living. Little attention has been paid to adult day services (ADS)--a nonresidential community service provided outside the home for less than a full day. Three major ADS models are generally recognized: a social model; a health or medical model, which is sometimes combined with the social model; and a specialized model. This report will refer to all models generically as ADS.¹

The first ADS program was a geriatric day hospital program established in 1960 in Greensboro, North Carolina. ADS evolved to become a community service that meets caregivers need for respite in order to work, fulfill other obligations, and recover from the demands of continuous care. Many caregivers who use ADS are providing care to family members with Alzheimers disease and other dementias who need constant supervision.

ADS programs are of interest to states because of their potential to delay or prevent nursing home placement in large part by supporting informal caregiving. Informal caregivers are the backbone of the nations long-term care system. Over seven million Americans provide 120 million hours of care to about 4.2 million elderly persons with functional limitations each week. The estimated economic value of this care ranges from $45-$96 billion a year.² Research has found that caregivers who experience stress and burden are more likely to institutionalize relatives suffering from dementia. Once caregivers physical resources decline and other home and community resources (paid or unpaid) are unavailable, nursing home placement is more likely.³

States are also interested in the potential of ADS to reduce health care costs by providing health monitoring, preventive health care, and assuring the timely provision of primary care, particularly for individuals at risk for incurring high medical costs. These include elderly individuals who are dually eligible for Medicare and Medicaid--called dual eligibles--who comprised 18 percent of all Medicare beneficiaries in 2000 but accounted for 24 percent of total Medicare spending. Similarly, in 2002, they represented 16 percent of all Medicaid enrollees but 42 percent of program spending.⁴

Purpose of Study

The purpose of this study is threefold: (1) to inform policymakers about ADS current and potential role in the health care and long-term care systems as determined by state regulation; (2) to identify operational and regulatory issues facing ADS providers under different ADS models and in different regulatory and financing environments; and (3) to provide information that can guide future research and policy analysis on ADS for elderly persons generally and on medically-oriented ADS specifically.

Methodology

Organization of Report

Following this introduction, Section 2 provides a brief overview of the limited research on ADS conducted to date. Section 3 presents an overview of state approaches to regulating ADS for elderly persons, which briefly summarizes the content of a companion report --Regulatory Review of Adult Services--conducted as part of this study.⁵Section 4 presents the findings from site visits to ADS providers in five states and Section 5 presents providers and stakeholders views on regulatory issues in their states. Section 6 presents conclusions and recommendations for future research and policy analysis.

Appendix A presents detailed information on the studys methodology. Appendix B provides regulatory summaries for the five site visit states. Appendix C lists the members of the Technical Advisory Group.

2. OVERVIEW OF ADULT DAY SERVICES RESEARCH

There is a paucity of empirical research on ADS. A 2001 review of the literature found only 45 articles published between 1975 and 1999 on a range of ADS topics.⁶ In 1987, the Robert Wood Johnson Foundation (RWJF) initiated the Dementia Care and Respite Services Program, the first national ADS demonstration program, in cooperation with the Alzheimers Association and the Administration on Aging. The national program office was located in the Wake Forest University School of Medicine. Studies funded through this program demonstrated that ADS programs for people with dementia can provide needed services--including medical services--to individuals with a wide range of needs and still be financially viable in the private pay market. RWJF then launched the Partners in Caregiving program to apply the lessons of the demonstration in 25 program sites. The program has since disseminated the lessons from these demonstrations to ADS programs throughout the country.

Between 2001 and 2002, Wake Forest University conducted a national survey of ADS providers that examined four major areas: (1) characteristics of the program such as age, type of organization operating the program, licensure or certification status, operational policies, and staffing; (2) services provided, such as meals, transportation, personal care services, and therapeutic, social, medical, and nursing services; (3) the characteristics of participants, including age, ethnicity, condition or diagnosis, Medicaid status, ADL status, living situation, length of stay, and reason for discharge; and (4) rates and reimbursement sources. The survey also asked providers about any operational concerns or problems.⁷

The study found that the 37 percent of ADS provider offered a social model of care (no nursing services furnished), 21 percent provide a medical model (nursing services and in some instances rehabilitation therapies furnished), and 42 percent provide a combined social and medical model. Twenty percent exclusively serve individuals with dementia. The average total enrollment was 42 participants and the average daily attendance was 25. The average length of stay was two years. The three major problems providers cited are inadequate funding; difficulty recruiting and retaining staff; and difficulty maintaining census and attendance levels needed to cover operating costs.

In 2001, Rutgers Center for Health Policy conducted several studies to guide policy regarding ADS in New Jersey. The state provides these services to over 9,000 beneficiaries through its Medicaid state plan as well as through certain waiver programs. With about 10-15 new facilities applying for licensure each year, the state is concerned about continued increases in annual Medicaid expenditures for adult day health services with no limits set on the number of participants.⁸

The first study was a literature review of adult day health services with a focus on studies that could inform the potential use of a needs-based reimbursement model for adult day health service participants.⁹ This review reported that the primary reason for using ADS is caregiver respite. Whether caregivers will use the service depends on the severity of impairment, nursing and rehabilitation needs, associated caregiver burden, and the fit between the services offered and the needs of the participant. Prior nursing home use, a history of mental illness, stroke, or cancer, and paying for services privately increased the likelihood of clients' full-time attendance at ADS programs.¹⁰

The typical user is a 75-year-old White woman who lives with a spouse or another relative. Many participants have chronic illnesses and multiple dependencies in ADLs including toileting and eating. ADS users are more likely than home health users to have some type of dementia that requires constant supervision. Other populations using day health services include children and adults with developmental disabilities and children who have unstable medical conditions and/or are technologically dependent.¹¹

The second study was a national survey of adult day health service programs.¹² Its purpose was to examine the characteristics of publicly financed adult day health services programs. The study focused on the largest program in each state, which in most cases was funded by either the Medicaid state plan or an Aged and Disabled waiver program.

The studys primary goal was to identify commonalities and differences across various program characteristics and reimbursement approaches. The program characteristics described for each state in the study are: type of funding; eligibility criteria; types of assessments used; services provided; and reimbursement methods. The report also provides an estimate of the number of facilities and participants.

A 2001 review of the literature on the effectiveness of ADS programs found that the majority of research focused on three major areas: (1) the ability of ADS programs to maintain or improve the functioning of participants; (2) the effect of ADS program use on caregiver characteristics, such as stress and care burden; and (3) the ability of ADS programs to delay or prevent nursing home placement.¹³ Most of the caregiver literature has focused on individuals providing care to family members with dementia.¹⁴

The authors of the review noted that because the literature on ADS is diverse in terms of focus, design, and client population, drawing conclusions is difficult. Nonetheless, they stated that ADS programs are more of a supplement to informal care than a substitute for nursing home care. Some analysts would dispute the validity of this conclusion based on methodological issues in the studies reviewed. In particular, the lack of a demonstrated effect on nursing home use may be due to insufficient use of ADS. For example, to prevent nursing home placement, ADS may need to be used 4-6 hours a day five days a week rather than four hours a day twice a week.

Research on caregiving and the institutionalization of cognitively impaired older persons suggests that the effect of community services on nursing home placement is also dependent on other factors in addition to the frequency and duration of ADS use. These include the timing of use--whether it occurs early in the caregiving experience or after a caregiver has burned out--and family preferences.

Another study of ADS funded by the National Multiple Sclerosis Society is currently underway. This study is conducting a comprehensive evaluation of Multiple Sclerosis Adult Day Programs (MSADPs), using case studies, cost analyses, and outcomes analysis. The study aims to determine the costs of developing and maintaining MSADPs, and to identify their outcomes, including quality of life, health status, functional status, rates of institutionalization, and complications.

Interest in ADS research among advocacy organizations for older and disabled Americans has been limited. The Alzheimers Association and the American Association of Retired Persons (AARP) offer fact sheets for their membership on choosing ADS providers, but neither has funded research on ADS. The National Council on Aging funded the National Institute on Adult Daycare in the early 1990s, but the institute is no longer operating.

3. OVERVIEW OF ADULT DAY SERVICES REGULATIONS

This section first describes four approaches to regulating ADS in key areas and highlights similarities and differences among them. It then provides an overview of key regulatory provisions. Its content is drawn from the Regulatory Review of Adult Day Services, which examines regulatory provisions particularly relevant to understanding the role ADS play in the health care and long-term care systems.¹⁵ For example, the review does not cover physical plant requirements or provisions related to record-keeping or medication storage policies. Because the focus of the review is on services for elderly persons, regulatory or Medicaid contractual requirements for ADS providers who exclusively serve individuals with mental retardation or other developmental disabilities are also not covered.

Regulatory Approaches

Exhibit 1 indicates each states regulatory approach. The majority of states regulate ADS by requiring either licensure or certification. A few states license one type of ADS and certify another, and 13 states have other requirements, sometimes in addition to licensing and certification.

Whatever the regulatory approach, the majority of states have requirements addressing the same issues, for example, required and optional services, medication administration, staffing, training, and monitoring. States that require licensure do not appear to have more requirements or more stringent or prescriptive requirements than do states that require certification or that use some other regulatory approach. In general, ADS providers who want to serve publicly-funded clients--including those eligible for Medicaid--must meet all applicable regulatory requirements. If there are none or they are not considered adequate, public programs have contractual requirements that providers must meet.

While many states have different standards for social and medical models of ADS, they do not mandate the provision of a particular type of care. However, ADS providers who want to serve Medicaid beneficiaries must generally--but not always--offer a medical or a combined model of care.

We did not identify any rationale that would explain why some states have chosen one regulatory approach over another. Anecdotally, we heard that adult day care is often perceived as an adult version of child care--providing meals, supervision, some activities, and not much else--and that the regulatory structure in some states has not yet caught up with industry practice. This could explain why some states, such as Washington, do not license what is essentially a medical service provided under its Medicaid state plan. Stakeholders in some states that do not require licensure said that the contractual requirements of public programs, particularly Medicaid, are sufficient.

The National Adult Day Services Association (NADSA), which represents providers, supports greater regulation to assure quality of care, for example, by requiring a minimum amount of activity programming. They would also like to see model regulations, which might help assure more uniform regulations among the states. However, as discussed later in this report, many ADS providers believe that compared to the regulation of other long-term care settings, ADS regulatory requirements are based on ideal rather than minimal standards.

Licensure

State approaches to licensure vary. Some states license a single type of program; others cover two or more program types under a single licensing category. For example, Maine licenses two types of programs--adult day health services and social ADS programs--as Adult Day Services. Some states require separate licenses for specific types of programs in addition to basic licensure. In Maine, either of the two program types may operate a night program that provides services to persons with dementia, but must have a separate license to do so and must keep record-keeping distinct.

Several states permit ADS to be co-located in other licensed facilities, for example, a nursing home or assisted living facility. Minnesota, for example, requires an identifiable unit in a licensed nursing home, hospital, or boarding care home that regularly provides day care for six or more functionally impaired adults, who are not residents of the facility, to be licensed as an adult day care center or ADS center.

States do not generally license by levels of care or license dementia-specific facilities or programs. However, many have specific provisions in their standard ADS licensing requirements for providers serving individuals with dementia. The provisions generally relate to staffing and training, such as requiring higher staff-to-participant ratios and dementia-specific training.

Certification

Ten states require certification in place of licensure. Of these, Alaska, Colorado, Ohio, Indiana, and Wisconsin require only Medicaid providers to meet ADS certification standards. Like states that license ADS providers, some states that require certification distinguish between different types of ADS programs. For example, Ohio requires ADS programs to be certified by the Ohio Department of Aging as enhanced or intensive.

A few states certify Alzheimers programs separately from other ADS programs. For example, Iowa certifies dementia-specific ADS programs and Colorado certifies specialized ADS centers to provide intensive health supportive services for participants with a primary diagnosis of Alzheimers or other dementias, Multiple Sclerosis, brain injury, chronic mental illness, developmental disabilities, or individuals post-stroke who require extensive rehabilitative therapies.

Both Licensure and Certification

Only four states have both licensure and certification requirements, generally for different types of programs. Kentucky licenses Medicaid providers of adult day health care but certifies adult day care and Alzheimers respite programs. Nevada requires all facilities offering adult day or adult day health care to be licensed (including Medicaid waiver and state plan providers) but requires Medicaid state plan providers to also meet adult day health care certification standards. Maryland licenses two types of ADS--day care and medical day care--but only requires certification for a social adult day care program. California licenses adult day programs and adult day healthcare centers (ADHCs) and requires the latter to also be certified.

Other Required Provider Agreements

States that neither license nor certify generally require publicly-funded ADS providers to enter into official, most often contractual, agreements with a state agency, specifying that they will comply with requirements. These states do not have any requirements for providers who serve only private pay clients. For example, Alabama requires adult day care providers receiving Department of Human Resources funds to enter into contracts with the Office of Social Service Contracts. Elderly and Disabled Waiver providers must have specific approval to offer adult day health care from the state Medicaid agency and must meet Medicaid requirements.

Washington requires adult day care or day health centers that serve Medicaid clients to contract with the Department of Social and Health Services, an Area Agency on Aging, or other departmental designees. Medicaid providers must comply with the rules in the Washington Administrative Code for adult day care and adult day health care services.

Two states have operating standards for providers. Michigans Office of Services to the Aging has operating standards for publicly-funded providers of adult day care services. Services may be provided only under an approved area plan through a formal contractual agreement between the Area Agency on Aging and the service provider. Oregon has only voluntary operating standards for ADS providers. All ADS providers (except for licensed long-term care facilities providing ADS programs) are required to register their programs with the Department of Human Services, Seniors, and People with Disabilities and state their intent to voluntarily comply with the standards.

The Commission on Accreditation of Rehabilitation Facilities (CARF) offers voluntary accreditation to adult day health services programs as a way to maintain standards and assure quality. Since 1998, CARF has provided accreditation for adult day healthcare services (ADHS) programs through an agreement with NADSA. One state--Idaho--developed provider guidelines in accordance with CARF standards and requires adult day care programs to operate under these guidelines.

State Definitions of Adult Day Services

The majority of states regulate only one or two types of ADS. In states with two types, the primary difference is that one has to furnish skilled nursing care and other health services and the other does not.

For example, in Washington, adult day care is defined as a supervised daytime program providing core services appropriate for adults with medical or disabling conditions that do not require the intervention or services of a registered nurse (RN) or licensed rehabilitative therapist acting under the supervision of the clients physician. Adult day health care is defined as a supervised daytime program providing skilled nursing and rehabilitative therapy services in addition to core services provided in adult day care.

Definitions of ADS generally do not state that they are a social, combined, or medical model. Rather, they include a statement of their purpose, thresholds for the number of people who can be served, limits on the number of hours a person may be served, and parameters for who may or may not be served. Several examples follow.

