VERMONT’S ADULT DAY CENTER SYSTEM


June 13, 2008		2008-R-0342
VERMONT'S ADULT DAY CENTER SYSTEM

By: Nicole Dube, Legislative Analyst II

You asked for information on Vermont's adult day center system, specifically how it is funded.

Vermont's adult day centers are community-based, nonresidential facilities where frail seniors age 60 and older and disabled adults can go during the day if they cannot be home alone. The state does not license adult day centers, but they must be certified by the Department of Disabilities, Aging, and Independent Living (DAIL) in order to receive state funding. Currently, 14 certified providers operate 16 facilities statewide.

Adult day centers provide a range of social and medical services including supervision, social and recreational activities, therapeutic activities, personal care, nursing services, meals, respite, and medical care. Vermont requires all centers to have the capacity to administer medications to attendees and a medication management policy that describes its medication management practices, which must be in accordance with state requirements, including the Vermont State Nurse Practice Act. A registered or licensed practical nurse must supervise medication management.

Adult day services are funded through both public and private funds. The main source of funding is daily client fees, which can be paid by the state or by the individual. The primary sources of state funding are two Medicaid programs--the Choices for Care Medicaid waiver and the Day Health Rehabilitation Services program. Additional funding is received from the state's general fund and other state programs. Centers also rely on charitable donations.

“Adult day centers" (also known as "adult day care centers") are community-based, nonresidential centers where frail seniors age 60 and older and disabled adults can go during the day if they cannot be home alone. They provide services to help these individuals remain independent in their own homes as long as possible. Their services include supervision, social and recreational activities, therapeutic activities, personal care, nursing services, meals, respite, and medical care.

Most attendees need some supervision or medical services and are able to travel to the center during the day; family members care for them at night and on weekends. The centers are one way for elderly or disabled people to avoid or delay entering a long-term care facility and to enable family members caring for them to continue working or have some respite during the day.

Adult day centers generally operate on either a "social model" or a "medical model." The social model serves people who need supervision and activities to reduce social isolation, but does not provide extensive personal care and medical monitoring. The medical model provides nursing, personal care, and other medical services. But, the Department of Disabilities, Aging, and Independent Living's Camille George characterizes Vermont centers as operating on a “holistic” model that incorporates social and medical services based on individual needs.

Vermont requires all centers to have the capacity to administer medications to attendees. Each center must have a policy that describes its medication management practices. These must be in accord with state requirements, including the State Nurse Practice Act. An adult day center must provide medication management under the supervision of a registered nurse or licensed practical nurse.

Vermont does not license adult day centers. But in order to receive state funding, centers must meet DAIL certification standards. A center could operate without certification if all its clients paid privately, but to qualify for state funding, it must meet the department's standards. DAIL is unaware of any un-certified centers currently operating. (The enclosed DAIL document “Standards for Adult Day Services in Vermont” provides details on the certification process, which include minimum standards for the physical space, personnel, a required direct care staff to patient ratio, staff training, record-keeping, recreation, nutrition, and other requirements.)

Currently 14 certified providers operate 16 sites statewide, serving approximately 1,100 people. According to DAIL, there are four “sizes” of adult day providers based on the hours of adult day services they provide (See Table 1).

The largest provider, Elderly Services, reported an average of 2,000 hours per week during FY 08, representing 21% of all service hours provided in the state. In contrast, the smallest provider, Oxbow Senior Independence Program reported an average of 155 hours per week.

FUNDING SOURCES

Vermont's adult day centers receive both public and private funding. The main source of funding is daily client fees, which can be paid by the state or the individual. Most funding is from the state, the majority of which comes from the Choices for Care Medicaid Waiver and the Day Health and Rehabilitation Services Program (DHRS), which is a Medicaid State Plan Service. Both programs pay an hourly rate, which is scheduled to increase from $13 to $15 per hour on July 1, 2008. According to the Vermont Association of Adult Day Service's Lynn Bedell, this rate is “all inclusive” and does not take into account client acuity levels. Providers are reimbursed the same rate regardless of the client's service needs.

