Adult day facilities for treatment, health care, and related services

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Adult day facilities for treatment, health care, and related services
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Trager, Brahna
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Table of Contents
    Front Cover
        Page i
        Page ii
    Preface
        Page iii
        Page iv
        Page v
        Page vi
    Acknowledgement
        Page vii
        Page viii
    Table of Contents
        Page ix
        Page x
    Part 1. The need for community services
        Page 1
        Page 2
        Page 3
        Page 4
    Part 2. "New" approaches in the United States
        Page 5
        Page 6
        Page 7
        Page 8
        Page 9
        Page 10
        Page 11
        Page 12
        Page 13
        Page 14
        Page 15
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
        Page 23
        Page 24
        Page 25
        Page 26
        Page 27
        Page 28
        Page 29
        Page 30
        Page 31
        Page 32
        Page 33
        Page 34
        Page 35
        Page 36
        Page 37
        Page 38
        Page 39
        Page 40
        Page 41
    Part 3. The community network
        Page 42
        Page 43
        Page 44
    Appendix 1. Issues in long-term care for persons disabled early in life; by Elizabeth M. Boggs, Ph. D.
        Page 45
        Page 46
        Page 47
        Page 48
        Page 49
        Page 50
        Page 51
        Page 52
        Page 53
        Page 54
        Page 55
        Page 56
        Page 57
    Appendix 2. Selected tables--adult day care in the United States--a comparative study (prepared by the TransCentury Corp.)
        Page 58
        Page 59
        Page 60
        Page 61
        Page 62
    Appendix 3. Report on day hospitals in Israel and Great Britain; by Edith G. Robins
        Page 63
        Page 64
        Page 65
        Page 66
        Page 67
        Page 68
        Page 69
        Page 70
        Page 71
        Page 72
        Page 73
        Page 74
        Page 75
        Page 76
        Page 77
        Page 78
        Page 79
        Page 80
        Page 81
        Page 82
        Page 83
        Page 84
        Page 85
        Page 86
        Page 87
    Appendix 4. Materials selected from home health care development, problems, and potential; by Marie Callendar and Judy LaVor
        Page 88
        Page 89
        Page 90
        Page 91
        Page 92
        Page 93
        Page 94
        Page 95
        Page 96
        Page 97
        Page 98
        Page 99
        Page 100
        Page 101
        Page 102
    Appendix 5. Selected tables from a report on research findings of a study of senior group centers; by Sara B. Wagner, Ed. D.
        Page 103
        Page 104
        Page 105
        Page 106
    Appendix 6. Community services for the aged: The view from eight countries; by Sheila B. Kamerman
        Page 107
        Page 108
        Page 109
        Page 110
        Page 111
        Page 112
        Page 113
        Page 114
        Page 115
        Page 116
    Back Cover
        Page 117
        Page 118
Full Text




94th Congress COMMITTEE PRINT
2d Session j









ADULT DAY FACILITIES FOR TREATMENT,


HEALTH CARE, AND RELATED


SERVICES


A WORKING PAPER




PREPARED FOR USE BY THE


SPECIAL


COMMITTEE ON AGING


UNITED STATES


SEPTEMBER 1976


Printed for the use of the Special Committee on Aging


U.S. GOVERNMENT PRINTING OFFICE


WASHINGTON : 1976


For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C. 20402 Price $1.40


72-862


SEN.j -






























SPECIAL COMMITTEE ON AGING
FRANK CHURCH, Idaho, Chairman


HARRISON A. WILLIAMS, JR., New Jersey
JENNINGS RANDOLPH, West Virginia
EDMUND S. MUSKIE, Maine
FRANK E. MOSS, Utah
EDWARD M. KENNEDY, Massachusetts
WALTER F. MONDALE, Minnesota
VANCE HARTKE, Indiana
CLAIBORNE PELL, Rhode Island
THOMAS F. EAGLETON, Missouri
JOHN V. TUNNEY, California
LAWTON CHILES, Florida
DICK CLARK, Iowa
JOHN A. DURKIN, New Hampshire