Georgia defines adult day services as a program for providing a safe group environment with coordinated health and social services aimed at stabilizing or improving self-care as well as preventing, postponing, or reducing the need for institutional placement. Their purpose is to provide support for elderly individuals who cannot fully function independently but who do not need 24-hour nursing care. Participants may have physical, social, and/or mental impairments, need assistance with ADLs less than that requiring placement in an institution, or have recently returned home from a hospital or institutional stay.
Rhode Island defines adult day services as a community-based group program designed to meet the bio-psychosocial needs of adults with impairments through individual plans of care. These structured, comprehensive, nonresidential programs provide a variety of health, social, and related support services in a protective setting. By supporting families and other caregivers, ADS enable participants to live in the community.

States also define ADS by setting thresholds for the number of participants that will trigger regulatory requirements and by setting minimum and maximum hours for service provision. States do not vary much with regard to thresholds. The maximum number that triggers regulation is typically between three and five individuals unrelated to the provider. Tennessee is an exception, setting the threshold at ten individuals.

States requirements regarding minimum and maximum services hours are more varied, and most set only maximums. In Idaho participants may be served during any part of the day but for fewer than 14 hours. Iowas maximum is 16 hours in a 24-hour period. Some states, such as Kansas, require only that programs operate fewer than 24 hours a day. Tennessee defines adult day care services as those provided for more than three hours but fewer than 24 hours per day.

Provider Requirements

The regulation of a service targeted to frail elders and individuals with disabilities needs to assure that providers can meet their clients needs. To do this, states specify parameters for who can be served, and service requirements, medication administration, staffing and training.

Parameters for Who Can Be Served

Most states lack specific admission, retention, and discharge criteria. States that have these criteria--such as Alabama--have general requirements only (e.g., requiring providers to discharge participants whose needs they can no longer meet or when participants present an immediate and serious risk to their or others health, safety, or welfare). The lack of specific admission and discharge criteria in effect allows providers to determine who they will serve.

Most states have provisions related to involuntary discharge. For example, Vermonts rules limit involuntary discharges to the following situations: (1) the participants care needs exceed those an adult day center is certified to provide, (2) an adult day center is unable to meet the participants assessed needs, or (3) the participant presents a threat to himself or herself or to other participants or staff.

In most states, parameters for who can be served are set indirectly by specifying mandatory and optional services. States that require or permit providers to offer skilled nursing services in effect allow them to serve individuals who need such services.

Required and Optional Services

All states list required and optional services for each type of ADS that they license, certify, or otherwise regulate, for example, for adult day care and adult day health care. States generally require all ADS providers to furnish ADL assistance and health monitoring. Health education; physical, occupational, and speech therapy; and skilled nursing services are less likely to be cited as either required or optional, but states generally require adult day health services or medical adult day service providers to furnish these services.¹⁶

For example, Virginia requires ADHCs to meet the needs of each participant, and specifies that a minimum range of services must be available to every Medicaid ADHC recipient, including nursing services and rehabilitation services. Virginia further specifies that centers can admit recipients who need skilled services only if professional nursing staff are immediately available on-site to provide them.

Generally, states permit medical models of ADS to serve individuals with a high level of nursing and medical needs, which is to be expected since the majority of states cover ADS in waiver programs that require individuals to meet the states nursing home level-of-care criteria. However, because states level-of-care criteria vary considerably, individuals who are nursing home eligible in one state may have greater or lesser needs than those who are nursing home eligible in another state.

A few states use a flexible approach to regulating services, basically requiring providers to meet the needs of their clientele, whatever they may be. Under this approach, if providers admit someone who needs physical therapy they must either furnish it or arrange for its provision.

Medication Administration

In most states medication administration is not a required service except for adult day health care providers. The majority of states require licensed personnel to administer medications.

States that permit unlicensed staff to administer medications generally require that they do so under nurse delegation provisions, though a few require only consultation with a physician or pharmacist, or specific medication training. Vermont, for example, requires an adult day center to have the capacity to administer medications to its participants and requires a medication management policy that describes a centers medication management practices with due regard for state requirements, including the Vermont State Nurse Practice Act. An adult day center must provide medication management under the supervision of a RN or a licensed practical nurse (LPN) who is under the direction of a RN.

Most states require providers to have written policies for medication management and administration. For example, Georgia requires adult day care programs to have a written policy for medication management designating specific staff to be authorized and trained to assist with the administration of medications, and designating the programs role in the supervision of self-administered medications and/or staff-administered medications.

Many states also specify requirements related to self-administration of medications. For example, Texas requires individuals who self-administer their medications to be assessed at least monthly by licensed nursing staff to determine if they are still capable of self-administration.

Staffing Requirements

States vary with regard to the number of staff required for ADS programs. Most mandate minimum staff-to-participant ratios, ranging from 1:4 to 1:10. Some states require different ratios for different types of ADS, and some states specify both a required ratio and a recommended ratio. Some states require more staff when serving participants with greater needs, but allow providers to determine when additional staff are needed.

Georgia, for example, requires programs to have, in addition to administrative staff, a minimum of one direct service staff person for each eight nonseverely impaired participants or for each four severely impaired participants. The state does not specify what constitutes severe or nonsevere impairment, leaving this determination to the provider.

Several states do not have minimum staff-to-participant ratios and allow providers to determine the number of staff, requiring only that they be sufficient to meet participants needs. For example, Idaho requires that staff be adequate in number and skill to provide essential services but does not define essential services. The state further specifies that the number of staff per participant must increase appropriately if the number of participants in day care increases, or if the degree of severity of participants functional or cognitive impairment increases. However, we identified no guidance for what constitutes an appropriate increase. The state has more specific requirements for Medicaid providers, who must have a minimum of one staff for every six participants, and a 1:4 ratio when serving a high percentage of participants who are severely impaired.

Staffing for persons with dementia. Twenty-five states have special provisions for serving individuals with dementia, most of which relate to staffing and training requirements. Required staffing ratios for persons with dementia are generally 1:4, though Michigan requires Dementia Adult Day Care programs to have a minimum staff/volunteer/student-to-participant ratio of 1:3.

Some states specify higher staff-to-participant ratios for people with cognitive impairment who may or may not have a dementia diagnosis. In Minnesota, adult day care/services centers that serve both participants who are capable of taking appropriate action for self-preservation under emergency conditions and those who are not, are required to maintain a staff-to-participant ratio of 1:5 for participants not capable of self-preservation and 1:8 for those who are capable.

Types of Staff. In addition to staffing ratios, virtually all states require specific types of staff for ADS programs. The major difference in requirements between adult day care and adult day health care is that states require the latter to have licensed nurses available in some capacity (e.g., as full-time or part-time employees or as consultants). Because most states require staffing consistent with participants needs, licensed nurses are required if they need skilled nursing services.

Colorado, for example, requires all ADS centers to provide nursing services to regularly monitor participants ongoing medical needs and supervise medication administration. These services must be available a minimum of two hours daily and must be provided by a RN or LPN, or by a certified nursing assistant (CNA) under the direction of an RN or an LPN. Supervision of CNAs must include consultation and oversight on a weekly basis or more according to the participants needs. Specialized ADS centers providing a restorative model of care must have sufficient staff to provide the following: (1) nursing services during all hours of operation provided by an RN or LPN, or by a CNA under the supervision of an RN or LPN, and (2) therapies to meet the restorative needs of the participants.

In some states, the Medicaid program has specific requirements for nurse staffing to assure that waiver participants needs are met. For example, South Carolina requires an LPN on site whenever waiver clients are present, and Texas requires a minimum of one RN or licensed vocational nurse on site eight hours per day, and further requires that sufficient licensed nursing staff must be on site to meet the nursing needs of the clients.

Training Requirements

Virtually all states have orientation, initial, and ongoing training requirements, but they are minimal. Some requirements are quite general, while others specify the type of training and the number of hours required. Most states require at least one staff trained in first aid and CPR on duty at all times. For direct care workers, Utah requires only eight hours of initial orientation training designed by the director to meet the needs of the program, plus ten hours of work-related training annually.

Delaware, on the other hand, requires aide orientation and training to include at least 40 hours of instruction and supervised practicum on specific topics, including personal care services; process of growth, development, and aging; principles of infection control; observation, reporting, and documentation of participant status; maintaining a least restrictive environment; and verbal/nonverbal communication skills.

South Carolina does not specify a minimum number of training hours, instead requiring each facility to: (1) provide a written orientation program to familiarize new staff members with the facility, its policies and procedures; and (2) an in-service program to ensure that all employees continue to understand their duties and responsibilities.

States with specific training requirements for ADS providers who serve persons with dementia generally specify the content of required training. For example, Minnesota requires that the facilitys direct care staff and their supervisors be trained in problem solving with challenging behaviors and communication skills. California requires training regarding the use and operation of egress control devices (i.e., those preventing participants from leaving the facility), the protection of participants personal rights, wandering behavior and acceptable methods of redirection, and emergency evacuation procedures for persons with dementia.

Monitoring

The majority of states require inspections--most of them annual inspections that coincide with an initial license application and annual license renewal. Several states also stipulate that unannounced visits by state personnel can occur at any time. Only one state--Alaska--does not have external monitoring. The state does not license ADS providers and requires only that adult day care programs conduct internal evaluations of their operation and services at least annually. However, site visit inspections are required for programs receiving state grant funds.¹⁷

States vary considerably in the frequency of required inspections. Delaware requires regular inspections only once in a three-year period but North Carolina monitors ADH Programs at least monthly to assure compliance with standards and also conducts an annual inspection. Arizona renews licenses for two years, as opposed to one year, if a licensee has no deficiencies at the time of the licensure inspection. Montana conducts routine, unannounced licensure inspections every one to three years and a licenses duration is dependant on the number and type of deficiencies found. If any deficiencies relate to the health, safety, and welfare of a resident, a provisional license or a one-year license is issued.

A few states specify provisions to address complaints. For example, the Arkansas Office of Long Term Care conducts complaint inspections in adult day health care facilities to determine their validity, and in Missouri the state makes unannounced visits for investigative purposes when complaints have been filed regarding a program.

Medicaid Contracting Requirements

All states fund ADS for elderly persons through either their Medicaid state plan or waiver program or both: six under the state plan only; 36 under 1915(c) waivers only; seven under both; and two under an 1115 waiver.

Providers of Medicaid-funded ADS must meet all applicable regulatory requirements: licensure, certification, or other arrangements. Also, Medicaid generally requires ADS providers who furnish adult day health services to waiver participants to meet additional standards than those the state requires for licensure or certification. Over half of the states require ADS providers to meet additional Medicaid provisions:

Alaska Arizona California Delaware District of Columbia Florida Georgia

Idaho Kansas Maine Maryland Minnesota Mississippi Missouri

Nebraska Nevada New Hampshire New Jersey New Mexico North Dakota Ohio

Oklahoma South Carolina Texas Vermont Virginia

Mississippis additional requirements for Aged and Disabled waiver providers include more detailed parameters regarding who they can and cannot serve. Missouri licenses adult day care but has more extensive staffing requirements for Aged and Disabled waiver providers of adult day health care. South Carolina licenses adult day care services but has additional requirements for Community Long-Term Care Medicaid waiver providers related to nursing staff-to-participant ratios and care managers.

EXHIBIT 1. Approach to Regulation by State
Licensure and Certification Requirements^a
State	Licensure Only	Certifiction Only	Both Required	Other
Alabama				X
Alaska		X
Arizona	X
Arkansas	X
California			X
Colorado		X
Connecticut		X
Delaware	X
District of Columbia		X		X
Florida	X
Georgia				X
Hawaii	X
Idaho				X
Illinois				X
Indiana		X
Iowa		X
Kansas	X
Kentucky			X
Louisiana	X
Maine	X
Maryland			X
Massachusetts				X
Michigan				X
Minnesota	X
Mississippi				X
Missouri	X
Montana	X
Nebraska	X
Nevada			X
New Hampshire	X
New Jersey	X
New Mexico	X
New York				X
North Carolina		X
North Dakota				X
Ohio		X
Oklahoma	X
Oregon				X
Pennsylvania	X
Rhode Island	X
South Carolina	X
South Dakota				X
Tennessee	X
Texas	X
Utah	X
Vermont		X
Virginia	X
Washington				X
West Virginia	X
Wisconsin		X
Wyoming	X
TOTAL	25	10	4	13
For more detailed information, please consult the individual state profiles in the Regulatory Review at http://aspe.hhs.gov/daltcp/reports/adultday.htm. For example, Kentucky requires licensure or certification depending on the type of services offered; adult day health care is licensed and adult day care is certified.

4. SITE VISIT FINDINGS

We conducted site visits in five states: Georgia, Illinois, Maryland, North Carolina, and Washington. See Appendix A for information about the methods used to select the states and the three to four providers we visited in each state. This section describes the characteristics of these providers.

General Impression of Physical Structure

Traditionally, adult day care has been offered by small nonprofit programs and located in donated or low-cost space such as a church basement. Several providers described these settings as sub-optimal primarily because they are not accessible for people with moderate to severe physical impairments, but also because they lack storage and office space, food preparation areas, and space for different program activities. Additionally, the physical setting is often not inviting, lacking daylight and comfortable attractive furniture.

While some social model ADS are still offered in such settings, the health or combined social/health model programs require physical settings that are accessible to individuals with severe physical impairments. Most of the programs we visited were recommended because they were considered state of the art and were in either retrofitted or purpose-built space designed to serve the needs of an impaired population. Only one program was in a very old freestanding building that clearly lacked adequate space, but it is relocating to a new purpose-built building in 2006.

Three programs were in commercially zoned buildings--one in a shopping center. All designed the interior to function as an ADS program, with multiple rooms for different functions. One program operating as part of a social service nonprofit, had sufficient space to run two separate programs--one for participants with moderate to severe cognitive impairment and one for higher functioning participants.

Some providers design their physical space to have a home-like ambiance. One program serving primarily urban African-American participants displays African-American cultural items thematically throughout its center to create a comfortable setting that affirms clients heritage. Another has separate rooms with different design themes, including a Mens Club for the few male participants who want to engage in activities that do not interest the predominantly female participants, such as playing cards.

Most providers stated that furnishing a pleasant physical setting that avoided an institutional character was critical to attracting participants. In their experience, if a programs physical environment is poor, it can decrease utilization, particularly by middle-class/private pay individuals, even if the program has a reputation for excellent care. With the exception of the programs in new purpose-built space, most providers said they would like to improve their space to better suit their needs. They cited a need for more storage, more office space, and additional space to fun activities simultaneously.

The primary factor that influenced the physical character of a building was, not surprisingly, affordability. Whether for-profit or nonprofit, providers said that the availability of financing was the key factor determining the quality of the physical structure and amenities, such as fully accessible bathing facilities, multiple rooms to permit activity programming according to participants functional level and interests, and attractive and secure outdoor space for smokers and wanderers. Some facilities had outdoor space that could not be fully utilized because it was not secured for persons who wandered. One center that served only persons with dementia designed their indoor space to safely permit wandering.

Nonprofits are able to raise private funds and several of the programs we visited were in well designed and nicely furnished buildings that had been built with funds obtained from a major donor or through a capital fundraising campaign. Programs affiliated with a parent organization often benefited from the availability of space that could be retrofitted, and one operated in a public housing site that provided a large amount of space at a very low rent.