Table 2 shows the funding sources for adult day services during the first three quarters of FY 2008.

During the first three quarters of FY 08, 54% of adult day center funding was provided by Vermont's Choices for Care program. Choices for Care was established in 2005 as an 1115 Medicaid waiver demonstration program that in effect turned federal Medicaid funding for long-term care (both nursing home care and home care) into a block grant for the state.

The program entitles Medicaid-eligible people in the designated highest need group to choose either nursing home care or home- and community-based care (HCBS). Adult day services are a home-and community-based service option under the program.

1. A highest need group entitled to either nursing facility or HCBS care. Individuals in this group must qualify for nursing home levels of care.

2. A high needs group that receives services as funds are available but is not automatically entitled to services. This group does not meet the functional criteria for the highest needs group but has extensive personal care and rehabilitation service needs.

3. A moderate needs group that includes people who do not meet nursing facility or HCBS waiver criteria but are at risk of admission to a nursing home. They also receive services only if funding is available. Functionally, this group does not qualify for institutional levels of care.

People must also be financially eligible for long-term care Medicaid. Individuals seeking adult day services who are in the high and moderate needs groups may be put on a waiting list if funds are not available. According to DAIS, in March 2008 three providers reported waiting lists ranging from 4 to 15 people.

OLR report 2007-R-0025 describes the Choices for Care program in greater detail.

Day Health Rehabilitation Services (DHRS) is the community Medicaid funding source for adult day services, separate from long-term care Medicaid in Choices for Care. It was established in 2000 as a Medicaid State Plan service for individuals with physical or cognitive impairments who are not in nursing homes or receiving enhanced residential services. Services provided under the program include:

The adult day center provider determines an individual's eligibility to receive services. An individual must require services in at least two of the following areas: personal care, nursing services, special therapies, social work, and nutrition. He or she must also be financially eligible for community Medicaid.

Approximately 19% of adult day services provided during the first three quarters of FY 08 were supported by this program.

State general funds are provided to help the 14 certified centers cover a portion of their general operating costs. According to George, each center received approximately $8,200 during FY 2008. In addition, the state legislature approved funding in 2000, 2004, and 2005 to support infrastructure enhancements for adult day centers. Centers have used these funds to expand and renovate existing facilities, move into larger facilities, and to install and purchase new equipment.

Several other state programs pay for adult days services if needed. The Department of Mental Health's Community Rehabilitation and Treatment program provides qualifying adults diagnosed with a mental illness with a range of services, including adult day services if needed. Services are funded by state and federal Medicaid money. The Veterans Administration also provides funding for adult day services to eligible veterans. And DAIL's Developmental Disability Services Medicaid waiver pays for services to people with developmental disabilities, including adult day care if it is needed.

Approximately 10% of adult day services were funded from private pay clients in the first three quarters of FY 08. Vermont requires all adult day centers to offer a sliding scale for fees for private pay clients depending on their income. Each center determines its own private pay rates.

Vermont Department of Disabilities, Aging and Independent Living, http://dail.vermont.gov/, last visited on June 9, 2008.

*Size*	*Number of Providers*	*Provider Name*
Large	1	Elderly Services, Inc.
Medium	7	Barre, Bennington, The Gathering Place, CarePartners, Riverside, Springfield, VNA of Chittenden, and Grand Isle Counties
Small	5	Gifford, The Meeting Place, Green Mountain, Out and About, and Rutland
Very Small	1	Oxbow Senior Independence Program


SFY 08 (1^st three quarters) –Adult Day Service Funding Sources
Funding Source	% of Total Adult Day Service Hours
Medicaid (both Choices for Care and DHRS)	73%
Private Pay	10%
Developmental Disability Services Waiver	4%
Sliding Fee Scale	4%
Department of Mental Health's Community Rehabilitation and Treatment Program	3%
Office of Veterans Affairs	3%
State General Funds	3%