Regulatory Review of Adults Day Services: Final Report


Kristin Siebenaler, Janet O'Keeffe, Christine O'Keeffe, David Brown and Beth Koetse

RTI International

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 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: or

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.


Below are the sections and exhibits associated with Regulatory Review of Adult Day Services: Final Report. Each section is a separate file (available in both PDF and HTML), as well as each state's summary from Section 2 being available as a separate PDF file. To view the material, simply clink on the PDF or HTML link beside it.

ACKNOWLEDGMENTS [PDF of cover, Table of Contents, Acknowledgments and Introduction]
INTRODUCTION [PDF of cover, Table of Contents, Acknowledgments and Introduction]
Licensing, Certification, and Other Requirements [HTML]
Definitions of Adult Day Services [HTML]
Parameters for Who Can Be Served [HTML]
Required and Optional Services [HTML]
Provisions Regarding Medications [HTML]
Staffing Requirements [HTML]
Training Requirements [HTML]
Monitoring [HTML]
Relevant Medicaid Contracting Requirements [HTML]
Endnotes [HTML]
SECTION 1 Exhibits
EXHIBIT 1. Approach to Regulation by States [HTML]
EXHIBIT 2. Staffing Ratios by State [HTML]
EXHIBIT 3. Special Provisions for People with Dementia by State [HTML]
EXHIBIT 4. Additional Medicaid Waiver and/or State Plan Adult Day Services Provider Requirements by State [HTML]
Alabama [PDF, this state only] [HTML]
Alaska [PDF, this state only] [HTML]
Arizona [PDF, this state only] [HTML]
Arkansas [PDF, this state only] [HTML]
California [PDF, this state only] [HTML]
Colorado [PDF, this state only] [HTML]
Connecticut [PDF, this state only] [HTML]
Delaware [PDF, this state only] [HTML]
District of Columbia [PDF, this state only] [HTML]
Florida [PDF, this state only] [HTML]
Georgia [PDF, this state only] [HTML]
Hawaii [PDF, this state only] [HTML]
Idaho [PDF, this state only] [HTML]
Illinois [PDF, this state only] [HTML]
Indiana [PDF, this state only] [HTML]
Iowa [PDF, this state only] [HTML]
Kansas [PDF, this state only] [HTML]
Kentucky [PDF, this state only] [HTML]
Louisiana [PDF, this state only] [HTML]
Maine [PDF, this state only] [HTML]
Maryland [PDF, this state only] [HTML]
Massachusetts [PDF, this state only] [HTML]
Michigan [PDF, this state only] [HTML]
Minnesota [PDF, this state only] [HTML]
Mississippi [PDF, this state only] [HTML]
Missouri [PDF, this state only] [HTML]
Montana [PDF, this state only] [HTML]
Nebraska [PDF, this state only] [HTML]
Nevada [PDF, this state only] [HTML]
New Hampshire [PDF, this state only] [HTML]
New Jersey [PDF, this state only] [HTML]
New Mexico [PDF, this state only] [HTML]
New York [PDF, this state only] [HTML]
North Carolina [PDF, this state only] [HTML]
North Dakota [PDF, this state only] [HTML]
Ohio [PDF, this state only] [HTML]
Oklahoma [PDF, this state only] [HTML]
Oregon [PDF, this state only] [HTML]
Pennsylvania [PDF, this state only] [HTML]
Rhode Island [PDF, this state only] [HTML]
South Carolina [PDF, this state only] [HTML]
South Dakota [PDF, this state only] [HTML]
Tennessee [PDF, this state only] [HTML]
Texas [PDF, this state only] [HTML]
Utah [PDF, this state only] [HTML]
Vermont [PDF, this state only] [HTML]
Virginia [PDF, this state only] [HTML]
Washington [PDF, this state only] [HTML]
West Virginia [PDF, this state only] [HTML]
Wisconsin [PDF, this state only] [HTML]
Wyoming [PDF, this state only] [HTML]


We would like to acknowledge the following for their contributions to this review: Lisa Gables, Executive Director of the American Society of Consultant Pharmacists Foundation (and former Executive Director for the National Adult Day Services Association); Judy Lucas and Nancy Scotto Rosato with the Rutgers Center for State Health Policy; and the many people in state agencies throughout the country who answered questions and provided copies of the statutes, regulations, and reports needed to develop the state regulatory profiles. We greatly appreciate the willingness of these dedicated professionals to share their knowledge and expertise.