HIRAM L. FONG, Hawaii
CLIFFORD P. HANSEN, Wyoming
EDWARD W. BROOKE, Massachusetts
CHARLES H. PERCY, Illinois
ROBERT T. STAFFORD, Vermont
J. GLENN BEALL, JR., Maryland
PETE V. DOMENICI, New Mexico
BILL BROCK, Tennessee
DEWEY F. BARTLETT, Oklahoma


WILLIAM E. ORIOL, Staff Director
DAVID A. AFFELDT, Chief Counsel
VAL J. HALAMANDARIs, Associate Counsel
JOHN GuY MILLER, Minority Staff Director
PATRICIA G. ORIOL, Chief Clerk


Prepared by Brahna Trager


(II)












PREFACE


Htigh costs of dealing with long-terin illness or di:alilitv ainoioirr
older Aiericans-together with growing con).cern about needless in-
stitutionalization of many elderly per ols (IaNle ( caused a Crowilni,
demnaid for so-called "a ternatives to expensive institutional care.
That demand. given impetus by the Xliite House Conferelce ou
Alring in 1971. has swelled considerally since, not only because of tle
factors mentioned above, but because of widespread scandal.s- aid
misgivings about nursing home care in the United States.1
But. as the author of the following paper points out, there is :solle
dt-lge in the use of the word "alternatives."' It seems to d(lnnl a
clear-cut, "either/or" division between nursing home or hospital caie
,nd all other health or help resources needed in a community. What
really is needed, she declares, is a more responsive and compri hensive
comnilunity-based sysfen? in which a number of options are available
to those who need assistance to maintain sei-independence. in wliicll
the full-time institutional bed is there when needed but not called
upon unless it is in the patient's best interest to do so.
The author also identifies two trends prevalent in attitudes toward
planning community-based services for the chronically ill and
disabled:
"One is a desire to define clearly 'health-related' services in order to
provide medical care and treatment as a health benefit in an in-szurance
program m.
"The second is a growing concern for large numbers of disabled
and chronically ill adults for whom life in the community becomes an
impossibility when access to health care and the capacity for complete
self-care are restricted because both complete mobility and certain
of the activities for daily living are not continuously possible.
To make those trends more compatible than they now are, legisla-
tors, other policymakers, health and social service providers. and con-
(erned citizens need much more information about the capacities and
limitations of programs intended to bridge the widening gap between
"complete self-care" on the one hand and total institutionalization on
the other.
This committee has already provided two reports 2 on home health
care in the United States and has recommended a wide number of
actions to encourage further development of in-home service systems.a
I See, for example. Nursing Home Care in the United States: Failure in Puilie Policly,
1974: and Supporting Papers. 1974-76. issued by the Subcommittee on Loing-Trin care,
U.S. Senate Special Committee on Aging.
2-Home Health Services in the United States. committee print report, April 1972 (Cat.
No. y4 :Ag4.1134 /11), and Home Health .'erviccs in the Unlited tate, : I4 Working 'aper
on Current Status, committee print. July 197) ((at. No. Y4.Ag4 .J7/ IND).
I Si-. for example. "ppecommendatjon" pp. 4'S-49. Dcrclopmi(int. in .gilll:q 1" atl d
Jan 'ary-Aiarch 1974, a report of the U.8. Senate Special Co'mmi ttee on Agi'. \i, r E:,
i! 74. M







