December 20, 2004
CONNECTICUT ADULT DAY CARE CENTERS
By: Helga Niesz, Principal Analyst
You asked about adult day care centers in Connecticut, particularly their number, programs, and sources of funding.
"Adult day care centers," (also known as "adult day centers," "adult day health centers," or "senior day care centers") are locations where frail seniors and disabled people can go during the day if they cannot be home alone. They provide supervision, social and recreational activities, personal care, lunch and snacks, and often medical care and health monitoring from a nurse on the premises. Most attendees need some supervision or medical services and are able to travel to the center during the day, but have family members who care for them at night and on weekends. The centers are one way for the elderly or disabled to avoid or delay entering a nursing home and to give family members caring for them a chance to continue working at their jobs or have some respite during the day.
The state does not license adult day care centers. But in order to receive per-patient fees for their services from the state for their clients whose income and medical condition qualifies them for assistance, they must meet the Connecticut Association of Adult Day Centers (CAADC) standards for certification, developed in cooperation with the Department of Social Services (DSS). There are currently 54 centers in Connecticut certified by CAADC serving clients who receive state assistance and two out-of-state licensed centers along the border also serving Connecticut clients, according to a DSS list. There is at least one center in Connecticut that is uncertified. Centers that do not receive state money do not need certification.
Adult day care centers can operate on a "social model" or a "medical model." The social model serves people who need supervision and activities to reduce social isolation, but not extensive personal care and medical monitoring. Only seven centers on the DSS list are social model centers. The rest are medical model, which also provides nursing, personal care, and other medical services.
The centers are funded by a mixture of public and private funds. Daily patient fees are the main source of funding. These can be paid privately by the individuals or, in a large number of cases, by the state. A major source is the state-funded or Medicaid portion of DSS's Connecticut Home Care Program for Elders (CHCPE), which serves lower-income seniors, but a few smaller state programs also pay these fees for qualifying elderly or disabled people. Centers can also receive various federal funds under the Older Americans Act distributed through the Area Agencies on Aging, as well as federal nutrition and transportation funding. While the state does not provide funding for starting up adult day care centers, it does provide a small allocation for Alzheimer's services at day care centers. Some centers receive grants or subsidies for some of their clients from charitable organizations and foundations.
NUMBERS OF ADULT DAY CARE CENTERS
Currently, 54 adult day care centers certified by CAADC in Connecticut serve clients receiving state assistance, according to a December 14, 2004 DSS list. In addition, the list contains two out-of-state centers, one just over the border in Rhode Island and one in Massachusetts, with which DSS contracts to serve residents living along the borders. At least one center is uncertified and there may be a few other uncertified centers, but we were not able to identify them. The number of centers appears to be declining, most likely because of financial problems; in 1999 there were 68, which was already a reduction from the 77 that existed in 1997 and 1998. The enclosed chart from DSS lists the centers with which DSS contracts, their locations, phone numbers, and whether they follow a medical or social model.
ADULT DAY CARE CENTER PROGRAMS
Adult day care centers are most useful for people who need some supervision or medical services and are able to travel to the center during the day, but who have family members available to care for them at night and on weekends. The centers are one of several ways that elderly individuals can avoid or delay entering a nursing home. In Connecticut, the centers have a range of about 40 to 150 enrolled clients, although the average daily census of attendees is typically about half of the enrolled clients, according to Michael Hebert, CAADC's advocacy chairman. This is because some people are only scheduled to attend on some days of the week, and others are absent for sickness, inclement weather, or other reasons.
The centers can take one of two forms. They can follow either a medical model that provides some medical services and more hands on care, such as help with bathing or grooming, or a social model that provides only supervision and a program of social and recreational activities. Individuals can generally attend a center from one to five days a week as needed (although some are also open on weekends), and they can be there for part of a day or a full day.
Centers in Connecticut are not licensed by the state. Instead, they are "certified" through a process developed jointly by the Connecticut Association of Adult Day Care Centers together with DSS. It is the association that certifies the centers. A center could operate without certification if all its clients paid privately, but to qualify for DSS payments, they must meet the association's standards. Most certified centers are members of the association, but it also certifies nonmembers. DSS itself certifies the two out-of-state centers, based on their being licensed by their own states. (The enclosed association document “Standards for Adult Day Care Centers in Connecticut” provides details on the certification process, which include minimum standards for the physical space, personnel, a required direct care staff/patient ratio, staff training, record-keeping, recreation, nutrition and other requirements.) A medical model center must have a nurse on site for at least half of each day. If the center provides nursing services, they must be provided by registered nurses or licensed practical nurses under the supervision of a registered nurse.
