Growing demand for adult day services is putting new expectations on providers, including a need to serve people with more medical needs. Here is a look at how some organizations are meeting the challenge.
According to data from the Centers for Disease Control and Prevention, there were 286,300 people receiving services from the nation’s 4,600 adult day programs on any given day (2015-16 data). This is good news for people in communities around the country—from the clients who want to stay in their homes to concerned family members who are getting a much-needed break from caring for their loved ones thanks to these programs.
This is also good news for the professionals who provide adult day services—which can include medication administration, personal care, and recreational programming—and have seen the growing need for their expertise in recent years. The National Adult Day Services Association (NADSA) reports that there has been a 65% increase in the number of people receiving adult day health services in the United States since 2002, and a 35% increase in the number of adult day programs providing these services. (NADSA also says it has identified more than 5,600 adult day programs, as of 2014.)
As a result of this growth, adult day health centers have become leaders in providing person-centered care, managing a range of challenges such as mental health issues, chronic and acute physical conditions, and addiction disorders.
“The essence of each individual participant is considered. First you do an interview and you understand what’s the real background behind this person, what is significant for them, what is important, and what really makes them tick,” says Corinne Jan, NADSA chair and CEO of Family Bridges, Inc., an adult day program based in Oakland, CA. “Then you manipulate the programming and the environment so this person will be optimally engaged in the program.”
The increase in this type of engaging care is great for clients and families alike, but it comes with a host of demands and challenges that professionals like Jan are expected to tackle head-on. Just as with other types of providers, NADSA finds that adult day health organizations are first and foremost expected to meet the quality expectations of the community.
“You want to be sure that your loved one has a safe place to go and it’s clean. You want to know that the staff are good people, and you want to know who the other participants that your loved one will be sitting with or engaging with are,” says Jan. “It takes considerable planning to manipulate the environment and your operations to make sure that everybody’s engaged in that way.”
Professionals also have to keep in mind that quality can mean many things to clients and their families, including the availability of programs tailored to specific health challenges, the type of food that is offered, the languages that are spoken in the centers, and the sensitivity to cultural needs afforded to participants. In addition, Jan says NADSA has observed other expectation trends over the years, such as accessibility, not only in terms of requirements from the Americans with Disabilities Act, but also regarding where centers are located and whether or not transportation is provided.
Of course, affordability is always on the minds of family caregivers, who are often tasked with making decisions about using their parents’ retirement funds to pay for treatment after a sudden health crisis makes adult day services necessary, or obtaining long-term care insurance to pay for services in light of ongoing health issues. Also, since many people who receive adult day services are low-income and may be socially isolated and living in precarious housing situations, providers are concerned about how state and federal policies will influence reimbursements from Medicaid and Medicare, as well as how they can best navigate payment challenges while still providing the quality care their clients need and deserve.
But just as the care at person-centered adult day programs is individualized, the challenges and expectations of each center are also dependent on the specific needs of the populations they serve. The following is a look at the unique issues that some adult day health centers face in their communities and how health care professionals have risen to these challenges.
Family Bridges offers a medical day program that specializes in caring for the Asian community, including Chinese, Korean, and Vietnamese clients. With 2 large sites that work with a total of 450 clients, the organization offers multidisciplinary services that include nursing, personal care, social work, and recreation, as well as physical, occupational, and speech therapies.
Over the years, Jan has observed that the services Family Bridges provides have had to increase in scope. Their clients on average are living with 6 to 8 chronic diagnoses—including diabetes, hypertension, or kidney disease—that require them to take 12 to 15 medications. This has made it difficult for clients to maintain their health at home, so in order to address this problem and help prevent hospitalizations and emergency room visits among this frail population, Family Bridges created an innovative care model that has expanded services into the community.
“We have created a model that allows our nurses and our other staff to go outside the center to accompany patients to their doctors’ appointments, go with them to the ER, and work with discharge planners in the hospital so the transition home will be smoother and better coordinated,” Jan says. “So we’ve taken the case management that we did originally within the confines of the adult day health center and taken those services out into the community, and it’s really made a big, big difference in outcomes.”
Given these extra responsibilities, and the fact that they serve a multilingual population, another issue Family Bridges has faced is attracting the right staff.
“It’s more challenging to find good bilingual staff, particularly bilingual professional staff, like the nurses, social workers, physical therapists, and occupational therapists,” says Jan.
Family Bridges has to offer higher pay for the language differential; however, the organization has been lucky in that once it does find the right employees, the retention rate tends to be high.