The author of those two papers, Ms. Brahna Trager, is also the
author of this report. She is recognized as a pioneer and respected au-
thority on home health care, having established one such program in
San Francisco, having intensively studied such activity in Europe, and
having served as consultant to the Department of Health, Education,
and Welfare and many other public or private agencies with a con-
cern about this important, but still beleaguered, component of our
loosely knit, and very expensive, national health care system.
Ms. Trager certainly recognizes that home health services cannot
exist in a policy and systems vacuum, any more than nursing homes
and hospitals can.
And so she agreed, when this committee asked for her help, to write
this paper because of her great interest in the development of what
she describes as the "essential components within the community" for
the provision of help wherever it is most appropriately given: in the
home, in institutions, or in a number of other arrangements which
enable the person in need of help to maintain "independent" living
quarters while making use of needed services.
Ms. Trager devotes most of this paper, as she was asked to do, to
what she calls "Adult Day Health Centers," in which individualized
care routines are provided to people who are usually called "partici-
pants" rather than "patients" in order to emphasize their ambulatory
status and their need for a widely varying mix of services which do
not necessarily fit neatly into health/social service categories.
In a very few years, such centers have proliferated and assumed
such titles as': "Senior Health Improvement Program," "Health-Care-
by-the-Day," "Daily Living Center," and "Senior Health Services
Center." In Rhode Island, one such unit is based in a church and is
called "Geriatric Day Care," even though its major emphasis is upon
social services or socialization.
One reason for the variety of names, according to Ms. Trager, "is
precisely to avoid the simplistic application of the child care concept
to a set of community services for adults which are as much a part of
the health/social care continuum, as essential a component in 'com-
prehensive' care, as the acute care hospital, the rehabilitation center,
or the various 'extended' institutional facilities which make up such a
large part of the health care resources in the United States."
If that is what day care centers can avoid, what exactly can they
achieve ? Ms. Trager provides this broad description:
"Adult day centers provide for group care during the day in a safe,
comfortable environment in which selected treatment, personal care
services, good food, and social opportunity are offered by professional
and paraprofessional staff which has both special training for, and
special interest in, the objectives of this method of care and in the indi-
viduals to whom it is adapted. A day center for health and related
services to adults who have physical and other limitations utilizes the
individual's 'own bed' and sustains his relationship to the environment
which he considers his home. That home may be with a spouse, with
members of his family, with friends or in a group-living arrangement,
in a place where he is living alone and, in rarer instances, in a facility







which utilizes the center to provide for transition from an institution
to community living."
Ms. Trager performs an important function by reporting on find-
ings thus far of several studies intended to test cost effectiveness, feasi-
bility, and clarification of varying purposes of day health centers.
But she also suggests areas for more intensive inspection. And she
points out that Federal interest is not only appropriate, but manda-
tory. Multiple funding is the rule in adult (lay care, which draws
from certain titles of the Older Americans Act for some funding, from
title XX of the Social Security Act, and (occasionally and partially)
from Medicare and Medicaid. Even revenue sharing and the old model
cities program provided support in scattered instances.
It is small wonder that Ms. Trager re ards fragmentation of fund-
ing sources as one of the most serious handicaps to establishment of
centers and to a real exploration of the total contribution that such
centers can make. Her other recommendations call for greater testing
and demonstration as among those reasonable and manageable steps
which can apply and further analyze the adult day health concept.
In addition, Ms. Trager discusses the British "day hospital" model,
which provides a full range of treatment and laboratory services for
visiting patients, usually in conjunction with a, hospital. As in other
sections of this report, she makes helpful comparisons of efforts, under-
way in this Nation and in Europe, where virtually all of the services
mentioned in this report have been developed, many of then over long
periods of time.
Among the other matters discussed in this paper is the "after-care"
program provided by a New York hospital to patients who are de-
livered in small groups to the hospital for afternoons of therapy and
social activity; the growing and potential role of senior centers and
senior clubs in supporting or providing services which maintain seni-
independence; the strategic and logistical problems related to "special-
needs" transportation, and the relationships of all components in the
"community networks," which Ms. Trager regards as critical ham-
pered by failures in Federal policy and practice.
As to the important matter of cost effectiveness, Ms. Trager feels
that a more energetic and cohesive effort should be made to obtain such
information.
She also points out:
"The impact of insufficient, inadequate, or poorly organized services
upon those who are particularly vulnerable to neglect does ... meas-
urably affect dependency, and increased dependency where it is avoid-
able will measurably affect dollar outlays."
In addition, poor services or no services have a clear-cut but im-
measurable effect upon life satisfaction. This is no small matter, and it
is of concern not only to older persons but-as _[s. Tra docunlnts-
to growing numbers of younger Americans, as well.
To Ms. Traer and those persons whose help she acknowledcTes. we
extend our thanks for a timely and useful documnnt. As in her earlier
works, Ms. Trager has produced a statement which is encomramn in
describing present successes and future possibilities, even wh ile she







warns of the serious practical difficulties that must be overcome if we
are to develop a more comprehensive, more humane, and more effective
way of providing the help that is needed-where it is needed-for
those who cannot live satisfactorily without it.
FRANK CHURCH, Chairman,
Special Con'mmittee on Aging.
HARRISON A. WILLIAMS, Jr., Chairman,
Subcommittee on Housing for the Elderly.
EDWARD M. KENNEDY, Chairman,
Subcommittee on Federal, State, and Com-
munity Services.
FRANK E. Moss, Chairman,
Subcommittee on Long-Term Care.