One nonprofit organization that provides ADS and nursing home services in different locations on a single campus built a very modern and well-equipped ADS center. Another program affiliated with a nonprofit hospital received an interest free multiyear loan to purchase a building and renovate it to serve as an ADS center. Another was developed as part of a new senior center, which was built with a significant amount of donated funds.

One nationally known program had a large enclosed outdoor terrace and garden so participants who wandered could do so safely. This same facility had toileting and bathing facilities specifically designed for persons with severe disabilities. For example, toilets were placed in the middle of a room rather than against a wall to facilitate two and three staff assistance. The bathing room had an adjustable height bathtub with a hinged door to enable safe transfers.

One program is newly housed in a multipurpose building physically connected with a Senior Center. The building is called a Health and Wellness Center and it houses other programs in addition to the Adult Day Health (ADH) Program. One of the Centers goals is to foster use by people of varying ages and needs in order to promote integration of different disability and age groups with the well elderly who use the senior center. This building has a state of the art exercise facility designed to serve both able-bodied and disabled individuals, and a $1.5 million computer center, donated by a foundation, which includes all the latest technology to enable people with all types of disabilities to use it. Participants in both the senior center and the ADH Program will use the computer center and exercise facility.

One unique program serving persons with HIV and AIDS shared a building with a nursing home with lots of outdoor space--patios and terraces--amenities for family and visitors, attractive décor and art work. Staff noted that the facility could not have been built without a multiyear capital fundraising campaign.

While the buildings that had many windows and lots of natural daylight were the most attractive, one program director said that windows in general, and particularly those with nice views are a major problem when serving people with dementia, who become distracted by the view. In many cases, the view of the outdoors cues the person to stop participating in activities and to leave the building.

Finally, some providers mentioned the need for stability as an important requirement for physical space. Two providers--one with a program in a nursing home and one in a church--were recently given short notice to find other space. In one case, the provider spent many months looking for new space, which he found in commercial space that he designed specifically for his program. While the new space is much more functional and attractive, the monthly rent increased by several thousand dollars, necessitating a major marketing effort to increase the daily census to cover the added cost.

Organizational Affiliations

The ADS programs we visited were either freestanding entities or affiliated with another organization. Parent organizations included a hospital, an organization providing a range of long-term care services in multiple settings, a nonprofit social service agency serving seniors, a for-profit company with centers in multiple states, a regional and national advocacy organization, and a health care organization that included nursing homes and rehabilitation facilities.

One program was provided by a nonprofit Community Council on Aging in a small town. Many of the parent organizations operated multiple ADS programs, and some provided other services including home health services. Providers described advantages and disadvantages for both freestanding and affiliated programs.

Several of the affiliated organizations felt that operating within a parent organization was not only desirable but necessary for financial viability. The program serving persons with HIV and AIDS said they could not operate as a freestanding facility because the hospital with which they were affiliated made substantial annual contributions, for example by providing group health insurance for its employees. Other programs mentioned both financial and in-kind contributions, including: administrative support; subsidizing the gap between the cost of ADS services and reimbursements; paying for liability insurance; facilitating equipment purchases; marketing/development and training support; and subsidizing transportation costs.

Several providers felt that being affiliated with a well-known and reputable entity gave them credibility within their community, ultimately helping to attract clients. However, others felt that being part of a larger organization offering multiple services could be a disadvantage because they were just one service among many competing for space and resources. One provider noted that the board of directors of the parent organization did not include anyone knowledgeable about their program. Another noted that the parent organization expected the program to contribute part of its revenue to overall operating expenses, but also noted that the organization subsidizes their costs when they have a shortfall.

Providers in freestanding centers cited the advantage of designing and running their programs according to their own vision, and having boards of directors who are very committed to the program. In several states, an individual with an interest in serving elderly and disabled persons in a particular community had established the freestanding center we visited. In one case, an individual established a center after experiencing difficulties in securing ADS for her elderly parent. This individual began her program in a church but later moved to a freestanding building when she became a Medicaid provider.

The primary disadvantage cited for being a freestanding facility was not having another entity to fall back on in the event of budget difficulties. One provider with a freestanding program said that three-month delays in Medicaid reimbursement made it difficult to cover costs.

One of the two for-profit programs we visited noted that they were disadvantaged by this status in the fundraising arena and would probably convert to nonprofit status because the for-profit status afforded no advantages.

In Washington, Georgia, and North Carolina, several nonprofit programs depended on annual fundraising for a significant portion of their revenue. The nonprofit programs in Maryland and Illinois relied instead on increasing and maintaining an adequate census and on financial and administrative support from parent organizations. However, one freestanding program did rely on annual contributions from board members and another received small grants from the organizations foundation arm. These funds are used to subsidize participants who can not afford the full number of days they would like to attend. Several providers expressed an interest in pursuing fundraising.

Population Served

The age of ADS participants in the five states ranged from 21 through 90+. With the exception of the program serving persons with HIV/AIDS, all of the programs served a primarily elderly population.¹⁸ For example, in one program, 71 percent of participants are between the ages of 70 and 89. Providers reported serving more females than males, although some programs with Veterans Administration (VA) funding had a higher proportion of males.

Most of the programs served a few younger adults. Whether younger adults are served often depends on the age-related eligibility requirements for publicly-funded programs. Generally, if ADS are covered by Medicaid programs that serve adults 18 and older, such as Aged and Disabled waiver programs or Washingtons state plan ADH Program, adults of all ages who meet the service criteria can be served. In Maryland, medical day care is funded through the Medicaid state plan for medically handicapped adults age 16 or older. If a state funds distinct ADS programs for older and younger adults--as does Illinois--all things being equal, programs in these states will be less likely to serve both older and younger adults in the same setting.

One provider noted that even if a program is marketed as a senior service, persons under age 65 or their families want to use the service because there are no other day programs available. One provider we visited has a specialized program for adults of all ages with acquired brain injuries, and most are under age 65.

Whether a program serves younger adults with mental retardation and other developmental disabilities (MR/DD) depends on a combination of factors. If a program has to be certified, licensed, or contracted separately to serve this population, it is less likely that providers who serve an elderly population will do so. In some states, a major incentive for providers to serve individuals with MR/DD is the more generous Medicaid reimbursement for individuals in MR/DD waiver programs. Several providers reported that the reimbursement they receive for just a few MR/DD participants makes up for the under-cost reimbursement rates for Aged and Disabled waiver participants. In Illinois, some providers were interested in serving persons with MR/DD in order to increase their daily census.

In three of the states providers said they are serving more younger adults and persons with MR/DD than they used to. Those they serve are not able to participate in traditional MR/DD programs either because of severe functional impairment, medical complexity, or multiple diagnoses. However, as noted above, providers have less of an incentive to serve this population if they need a separate contract or need to meet additional regulatory requirements to do so.

One provider noted that interest in ADS by the MR/DD community is growing significantly because a lot of services for younger people are not accessible or are not available five days a week. Another provider said that some parents do not want to send their family member to settings that serve only individuals with MR/DD, preferring a more heterogeneous population in terms of age and diagnosis. She also noted that while many of the MR/DD participants have individual goals that need to be addressed during the day they can also participate in the regular programming. One provider in North Carolina noted that the MR/DD case managers usually are impressed with the care, the level of activity and involvement, and the socialization these individuals receive from his program.

Another provider noted that these participants only other options would be to stay at home with a full-time caregiver or be in an institution. They come to ADS for the same reasons as do senior participants: safety; socialization; activities; health monitoring and nursing services; and caregiver respite. After finding that they could successfully work with young adults with MR/DD, one program began marketing to adults of all ages with special needs and about 40 percent of their participants are under 65. Another program reported that about 20 percent of its participants are persons with MR/DD and all are in the Aged and Disabled waiver serving persons 18 and older.

Participants Functional Limitations

With the exception of the program serving persons with HIV/AIDS, the majority of program participants have extensive functional limitations due to physical or mental impairments or a combination of both. Many programs reported that over half their participants needed help with ADLs including help with eating and toileting. Many have had strokes and both physical and cognitive impairments as a result. One program reported that over half of its participants who are on the waiver receive some in-home assistance in addition to ADS.

The prevalence of dementia is high. All providers said over half of their participants have dementia and many without this diagnosis have cognitive impairment of some type, caused by stroke, Multiple Sclerosis, acquired brain injury, or MR/DD. One program reported that in all four of its sites, 80 percent or more of the participants have cognitive impairment, whether or not they have a dementia diagnosis.

Providers in general said that mixing ages, functional levels, and diagnoses in a program had advantages. In most cases, it can be a positive experience because participants interact with and take care of each other in many ways, thereby encouraging socialization and mental stimulation. However, they noted that activities need to be structured according to functional abilities and that individuals with behavioral issues often require separate programming so they will not disturb the other participants.

One provider said that when designing activities, differences in age were less of an issue than differences in functioning, with the exception of music-related activities, with musical preferences being clearly differentiated by age group. The Alzheimers Family Care Center believes it is essential to operate their programs according to a clustering of care philosophy, which separates participants by stages of the disease. One provider noted that cognitively intact persons relate better to those with MR/DD than do persons with dementia who do not understand their condition. Another said that some of their elderly participants assume a teaching and mentoring role with the MR/DD participants.

Health and Medical Conditions

Many participants have significant medical needs, requiring daily health monitoring and skilled nursing services. In Washington, because Adult Day Health Care is a Medicaid state plan medical service that requires participants to need skilled nursing or rehabilitation services on a daily basis, participants have a high level of need. In Maryland, Medical Day Care is also a Medicaid state plan service that requires participants to be medically handicapped and in need of health maintenance and restorative services. In Georgia, Illinois, and North Carolina, where Medicaid participants were receiving ADS through the waiver program, many had chronic health conditions, such as diabetes, high blood pressure, or congestive heart failure, which they cannot self-manage due to cognitive impairment. Their nursing needs included catheter and dressing changes, blood sugar testing, daily medication management and administration, and health monitoring.

The primary service provided by the ADS program serving people with HIV/AIDS is medication management and administration. The population this program serves is at high risk for noncompliance because of the large number of medications they need--the minimum is thirteen--and a high proportion have co-occurring disorders such as serious mental illness and chemical dependency, many with associated cognitive impairment. In addition, many are dually diagnosed and some are homeless and considered un-housable due to drug use and criminal activity, including setting fires.

Because lack of compliance could lead to the development of drug resistance, assuring a 95 percent medication compliance rate is the programs major goal and the outcome by which they measure their success. The program gives the participants their doses in whatever form they need them: daily, weekly, or monthly. The provider said that without this medication service, individuals would have to go to a pharmacy every day because Medicaid will not fill a prescription more than five days prior to the renewal date.

Increase in Acuity

Most providers felt that the level of participants needs has increased over the past few years for a number of reasons: (1) a higher prevalence of people with moderate to severe dementia; (2) participants staying for longer periods and becoming more frail as they age (the average stay in the programs was two years and some as high as four years); (3) prospective payment systems for acute care resulting in people being discharged from the hospital with greater needs; (4) tightening of states nursing home level-of-care criteria; (5) a certificate of need program for nursing homes, resulting in a shortage of nursing home beds and more impaired people in the community; (6) new medications keeping people living longer with chronic conditions; and (7) a general movement of younger people with disabilities out of institutions to the community. Some stated that ADS provides a support network to keep these people in the community because their informal caregivers cannot provide care without respite, particularly if they are working.

Several providers felt that increased acuity levels were due to the increasing recognition of ADS as a viable alternative to nursing home and assisted living placement. Caregivers who can not afford those options utilize ADS when a family member becomes more frail or impaired. The provider who said she did not see too much of a change in participants level of need over the past ten years, said that families are requesting more services, such as bathing, personal care, more weekday hours, and Saturday hours.

Limitations on Who Can Be Served

Overall, providers reported that they try to accommodate everyone who needs assistance, but noted that they take clients on a case-by-case basis and have turned away individuals who exhibited aggressive behavior towards others or were a clear danger to themselves. Most noted that ADS are usually a caregivers last hope of maintaining their family member in the community, and so they try to serve everyone who needs services.

One program with limited space said it could not accept participants with behavior problems that agitate other participants (e.g., roaming too much, shouting, or grabbing objects). Most of the programs said they use a trial period--from two to four weeks--for new participants if providers have concerns about being able to meet their needs and having them adequately adjust. The most common cause for not serving an individual was uncontrollable combative or violent behavior.

Another factor that restricts who can be served is the amount of assistance needed, generally for toileting. If it takes more than one staff person to assist in toileting --and particularly more than two--whether or not a person can be served will depend on staffing and how many others with this level of need they are already serving. One provider said they serve one person who needs a three person toileting assist, but only because he has been in the program for 18 years. All programs can usually serve a few individuals who need this level of assistance, but if many needed it, they would have to hire more staff and the reimbursement rate would not cover expenses. In order to handle very heavy care clients without increasing staff, some programs stagger attendance for these individuals; for example serving one from 9 AM to 1 PM and the other from 1 PM to 5 PM.

Once admitted, providers said they try to keep participants as long as they need the service and noted an average length of stay of over a year up to several years--with most citing two years. One provider felt the length of stay may shorten in the coming years because participants are arriving sicker and more impaired. A common reason for leaving is a move to institutional care--often after an acute episode--and some providers noted that participants often die within a year of leaving.

One provider said its waiver participants generally stay in the program an average of 26 months and the majority do not leave for nursing home placement but for other reasons, including a family move or death. A provider serving primarily African-American participants reported that those who are discharged typically stay in their homes due to cultural fears of potential mistreatment in a nursing home. Several other providers also noted that African-Americans are less likely to utilize nursing homes than are Caucasians.

Providers stated that from half to 80 percent of their participants--virtually all with dementia--would not be able to live without a full-time caregiver and the respite afforded by ADS. ADS are the only option for caregivers who work and cannot afford private help at home. All providers believed their programs prevented or delayed nursing home placement, while acknowledging that some caregivers will never willingly put their loved one in an institution.

Services

Programs identified ADL assistance and medication administration as key services. In addition, programs operating as a combined social/health model or a health/medical model provided other nursing services--health monitoring, health education and skilled nursing services--delivered by RNs. Providers must either directly provide services to meet participants needs--in accordance with state regulatory or contractual requirements--or arrange or contract with others to provide them. Physical, occupational and speech/language therapies were generally provided on-site by therapists who directly bill Medicare or Medicaid, but some providers furnished or arranged for transportation from the program site to facilities that offer these therapies.

The level of social work services varied. One program provides social work as a core service and has a full-time social worker who handles the initial participant assessment, participates in case reviews with the RN/Director, and helps families resolve issues that might lead to a refusal to admit or a discharge based on an individuals behavioral issues. Other programs had part-time or contractual social work staff.

The primary service that distinguishes ADS from other long-term care settings is activity programming. While residential care and nursing homes provide some level of activities for their residents, their availability is not the primary reason the resident is in these settings.

ADS providers, on the other hand, view the provision of activities as a primary purpose of their programs. Activity programs are designed to encourage participants to function at their highest possible level and most providers tailor programs by functional level--both physical and cognitive. Several programs run 2-4 activity groups concurrently. Two providers assign individuals to specific activities based on a cognitive assessment, and one noted they may choose to join a different activity group as long as they are not disruptive in that group.