Although adult day care and adult day health care are increasingly promoted as key community-based services for older persons, little is known about their provision, utilization, or outcomes; this is largely due to a paucity of data. This review examines state approaches to regulating these services, hereafter referred to generically as adult day services (ADS), as a means to better understand their role in the health care and long-term care (LTC) systems. This review is a component of a larger study of ADS intended to provide information to guide future research and policy analysis on ADS generally and on medically oriented adult day services specifically.

Section 1 provides an overview of states' approaches to regulating ADS by highlighting similarities and differences in specific areas such as staffing and training requirements. Section 2 includes a profile for each state describing its overall approach to regulating ADS providers, selected regulatory provisions, and Medicaid requirements (if any) specific to adult day services. These provisions and requirements determine to a large extent the characteristics of the population ADS providers may serve and the type and range of services they must or may furnish.


To inform our selection of the regulatory provisions to include in each state profile, we consulted with the project officers, Technical Advisory Group members, and other experts. (Section 2 describes each regulatory category included in the profiles and lists those not included.) We then conducted a search to identify regulatory and Medicaid contracting requirements for ADS providers in each state. The National Adult Day Services Association provided links to requirements in some states. For the majority of states, however, 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 providers of ADS.

The information in each state's and the District of Columbia's profile (hereafter, "states") is based on statutes, regulations, and contracting requirements for ADS providers. To ensure the accuracy of the information reported, we completed a rigorous validation process. We conducted Web searches and multiple telephone inquiries to identify the appropriate state officials to review the profiles. In many states, we identified Medicaid staff as well as aging department and licensing/certification staff who have knowledge of and/or responsibility for oversight of ADS providers. After identifying the appropriate reviewers, we sent each an electronic copy of the draft profile for review, verification, and any changes. In most states, several state staff reviewed the profiles. We revised the profiles based on reviewers' comments and reconciled any conflicting comments among reviewers in the same state, often through follow-up phone calls.


Little research has been conducted on adult day services. Research has been hampered by the considerable variation in ADS models, both within and across states, and a lack of data. We identified no published research that examined the health and functional outcomes of ADS participants. Much of the published research on ADS has centered on caregivers, their decision-making process in utilizing ADS, and the impact of these decisions on their caregiving burden.1 Other studies have focused on the cost-effectiveness of ADS in delaying or preventing institutionalization.2

In 1987, Robert Wood Johnson Foundation (RWJF) initiated the Dementia Care and Respite Services Program, the nation's first national ADS demonstration program, in cooperation with the Alzheimer's Association and the Administration on Aging (AoA), with the national program office located in the Wake Forest University School of Medicine. Studies funded through this program demonstrated that adult day care centers for people with dementia could provide needed services, including medical services, to individuals with a wide range of needs and still be financially viable in the private pay market. The 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 adult day care centers across the country.3

Two recent national studies--one conducted by Rutgers Center for Health Policy and the other by Wake Forest University--(described below) provide information on provider characteristics, operational features of ADS facilities, and publicly funded program requirements; one also examined participants' characteristics. In 2002, Rutgers also conducted a literature review of adult day health services, which is available at

A comprehensive evaluation of Multiple Sclerosis Adult Day Programs (MSADPs)--funded by the National Multiple Sclerosis Society--is currently underway. Using case studies, cost analyses, and outcomes analysis, the project aims to calculate the full 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 Alzheimer's 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 had the National Institute on Adult Daycare in the early 1990s, but the institute is no longer operating.

The remainder of this section provides a brief description of the two most recent national studies of ADS.

State Adult Day Health Services Programs: A National Profile (2001-2002).5 The purpose of this study conducted by the Rutgers Center for State Health Policy was to examine publicly financed adult day health services (ADHS) programs.6 The study methods includes a review of program standards, and the report provides information on the program's licensure and/or certification status and monitoring requirements. However, it does not include information on the content of states' licensing and certification requirements other than those related to monitoring. Instead, the study report summarizes the characteristics of the major publicly funded ADHS program in each state. Medicaid funded these programs in most states either through the State Plan or Aged and Disabled Waiver programs.