ACKN0WVLEDGOMENT S


Ti:s report was prepared with nv'alule as-44a(c. information.
and advice from iMiss Eileen Lester of the Division of Long-Teriin
Care, Oflice of the Administrator, Health Resources A(il iin istrat ion.
Department of Health, Education, and Welfare. wlio provided
imp ortant observations and early data concerning the Traiiscentury
Report on Adult Day (are. and from Mr. Jules Pellegrino (I)IIEW)
project officer for the report. Mrs. Edith Robin s of the Division of
Long-Term Care provided information and interpretation concernmn
day care programs in the Nation and abroad. Program directors. con-
sultants, and staffs of service programs and facilities who generously
provided field experience and information to the writer were Prof.
Theodore Koff, associate professor, project director, retirement 11os-
ing administration, department of public adi straino. hniversitv
of Arizona; Marian Lupu, director of the Pima Council on Aging,
Tucson, Ariz.: Betty McEvers, assistant director of the Pima Council
on Aging; Richard S. LaInden. executive director, Handmaker ,ewish
Home for the Aging, Tucson, Ariz.; Carol S. Parks, ITRS, Sharon
Naughton. OTR, MTRS, of the multisite day centers in Tucson,
Ariz.: and Gloria Dulgov, director of the Tucson nutrition and sociali-
zation program in Tucson, Ariz.: Carl Anderson of the city of Ticson
Department of Transportation. In San Diego, Calif., Catherine Wat-
son and the staff of the multisite senior day care program: and Marie
Louise Ansak of On Lok in San Francisco, Calif., enlarged this
experience.
Important data and experience concerning the day hospital was pro-
vided by Charlotte M. Iammil and Robert C. Oliver of the day hos-
pital at Burke Rehabilitation Center in White Plains. N.Y. After care
was demonstrated and described by George Vagias. RPT. and the staff
of the after care program at Montefiore Hospital in New York. William
Pothier. executive director of the San Francisco, Calif., Senior Center,
member of the board of directors, National Council on the Aging. presi-
dent. National Institute of Senior Centers, and Florence Viekerv, who
initiated the San Francisco center, provided extensive information on
history and development. Judy LaVor, Office of Assistant Secretary
for Planning and Evaluation, DHEWV, provided current information
concerning medicaid and home health services.


(VII)













CONTENTS

Page
Preface ii
Acknowledgments vii
PART 1
The need for community services --------------------------------------1
Still at early stages in United States ------------------------------ 3
Questions about "alternatives" ------------------------------------4

PART 2
"New" approaches in the United States ---------------------------- 5
I. "Adult day health" centers ----------------------------------- 5
Differences in definition -------------------------------- 7
Interdependence of components ---------------------------10
A. The adult day center, general description ------------ 10
The services -------------------------------------11
B. Variations in current day center objectives ------------- 15
Factors affecting utilization ----------------------- 18
The participants ----------------------------------18
C. Funding sources -------------------------------------- 21
Program costs ------------------------------------21
Summary and recommendations ------------------------- 22
II. The "day hospital" -------------------------------------- 3
The English day hospital --------------------------------- 24
Distinctions: United States and the British ----------------25
Summary and recommendations ----------------------- 28
III. "After-care" ------------------------------------------------28
Problem: Sustained physician care ------------------------ 30
Assessment of advantages --------------------------------31
Comment -----------------------------------------------32
IV. Senior group programs (senior centers and senior clubs) -------- 32
Findings from recent studies ----------------------------33
Characteristics of participants ---------------------------34
Summary and recommendations --------------------------35
V. Home health services --------------------------------------- 36
"An absence of action" -----------------------------------36
The major obstacle -------------------------------------- 39
VI. "Special needs" transportation ------------------------------- 40
The Tucson experience ----------------------------------- 40