Many programs have some physical activity programming, which are designed so that individuals with different functional levels can participate, some with staff assistance. One program alternates between active (exercise) and passive (reminiscing) activities in addition to having programming tailored to functional level. Several providers said that caregivers of persons with dementia reported that engaging in a wide range of activities helped participants sleep better at night because they were more tired than if they had just spent the day at home watching television. This in turn allowed caregivers to sleep better and decreased their stress.

Many providers and direct care staff felt that the ability to offer breakout sessions and simultaneous programming by functional level was integral to insuring that their participants perform at the highest possible physical and mental level. Several providers noted that family members are often surprised when they see their family member engaged in a range of activities because while they are at home they only watch television. Providers believe that the social environment and activities offered in their programs maintains and in some cases improves both physical and cognitive functioning.

Role of Adult Day Services in the Health and Long-Term Care Systems

Providers felt strongly that ADS are an important component of community-based long-term care and play a key role in preventing and delaying both assisted living and nursing home placement. They felt that they offer programming and services that maximize participants cognitive and physical functioning, by both maintaining function and restoring function lost due to social isolation and lack of stimulation.

Some providers stated that receiving assistance with ADLs in an ADS program benefits participants more than receiving the same assistance in their homes because participants develop supportive relationships with both staff and others attending the program, and engage in physical and mental activities not available at home. Several providers noted that the higher staff-to-participant ratio in ADS programs allows for more one-on-one contact with staff than is available in assisted living and nursing facilities.

Providers also felt that ADS play a crucial role in chronic care management for community-dwelling adults of all ages who have disabilities. They believe that the provision of medical and nursing services on-site, particularly health monitoring, health education, and skilled nursing services, enables them to successfully serve an increasingly impaired population with complex medical needs and chronic health problems.

They noted that because all staff know the participants, they can quickly identify emerging health problems, which are quickly addressed, thus preventing or delaying the development of acute conditions necessitating emergency room or hospital use. Washingtons Medicaid agency is conducting a study examining clinical outcomes and medical expenditures for Adult Day Health participants who reside in Adult Family Homes. While the final results of this two-year study are not yet available, preliminary analysis has demonstrated overall cost-savings. The Medicaid agency is using these findings to support a request for a rate increase.

Several providers remarked that their participants rarely, if ever, have open wounds or other skin problems that often lead to infections and additional medical problems because staff routinely monitor skin condition and provide skin care.

Several providers felt that Medicare should cover the medical services they furnish, in addition to paying for speech/language, physical and occupational therapy. However, a nurse in one program opposed Medicare payment, because she felt it would turn what is essentially a social program that also meets participants health needs into a medical program with too much regulation.

Operational and Policy Issues

We asked providers to tell us about operational and policy issues and how these issues have affected their ability to provide services. (Provider views on regulatory issues are discussed in the next section.)

Funding

Nearly all of the providers receive a significant percentage of their operating revenue from Medicaid and other public funding sources such as VA programs, the Social Services Block Grant, Older Americans Act, and state programs. Private long-term care insurance provided a very small amount of revenue in a few programs. One provider said that reimbursement by long-term care insurance companies is increasing, but that people with long-term care insurance seem to move more quickly to assisted living because it is a covered service.

The proportion of revenue from private payments varied among programs. In one program, half of the participants were covered by Medicaid, about 28 percent by other public funding sources, and only 18 percent were private pay. Other programs have between 20 and 50 percent private pay participants. According to one provider the proportion that is private pay depends on the socioeconomic status of the neighborhood where the program is located.

Some providers set their private pay rate higher than cost to subsidize the lower than cost reimbursement from public programs. However, they said they had to be careful not to set it so high that it deters private pay participants. Several programs offer sliding scale subsidies for their private pay participants. They generally use public funding sources--such as Older Americans Act funds--or charitable contributions--such as United Way funds--to subsidize private payments.

A provider in Georgia noted that some nonMedicaid funding sources had recently changed their financial eligibility policy to deem the income of family members to be available to the participant. This policy has resulted in higher required co-payments, which some people cannot afford, causing them to leave the program. This provider noted that Medicare Part D prescription coverage could have a similar effect because people who are no longer deducting prescription drug costs will have higher available income for purposes of determining eligibility for public funding and calculating co-payments.

Most publicly-funded participants receive ADS through one source of payment, typically Medicaid. But a number of programs combine funding sources to provide comprehensive care, for example, using VA funds to pay for two days of services a week and block grant funds for a third day. Virtually all providers we visited said they could not operate their programs without Medicaid funding.

To assure a daily census that meets operating costs, providers have to continually market their services, and some have had to allocate a substantial amount of their budget to do so. Some of the programs in Washington, Georgia, and North Carolina said they could not survive financially without substantial fundraising, in-kind contributions, and volunteer services. One center had an annual budget of $985,000, of which $172,000 comes from fundraising activities. Two programs said they have to raise $500,000 annually to cover expenses.

Several programs depend on a significant amount of in-kind contributions and volunteers. One program said the landlord had not raised the rent for a number of years as a way of contributing and hundreds of volunteers provided assistance with activities, socialization, special events, landscaping, and building upkeep. In addition, 25 volunteers spent significant time over a year to raise over $2 million to build a new facility.

Many programs rely on subsidies from parent organizations and charitable organizations during budget shortfalls. For example, when Georgia froze waiver admissions and one program had insufficient revenue to cover costs for 18 months, its parent organization used its reserves to keep the center open. On another occasion when Medicaid cutbacks and a new claims processing systems resulted in diminished revenues, United Way and county funding was used to meet expenses.

One provider planned to establish an endowment to support its program. Two programs are starting weekend respite to increase revenue and one is considering renting its buses to outside groups when not being used (e.g., on evenings and weekends) to generate revenue. Two providers were considering becoming a home care provider to serve their adult day participants at home.

Despite the reliance on Medicaid funding, all of the providers said that the Medicaid rate does not cover costs. For example, in North Carolina, the statewide median cost for a combined social/health model is $51 a day, but the waiver program pays only $36.51 a day. Some states require a minimum number of hours for their daily rate--none less than four. Others do not specify a minimum. Many providers said their state is paying for a basic level-of-care but the participants need intermediate or intensive services, which state regulations require them to furnish.

In 2004, both Maryland and Illinois raised the Medicaid reimbursement rate, but providers reported it still did not cover costs. ADS providers in North Carolina last received a rate increase in 1999 and the Washington Medicaid agency is supporting a 16 percent rate increase, which the state association hopes will be approved in 2006. In Georgia, providers did not expect an increase in Medicaid reimbursement rates sufficient to cover the costs of providing ADS.

In several states, the state Medicaid agency and/or state legislatures are examining ADS programs and funding within a larger context, including Medicaid waiver applications and statewide long-term care systems change, but it is not clear how these efforts will affect the ADS industry. For example, Maryland is awaiting Centers for Medicare and Medicaid Services approval of an 1115 Medicaid Managed Care Waiver program--called Community Choice--that will include medical adult day care. ADS providers are hoping that the managed care organizations (called community care organizations under the waiver) will contract with adult day medical service providers to furnish services and manage clients with chronic health conditions to prevent hospitalizations. They are also hoping they will be paid based on the level-of-care a person needs rather than the current flat daily rate.

Nonprofit providers can apply for grant money, accept tax-deductible donations, and can receive other state or local tax exemptions, such as a fuel tax exemption in Maryland. For-profit providers are not eligible for these subsidies to cover operating costs yet face the same funding challenges as nonprofit providers.

Transportation

Because some states require ADS providers to furnish transportation and others do not, transportation issues varied among the states. ADS providers in Illinois and Maryland are required to provide transportation and several felt that the two primary challenges were high gas prices and logistical issues related to transporting multiple clients who attend the program at different times from a wide geographic area.

Maryland includes transportation in its Medicaid ADS rate and Illinois Medicaid pays for transportation using a separate rate. In both states, providers said they needed to provide their own drivers and lease and/or buy transport vehicles, which were very expensive. Para-transit services are not available in all areas but one provider noted that when it is available, some participants with mild impairments are able to use it.

In neither state does the transportation reimbursement rate cover actual costs, and to subsidize the rate, some programs charge private pay clients a separate transportation fee. One restricts the programs service area because the state only requires the provision of transportation within a designated service area. Participants who live outside this area have to make their own arrangements and most are brought to and from the program by family members.

Whether or not they were required to provide transportation, and apart from funding concerns, virtually all providers said that participants transportation needs posed a major logistical challenge, which took up a great deal of staff time. Some larger programs had full-time transportation coordinators. In other programs, staff spent a considerable amount of time arranging and coordinating transportation across a large service area and coordinating transportation scheduling with programming. In many programs, drivers make several morning and afternoon trips and some participants spend as much as an hour getting to and from the program because the driver has to pick them and others up from a large geographic area.

North Carolina, Georgia and Washington do not require ADS providers to furnish transportation, yet most providers cited transportation issues--both cost and logistical--as a major problem and a barrier to program attendance. A provider in Georgia said that even if participants were able to use public transportation, it would be unaffordable for many families, with round-trip bus fare costing $80 a month. Providers noted that many participants are transported by family members and the remainder use nonprofit or publicly-funded transportation. Providers in Washington mentioned logistical issues more often than cost issues because the state has an effective para-transit program that charges only $1.50 per round trip.

Providers in Georgia cited the most problems, which they blamed on the states recent decision to outsource transportation for all disability programs to a for-profit company. The drivers have not been trained to deal with riders who have mental disabilities and there is considerable turnover among transportation providers. One company gave only a days notice that it would no longer be providing services.

When gas prices increased after Hurricane Katrina, the state ruled that ADS programs were not medically necessary and did not provide transportation for two days. Because many participants had no other source of transportation, the programs nurse had to drive to their homes to give them their medications and no reimbursement was provided for her time.

Georgia providers also cited Medicaid transportation rules as a barrier to program participation (e.g., limits on the number of trips per day). One participant who needed to visit his physician had to be taken home rather than back to the program because Medicaid would not pay for a third trip from the program back to his home. One provider said that while transportation funding is drying up in their geographic area the demand is growing due to an increase in both the aged population and in need.

Staffing

Programs varied with regard to recruitment and retention issues--some had them and some did not. Those that reported difficulty recruiting did so for professional staff--RNs and rehabilitation therapists--noting that professional staff can earn more in other health care and long-term care settings. Another program said they had been successful recruiting professionals largely because they offer tuition reimbursement.

Several programs reported high retention rates for CNAs and other staff such as activity directors. Several had direct care staff with fairly lengthy tenures, in some cases, averaging five or more years, but other programs said that CNAs do not stay long because of the low pay.

For those who stay, providers attribute their retention to the work environment, which is less demanding than other long-term care settings, which often require shift rotations, night work, 12-hour shifts, and more physically demanding work with bed-bound clients. They also cited higher staff-to-participant ratios than are found in assisted living and nursing facilities, which lowers the caseload for direct care staff. Finally, providers said that staff value their role in a program that has a mission to serve the community as well as their long-term relationships with participants.

Several programs use part-time, flex-time, and on-call staff so they do not have to carry staff overhead when the census is low. One noted that they purposely under-staff and call on a pool of temporary and part-time workers when needed.

Virtually all providers we spoke with felt that the state-mandated staff-to-participant ratios were needed to provide good care. A provider in North Carolina noted that the mandated staff ratios for ADS are higher than those for any other long-term care setting including nursing homes.

5. PROVIDER AND STAKEHOLDER VIEWS ON REGULATORY ISSUES

This section presents the views of ADS providers and stakeholders on regulatory issues in their respective states. Stakeholders comprise state regulatory and Medicaid staff and representatives of state provider associations. Please refer to Appendix B for a regulatory summary of each of the five states.

Providers in several states said that compared to other long-term care settings, ADS regulations set ideal rather than minimum standards. One noted that while higher standards are desirable from a quality of care perspective, given low reimbursement rates they are not affordable from a business perspective.

Providers in the five states we visited felt that most state requirements regarding staffing and training were appropriate, but objected to requirements that they believed increased costs without increasing the quality of care. For example, a provider in Washington said that the state requires ADS providers--but not nursing homes and hospitals--to have bacteria resistant carpet or other approved flooring. He said he could not afford to replace all of the carpet in his facility with this type of carpet or, alternatively, with some other approved material. Providers in several states mentioned that some documentation requirements were unnecessary and burdensome, such as the need to document staff arrival and departure times. Other regulatory issues are unique to each state and are described next.

Georgia

The state currently has a voluntary licensing standard because it has not appropriated funds to administer the licensing program. If funds are appropriated and licensing mandated, some providers are concerned that licensing requirements will not replace the existing Medicaid contract requirements, but will be added to them. One provider noted that home health agencies are licensed by the state but must meet Medicaid requirements to be reimbursed. Because the Medicaid and licensing requirements are similar but not identical, providers have to document the same task twice to meet the different requirements, causing a great deal of additional work. The staff training requirements also differ because the two monitoring entities did not agree on a single standard, which has doubled the requirements. Providers are concerned that if ADS licensure is mandated, a similar situation will occur with ADS.

One provider said that the state used to have separate regulations for the ADS social model for people with dementia but subsequently merged them with Medicaids requirements. The merger doubled providers costs because in every instance the higher standard was adopted for both dementia and nondementia participants: space per client, staff ratios, staff qualifications, staff training, and record-keeping.

Another provider complained about the fast pace of regulatory change--every few months instead of every 2-3 years--which made it difficult for providers to adapt and comply. For example, the state changed the nutrition regulations to require providers to furnish two additional servings of specific food items per day. To do so, providers had to either find cost-savings in other program areas or increase revenues, which is difficult to do without sufficient advance notice. This provider also expressed concern that regulations were being promulgated without industry input.

The Medicaid agency recently enacted a policy change that requires programs to be in operation a full year before applying to be a waiver provider, a process that can take an additional six months. The rationale is to prevent new programs from expecting that Medicaid will fund their center, but one provider noted that its effect could be to deter the establishment of any new ADS programs.

Illinois

Providers and stakeholders did not mention any regulatory issues, possibly because the state does not require ADS providers to be licensed or certified. ADS providers who want to serve Medicaid clients must contract with the state Department on Aging (DOA) under the Community Care Program (CCP). Providers and state-level contacts in Illinois felt that licensure or certification requirements were not needed because the CCP regulations are equivalent to such requirements.

They said that to date, the lack of licensure has not negatively impacted the industry. Providers noted that the contracts with the states DOA have been accepted by long-term care insurers in lieu of licensure. However, they indicated that if insurers did not accept the contract, they would probably support ADS licensure or certification. One informant noted some resistance to licensure from the DOA because it would place ADS programs under the Department of Public Health, which would then be responsible for oversight.

Maryland

The state published new draft licensing regulations in November 2004, but they have not yet been adopted. Several providers felt that some of the proposed staffing requirements were more appropriate for nursing facilities that have greater financial resources than adult day centers. In particular, they expressed concern about a proposed requirement to have a full-time director for a center with 35 or more participants, stating that this requirement would impose a financial burden on smaller centers. Currently, a full-time director can work part-time at multiple centers operated by the same organization.

