Thursday, September 15, 2016

More on Staying at Home – Adult Day Services as a Valuable Option

One of the most critical, yet least used services to help older people stay at home is adult day services.  For many people, adult day services can make the difference between staying at home and going into a nursing home or assisted living.

I have written before about adult day services, but I just got back from attending a board meeting of the National Adult Day Services Association (NADSA) and made some observations that I think are worth recounting. 

Perhaps what has stood out for me most during this meeting and during past board meetings and the annual NADSA conference is the idealism of the people involved in running adult day services programs.  They genuinely care about the people they serve and about doing the best possible job.  During the board meeting this past week, we were talking about new directions and goals for the association and for individual programs.  One board member, who was trained as a CPA and who has been in the business for a while stood up to talk.  You might think someone with his background would talk about money.  Instead, he passionately argued that the main focus has to be on the quality of life of the people adult day programs serve.  In my time on the board, I have never heard a discussion of how to increase profits, but only how programs can reach more people and improve how they serve them.

I also heard about some innovative adult day service programs.  One of the biggest problems that adult day service programs face is an initial reluctance of families to enroll a parent or spouse.  People see these programs as nothing more than baby-sitting for elders, with meaningless activities.  But good programs provide a rich program of activities that provide cognitive, social and physical stimulation.  When done well, these activities may help keep people active longer.

A program in Indianapolis has overcome this initial reluctance to use an adult day services program.   Along with regular activities, the program provides physical and occupational therapy for individuals who need it.  For everyone else, there is a regular walking program as well as other activities.  According to the director, families are not reluctant to use the program, because it offers therapy.  Ongoing or intermittent PT and OT may also lead to gains in functioning or at least prevent or slow decline.  In its “penny-wise-pound-foolish” way regarding anything except medical tests and procedures, Medicare does not see the benefit of this type of maintenance. 

Why don’t more adult day service programs do something like this?  Here the answer is money.  Most programs would have trouble covering the cost.  Medicare will pay for OT and PT for a limited time following a hospitalization or other new problem.  OT and PT can be offered on an outpatient basis, including in an adult day program that meets Medicare regulations.  Indeed, it would be a cost-effective way of doing so compared to a nursing home or rehabilitation hospital, since the participant would be living at home.  But once Medicare coverage runs out, the adult day program would have to charge the full Medicare rate for participants to continue, whether or not they are able to pay.  Medicare does not allow different rates for different people or sliding fee scales.  The Indianapolis program, which is a religious-sponsored non-profit, covers costs not by billing Medicare but by raising donations, and they have been successful in doing so for 20 years. 

But the bottom line is that, with or without PT and OT, adult day services can provide meaningful activities that support cognitive, social and physical functioning.  Participants can engage in enjoyable activities, whereas at home, they are more likely to be inactive.  Furthermore, there is an increasing emphasis among adult day service programs to offer person-centered programming, that is, activities that are tailored to each person’s preferences.  And their family caregiver will get time away from caregiving.  Finally, the program is likely to be run by energetic and committed people, who, like the NADSA board members, place quality of life as the central goal.

If your goal is to stay at home no matter what, a good adult day services program can do this.  A couple of program directors talked about how they are able to maintain people until near the end of life, when they are discharged from adult day services directly to hospice, usually at home.  People are able to live and die how they want, not in the sterile and often demeaning nursing home environment.

As a postscript, let me explain Medicare’s reasoning.  They provide support for OT and PT for only a limited time, because they view it as a specific treatment response to an acute problem, such as a fall or a stroke.  They believe that after a certain amount of time, all the potential gain that could be made, has been made.  How was this determined?  Not by empirical evidence.  At some point in the past, a physician who may or may not have been a rehabilitation expert may have stated a number of days after which no further benefits would occur.  Or even worse, a health economist may have concluded that the cost-benefit of additional days of OT and PT was not worth it.  Medicare would also argue is also no evidence that treatment such as done at the Indianapolis adult day services program helps maintain functioning over time. But does it work?  As far as I know, evidence is limited although a recent article suggested that OT in the home along with other services led to improved functioning.

About the photo:  The NADSA Board Meeting and Annual Conference was held at the Crown Plaza Union Station Hotel in Indianapolis.  The hotel is built into the old railway station.  I stayed in one of about 24 rooms that are located in renovated train coaches.  It was very cool and quite comfortable.

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