PART 3
The community network ---------------------------------------------42
Cost ----------------------------------------------------------43

APPENDIXES
Appendix 1. Issues in long-term care for persons disabled early in life; by
Elizabeth M. Boggs, Ph. D -----------------------------------------45
Appendix 2. Selected tables-adult day care in the United States-a com-
parative study (prepared by the TransCentury Corp.) ------------------5S
Appendix 3. Report on day hospitals in Israel and Great Britain; by
Edith G. Robins -------------------------------------------------- 63
Appendix 4. Materials selected from home health care development, prob-
lems, and potential; by Marie Callendar and Judy LaVor --------------- 8
Appendix 5. Selected tables from a report on research findings of a study
of senior group centers; by Sara B. Wagner, Ed. D --------------------103
Appendix 6. Community services for the aged: The view from eight coun-
tries; by Sheila B. Kamerman -------------------------------------107
(IX)


















Digitized by the Internet Archive
in 2013













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ADULT DAY FACILITIES FOR TREATMENT,
HEALTH CARE, AND RELATED SERVICES
Prepared by Birahna Trager*


PART 1

THE NEED FOR COMMU-NITY SERVICES
Chronic disease and/or disability in any age group presents the
affected individuals and those involved in their welfare with problenis
which cannot be resolved by isolated or fragmented ineasures. For
those who must live with limitations imposed by impaired health
and physical disability and for those who are intimately involved in
their care and support-whether that support is economic, pliysical,
emotional, or all three-the expectation that the traditional self-
reliance and independence, which are our cultural conventions, should
prevail are bound to be unrealistic.
Changes in the structure of the family and the presence in our
population of large numbers of individuals who are limited in their
capacity for self-care or for full participation in coimunitv life
create responsibilities which extend beyond the ability of the indi-
vidual or the family. The need for services which are required for the
health and safety of population groups becomes the responsibility
of the community in the largest sense of the word.
During 19 72 an estimated 12.7 percent of the population.
or 23,868,000 persons, in the civilian noninstitutionalized
population, were reported to be limited to some extent in
activity due to chronic disease or impairment. About 3 per-
cent of the population, or 6,031,000 persons, were unable
to carry on their major activity (working, keeping house,
going to school). About 6.6 percent were limited in the
amount or kind of major activity, and 3.1 percent, or
6,279,000 persons, were limited in other activities such as recre-
ational, church, or civic activities. Over the 15 years of the
survey, the percentages of the population in each degree of
activity limitation have been quite stable. As age increases
and income decreases, the proportions of persons with limita-
tions of activity and mobility rose regardless of sex or race.
This information is important in estimating the present and
future population in need of long-term care. (App. 1. p. 45.)
*Brahna Trager is research health care administrator in long-term care. school of publi]
health, environmental health sciences, University of California. She is the author of Hoe
Health Services in the United States (1972) and Home Health Services in the Init(d
States-Current Status (1973), prepared for the U.S. Senate Special Committee on :
she is the author of the textbook Homemaker-Home Health Aide Services in the nited
States (1973) and of Home Health in Chinatown (1973), prepared for DHEW, and has
written and consulted extensively in the health care field.
(1)