Providers also felt that a proposed requirement for health care practitioners to review assessments every 30 days is burdensome and they also expressed concerns about the amount of proposed civil penalties for deficiencies. Currently the state levies no penalties and providers feel those proposed are very high. One regulatory issue that has divided providers is a change in the staff-to-participant ratio from 1:6 to 1:7. The Maryland Association of Adult Day Services supported the change as a cost-saving measure, but another provider association--Leaders of Excellence in Adult Day Care--did not because they believed it would have a negative impact on the quality of care.

North Carolina

Providers noted that the industry is covered by rules and regulations imposed by agencies that are not under the control of the certifying body. Some feel that new sanitation, building, and fire codes--particularly the requirement for sprinklers--have made it nearly impossible to open, expand, or even change ownership of an ADS program, because changing ownership requires a new certification, which results in the building no longer being grandfathered under the old codes. The states Provider Association said that many programs operate in older buildings that do not meet the new codes.

This problem has been compounded by the recent enactment of legislation regarding the provision of specialized care in group homes and family care homes. One provider noted that any county or state monitor can decide that an ADS program serving people with a particular diagnosis is providing specialized care, which requires that the program be re-certified as such. When re-certified, the program loses its grandfathered status under former building codes, and the program has to close until current codes can be met. In many cases the program closes permanently because it has been operating in a facility, such as a church, which does not have sprinklers, and the program cannot afford to install them.

Another regulatory issue cited by some providers is the lack of a uniform interpretation of certification standards statewide and widely varying enforcement. The lack of consistent interpretation and enforcement of certification standards by county departments of social services is particularly difficult for providers who have centers in different counties. Fifty-eight of the states 100 counties have ADS and each county monitor can interpret the standards differently. Another complaint is that ADS are monitored monthly--much more frequently than nursing homes, adult care homes, or any other senior/adult service.

One provider felt that ADS regulations were increasingly driven by a medical model of care that increased costs, sometimes unnecessarily. For example, requiring an RN for eight hours a day to perform medical monitoring when in most cases an LPN could handle this responsibility, particularly in small programs, drives up costs unnecessarily. On the other hand, an RN in another program said she needed to be on site eight hours a day because the 45 participants attended the program at different times--some in the morning and some in the afternoon.

Washington

The state does not require licensure and one provider felt that it was needed for reimbursement, reputation, viability, and credibility. He said that his program is accredited by CARF and without this accreditation, long-term care insurers would not reimburse then for services provided. Another provider who is receiving long-term care insurance payments for a few participants said that not having licensure was a major hurdle to receiving payment. One said that they could not compete for the Medicare Demonstration project because they are not licensed.

As in North Carolina, providers were concerned about major variations in counties interpretations of regulations for enforcement purposes. For example, one county wants to know exactly how much time is spent on rehabilitation services for each participant, while another county is not interested in this information. One provider noted that many participants are eligible for Medicaid coverage because they need daily rehabilitation services and that requiring providers to furnish a specific amount of rehabilitation services to maintain eligibility can be a major problem for some programs given the low Medicaid reimbursement rate.

One provider said that staffing requirements can be unrealistic, noting that to open a program, the state requires an administrator, program director, RN, activity coordinator, a physical therapist/occupational therapist or speech therapist, and a social worker. While the administrator and program director may be the same person, all of these staff are required even if the program at start-up has only eight or ten participants. Several providers expressed concerns that the recent increases in requirements for RN and skilled rehabilitation personnel staffing were not matched by an increase in reimbursement.

One informant said that many providers feel the Medicaid ADS eligibility criteria are too stringent; others are upset because the state no longer allows ADS providers to determine eligibility. Because the state felt that some providers were admitting people who should not be eligible, it recently delegated eligibility determinations to the Area Agencies on Aging. However, because no funding was appropriated for this activity, eligibility determinations are often delayed, creating funding problems for providers.

6. CONCLUSIONS AND RESEARCH RECOMMENDATIONS

Based on our study findings, we have drawn several conclusions.

Regulation

The method states use to regulate ADS varies considerably, as does the content of the regulations. However, states generally distinguish between ADS and adult day health services, and have more extensive requirements for the health model. In general, staffing requirements are more stringent than those for residential care settings, particularly requirements for licensed nurse staffing in adult day health programs and programs that combine a social and medical model of care.
In some states, regulations appear to limit providers flexibility to provide services that meet caregivers needs, for example, arbitrary restrictions on the number of service hours that may be provided on weekends.
It is likely that the considerable state variation in regulatory approaches will continue in the near future. In states without licensure, providers disagree about whether the industry should be licensed. One argument for doing so is that long-term care insurers will not reimburse ADS unless furnished by licensed entities. Providers in Washington noted this difficulty but those in Illinois did not.

Some providers would support licensure if it led to an increase in reimbursement rates and others believe it would aid in their marketing efforts to recruit private pay participants. However, in states that do not license ADS providers, some fear that that licensing would be added to Medicaid requirements rather than replacing them.
Adult day health services are part of the continuum of both health and long-term care services. In the states we visited, ADS providers are furnishing preventive care, health monitoring, and skilled nursing services to individuals with chronic illnesses and physical and cognitive impairments. Some providers are also serving adults under age 65, depending on regulatory requirements and the funding streams for this population.

Because ADS providers must meet Medicaid state plan or waiver contracting requirements to furnish services to Medicaid beneficiaries--either in addition to or in lieu of state licensing or certification requirements--they are regulated at a level which allows them to furnish health-related and medical services as well as long-term care services to elderly persons with a high level of nursing and medical needs.

Program Models

The number of purely social ADS programs may decrease as more providers offer combined or health/medical models. Social programs appear to be at a disadvantage because many participants dis-enroll as they age and their health and functional needs increase. A combined program offering both a social and medical model appears to be the most financially viable.

The literature on caregiver stress has pointed out the need to use a social model of ADS when people are not so impaired, to help prevent burnout and many providers noted a need for this model. Others point out that specialized social programs are essential for individuals with dementia who do not have ADL impairments and medical needs. However, these programs may not survive due to: (1) the pressure to serve large numbers in order to meet fixed overhead costs and regulatory requirements; and (2) the need to meet the health and functional needs of increasingly older and more impaired participants, particularly if they want to be Medicaid providers.

Funding and Reimbursement

A unique feature of ADS relative to nursing homes and residential care settings, is their reliance on multiple funding sources to cover operating costs. While Medicaid is the primary public funding source for ADS providers through either a waiver program or the state plan, in the five states we visited reimbursement rates were not sufficient to meet costs. To remain financially viable and serve nonMedicaid eligibles who cannot afford to pay for some or all of the services they need, ADS programs must find other sources of funding.

Other funding sources include: state and local program funds, VA funds, the Social Services Block Grant, Older Americans Act funds, private payments--both out-of-pocket and from long-term care insurance--contributions from local service agencies such as United Way, and charitable contributions obtained through significant and ongoing fundraising efforts. Every ADS program we visited also relied extensively on in-kind contributions and numerous volunteers. The combination of funding sources, each with its own rules, greatly complicates the administration of ADS, and can limit providers flexibility to meet consumers needs.
States that pay flat rates create a distinctive for providers to admit participants with severe impairments. Some states pay either hourly rates or have tired rates for different levels of care.
The cost of ADS is relatively inexpensive compared to home care. Agencies can charge as much as $20-$25 for an hours visit by a home health aide and $85 or more for a half-hour visit by an RN.¹⁹ The national average daily cost for the social model of ADS is about $54, for the medical model about $59, and for the combined model about $57.

In the five states we visited, some providers furnished only the minimum number of hours required by public programs to receive the daily rate--never fewer than four. In other states, providers furnished up to 11 hours a day on the daily rate. Despite the relatively low cost of ADS, the five states we visited do not appear to be interested in expanding the availability of ADS generally--or medically-oriented ADS specifically.

Operational Issues

Lack of transportation and the high cost of transportation are major impediments to the use of ADS.
Without greater public recognition of the role ADS can play in maintaining adults of all ages with disabilities in home and community settings, it is unlikely that ADS programs will see an increase in private pay participants.

Although some providers and experts feel that public knowledge about ADS has improved, all acknowledge that it lags way behind public knowledge and understanding of other long-term care options. Even though ADS allow significantly impaired nursing home eligible participants to remain at home or living with family, providers believe that the public still thinks that ADS are the adult equivalent of child care. This perception would appear to be widespread, as evidenced by a 2002 article in the Wall Street Journal titled When Your Parents Need a Baby-Sitter: Adult Day Care Centers in Short Supply.²⁰

Other erroneous perceptions are that ADS are only for the poor, only for the rich, only for old people, or only for people with dementia. To alter these perceptions, the industry may need to engage in public education efforts. While the national ADS association supports a change in the name from adult day care to ADS, providers need to use the terms that public programs use in order to qualify for funding.

Recommendations for Future Research and Policy Analysis

Based on anecdotal evidence from providers and families, ADS enable informal caregivers to continue providing care in the home, thereby delaying or preventing institutionalization. More research is needed to document the long-term care cost savings of these programs. Such research could guide state policymakers who have to carefully target expansions of home and community services to assure the cost-effectiveness of limited resources.

ADS also appear to offer a means to reduce health expenditures. Washingtons Medicaid agency is conducting a study examining clinical outcomes and medical expenditures for Adult Day Health participants who reside in Adult Family Homes. While the final results of this two-year study are not yet available, preliminary analysis has demonstrated overall cost-savings. Given the potential for health care cost-savings, particularly as the population is aging, other states may want to consider analyzing Medicaid data to determine the cost-effectiveness of ADS.

Such research would provide much-needed documentation to determine whether an expansion of ADS that provide health services is warranted.

ENDNOTES

Discussions of other studies or states that use different terms will use those terms.
Numbers are based on data from the 1994 National Long-Term Care Survey. More recent data are not readily available. Supporting Informal Caregiving in Smith, G., OKeeffe, J., et al. (2000). Understanding Medicaid Home and Community Services: A Primer. U.S. Department of Health and Human Services. Available at http://aspe.hhs.gov/daltcp/reports/primer.htm.
Gaugler, J.E., Kane, R.L., Kane, R.A., Clay, T., Newcomer, R. (2003). Caregiving and Institutionalization of Cognitively Impaired Older People: Utilizing Dynamic Predictors of Change. The Gerontologist, 43(2), 210-229.
Dual Eligibles: Medicaids Role for Low-Income Medicare Beneficiaries. (January 2004). Kaiser Commission on Medicaid and the Uninsured. Available at http://www.kff.org/medicaid/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=30741.
Siebenaler, K., OKeeffe, J., OKeeffe, C., Brown, D., Koetse, B. Regulatory Review of Adult Day Services: Final Report. RTI International. August 26, 2005. Available at http://www.aspe.hhs.gov/daltcp/reports/adultday.htm.
Gaugler, J.E., Zarit, S.H. (2001) The Effectiveness of Adult Day Services for Disabled Older People. Journal of Aging and Social Policy, 12(2):23-47.
A presentation of key findings from this study are available at: http://www.rwjf.org/reports/grr/037535.htm#contents.
Scotto Rosato, N., Lucas, J.A., Howell-White, S. (May 2005). State Adult Day Health Services Programs: A National Profile (2001-2002). Rutgers Center for State Health Policy. Available at http://www.cshp.rutgers.edu/PDF/StateAdultDayNationalProfile-June%202005.pdf.
Lucas, J.A., Scotto Rosato, N., Lee, J.A., Howell-White, S. (August 2002). Adult Day Health Services: A Review of the Literature. Rutgers Center for State Health Policy. Available at http://www.cshp.rutgers.edu/PDF/AdultDaycareLitRev.pdf.
Ibid.
Ibid.
Scotto Rosado, N., Lucas, J.A., Howell-White, S. (May 2005). State Adult Day Health Services Programs: A National Profile (2001-2002). Rutgers Center for State Health Policy. Available at http://www.cshp.rutgers.edu/PDF/StateAdultDayNationalProfile-June%202005.pdf.
Gaugler, J.E., Kane, R.L., Kane, R.A., Clay. T., Newcomer, R. (2003) Caregiving and Institutionalization of Cognitively Impaired Older People: Utilizing Dynamic Predictors of Change. The Gerontologist, 43(2):219-29.

Hedrick, S.C., Rothman, M.L., Chaka, M., Inui, T.S., Kelly, J.R., Erath, J. (1993) Overview and Patient Recruitment in the Adult Day Health Care Evaluation Study. Medical Care. 31(9 Suppl.), SS 3-14.

Hedrick, S.C., Chaka, M., Erath, J., Rothman, M.L., Kelly, J.R., Inui, T.S. (1993) Implication of the Adult Day Health Care Evaluation Study for Program Revision and Research. Medical Care. 31(9 Suppl.), SS 104-15.

Another study by the Department of Veterans Affairs in the early 1990s--the Adult Day Health Care Evaluation Study--utilized randomized assignment to treatment and control groups and found that while the program supplied appropriate care, the results for cost-effectiveness were mixed. The authors recommended better targeting and cost controls as possible ways to improve cost-effectiveness.
Joseph Gaugler of the University of Kentucky built on his research in long-term care for chronically disabled older adults and Alzheimers Disease, collaborating with experts in the area of caregiving research, such as Steven Zaria, to address ADS in several studies reported in the research literature. Their published research includes:

Gaugler, J.E., Zarit, S.H. (2001) The Effectiveness of Adult Day Services for Disabled Older People. Journal of Aging and Social Policy, 12(2):23-47.

Gaugler, J.E., Jarrett, S.H., Zaria, S.H., Parris Stephens, M.A., Townsend, A., Greene, R. (2003) Adult Day Service Use and Reductions in Caregiving Hour: Effects on Stress and Psychological Well-being for Dementia Caregivers. International Journal of Geriatric Psychiatry, 18(1):55-62.

Gaugler, J.E., Jarrett, S.H., Zaria, S.H., Parris Stephens, M.A., Townsend, A., Greene, R. (2003) Respite for Dementia Caregivers: The Effects of Adult Day Service Use on Caregiving Hours and Care Demands. International Psycho geriatrics, 15, 37-58.
Siebenaler, K., OKeeffe, J., OKeeffe, C., Brown, D., Koetse, B. Regulatory Review of Adult Day Services: Final Report. RTI International. August 26, 2005. Available at http://www.aspe.hhs.gov/daltcp/reports/adultday.htm.
Because the purpose of this study is to better understand the role of ADS in addressing elderly persons health and functional needs, we did not look at services such as emergency services and nutritional services that are provided to all residents regardless of their functional or health status.
We did not identify this requirement in the rules; a state staff person who reviewed the profile provided this information.
The director of the Illinois Adult Day Services Association reported that out of 60 member programs, only two target a nonelderly population; one predominately serves persons with MR/DD, and the other persons with mental illness.
Costs cited by home health agencies in North Carolina. Costs in other states and major cities may be higher.
"When Your Parents Need a Baby Sitter: Adult Day-Care Centers in Short Supply, Wall Street Journal, December 19, 2002.

APPENDIX A. METHODOLOGY

The study utilized several qualitative research methods, which are described below.