The study's primary goal was to identify commonalities and differences across various features of state programs, reliable and standardized assessment instruments, reimbursement models, and promising program approaches. The program characteristics described for each state are type of funding, eligibility requirements, types of assessments used, licensure and certification status and program monitoring procedures, services provided, reimbursement methods, expenditure rates, and an estimate of the number of facilities and participants.

National Study of Adult Day Services (2001-2002).7 Wake Forest University conducted a national survey of ADS providers that addressed four major areas: (1) background information such as the age, type and organization of the center, licensure or certification status, problems and concerns in center operation, center operational policies, and staffing; (2) services provided, such as meals, transportation, personal assistance and personal care services, and therapeutic, social, medical, and nursing services; (3) the characteristics of center 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.8

Major study findings include the following:

  • The average overall enrollment in adult day centers was 42 participants; average daily attendance was 25. The average length of stay was 2 years.
  • Among adult day centers, 78 percent reported that they were nonprofit organizations; 22 percent reported that they were for-profit organizations.
  • Among adult day centers, 37 percent provide a social model of care (with no nursing services provided), 21 percent provide a medical model (providing nursing services and in some instances rehabilitation therapy), and 42 percent provide a combined social and medical model. Twenty percent exclusively serve individuals with dementia.
  • The three major problems cited by adult day center providers are inadequate funding, difficulty recruiting and retaining staff, and difficulty maintaining census and attendance levels needed to cover operating costs.

Despite providers' stated concerns about under-utilization, the study concluded that the current number of adult day centers (3,407) falls short of the number needed to serve the population of adults with chronic, debilitating illnesses and their family caregivers.


  1. Joseph Gaugler of the University of Kentucky built on his research in long-term care for chronically disabled older adults and Alzheimer's Disease, collaborating with experts in the area of caregiving research, such as Steven Zarit, to address ADS in several studies reported in the research literature. Their published research includes:

    1. Gaugler JE, Zarit SH. (2001) The Effectiveness of Adult Day Services for Disabled Older People. Journal of Aging and Social Policy.

    2. Gaugler JE, Jarrott SH, Zarit SH, Parris Stephens MA, 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.

    3. Gaugler JE, Jarrott SH, Zarit SH, Parris Stephens MA, Townsend A, Greene R. (2003) Respite for Dementia Caregivers: The Effects of Adult Day Service Use on Caregiving Hours and Care Demands. International Psychogeriatrics, 15, 37-58.

  2. Gaugler JE, Kane RL, Kane RA, Clay T, Newcomer R. (2003) Caregiving and Institutionalization of Cognitively Impaired Older People: Utilizing Dynamic Predictors of Change. The Gerontologist.

    Hedrick SC, Rothman ML, Chapko M, Inui TS, Kelly JR, Ehreth J. (1993) Overview and Patient Recruitment in the Adult Day Health Care Evaluation Study. Medical Care. 31(9 Suppl), SS3-14.

    Hedrick SC, Chapko M, Ehreth J, Rothman ML, Kelly JR, Inui TS. (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.

  3. Robert Wood Johnson National Program Report: Partners in Caregiving: The Dementia Services Program.

  4. Lucas JA, Scotto Rosato N, Andrew Lee J, Howell-White, S. (2002) Review of Adult Day Health Services: A Review of the Literature. Rutgers Center for Health Policy.

  5. Howell-White S, Rosato NS, Lucas JA. (2005) Adult Day Health Services Programs: A National Profile (2001-2002). Rutgers Center for State Health Policy. The study is available on-line at the Center for State Health Policy Web site at

  6. The reported survey findings do not include Idaho, Iowa, Tennessee, Utah, and Wyoming--states that reported funding only social adult day care.

  7. National Study of Adult Day Services, 2001-2002. Winston-Salem, NC: Partners in Caregiving: The Adult Day Services Program, Wake Forest University School of Medicine, 2002. Funded by Robert Wood Johnson Foundation. A summary of this report is available on the Robert Wood Johnson Foundation Web site at

    Robert Wood Johnson National Program Report: Partners in Caregiving: The Dementia Services Program.

  8. The study verified 3,407 centers and achieved a response rate of 71 percent.