Youth, or relative youth, does not provide immunity either from
(disability or from the risks which disability combined with poverty
impose. In the childhood population significant numbers of children
vre in need of long-term care (as of 1972 over 1 million children under
the age of 17) and in the working age population almost 3 million
persons are unable to work because of major physical disability and
8 inillion persons are limited in the amount and kind of work they
Cre able to undertake because of disability. (App. 1, p. 45.)
Alone a scale in which multiples of personal distress and economic
pressures increase those in the older age group suffer disproportion-
afey when disability and/or chronic disease is a central problem and
when economic and personal deprivation call for resources which
require a broader base than that which the individual or the family are
able to provide. The blessings of the increased longevity which a
qenc2'a~ly higher standard of living has produced in industrialized
societies have not been unmixed. For those in the older age range
who are chronically ill and/or disabled; for those in these groups
who are also economically deprived, neglect, isolation, the prospect of
years spent in an indifferent environment offer few rewards.
More than 4 million people in the noninstitutionalized population
over the age of 65 are limited in the amount or kind of major activity
they are able to undertake and more than 3 million are unable to carry
on major activity.
The severely disabled especially showed a positive relation-
ship of functional disability to age. (App. 1, p. 45.)
A study of the disabled population under age 65 presents a situa-
tion in which "three-fourths of those in the group (of severely dis-
abled) aged 55 to 64 were dependent on others for self-care and
mobility." 1
Economics in all age groups, but particularly for older persons, is a
major factor in disability and dependency. The effects of poverty on
both the prevention of disability, the potential for rehabilitation by
means of adequate environment, decent food, good medical care, and
the supplementary supports necessary to achieve these objectives have
been subjectively documented repeatedly. Statistical evidence as well
indicates that approximately five times as many individuals over age
65 are unable to carry on major activity in income ranges of $3,000
or less as those whose incomes are in the $10,000 to $15,000 range;
and major disability occurs in decreasing proportion to increasing
income. (App. 1, p. 45.)
The present challenge is one which places, upon planners and orga-
nizers of facilities and services, and upon public and private funding
sources, the necessity to provide for community based ambulatory
treatment, rehabilitative and compensatory supports by means of a
multifaceted community-based approach in order to assure to disabled
members of the population an equitable share of that societal concern
which is the basis of all civilized cultures.
Isolated examples of resources and services geared to the long-term
needs of high-risk members of the population have been demonstrated
1 Allan, Kathryn and Cinsky, Mildred E., "General Characteristics of the Disabled
Ponmfaition. "Social Security Bulletin, August 1972. U.S. Department of Health, Education,
and Welfare, Social Security Administration, DUEW Pub. No. (SSA) 73-11700, p. 8.







in the United States; the nee(le( lepehnive network of erviees
has not. either in fact or as public policy. vet been develope(1.
The examples of noninstitutional er ie wlc pI oi(le t ret t )en tv
health supervision, safe inaintenance, social opprtu tity, and obility
for those who-e need for such services may extend over long periods
or over a lifetime are described in this report, along with some indic,-
tion of their potential usefulness in such a network.
Major emphasis is placed upon older age groups in the services de-
scribed. Planning for these groups has become a central concern
because of rising costs in existing approaches to care, and because
growth in this age range points to a pressing need for rational plan-
ning. The same need exists in large numbers of younger persons-
adults, children, and infants for whom neglect carries the same im-
plications. (App. 1, p. 45.)

STILL AT EARLY STAGES IN UNITED STATES
Many of the services described are new only in the United States. al-
though in some instances they have been planned and demonstrated
here with considerable sophistication and imagination. The coinpara-
tive numerical count and population coverage are small here. however.
In other industrialized countries which still have their roots deeply
imbedded in concern for the protection of family and community rela-
tionships the deemphasis on institutional approaches and te develop-
ment of community services probably represent a continuity of cultural
understanding of, and interest in, the preservation of these aspects of
individual life as much as they represent the search for economical solu-
tions to a growing population need for long-term care resources. Com-
munity efforts have, in other countries, been directed toward the repli-
cation of what may previously have existed for the individual: the
home, as a natural base which supports personal identity the nuclear
and extended family (now rapidly disa ppearint) : participation in the
broader aspects of social and community life. The use. in these ap-
proaches., of such a replication in a variety of organized community,
individual. and group care services is thus intended to support or re-
store individual identity. physical. psychological. ind social function-
ing with a view to maintaining a humanistic social ideology in public
policy-but with an equally important emphasis upon economicc-
upon approaches to prevent or delav total dependency in a growing
section of the population-and to avoid inititutiona approaches -thpna
reducing the need for patterns of care which become increasingly cotly
to create and increasingly difficult to support and maintain dec ntlv.
The social idleolov upon which such approaches are based -!o ex-
ists in the United States, confused. perhaps. by an unreali4ic nnder-
standiny of what is happening to family reFoircees which in the 1ast
have been judged on the basis of initiative anl foresiht: and p
even more by an ovelridiilo interest in eficency an(d an almost in-
grained disdain for obsolescence of all kinds. I1-t7tutional cre may
be seen as an "efficient" method of care, and decreed (livial pro
ductivitv, real or imagined, as a form of human oh- olezo >nce. On the
positive side of the American culture there coexists a very real sens of
societal responsibility for the weak and the lhelpless. and a ieal in-
terest in the extension of the talent for efli'iencv to prompt re o.f.i-
tion of what, in business or in care. has ceased to funr tion ercctivlv
as a method and has therefore become Unecon(llical.