Technical Advisory Group

We recruited a technical advisory group (TAG) comprising individuals with direct knowledge of the adult day services (ADS) industry, including representatives from state-level health and human services agencies, for-profit and nonprofit ADS provider organizations, and advocacy organizations. See Appendix C for a list of TAG members.

In addition to phone consultation with TAG members on an as-needed basis, the Research Triangle Institute (RTI) held a one-day meeting with the TAG in March 2005 in Washington, DC. During this meeting, TAG members provided their views on a number of issues facing the ADS industry and recommended states to visit.

Regulatory Review

RTI conducted a Web search to identify statutes, regulations, and Medicaid contracting requirements for ADS providers in each state. For the majority of states, we conducted extensive Web searches of state departments and offices of health, human services, and aging to locate licensing, certification, and any other requirements for ADS providers. We also conducted Web searches to find any additional requirements for Medicaid ADS providers.

We used this information to prepare regulatory profiles for each state. The regulatory categories in the profiles, such as mandatory services and staffing, were selected based on the interests of the funding agency with the input of the TAG. We then identified appropriate reviewers in each state and sent them an electronic copy of the draft profile for review, verification, and any changes. We revised the profiles based on reviewers comments and reconciled any conflicting comments among reviewers in the same state. The profiles are available in a separate publication--Regulatory Review of Adult Day Services--available at http://www.aspe.hhs.gov/daltcp/reports/adultday.htm.

Consultation with Experts, State Staff, and Provider Associations

In addition to consulting with expert TAG members, we consulted with other experts, state licensing and Medicaid staff and provider associations in the site visit states. Providers we interviewed during the site visits included program directors and other senior staff, generally a registered nurse or activity director. In some instances providers held senior positions in the states provider association, and we interviewed them in both capacities.

Site Visits

RTI used feedback from the TAG and information obtained through the regulatory review to recommend 5-8 potential states to visit. We recommended states with varying characteristics of interest including Medicaid funding of ADS (e.g., Aged and Disabled Waiver or State Plan) and regulatory approach (e.g., licensure, certification, both, or some other type of arrangement. In consultation with the funding agency, we selected Georgia, Illinois, Maryland, North Carolina, and Washington.

Once we selected the states, we consulted with the TAG to obtain recommendations for providers to visit. They recommended providers that had good reputations and who together varied along several characteristics (e.g., nonprofit and for-profit status; target population; and organizational affiliation). Based on their input and in consultation with the funding agency, we selected 3-4 providers in each state.

RTI staff then obtained approval from the RTI Institutional Review Boards for all of the discussion guides and the site visit data collection plan.

To gain additional information about the ADS industry in the states we visited, we first spoke with the state staff person who had reviewed the regulatory profile and with the executive director of the states ADS association. RTI staff sent the interviews to the interviewees via electronic mail for clarification of any questions and to confirm the accuracy of our notes.

On-site, RTI staff conducted in-person interviews lasting approximately 60-90 minutes with the center director and 1-2 other staff knowledgeable about the programs participants and services. Generally, these staff were nurses, social workers, or activity directors. RTI staff also toured each center and collected additional documentation when available on the population served, costs, programming, and services. After the visit, RTI staff sent the interviews to the interviewees via electronic mail for clarification of any questions and to confirm accuracy.

APPENDIX B. REGULATORY SUMMARIES

GEORGIA

[PDF of this state profile also available]

Overview

The states adult day services (ADS) licensing standards, developed after the legislature approved licensing authority in 2003, are currently voluntary due to lack of funding for the licensing agency to administer the licensing process. However, the Division of Aging Services in the Department of Human Resources has standards that must be met by providers in the statewide aging network who provide day services through contracts with the Area Agencies on Aging (AAA). The standards could become a part of, or serve as a basis for, future licensing regulations. These standards for ADS recognize two types of ADS programs--basic social and medical--and four service delivery models. This profile describes these standards. The Division of Aging Services will work with the new licensing agency to develop regulations for day service operations and cooperate with the agency in administering the licensing process for the provision of ADS as part of its nonMedicaid Home and Community-Based Services program. Adult day health (ADH) services in Georgia are offered under the Community Care Services Waiver Program, administered by the Division of Aging Services. Providers of ADH services under the waiver are required to follow specific Medicaid-only requirements for the provision of these services. Once the licensing process is operational, Medicaid ADH services providers will be required to be both licensed and enrolled with the State Department of Community Health as Medicaid providers and subject to the regulations of that Department.

Licensure and Certification Requirements

Licensure Only

Certification Only

Both Required

Other

standards for providers receiving public funds

Definitions

Adult day services provide support for elderly individuals (and their families, if present) who do not function fully independently, but who do not need 24-hour nursing care. Participants may have physical, social, and/or mental impairments; need assistance with activities of daily living (ADL) less than that requiring placement in an institution; or be recently returned home from a hospital or institution. These services are comprehensive and are based on participants individual needs; they are family-focused when families are involved. They are outcome-oriented with a goal of enhanced independence. The programs provide safe group environments with coordinated health and social services aimed at stabilizing or improving self-care. ADS may prevent, postpone, or reduce the need for institutional placement. Combined social and medical model programs can be combined within the same center or facility. Service Delivery Models for Adult Day Services Adult day care consists of community-based programs that provide nonmedical care--primarily social and recreational activities--to persons 60 years of age or older in need of limited personal care assistance, supervision, or assistance essential for sustaining ADL; or for the protection of an individual on a less than 24-hour basis. Adult day support consists of community-based programs that provide nonmedical care to meet the needs of functionally impaired elderly (age 60+) adults, according to individual plans of care in a structured, comprehensive program that provides a variety of social, psychosocial, and related services in a protective setting on a less than 24-hour basis. Participants demonstrate moderate impairments in functioning and cognition. Adult day health care consists of community-based programs that provide social, rehabilitative, and minor health services to physically and/or mentally functionally impaired elderly (age 60+) adults, for the purpose of restoring or maintaining optimal capacity for self-care. These programs provide services through individual plans of care and target elderly persons who could be at risk of institutional placement if intervention is not provided. These may be persons who are ineligible for or do not wish to participate in the waiver program, but whose need for assistance is greater than that of participants in the basic adult day care program. Participants have moderate to substantial degrees of impairments in functioning and cognition. Alzheimers day care consists of community-based programs that provide day care for persons in the various stages (mild, moderate, or severe) of Alzheimers disease or other dementias, regardless of age. The programs also provide support and educational services for family caregivers and the community at large. These centers identify the psychosocial, emotional, functional, and cognitive needs of participants and assist them, through individual plans of care, to function at the highest degree possible.

Parameters for Who Can Be Served

The parameters for who can be served are defined generally in the definitions of the different service delivery models (above). The state also specifies that ADS can be provided to persons 60 years of age or older (and collaterally their spouses/caregivers) who are limited in their ability to perform ADLs and instrumental ADLs due to physical and/or cognitive impairment, and who lack access to, or do not desire to receive, services offered through other funding sources or programs. Adults of any age (and collaterally their spouses or caregivers) who are known to have or who exhibit symptoms of Alzheimers disease or other dementias may be appropriate candidates for ADS provided through State Funds for Alzheimers Services. These program requirements supersede requirements for day care services provided through state Alzheimers funding, issued by the Division in 1991. Basic social model centers are not permitted to serve individuals who: (1) are bed bound or do not have the stamina or strength to attend the center, due to extreme frailty or fatigue; (2) have emotional or behavioral disorders that are so severe in nature as to cause them to be destructive to themselves or others, or who are disruptive in a group setting, unless the center has the capacity, through adequate and qualified staffing, to appropriately manage the behaviors; or (3) would not benefit from the activities and services offered at the center, due to significantly higher levels of physical and cognitive functioning.

Inspection and Monitoring

Yes

The AAA shall monitor providers of adult day care services for compliance with the requirements and evaluate program effectiveness, including client and program outcomes, at least annually.

Required and Optional Services

Adult Day Services

Required

Optional

Activities of Daily Living (ADL) Assistance

Health Education and Counseling

Health Monitoring/Health-Related Services

Medication Administration

Nursing Services

Physical Therapy, Occupational Therapy, or Speech Therapy

Skilled Nursing Services

Social Services

Transportation

Provisions Regarding Medications

Clients who choose not to or who cannot self-administer their medications must have their medications administered by a person who holds a current license under state law that authorizes the licensee to administer medications. Licensed nursing staff may provide assistance to individuals who are incapable of self-administering medications independently, including and limited to providing reminders, obtaining medications from and returning them to storage, opening and closing packaging, and pouring prescribed dosages. Clients who are able to administer their own medications must be assessed at least once a month by licensed nursing staff to determine their continued ability to self-administer their medications/treatments. The adult day care program shall have a written policy for medication management designating specific staff to be authorized and trained to assist with the administration of medications and the programs role in the supervision of self-administered medications and/or staff-administered medications.

Provisions for Groups with Special Needs

Dementia

Mental Retardation/ Developmental Disabilities

Other

Staffing Requirements

Type of staff. Each program shall have a program administrator. Other required staff are the activities director, nursing staff, and day care assistants, as well as volunteers. The facility nurse must be either a registered nurse (RN) or a licensed practical nurse (LPN). The activities director may fulfill the function of program administrator if she/he meets all qualifications. The program may contract for certain staff services, including activities director, as long as all program requirements ordinarily fulfilled by employees are met. If the program administrator also is the facility nurse, and leaves the facility to perform other duties related to the provision of the day care program, another licensed nursing professional must fulfill the duties of the facility nurse during his/her absence. Staffing ratios. Each program shall be operated with adequate numbers of qualified staff, according to the target population(s) and models of programming provided. At least one staff member 18 years of age or older shall be on the premises at all times participants are present. In addition to administrative staff, there shall be a minimum of one direct service staff person for each eight nonseverely impaired participants, or for each four severely impaired participants. The characteristics of the participants will determine the number and types of staff required. If a mixed model of programming is proposed, the staffing required for the highest level-of-care will be ensured. Volunteers who meet the same standards, requirements, and training as employees, and who have signed a written job description, may be counted as part of the staff-to-participant ratio.

Training Requirements

All adult day care staff who interact with participants, and volunteers who are included as part of the staff-to-participant ratio, must complete an orientation within the first two weeks of employment. Content shall include but not be limited to participant rights, program policies (including the client population served), medical and safety emergencies, health care delivery, universal precautions, and abuse. Substitute consultant staff, if any, must complete three hours of orientation. Within 90 days of employment, all employees who provide care to participants shall have received a minimum of 18 hours of training in the areas that are relevant to their job, including the needs and abilities of the participants, physical and psychological aspects of each participants disabilities, personal care techniques, and interpersonal communications skills, including patient rights. Staff employed as substitutes on an infrequent basis are not required to complete the 18 hours of initial training. Substitutes for direct service staff used on a regular basis with an on-call or other ongoing agreement must complete all training requirements. After the first year of employment, all employees who have direct care or program activity responsibilities, including the program administrator, shall complete three hours of continuing education quarterly, or 12 hours in total annually, on pertinent topics. The adult day care program shall provide orientation, training, and supervision to program volunteers.

Relevant Medicaid Contracting Requirements for ADS Providers

ADH services in Georgia are offered under the Community Care Services Program Waiver, administered by the Division of Aging Services and reimbursed by the Department of Community Health. Services are offered to members at two levels: Level I services require minimal ADL and self-care assistance, medical monitoring, and oversight for safety; Level II services are more intensive and may include specialized nursing services. Relevant requirements outlined in provider manuals are as follows: Definitions. ADH is a community-based medically-oriented day program for individuals who are functionally impaired. The goal is to promote medical stability, maintain optimal capacity for self-care, and maximize functional ability. Services help members to recover from acute illnesses or injuries, facilitate rehabilitation, support members with a chronic illness, and increase opportunities for members to participate in cultural and social activities and engage in multifaceted activities. All services provided reflect the individuals needs as indicated in a comprehensive care plan. Required services. Skilled physical, occupational, and speech therapy; assistance with ADL; health monitoring and health-related services; nursing services; and skilled nursing services. Optional services. Transportation. Medications. The RN and LPN assist members with medications when indicated. Staffing type. Required positions are center director, RN, aide(s), activities professional, and occupational, physical, and speech therapist (by contract). Suggested staff positions include LPN and driver/aide. Staffing ratios. A minimum staff-to-participant ratio is 1:8 for Level I members and1:4 for Level II members. Training. Any staff member providing direct member care is required to have current certifications in cardiopulmonary resuscitation (CPR) and first aid. The ADH provider must develop an ongoing in-service training plan and schedule for staff, subcontracted individuals, and volunteers. The plan must include, at a minimum, the following topics: orientation to the agency; Community Care Services Program overview including program policies and procedures; sensitivity to the needs and rights of older individuals; recertification and/or training in techniques of CPR and first aid; member rights; infection control procedures; fire safety and accident prevention and safety; confidentiality of member information; medication management; disaster planning/emergency procedures; caring for members with Alzheimers and related illnesses, an overview of Alzheimers disease; understanding communication techniques; understanding common behaviors of members with Alzheimers disease; care and management skills; activities appropriate for aging or chronically ill participants; safety and accident prevention; medications and side effects; elder abuse reporting; advance directives; and nutrition care, food safety, and safe feeding.

Location of Licensing, Certification, or Other Requirements

Citations

Adult Day Care/Day Health Services Requirements. Georgia Department of Human Resources Division of Aging Services Requirements for Non-Medicaid Home and Community Based Services §302. [7/2002]
(Medicaid) Part II-Chapter 1100 Policies and Procedures for Adult Day Health Services(ADH) (Community Care Services Program) Department of Community Health--Division of Medical Assistance and Department of Human Resources--Division of Aging Services. [Revised 4/2004]
Adult Day Center for Aging Adults Licensure Act. House Bill 318. Georgia General Assembly. [7/1/2003]
Policies and Procedures for Community Care Services General Manual. Georgia Department of community Health. Division of Medical Assistance. [4/1/2005]

Additional Information

The Division of Aging Services operates a Mobile Day Care program under the nonMedicaid Home and Community Based Services Program in which staff members, traveling with materials and supplies, provide day care services in different locations around the state on a rotating basis to provide respite for caregivers. It was initially designed to assist caregivers of persons with Alzheimers disease and is now made available to other caregivers. The state has amended the Community Care Services Program waiver to cover the Mobile Day Care model, and is awaiting Centers for Medicare and Medicaid Services approval.

ILLINOIS

[PDF of this state profile also available]

Overview

The State of Illinois does not require licensing or certification for adult day care providers. The Department on Aging Community Care Program (CCP) funded by state general revenue and the Medicaid Waiver provides services designed to prevent premature and unnecessary institutionalization to individuals over 60 years of age who are determined eligible to receive such services. The regulations for CCP, as stated in the Administrative Code, require all adult day services (ADS) providers to comply with the applicable local and state building, fire, health, and safety codes and standards in addition to specific accessibility and environmental barrier codes, and food service sanitation and vehicle codes. There are no provisions for adult day care other than those stated in the Administrative Code for the CCP, which are detailed in this profile.

