Adult Daycare Program Offers Nursing and Rehabilitative Services, Leading to Improved State of Mind for Low-Income Elders and Disabled Adults

Problem Addressed

• Desire to remain at home: More than 90 percent of older Americans want to remain in their homes, where they have ties to the community. However, many seniors are forced to move to nursing homes because of declines in physical and functional health status and the gradual erosion of caregiver and other social support networks.² 
• High costs for those who end up in nursing homes: The cost of living in a nursing home is high—an average of $64,000 annually for a semi-private room and $74,000 for a private room.³ The cost often drains individuals' savings and/or puts a heavy burden on taxpayers. 
• Need for respite services to delay institutionalization: A controlled trial of 50 families who provided full-time care for an elderly relative confirmed the benefits of formal and informal respite services to aid their ability in providing this kind of care and in preventing or delaying institutionalization.⁴

Description of the Innovative Activity

• Facilities: ElderHealth operates six centers in the Seattle area. Five of the centers operate Monday through Friday, while one is open 7 days a week (including holidays) and accepts clients from any of the other centers on weekends/holidays. Most centers operate two separate 4- to 5-hour programs—one in the morning and one in the afternoon.
• Referral/community outreach: Targeted outreach efforts focus on reaching racial or ethnic minorities, including African Americans and Latinos who are often attracted to the idea of keeping their loved ones at home. Without access to the adult day health program, many low-income clients would likely be placed in long-term care facilities. Referrals come from state case workers through the Department of Social and Health Services system, discharge planners from hospitals and nursing facilities, and caretakers.
• Initial intake, assessment, and care plan: Clients receive an initial clinical assessment to determine their nursing, rehabilitative, and social needs. This assessment forms the basis for development of an individualized care plan that includes, depending on client need, occupational therapy, nursing services, patient goals, nutrition services, speech therapy, social work, and psychiatry. Assessments and care plan development are repeated on a quarterly basis. 
• General program services: The traditional program serves older adults who typically participate two or three times a week in a variety of individual and group activities, as determined by their care plan. Services include:
  • Health care services: Clients can receive nursing assessment and treatment (e.g., oxygen, catheter care), health education (e.g., on nutrition, managing chronic disease), diabetes management (e.g., insulin injections, blood glucose testing), podiatry, medication management, and wound care. Nursing staff communicate with the client's regular physician to ensure coordination of care.
  • Rehabilitative therapy: Clients engage in occupational and physical therapy (including fall-prevention activities, strength and endurance exercises, and learning how to transfer themselves safely from a chair or bed); exercise and walking programs; and training on the use of walkers, canes, and other equipment.
  • Social work services: Social workers consult with clients, caregivers, and families to develop individualized care management plans, with referrals made to community resources as needed.
  • Mental health services: Clients receive periodic psychiatric evaluations and treatment as needed, including participation in education and support groups, stress management, and grief counseling.
  • Group activities: Group educational and recreational programs are designed to challenge the client's minds, keep bodies moving, and lift spirits. Participants can choose from numerous offerings that change each season, such as sports and activities, educational groups, creative groups, games, and field trips.
• Specialized programs for specific populations: ElderHealth runs three additional adult day health programs that cater to individuals who need additional support and services. The unique features of each of these programs are described below:
  • Get Active program: Get Active provides care for adults with developmental disabilities. Clients receive nursing and rehabilitative services, including assistance with activities of daily living; behavioral and social skills building; and participation in recreational activities, such as woodworking, reading, and field trips. 
  • Dementia program: To reduce the incidence of patient agitation, the dementia program operates in a separate space from the traditional program, with a calmer environment and more staff supervision. Staff offer assistance with toileting and feeding and lead appropriate activities designed to stimulate the mind and make socializing easy.  
  • "Heads Up" program: The "Heads Up" program offers specialized services for adults aged 18 to 59 years living with acquired brain injuries. "Heads Up" strives to foster independence, responsibility, and integration into community life. Clients learn skills that promote greater autonomy, engage in social activities (e.g., field trips, exercise, music, word games, arts and crafts), and receive services designed to help them remain healthy (e.g., nursing services, medication management, and occupational therapy). 
• Extended care: For family members or other caregivers who work full time and/or otherwise need additional services, ElderHealth offers an extended care option that allows participants to stay longer than the typical 5-hour session.
• Program fees: Medicaid and other public and private insurers typically cover program services. Program fees are kept low so that people from all backgrounds can afford the services. ElderHealth offers a sliding-scale fee schedule for uninsured clients who cannot afford the program fee. 