MAJOR FUNDING SOURCES
Connecticut Home Care Program for Elders (CHCPE)
DSS is authorized to pay adult day care centers as an alternative to home care for qualifying individuals. CHCPE provides home health and other community-based services to individuals age 65 or older who meet financial criteria and have difficulty with the activities of daily living. On average, roughly 55% of clients attending the centers received help from CHCPE, according to CAADC. The program has two components: (1) a "Medicaid waiver" portion, and (2) a completely state-funded portion.
Medicaid Waiver. CHCPE's “Medicaid waiver” portion is funded by the Medicaid program (which uses matching state and federal funds to pay medical bills for very poor people). States can receive federal waivers from normal federal Medicaid rules to provide home and community-based services to recipients who meet the criteria for institutional long-term care services. This waiver was designed to correct a bias toward expensive institutional care in Medicaid services for chronically ill people, by instead allowing them to receive less costly at-home or community-based care.
The state receives federal reimbursement for half of what it spends on Medicaid services to qualifying individuals. To qualify, an individual's income can be no more than $1,692 a month. A single person can have only $1,600 in countable assets. A couple who both receive services can have only $3,200 in assets. If only one person in the couple receives services, their combined assets can be $20,152 or in some cases a higher amount that results from a special DSS assessment of spousal assets. The home, furnishings, personal belongings, a motor vehicle needed for transportation, burial funds and burial plots, and certain life insurance policies are exclusions from this asset determination.
State-Funded. The CHCPE's state-funded component has somewhat more liberal eligibility requirements. It pays for services to those who have more income or assets than Medicaid allows or who otherwise do not meet Medicaid requirements. It has no specific monthly income limit as long as the patient would otherwise have to be in a nursing home. Countable asset limits are $18,552 for a single person and $27,828 for a couple, regardless of whether one or both are receiving services.
Rates and Payment Mechanisms. As of July 1, 2004, CHCPE pays $54.93 a day per person for the medical adult day care model and $51.58 for the social model for a full day and $33.63 for a half day for both types. This rate is intended also to cover transportation to and from the center. Payments for home care and adult day care services are funneled from DSS through its access agencies, which do screening and assessments and contract for the services with the providers. These access agencies, which bid for contracts with DSS, include two of the five Area Agencies for Aging and, in other areas, Connecticut Community Care, Inc. The case manager at the access agency, who looks at all the client's circumstances, makes the recommendation for adult day care instead of at-home services.
Donna Lange, CAADC's president, attributes the declining number of centers to inadequate funding and the shortfall between the roughly $55 a day that the state pays for its eligible clients and the center's daily costs per person, which now average $76.80, according to the association's recent survey of its members. Although rates for private pay patients can range up to $80 a day, this does not alleviate the shortfall much, since often between 40% and 80% of centers' clients receive assistance, according to Lange.
State-funded Alzheimer's Respite Program
The state started a program in 1998 that provides respite care for families caring for people with Alzheimer's or related disorders. To qualify, the patients must meet certain income and asset limits. The program provides up to $3,500 worth of care annually for patients with incomes up to $30,000 a year and liquid assets up to $80,000. The care can take place in the individual's home, a nursing home, or an adult day care center. DSS runs the program in cooperation with the Alzheimer's Association and the Area Agencies on Aging.
Other State Programs
Several other state programs pay for adult day care if it is needed. The Community-Based Services/Essential Services Program, which provides qualifying disabled people under age 65 with up to $650 a month worth of an array of services including adult day care if needed, is funded by state money and federal social services block grant money. The Elderly Protective Services program uses state money to provide services to elders who have been abused or neglected and if needed may also pay for adult day care on a short-term basis. And the Department of Mental Retardation waiver uses Medicaid money to pay for services to people with mental retardation, including adult day care if it is needed.
Other than the patient fees described above, the only direct state funding for centers is a small allocation for those that specialize in Alzheimer's and related diseases to help pay for extra aides trained in those conditions. DSS makes these grants to the Area Agencies on Aging, which actually disburse the funds to centers that apply for them.
Some centers also receive limited amounts under the federal Older Americans Act Title III through the Area Agencies on Aging. They use this federal money to pay daily fees for patients who do not qualify for the CHCPE. In some cases, the Veterans' Administration pays patients' adult day care fees. More recently, limited subsidies have been provided under the federal National Family Caregivers' Act for qualifying people not covered by other programs.
Other sources include fees from private pay clients, grants from private organizations, town funding, and charitable donations. Centers often have a sliding scale for fees for private pay clients depending on their income. Reimbursement from long-term care insurance or other private health insurance is not a large factor now, but could become more important in the future.
The state does not contribute any funds directly to starting up adult day care centers. These are usually started by nonprofit organizations or for-profit corporations. Sometimes a town will start one up in connection with its senior center. Other times, people starting an adult day care center might apply for a small business loan or, if they are women, special loans for women starting businesses.