Licensure and Certification Requirements

Licensure Only

Certification Only

Both Required

Other

CCP providers must follow CCP rules to offer ADS

Definitions

Adult day service is the direct care and supervision of adults 60 years of age and over in a community-based setting for the purpose of providing personal attention and promoting social, physical, and emotional well-being in a structured setting.

Parameters for Who Can Be Served

Other than the general parameters included in the definition (above), none are specified.

Inspection and Monitoring

Yes

The Department shall have the authority to conduct performance reviews of a contracted provider agency at any time during the course of the providers contract period. The Provider Performance Review consists of reviewing a sample of client and employee files to evaluate provider compliance with administrative rules; ensure adherence to the policies and procedures established by the Department and the ADS provider; and ensure that Request for Proposal provider requirements are met or exceeded.

Required and Optional Services

Adult Day Services

Required

Optional

Activities of Daily Living (ADL) Assistance

Health Education and Counseling

Health Monitoring/Health-Related Services

Medication Administration

Nursing Services

Physical Therapy, Occupational Therapy, or Speech Therapy

Skilled Nursing Services

Social Services

Transportation

Provisions Regarding Medications

An ADS provider shall have on file and utilize written procedures to manage storage and administration of medications, including ensuring that prescribed medication is administered by an appropriately licensed professional to those ADS clients who are unable to self-administer medications; and that judgment of a clients inability to self-administer medications shall be documented by a physicians order or the Case Coordination Unit plan of care and/or the ADS plan of care by the program nurse.

Provisions for Groups with Special Needs

Dementia

Mental Retardation/Developmental Disabilities

Other

Staffing Requirements

Type of staff. A separate and identifiable staff person must be designated for sole use by the ADS program. Each ADS provider shall have adequate personnel in number and skill (a minimum of two staff persons) at the ADS site to provide for program and fiscal administration; nursing and personal care services; nutritional services; planned therapeutic/recreational activities; and provision or arrangement of transportation to and from the ADS site. The program coordinator/director may perform the responsibilities of an ADS program administrator; and must be on duty full time when clients are in attendance or have a qualified substitute. A program nurse must be on duty at least one-half of a full-time equivalent (FTE) work period when clients are in attendance, either as staff or on a contractual basis. With written Department approval, the responsibilities of a program nurse may be performed by the program coordinator/director or administrator, in which case that person must be full time and must meet the qualifications for a program nurse and fulfill responsibilities for all assigned positions. Nutrition staff shall include: (1) at least one staff person who meets the food service sanitation guidelines issued by the Department of Public Health; and (2) a nutrition consultant/dietitian, either paid or in-kind, who shall be a registered member of the American Dietetic Association with experience in an agency setting. Drivers of ADS vehicles that transport clients, and at least two ADS program staff, shall be certified in cardiopulmonary resuscitation and trained in first aid, and at least one of such trained staff shall be on-site when clients are present. The ADS team consisting of program coordinator/director and program nurse may include other staff at the option of the program coordinator/director. Staffing ratios.The minimum ratio of full-time staff (qualified ADS staff, trained volunteers, or substitutes) or FTE staff present at the ADS site to clients, when clients are in attendance, shall be: two staff for every 1-12 clients; three staff for 13-20 clients; four staff for 21-28 clients; with one additional staff person for each seven additional clients. Fifty percent or more of a staff members time shall be spent in on-site direct service or supervision on behalf of one or more clients in order to be considered in the ratio.

Training Requirements

Each ADS employee shall have initial training totaling a minimum of 12 hours face-to-face training within the first week of employment (exclusive of orientation). A worker may be exempted from initial training by the provider if the worker has had previous documented training equivalent to 12 hours, with another CCP contracted agency, or in a related field, within the past two years prior to this employment or holds a CNA, RN, LPN, BA, BS, BSW, or higher degree. A minimum of 12 hours continuing education per year shall be mandatory for all ADS employees.

Relevant Medicaid Contracting Requirements for ADS Providers

There are no additional Medicaid requirements for ADS providers. The CCP requires all providers to adhere to the same rules and regulations irrespective of funding sources.

Location of Licensing, Certification, or Other Requirements

http://www.ilga.gov/commission/jcar/admincode/089/08900240sections.html

Citations

Administrative Code (Title 89: Social Services, Chapter II: Illinois Department on Aging, Part 240--Community Care). Joint Committee on Administrative Rules. [Effective 5/21/2004]

MARYLAND

[PDF of this state profile also available]

Overview

Maryland licenses two types of adult day services--day care and medical day care--through the Office of Health Care Quality in the Department of Health and Mental Hygiene. Day care services are offered and managed by the Departments Office of Health Services (OHS) through state-funded contracts, and are subject to the states licensing requirements. Medical day care services are offered and managed by OHS under the Medicaid state plan. Licensed providers may also serve private pay participants. In addition to meeting the same licensing requirements as day care service providers, medical day care providers must meet the general requirements for participation in the Medicaid program and the specific requirements for Medicaids medical day care program. This profile describes both day care and medical day care licensing requirements. The Maryland Department of Aging (MDoA) also offers a small social adult day care program called Senior Center Plus. Senior Center Plus providers do not have to be licensed but must meet MDoA certification requirements; to be reimbursed by Medicaid, they must also meet waiver standards. Providers already licensed for medical day care may also provide Senior Center Plus services. Certification requirements are found under Additional Information at the end of this profile.

Licensure and Certification Requirements

Licensure Only

day care and medical day care

Certification Only

Senior Center Plus

Both Required

Other

Definitions

Day Care Day care center for adults means a place that is operated to provide, with or without charge, care for medically handicapped adults. Centers are designated as group day care for four or more medically handicapped adults or as a family home that provides day care for two or three medically handicapped adults. Day care center for the elderly means a place that is operated to provide, with or without charge, care for elderly individuals. Centers are designated as group day care for at least four elderly individuals or as a family home that provides day care for two or three elderly individuals. Elderly individual means an individual who is 55 years old or older; lives alone or with a spouse, family relative, or friend; needs temporary care and supervision during part of the day in a protective group setting; and has a disability that prevents gainful employment or the accomplishment of a routine of normal daily activities without assistance, or a permanent and recurrent mental impairment. Medically handicapped adult means an individual who is 16 years of age or older; lives alone or with a spouse, relative, or friend; and has a disability that is a reasonably static physical impairment that prevents gainful employment or the accomplishment of a routine of normal daily activities outside of an institutional or sheltered environment or a permanent and recurrent mental impairment that requires domiciliary or institutional care in a sheltered environment.Medical Day Care Medical day care means a program of medically supervised, health-related services provided in an ambulatory setting to medically handicapped adults who, due to their degree of impairment, need health maintenance and restorative services supportive to their community living. Medical day care center means a facility operated for the purpose of providing medical day care services in an ambulatory care setting to medically handicapped adults who do not require 24-hour inpatient care, but, due to their degree of impairment, are not capable of full-time independent living. Participant means a health-impaired adult who is certified by the Department as requiring nursing facility services, but whose illness or disability does not require 24-hour inpatient care, unless medical day care services are not available; and whose disabilities and needs cannot be satisfactorily and totally met in an episodic ambulatory care setting, but require participation at least one day a week in a day-long rehabilitative or maintenance ambulatory care program that provides a mix of medical and social services.

Parameters for Who Can Be Served

The target populations are elderly and medically handicapped adults. Parameters for individuals who can be served are specified generally in the definitions of day care and medical day care (above). Providers may not serve individuals whose needs they cannot realistically meet. Providers may not deny admission to or involuntarily discharge individuals solely because they have a communicable disease. However, providers that intend to serve such individuals shall notify the licensing authority before admission; the authority may prohibit the admission if it is determined that doing so could pose a risk to the health, safety, or welfare of any other individuals associated with the center.

Inspection and Monitoring

Yes

Upon application for a license, the Departments authorized representative shall inspect the proposed facility. A reinspection of the center shall be made for renewal of a license and periodic reinspection of a center may be conducted by the Department at any time.

Required and Optional Services

Day Care

Medical Day Care

Required

Optional

Required

Optional

Activities of Daily Living (ADL) Assistance

Health Education and Counseling

Health Monitoring/Health-Related Services

Medication Administration

Nursing Services

Physical Therapy, Occupational Therapy, or Speech Therapy

Skilled Nursing Services

Social Services

Transportation

* Required if in the care plan.

Provisions Regarding Medications

Providers must have written policies specifying the individual authorized to procure, receive, control, and manage the drug program. Participants who are independently responsible for taking their own medication at home shall be permitted, if authorized by the participants physician, to continue to be responsible for taking their own medications during the hours spent in the center. If any participant requires supervision of medication, all federal, state, and local laws, ordinances, standards, and codes shall be followed. Medication may not be administered without a written order signed by the attending physician. Only licensed nurses may give injectable medications. For participants not capable of self-medicating, the individual assigned the responsibility of administering medications shall prepare the dosage, observe the participant swallowing the oral medication, and document that the participant has taken the medication. If a reaction to medications is observed, the participants physician or the physician on call shall be called immediately.

Provisions for Groups with Special Needs

Dementia

Mental Retardation/Developmental Disabilities

Other

psychiatrically impaired

Staffing Requirements

Day Care Type of staff. Required staff include a full-time director, who may work half time in each of two facilities if the employing organization operates more than one center; a half-time registered nurse; a full or half-time activities coordinator; and program assistants as needed to meet program goals and the staff-to-participant ratio. A full-time center director who is a registered nurse may also serve as the registered nurse. If a center is part of another facility, the center shall have its own full-time director and program staff. At least one staff member who is trained in first aid and cardiopulmonary resuscitation (CPR) shall be present at all times at the center, during outings, or during transportation of participants. Staffing ratios. The staff ratio shall be one staff to six participants exclusive of the director, volunteers, and consultants, and any staff member who does not provide direct care to participants may not be included in computing the staff ratio. Medical Day Care Type of staff. The medical day care center shall have adequate staff capability to monitor and appropriately serve the participants at all times. Medical services must be supervised by a staff physician. The composition of the staff depends in part on the needs of the participants and on the number of participants the program serves. When regular employment, full-time or part-time, is not justified by the needs of the participants, contractual employees may be used to meet the service and training needs of the center. As a minimum, the medical day care center shall have a full-time registered nurse (additional nursing services may be required due to the number or level of impairment of the participants), an activities coordinator (full-time or part-time), a medical social worker (full-time or part-time), and a staff physician (full-time, part-time, or contractual). The provider shall designate a program director and a health director. The program director shall be full-time and have either a bachelors degree or be a registered nurse. The health director shall be the registered nurse or the staff physician if the staff physician is required to be present at least half of the hours the medical day care center is open. For mandatory services that required staff cannot perform, such as physical therapy, occupational therapy, and nutrition, the medical day care center has the option of adding staff or establishing written agreements with licensed specialists. At least one staff member trained in first aid and certified in CPR shall be on the premises at all times that participants are in attendance. Staffing ratios. The medical day care center shall have adequate staff capability to monitor and appropriately serve the participants at all times with the same minimal staffing ratio as for day care programs.

Training Requirements

The program director shall ensure that staff and volunteers receive orientation and training and that an ongoing educational program is planned and conducted for the development and improvement of all personnels skills, including training related to problems and needs of the elderly, health-impaired, and disabled. The center shall provide a minimum of eight in-service training sessions annually, which shall include at least prevention and control of infections, fire prevention and emergency safety procedures, accident prevention, care of persons with Alzheimers disease or other dementias, and recognition and reporting of abuse. First aid training shall be taken from the American Red Cross or another source approved as comparable to the Red Cross. At a minimum, training shall be taken every three years. Recertification in CPR shall be obtained annually.

Relevant Medicaid Contracting Requirements for ADS Providers

Maryland provides medical day care under the Medicaid state plan. In addition to state licensing requirements, Medicaid providers must also meet the general requirements for participation in the Medicaid program and the specific requirements for the Medicaid medical day care program. Provider means a licensed medical day care facility furnishing services through an appropriate agreement with the Department and identified as a program provider by the issuance of an individual account number. Provider agreement means a contract between the Department of Health and Mental Hygiene and the provider of medical day care, specifying the services to be performed, the methods of operation, and financial and legal requirements that must be in force before program participation in medical day care. Providers who are certified by the MDoA for the Senior Center Plus program may serve waiver clients, but do not need to be licensed as with day care and medical day care. Licensed medical day care providers may also provide Senior Center Plus services.

Location of Licensing, Certification, or Other Requirements

Citations

Day Care for the Elderly and Medically Handicapped Adults. (Title 10 Department of Health and Mental Hygiene Regulations, Subtitle 12 Adult Health, Chapter 04). COMAR. [11/10/2004]
Medical Day Care Services. (Title 10 Department of Health and Mental Hygiene Regulations, Subtitle 09 Medical Care Programs, Chapter 07. [Most recent revision 11/24/2003]
Senior Center Plus. (Title 10 Department of Health and Mental Hygiene Regulations, Subtitle 09 Medical Care Programs, Chapter 54). [Most recent revision 06/21/2004]
Health-General Article, Title 14, Subtitles 2 and 3, Annotated Code of Maryland. [Effective date 1982]

Additional Information

Day Care The state drafted revised regulations for Day Care for the Elderly and Medically Handicapped Adults in November 2004, but they are not yet scheduled for adoption. The purpose of the revision is to: (1) update licensure requirements to achieve quality of care and safe outcomes for adult day care services participants; (2) establish a license fee; and (3) reorganize the regulations for ease of reading and interpretation. Senior Center Plus Senior Center Plus services designed for elderly disabled individuals include a program of structured group recreational activities, supervised care, assistance with activities of daily living (ADLs) and instrumental ADLs, and enhanced socialization, provided for at least four hours a day, one or more days a week on a regularly scheduled basis in an out-of-home, outpatient setting. The program is designed to promote participants optimal functioning and have a positive impact on their cognition. The center shall provide social and recreational activities and one nutritious meal, but not direct health care or transportation. To participate in the program a provider must: (1) be approved and monitored by the Maryland Department of Aging as a nutrition service provider; (2) be issued a provider number by the program to be used only for billing Senior Center Plus services for participants; and (3) meet all local and state requirements to operate as a nutrition site. There must be at least one staff person per eight clients, with additional staffing if required by the Maryland Department of Aging, depending on participants functional levels. The provider must employ as the centers manager or in another staff position an individual who: (a) is a licensed health professional or licensed social worker; (b) has at least three years experience in direct patient care at an adult day care center, nursing facility, or health-related facility; (c) is literate and able to communicate in English; and (d) participates in training specified and approved by the Maryland Department of Aging.

NORTH CAROLINA

[PDF of this state profile also available]

Overview

Providers of adult day care and day health services must meet certification standards. The Division of Aging and Adult Services in the Department of Health and Human Services oversees the standards, which are based on North Carolina Administrative Code. These standards are summarized in this profile. Adult day health programs and programs that provide adult day health in combination with adult day care must meet applicable state standards to be eligible for Medicaid reimbursement funds. There are no additional Medicaid provider requirements beyond the certification standards.

