January 14, 2011
ADULT DAY CARE CENTERS
By: Robin K. Cohen, Principal Analyst
You asked for general information on adult day care centers. You also are specifically interested in Enfield's town-run center.
This report updates OLR report 2004-R-0774.
“Adult day care centers,” (also known as “adult day centers,” “adult day health centers,” or “senior day care centers”) are facilities where frail seniors and disabled adults can go during the day if they cannot, or do not wish to, 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. Family members 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 who care 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 any per-patient fees for their services from the state, they must be certified by the Connecticut Association of Adult Day Centers (CAADC). There are currently 48 CAADC-certified centers in Connecticut serving clients who receive state assistance and centers in border states also serving Connecticut clients. There is at least one uncertified center in Connecticut.
Adult day care centers are operated 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 a Department of Social Services list of CAADC member centers are social model centers. The rest are medical model centers, which, along with social activities, also provide 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. A few smaller state programs also pay adult day care fees for qualifying elderly or disabled people. For example, money from the state's Alzheimer's Respite Care Program is available to centers that provide care to seniors who qualify for that program. The state currently pays about $66 per day for adult day care services, while the average cost of providing these services is $84, according to the CAADC.
Centers can also qualify for various federal funds under the Older Americans Act as well as federal nutrition and transportation funding. Some centers receive grants or subsidies for some of their clients from charitable organizations and foundations.
The town of Enfield runs one of the two adult day care centers located in the town. It offers services to individuals age 60 and older and younger adults with disabilities. Its services include medicine administration; showers and personal care; counseling; and field trips, among others. The center employs seven people (six are full-time) and has estimated FY 11 costs of $410,000. Most of the center's revenue comes from client fees, much of which is paid by the state under the CHCPE.
NUMBER OF ADULT DAY CARE CENTERS
Currently, 49 adult day care centers operate in the state; 48 of these are certified by CAADC, according to Katherine Donohue, president of CAADC. Certification enables the centers to have qualified clients' care paid for by DSS. In addition, two out-of-state centers, one just over the border in Rhode Island and one in Massachusetts, contract with DSS to serve residents living along the borders.
The number of centers has declined over the last 10 years or so, most likely because of financial problems. For example, in 1998, there were 77; in 1999, the number had dropped to 68. (The enclosed chart from CAADC lists the CAADC member centers, their locations, phone numbers, and whether they follow a medical or social model. The chart does not include a newer member center—Mulberry Gardens in New Britain—which is also CAADC-certified.)
ADULT DAY CARE CENTERS
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 or others 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 enrolled clients, although the average daily attendance is typically about half of the enrolled clients, according to CAADC's Donohue. 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” by CAADC through a process developed jointly by CAADC and DSS. 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.
The certification standards for centers 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.
DSS itself certifies the two out-of-state centers, based on their being licensed or otherwise eligible for Medicaid reimbursement in their home states.
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 through the CHCPE. CHCPE provides home health and other community-based services, including adult day care, to individuals age 65 or older who meet financial criteria and have difficulty with the activities of daily living.
The program has two components: (1) a “Medicaid waiver” portion, and (2) a completely state-funded portion. In 2004, the latest year for which we have data, roughly 55% of center clients were eligible to have their care paid by CHCPE, according to CAADC. We are trying to get an updated figure and will get it to you once we do.
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 the Medicaid program for chronically ill people, by instead allowing them to receive less costly at-home or community-based care, such as adult day care services.
The state generally receives federal reimbursement for half of what it spends on Medicaid services to qualified adult day care clients. To qualify, an individual's income can be no more than $2,022 a month. A single person can have $1,600 in countable assets. A couple who both receive services can have $3,200 in assets. If only one person in the couple receives services, the couple's combined assets can be $23,512, or in some cases, a higher amount that results from a special DSS assessment of spousal assets. Homes, furnishings, personal belongings, a motor vehicle needed for transportation, burial funds and plots, and certain life insurance policies are generally not counted in this asset test.
To “functionally” qualify for the Medicaid-funded portion of the program, an applicant must be very frail (need help with at least three activities of daily living).
State-Funded. CHCPE's state-funded component has more liberal eligibility requirements. It pays for services to elders who (1) are moderately to very frail and (2) 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 likely have to be in a nursing home. Countable asset limits are $32,868 for a single person and $43,824 for a couple, regardless of whether one or both are receiving services. Clients pay a percentage of their care costs.