References/Related Articles

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Results

Results from ElderHealth

• Improved state of mind: Anecdotal reports from long-time ElderHealth staff suggest that the social interaction offered by the program has a significant, positive impact on most clients' state of mind. Staff report that clients who had been very isolated before enrolling in the program often achieve dramatic, quick improvements in their emotional state.

• Improved participant memory and behavior: The University of Washington Northwest Research Group on Aging is analyzing the impact of the adult daycare program offered by Seattle’s Dementia Partnerships Project. Early findings suggest that program participants demonstrate meaningful improvements on all memory and behavioral measures at 6-month assessment. For example, participants demonstrated improvement or stability in the frequency of behavioral problems, while the frequency of such problems increased in the comparison group.⁵
• Reduced caregiver stress: A study using a quasi-experimental design found that, compared to a control group in which dementia patients did not participate in adult daycare programs, caregivers in a treatment group (in which dementia patients attended at least 2 days of adult daycare weekly) experienced lower levels of stress, worry/strain, depression, and anger; differences were found for both short-term (3 months) and long-term (12 months) participants.¹ Similarly, the University of Washington study cited above found that caregivers with a family member in the adult daycare program experienced a smaller decline in emotional functioning over time than members of a comparison group.⁵

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Securing funding: In the early 1970s, community leaders formed a nonprofit organization (ElderHealth) to apply for development funds from the Federal government. These funds covered the initial planning and implementation of the adult daycare program. Over the years, additional funding has been secured to cover operational shortfalls (because program fees do not cover all costs), renovate space, and develop new services; funds have been raised from a variety of sources, as described in the Funding Sources section below. 
• Training: All ElderHealth staff receive training in a variety of areas, including cardiopulmonary resuscitation, first aid, transferring and ambulating patients, and facilitation of developmentally appropriate recreational activities. 

Resources Used and Skills Needed

• Staffing: Each center is staffed with two multidisciplinary teams: one each for the morning shift and afternoon shifts. Teams consist of a site manager, an individual with nursing experience (either a registered nurse or licensed practical nurse), a rehabilitation professional, a social worker, an activities director, and program assistants. To cater to ElderHealth's diverse clientele, staff members are available who speak English, Spanish, German, French, Mandarin, and many other languages. For the general program, the staff-to-client ratio is approximately one to six, while for the specialized programs a one-to-four ratio is used. The "Heads Up" program team includes an occupational therapist with expertise in working with persons who have an acquired brain injury, while the Get Active program includes team members with expertise in developmental disabilities. 
• Costs: The cost of the program is between $0 and $65 per day based on a sliding scale.

Funding Sources

Getting Started with This Innovation

• Convince community leaders to support program: Because adult daycare centers are a low-margin standalone business, leaders will need to be convinced of the merits of the program. Share data on the potential benefits, including reductions in ED visits, hospitalizations, and nursing home admissions; physical and mental health benefits for participants; and reduced stress, anxiety, and depression for caregivers. 
• Secure initial funding: Funds will be needed to cover initial program development. Local foundations and corporations are often a good source for obtaining grants. 

Sustaining This Innovation

• Believe passionately in the model: The strong, passionate, ongoing commitment of program leaders is critical to long-term success.
• Continue fundraising efforts: As noted, additional funds will likely be needed to cover ongoing operations and to fund program expansion and modification. 
• Consider targeting a broader clientele: Many of ElderHealth Northwest's centers are in low-income areas, and most marketing efforts focus on the neighborhoods surrounding the center. However, broadening these marketing efforts and/or expanding into more affluent neighborhoods could potentially attract more clients able to pay full fees, thus providing additional funds to subsidize low-income clients and fund program/service expansions. 
• Treat the program as standalone entity (even if part of larger organization): Adult day health programs that are part of larger organizations (e.g., hospital/health systems, nursing homes chains) sometimes suffer from a lack of resources, because other parts of the organization take priority. ElderHealth Northwest, for example, took over a struggling adult daycare program run by a local provider system in which leaders were skeptical of the program's viability in the local community. ElderHealth revitalized and expanded the center and later opened a second facility in the county. 
• Refine the model over time (with input from clients): Continually solicit input from clients and other stakeholders on how to improve the program. Consider allowing clients to become involved in leading day-to-day group activities.
• Tap into existing, low-cost training programs: Local and national associations exist that can help train staff, including organizations that specialize in day centers and in working with special populations (e.g., dementia patients).

Additional Considerations and Lessons

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