Licensure and Certification Requirements

Licensure Only

Certification Only

Both Required

Other

Definitions

Adult day care means the provision of group care and supervision in a place other than their usual place of abode on a less than 24-hour basis to adults who may be physically or mentally disabled. Adult day health services is the provision of an organized program of services during the day in a community group setting for the purpose of supporting an adults personal independence and promoting his or her social, physical, and emotional well-being. Services must include health care services as defined in state standards and a variety of program activities designed to meet the individual needs and interests of the participants and referral to and assistance in using appropriate community resources. Services must be provided in a home or a center certified to meet state standards for such programs. Adult day care homes can operate a day care program for 2-6 people in a single family dwelling. Adult day care centers can operate a day care program in a structure other than a single family dwelling. Adult day health centers and adult day health homes can operate day health programs in a structure other than a family dwelling, but day health programs for 2-5 persons can operate in a single family dwelling. Adult day health combination programs can operate both adult day care and adult day health in one program. A minimum of 25 percent of the participants in daily attendance in a combination program must be enrolled for adult day care services. Special care services are services by a certified adult day care center that promotes itself as providing programming, activities, or care specifically designed for persons with Alzheimers disease or other dementias; mental health disabilities; or other special needs, diseases, or conditions as determined by the Medical Care Commission.

Parameters for Who Can Be Served

General. Providers must have specific enrollment policies to guard against enrolling people whose needs cannot realistically be met by the planned activities. The policies should also provide for dismissal of participants whose needs can no longer be met or who can no longer be cared for safely. Providers may serve both semiambulatory and nonambulatory persons. Adult day health programs have additional requirements. Day health programs shall not enroll or continue to serve persons whose needs exceed the capability of the program. Providers may serve individuals who are 18 years of age or older who need day health services in order to support their independence and who require: (1) monitoring of a medical condition, (2) provision of assistance with or supervision of activities of daily living (ADLs), and (3) administration of medication, special feedings, or provision of other treatment or services related to health care needs. A participant transferring from standard day care services to special care services must meet the criteria for the special care service.

Inspection and Monitoring

Yes

Adult day care and adult day health care programs shall be inspected annually and monitored at least monthly to assure compliance with standards. The certificate will be in effect for 12 months from the date of issuance unless it is revoked for cause, voluntarily or involuntarily terminated, or changed to provisional certification status. Following review of the certification application, a precertification visit may be made by staff of the state Division of Aging and Adult Services.

Required and Optional Services

Adult Day Care

Adult Day Health Care

Required

Optional

Required

Optional

Activities of Daily Living (ADL) Assistance

Health Education and Counseling

Health Monitoring/Health-Related Services

Medication Administration

Nursing Services

Physical Therapy, Occupational Therapy, or Speech Therapy

Skilled Nursing Services

Social Services

Transportation

Adult day care requires five types of activities to be provided on a daily basis: diversional, educational, social, volunteer service, and program assistance.

Provisions Regarding Medications

Participants may keep and administer their own medicines while attending the day care program. If a participant is determined to be unable to be responsible for his or her medication, it shall be kept for him or her during the time the participant is present at the program and given at the prescribed time and dosage by the health care coordinator.

Provisions for Groups with Special Needs

Dementia

Mental Retardation/Developmental Disabilities

Other

mental health disabilities, or other special needs, diseases, or conditions

Staffing Requirements

Type of staff. Adult day care and adult day health centers must have a full-time director.Adult day health centers must have a health care coordinator (a registered nurse (RN) or a licensed practical nurse (LPN) currently licensed to practice in North Carolina). If the health care coordinator is an LPN, supervision must be provided by an RN consistent with the Nursing Practices Act and on-site supervision by the RN must occur no less frequently than every two weeks. In adult day health centers with ten or fewer participants, the director may also serve as the health care coordinator. Adult day care homes must have an operator. Staffing ratios.The staffing pattern shall be dependent upon the enrollment criteria and the particular needs of the participants who are to be served. The ratio of paid staff to participants shall be adequate to meet the goals and objectives of the program. The minimum ratios shall be as follows:

Adult day care homes--One paid staff person for up to six participants.
Adult day care centers--One paid staff person for each eight participants.
Adult day health centers and adult day health homes--One paid full-time equivalent staff person with responsibility for direct participant care for each five participants.
Adult day health combination--One paid full-time equivalent staff person with responsibility for direct participant care for each six participants.
Special care services--Adult day care program must disclose in writing procedures that addressstaff-to-participant ratios in the special care service to meet the needs of participants.

Training Requirements

Special care services. An adult day care program providing special care services shall assure that special care services staff document receipt of training specific to the population(s) to be served; have a written plan for training staff that identifies content, sources, evaluations and schedules of training; assure that within one month of employment each staff person assigned to special care services shall demonstrate knowledge of the needs, interests, and levels of abilities of the participants; and assure that within six months of employment, each staff person assigned to special care service shall complete three training experiences including but not limited to population-specific techniques for communication, behaviors, and ADL. An adult day care program must disclose in writing procedures that address the amount and content areas of staff training both at orientation and annually based on the special care needs of the participants. An adult day care program providing special care services shall assure that special care services staff receive at least the following orientation and training: (1) the program director shall assure that within a month of employment, each staff person assigned to special care services shall demonstrate knowledge of the needs, interests, and levels of abilities of the participants; (2) within six months of employment, each staff person assigned to special care service shall complete three training experiences, including but not limited to population-specific techniques for communication, behaviors, and ADL; and (3) each staff person working directly with participants in special care service shall complete a minimum of two population-specific educational experiences annually.

Relevant Medicaid Contracting Requirements for ADS Providers

Adult day health programs and programs that provide adult day health in combination with adult day care must be certified as meeting these standards in order to be eligible to receive Medicaid funds. The certification process is described in Section VI of the Adult Day Care and Day Health Services Standards for Certification.

Location of Licensing, Certification, or Other Requirements

http://www.dhhs.state.nc.us/aging/adcdhstd.pdf

Citations

Adult Day Care and Day Health Services Standards for Certification 10A NCAC 06R.0101 and 06S.0101 (previously 10 NCAC 42E.0704 and 42Z.0501). North Carolina Department of Health and Human Services, Division of Aging and Adult Services. [9/2003]

Additional Information

The certification standards include additional requirements for both adult day health care programs and adult day care programs who market themselves as providing special care services. Special care services. An adult day care program that provides or that advertises, markets, or otherwise promotes itself as providing special care services for persons with Alzheimers disease or other dementias, a mental health disability, or other special needs, disease, or condition shall provide written disclosures to the Department and to persons seeking adult day care program special care services. The disclosure must address the process and criteria for enrollment in and discharge from special care services. Only programs that meet these requirements may advertise or represent themselves as providing special care services. However, an adult day care program that does not advertise, market, or otherwise promote itself as providing special care services for persons with Alzheimers disease or other dementias, is not prohibited from providing adult day care services to persons with Alzheimers disease or other dementias, a mental health disability, or other special needs disease or condition.

WASHINGTON

[PDF of this state profile also available]

Overview

The Washington Administrative Code requires adult day care or day health centers that contract with the Department of Social and Health Services, an area agency on aging, or other department designee to provide Medicaid services to department clients, to abide by specific contracting requirements. An area agency on aging that elects to provide adult day services using Senior Citizens Services Act funding or respite care funding must contract with an adult day center that meets all administrative and facility requirements under WAC 388-71-0736 through 388-71-0774. The adult day care or day health services funded through the Senior Citizens Services Act or respite care funding must be the same as the required Medicaid day care services or the day health services required under WAC 38871-0704 and 388-71-0706. The Medicaid contracting requirements are documented in this profile. We were not able to identify any requirements for providers who do not receive public funding.

Licensure and Certification Requirements

Licensure Only

Certification Only

Both Required

Other

Medicaid contracting requirements

Definitions

Adult day services is a generic term referring to adult day care and adult day health services. Adult day centermeans an adult day care or adult day health center. A day care or day health center for purposes of these rules is a center operating in a specific location, whether or not the centers owner also operates adult day centers in other locations. Adult day care is a supervised daytime program providing core services appropriate for adults with medical or disabling conditions that do not require the intervention or services of a registered nurse (RN) or licensed rehabilitative therapist acting under the supervision of the clients physician. Adult day health is a supervised daytime program providing skilled nursing and rehabilitative therapy services in addition to core services provided in adult day care. Adult day health services are only appropriate for adults with medical or disabling conditions that require the intervention or services of an RN or licensed rehabilitative therapist acting under the supervision of the clients physician.

Parameters for Who Can Be Served

The Medicaid Program has different eligibility criteria for adult day care and adult day health care. These criteria indicate the parameters for who can be served in these settings. Adult day care. Participants who need the following services may be served: (1) personal care services; (2) routine health monitoring with consultation from an RN; (3) general therapeutic activities; and (4) supervision and/or protection when necessary for client safety. Individuals cannot be served if their needs exceed the scope of authorized services that the adult day care center is able to provide or if they are not capable of participating safely in a group care setting. Adult day health care. Participants 18 years of age or older who need the following services may be served: (1)skilled nursing or skilled rehabilitative therapy; or (2) personal care. Individuals cannot be served if their needs exceed the scope of authorized services that the adult day health center is able to provide or if they are not capable of participating safely in a group care setting.

Inspection and Monitoring

Yes

The department, or an area agency on aging, or other department designee, must determine that the adult day care or adult day health center meets the applicable adult day care or day health requirements and any additional requirements for contracting through a COPES or Medicaid provider contract. The area agency on aging or other department designee monitors the adult day center at least annually to determine continued compliance with adult day care and day health requirements and the requirements for contracting.

Required and Optional Services

Adult Day Care

Adult Day Health Care

Required

Optional

Required

Optional

Activities of Daily Living (ADL) Assistance

Health Education and Counseling

Health Monitoring/Health-Related Services

Medication Administration

Nursing Services

X (consultation)

Physical Therapy, Occupational Therapy, or Speech Therapy

Skilled Nursing Services

Social Services

X (consultation)

Transportation

Additional required or optional services in adult day care and adult day health care, which are not identified above, include meals and snacks (required), general therapeutic activities (e.g., relaxation therapy and cognitive stimulation) (required), and assistance with arranging transportation (required). Psychological or counseling services are required in adult day health care.

Provisions Regarding Medications

The center must develop written policies that are explained and accessible to all staff, contractors, volunteers, and participants The requirements for those policies and medication administration are found in WAC 388-71-0764. Participants who need to take medications while at the center, and who are able to self-medicate, must be encouraged and expected to bring and take their own medications as prescribed. Some participants may need assistance with their medications, and a few may need to have their medications administered by qualified program staff. In order for center staff to administer any prescribed medication, there must be a written authorization from the participants authorizing practitioner stating that the medication is to be administered at the program site.

Provisions for Groups with Special Needs

Dementia

Mental Retardation/Developmental Disabilities

Other

Staffing Requirements

Type of staff.Minimum staffing requirements for adult day care centers include an administrator/program director, activity coordinator, consulting RN, and consulting social worker. Minimum staffing requirements for adult day health centers include an administrator, program director, RN, activity coordinator,a physical therapist/occupational therapist or speech therapist,and a social worker. The administrator and program director may be the same person. If the center hires staff commonly used by both adult day care and adult day health centers (e.g., nurse, activity coordinator, social services professional, and personal care aides), the staff must meet specific requirements. The nurse must be an RN with valid state credentials and have at least one year of applicable experience (full-time equivalent). In addition to an RN, an adult day center can utilize a licensed practical nurse (LPN), but the LPN must be supervised in compliance with all applicable nursepractice acts and standards. The LPN must have valid state credentials and at least one year ofapplicable experience (full-time equivalent). Staffing ratios.The ratio must be a minimum of one staff to six participants. Staff counted in the staff-to-participant ratio are those who provide direct service to participants. When there is more than oneparticipant present, there must be at least two staff members on the premises, one of whom is directlysupervising the participants.

Training Requirements

Provision must be made for orientation of new employees, contractors, and volunteers. All staff, contractors, and volunteers must receive, at a minimum, quarterly in-service training and staff development that meets their individual training needs to support program services. Staff, contractors, and volunteers must receive training about documentation, reporting requirements, and universal precautions. At a minimum, one staff person per shift must be trained and certified in cardiopulmonary resuscitation. Staff and volunteers must receive training on all applicable policies and procedures.

Relevant Medicaid Contracting Requirements for ADS Providers

Medicaid providers must follow the rules for adult day services found in the Washington Administrative Code that regulate the provision of all adult day care and adult day health care services in the state.

Location of Licensing, Certification, or Other Requirements

http://apps.leg.wa.gov/WAC/default.aspx?cite=388-71-0702

Citations

Washington Administrative Code--Department of Social and Health Services--Home and Community Services and Programs--Adult Day Services--(Title 388 Chapter 71-0702 through 71-0776).

APPENDIX C. TECHNICAL ADVISORY GROUP MEMBERS

Nancy Cox, M.S.W. Department of Psychiatry Wake Forest University Health Sciences

Lisa Gables Executive Director American Society of Consultant Pharmacists Foundation Formerly Executive Director of the National Adult Day Services Association

Robert Greenwood National PACE Association

Merle D. Griff, Ph.D. President/CEO Sarah Adult Day Services, Inc.

Jed Johnson Assistant Vice President Adult & Senior Services Easter Seals National Headquarters

Beverly R. Littlefield Manager Georgia Department of Human Resources

Judith Lucas, APRN, BC, Ed.D. Senior Researcher Rutgers University

Christine MacDonell Managing Director, Commission on Accreditation of Rehabilitation Facilities (CARF)-Continuing Care Accreditation Commission-Adult Day Services and Assisted Living

Judy Riggs Consultant Former legislative/policy analyst Alzheimers Association

Linda Velgouse Center for Planning and Policy Development U.S. Administration on Aging Formerly interim Executive Director of the National Adult Day Services Association

Files

keyADS-WA.pdf (pdf, 177.99 KB)

Topics

Home- & Community-Based Services (HCBS) | Behavioral Health

Populations

Older Adults

Program

Program of All-Inclusive Care for the Elderly (PACE)

Adult Day Services: A Key Community Service for Older Adults

Janet O'Keeffe and Kristin Siebenaler

RTI International

July 2006

TABLE OF CONTENTS

Purpose of Study

Methodology

Regulatory Findings

Site Visit Findings

Conclusions and Research Recommendations

Recommendations for Future Research and Policy Analysis

Purpose of Study

Methodology

Organization of Report

Regulatory Approaches

State Definitions of Adult Day Services

Provider Requirements

Monitoring

Medicaid Contracting Requirements

General Impression of Physical Structure

Organizational Affiliations

Population Served

Participants Functional Limitations

Health and Medical Conditions

Increase in Acuity

Limitations on Who Can Be Served

Services

Role of Adult Day Services in the Health and Long-Term Care Systems

Operational and Policy Issues

Georgia

Illinois

Maryland

North Carolina

Washington

Recommendations for Future Research and Policy Analysis

Technical Advisory Group

Regulatory Review

Consultation with Experts, State Staff, and Provider Associations

Site Visits

Connect with Us

Participants Functional Limitations