QUESTIONS ABOUT "ALTERNATIVES"
The concept of "alternatives to institutional care" which has become
so common in all discussions, research, planning, and in attempts
toward program development is perhaps an expression both of this
sense of social responsibility for a numerically growing population in
present or potential need, and an increased recognition that economic
considerations will become increasingly important in meeting this need.
This use of the term "alternatives to institutional care" to describe a
relatively small number of community approaches is unfortunate since
it seems to imply either/or solutions with, more often than not, an
implied rationale based entirely on economic considerations. In fact,
what could emerge from sensible community development might be a
combination which represents personal choice-appropriateness and
economy-in the long run. It may be impossible to demonstrate sub-
stantial cost savings during the initial developmental period of such
new approaches; it is demonstrably impossible to compare the cost of
one method of care with another which is totally or even partially dis-
similar, or of a different level of quality; it is difficult to compare the
cost of an hour or a day or a week of a given method of care with one
which spreads such costs over a month or a year. The use of the term
"alternatives to institutional care," therefore, appears to be an attempt
to express the search for services which make the combination-per-
sonal choice-appropriateness-economy possible and this does not ex-
clude the use of the long- or short-term institution; it represents an
addition of care components which allows for greater dilution in some
approaches and greater concentration in others-with appropriateness
as the decisive factor.











PART 2

"NEW"2 APPROACHES IN THE UNITED STATES

The programs which are described here represent a variety of com-
munity approaches : "After-care"; the "day hospital"; "adult day care
centers" (variously labeled by providers) ; "socialization and nutri-
tion centers"; and "senior group centers." Related to these are ele-
ments in a "community network" which either supplement, enable, or
support them or which they, in turn, supplement, enable, or support:
"Home health services," "meals-on-wheels," "special needs," transpor-
tation, and related community services focused on socialization and
surveillance, assistance in the location of appropriate services, educa-
tion and information for those in need concerning existing or non-
existing resources.
In all of the components of community-based care described, there
are both an expressed conviction that a basic community network of
services is essential to the full realization of the potential of the indi-
'cidual components as a system of care, and the realization that e/fec-
th'e utilization of the services will be limited 'when needed elements
which are essential to the system are inadequate in kind and quality,
limited in coverage, or unavailable.

I. "ADULT DAY HEALTH" CENTERS
Most providers of day care services for adults prefer to avoid the
use of the term "adult day care" when they describe their facilities.
This resistance is apparently based upon an unwillingness to allow
a set of progressive, specialized, community facilities and services to
become identified by planners, consumers, and in general public under-
standing with the "child care" center concept of which they are most
certainly not a prototype. If these adult service centers are variously
titled "senior health improvement program," "health care-by-the-
day," "daily living center," "adult day health center," "senior health
services center," it is precisely to avoid the simplistic application of
the child care concept to a set of community services for adults which
are as much a part of the health-social care continuum, as essential a
component in "comprehensive" care, as the acute care hospital, the
rehabilitation center, or the various "extended" institutional facilities
which make up such a large part of the health care resources in the
United States.
2 Virtually all of the services described have been developed in other countries. Many
of them have existed over long periods of time and have been built into community health
and welfare services with substantial government support. Essential linkages continue to
develop between various methods: between mechanisms for early discovery, levels of care,
varieties of care, and provision for coordination and movement between institutional and
community or in-home services, and between long- and short-term care systems. This
coordination and the availability of the essential components within the community are
recognized by innovators and providers of such care in the United States as well as in
systems in other countries as essential to effective long-term care.
(5)