Rates and Payment Mechanisms. As of July 1, 2010, CHCPE pays $66.22 a day per person for the medical adult day care model and $62.18 for the social model for a full day and $40.54 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.
Access Agencies. The access agencies, which bid for contracts with DSS, include two of the five Area Agencies on 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. In some cases, the client self-directs his or her care and does not have a case manager.
State-funded Alzheimer's Respite Program
The state started a program in 1998 that provides respite care, which includes adult day care, for families caring for people with Alzheimer's or related disorders. Clients must meet certain income and asset limits to qualify. This 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. DSS runs the program in cooperation with the Alzheimer's Association and the Area Agencies on Aging (CGS § 17b-349e). The program pays the adult day care centers the same rates as those for the CHCPE.
Other State Programs
Several other state programs pay for adult day care if it is needed. The DSS-run Community-Based Services/Essential Services Program, which provides qualifying disabled people under age 65 with up to $650 per month worth of an array of services, including adult day care if needed,
is funded by state appropriation and federal social services block grant money. The CHCPE rates are paid to centers serving clients eligible for this program. (This program is no longer taking new clients.)
DSS' Elderly Protective Services program uses state money (same rates as CHCPE) 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. (In 2004, the Department of Developmental Services' (DDS) waiver used Medicaid money to pay for adult day care services provided to people with mental retardation, including adult day care. We have asked DDS if this still occurs.)
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 caring for these clients. DSS makes these grants to the Area Agencies on Aging, which disburse the funds to centers that meet eligibility requirements.
Some centers also receive relatively small amounts under Title III of the federal Older Americans Act administered by the Area Agencies on Aging. They use this federal money to pay daily fees for clients who do not qualify for the CHCPE. In some cases, the Veterans' Administration pays patients' adult day care fees. The U.S. Department of Agriculture provides payments to centers to offset their costs of providing nutritious meals to adults over age 60.
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 so in the future.
The state does not directly fund start-up costs for adult day care centers. These are usually started by nonprofit 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.
TOWN OF ENFIELD—ENFIELD ADULT DAY CARE CENTER
Enfield has two adult day care centers. The town-run center operates in a rent-free space adjacent to the Mark Twain congregate living center. The center offers services to up to 40 individuals age 60 and over and any adult with a disability.
The center provides the following services to Enfield residents, as well as adults from Somers, Suffield, East Windsor, Stafford, Windsor, Windsor Locks, and Longmeadow, Massachusetts:
1. medicine administration,
2. pacemaker checks,
3. occupational and speech therapy,
4. showers and personal care,
5. treatments (e.g., respiratory, oxygen),
7. support groups,
11. field trips,
12. hot meals and snacks, and
13. beautician services.
The Town of Enfield provides rides to and from the center to its residents only. The Somers and Suffield Dial-a-Ride programs transport those towns' residents. The other towns' residents have to secure their own transportation, according to one of the center's staff nurses, Kathleen Schumann.
Because the center uses the medical model, it has medical staff on site, including four full-time health aides and a half-time nurse. Additionally, it employs a full-time director and clerk typist. In FY 11, it also has funds reserved for a substitute nurse.
The center's budget for FY 11 is $410,072. Most of this is personnel costs, including employee benefits. Table 1 provides a breakdown of FY 11 estimated expenditures.
Table 1: Town of Enfield Adult Day Care Center FY 11 Budget Expenditures
Purchased professional and technical services
Other purchased services
Supplies and materials
Source: Town of Enfield budget documents
According to the center's executive director, Paula Viceakauskas, the center has no rent costs. It is located at the Mark Twain congregate living facility, but has its own separate entrance. The town presently pays no rent (the housing authority manages the congregate living center) but it provides free maintenance (e.g., snow removal) to the congregate living facility.
Most of the center's revenue comes from client fees, with the majority of those fees paid by the CHCPE. The center charges private pay clients $71 (which is between $5 and $10 more than what the CHCPE pays for its clients) per day to use the center. We asked center director, Vicekauskas, for a breakdown of client revenues by payment source and will forward this to you when we receive it. Schumann reports that about half of the clients are CHCPE participants and about one-tenth have their care paid by the Alzheimer's respite program.
Table 2: Town of Enfield Adult Day Care Center FY 11 Revenues
Supportive grant from North Central Area Agency on Aging
Child and Adult Care Food Program (United States Department of Agriculture)
General Fund Transfer (funds transferred to other town program)
Source: Town of Enfield budget document
 The town historically has received funds from the state's Alzheimer's Respite Program. We are attempting to find out why this number is zeroed out in FY 11.