When Funding and Expectations Collide
Like many adult day health programs, The Community Family (TCF) in Massachusetts has faced challenges caused by governmental regulations that have affected their funding. Founded in 1978, the organization has 4 adult day health programs—located in Everett, Medford, Lowell, and Wakefield—that provide various services, like dementia-specific care, nursing, nutrition, mental health, and social services. However, despite decades of serving the community, the combination of state regulations and new, national providers moving into the area has negatively affected TCF’s reimbursements—forcing the organization to do more without the benefit of a rate increase.
But the lack of rate increase has not decreased the needs and expectations of TCF’s stakeholders. With 300 people enrolled in their programs at any given time, Executive Director Anne Marchetta has found that since more people are staying in their homes, their populations have more needs than ever before.
“Over time, we are serving a more medically needy population than maybe 25 years ago, and I think that’s reflected in all community health,” she says. “More people are living in the community with more health issues.”
In addition to addressing increased health challenges, there is also an expectation of receiving services that are stimulating and fun. Luckily, despite issues with government funding, TCF has been able to meet this growing demand thanks to grant support that has funded a new computer system and additional activities like music and art therapy and exercise programs.
“That’s what the clients love. They come here for the fun and for the companionship, and they get medical care, but it’s not the thing that drives them to come,” Marchetta says. “They expect fun-filled days and to be able to spend time with their friends.”
Cultural Shifts Spark Changes in Client Care
Just as the medical needs of the community where Mary Immaculate Adult Day Health Center is based have changed—with more frail people requiring skilled nursing care—the cultural makeup of the area has shifted in ways that have caused the organization to update how it does business.
“As a community, there have been cultural changes and changes in the people that live here, so over time we’ve evolved from providing services to a more English-speaking clientele,” says Director Denise Legrow. “Now we have a large-sized English speaking program, but we also have services that are provided in Spanish and a couple of bilingual programs to meet the needs of the growing Latino population that’s here.”
As a result, Mary Immaculate—which provides services in the Lawrence, MA area—has been tasked with not only meeting clients’ physical, behavioral and social needs, but also tailoring these services to the Latino community. This is especially important because the facility works with clients who have dementia, so being able to create an environment that connects them to the memories they cherish from their early life is imperative in their care.
“On a day-to-day basis, providing services to a multicultural population is complex and it’s hard to make it work for everybody, but we feel like we’ve really been growing with the community as it’s grown,” says Legrow. “We’ve really developed some good programs that meet those needs—and those things can be anything from meeting the medical needs of somebody from a different culture to meeting their dietary likes and dislikes to growing and providing services that are meeting their cultural needs as well.”
Luckily, changes in the entire community have not hindered the program’s ability to find qualified bilingual staff, since many health care professionals in the area are Spanish-speaking. In addition, since Mary Immaculate has long roots in the community that have grown for over a century, the organization has a built-in reputation for being a great employer, which helps it attract and retain staff.
Serving a Mixed Population
“One of the common misconceptions about medical day programs is that people just play games all day here, and they’re all old ladies that have dementia,” says Chris Tanchak, director of the Daybreak Adult Medical Day Program in Syracuse, NY, part of the Loretto system. “That’s more of a social day program.”
However, at Daybreak—which provides a host of services, such as administering medications, checking blood sugar levels, providing personal care, and feeding those who are unable to do it themselves—clients range in age from 18 to 90-something. In addition, the organization serves clients with diverse cognitive and medical issues as well as living arrangements. Daybreak could be providing treatment to developmentally disabled 18-year-olds living with their parents or septuagenarians with dementia who live in a supportive housing setting. It also means that delivering patient-centered care can be incredibly complicated.
“With such a diverse population, to make sure that you’re meeting the needs of each individual in a group setting can be very challenging,” Tanchak says. “We have, on any given day, between 45 and 55 people in our program, and so while we’re doing a recreation program, clients are also having to step out and get their insulin, go to physical therapy, get their shower, or have somebody help them in the bathroom or have lunch. It’s also challenging because they’re pulled out of the recreation program to have their other needs met.”
In addition, since Daybreak works with younger people, some of whom have addiction disorders, there are often problems with client compliance, which can include not eating properly, taking prescribed medications, or even showing up to the program at all. In these cases, the organization will work with the clients’ case managers or family caregivers to create solutions that ensure they’re getting the most out of the program.
Another challenge Daybreak has faced has been getting the community to understand what services they actually provide because it is often confused with a social day program, so people who need their services may assume the facility does not offer them.
“It’s always a struggle to educate the community about what we provide because people think of our program as a place to come play games and maybe get lunch. They don’t realize all of the medical services that we provide, so we constantly have to educate the community that we are a medically-based program and people can’t enroll in our program unless they have a medical condition,” says Tanchak.
“People know what a nursing home is, people know what assisted living is, people know about mental health services and developmental disability services, but they don’t know that there are these day programs that can serve people with medical issues—it’s just not common knowledge.”
Kenya McCullum is a writer who lives in San Francisco, CA.