We object to the comparison to child care because it is
inaccurate. We are not a place where people are left in safety
as children are left, until someone is ready to "pick them up"
ag-ain. Our services have an objective, and those who are con-
sumers are not children. They are adults who may be limited
for shorter or ]onger periods of time in their capacities for
total self-care-but they are participants in their own care
programs with everything that the term implies.3
There is, as a first attribute of these centers, a firmly established
unwillingness to accept the stereotype equations: aging-debility-
senility; or, physical fragility-limitation in self-determination-in
fact, most of what the term "patient" has come to mean particularly
when it is applied to older and/or disabled individuals. Most adult
day health facilities refer to consumers of their services as "partici-
pants," and the term is apt since the services provided involve choice
and full participation in individualized care routines.
As a part of the current interest in "alternatives" to institutional
care, the "day care option" is being tested with respect to cost effec-
tiveness, to feasibility, to clarification of its various purposes to de-
lineation of "health-related" versus other models.
Although such testing does have relevance in the United States, the
concept of facilities for adult health care in community day centers
did not originate in the United States. In Western European coun-
tries, and in Great Britain particularly, group care centers of various
kinds developed naturally out of attitudes toward health and social
care which differ substantially from those in the United States. The
services are not seen as "alternatives" or "options," but rather as a
basic component in community services in systems which contain very
few long-term care institutions; and where there is a tendency to limit
acute care institutions to very specific uses, community resources are
expected to provide for a range of health and social needs, particularly
for the chronically ill and disabled which, in the United States, might
be considered feasible only in 24-hour institutional settings. In the
resources of the local health authority, in the very extensive use of
"home helps," of day care centers and "social clubs" which offer more
than "socialization" and of intermittent 24-hour care for social as well
Cas health needs, the services are considered effective as measures which
are usually provided in proportion to the level of need.
A distinction which is even more marked is an attitude in planning
w 7ich recognizes responsibi71ty for lovg-term care and for the pro-
,vision of such care in the community as possible and capable of realiza-
tion. Such community services are intended to offer resources which
may maintain more or less disabled individuals for very long periods
of time, or for a lifetime, without necessitating radical adaptation to
c1 anges in the essential personal environment.
Early developments in adult day care, both abroad and in the United
States, stressed care which could meet the needs of psychiatric
patients:
3 Lupu, 'Marian. "Areawide Model Project on Aging," Pima Council on Aging, interview
Mlay 1975.
4Tr,,inscentury report, "Adult Day Care In the United States." A comparative study.
Proparcd in accordance with provisions of contract No. HRA-106-74-148, awarded by the
National Center for Health Services Research, Health Resources Administration, PIIS,
DIIEW, June 30, 1975, p. 14.







All of the well known initial prowams ere '!Irnl(
with psychiatric care. Day care services for )/( ,,./( lti
are believed to have started at the ( rowly toad INovpital in
Oxford, England, in 19f58. Great, Brit' a took a lead in ex-
panding such services by also including younger adult pa-
tients. The0y Set up two tvpes of plrorrains: that is. "I)av Cen-
tres" and "Dav Hospitals." A day center, according to
Brocklehurst would ". . provide social fiies- -
pany, a cooked meal, possibly a bath and chiropody, 1)ut
none of the remedial services found in the day hospital." le
further defined a day hospital as ". . a building to which
patients may come, or be brought, in the morning, where they
may spend several hours in therapeutic activity and whence
they return subsequently on the same day to their own homes."
In 1969, there were at least 90 day hospitals oper-a.tig in t 1e
United Kindom. Since that time, numerous other facilities
of this kind have been opened in that country. In contrast, 1w
November 197"), there were only 15 day. health centers oper-
ating in the United States, exclusive of psychiatric day care
centers. It is indicative of the embryonic state of systeatic
health care in the United States that a county such as Great
Britain, with about one-quarter the population and sicnifi-
cantlv smaller economic resources. has established at least six
times the number of day care facilities to improve adult
health.5
DI= RFEENCES IN DEFINITiON
The above description of services is riot eritirelv accurate when it is
applied to adult day health centers in the United States. Most thera-
peutic services described by Brocklehurst as appropriate to the "day
hospital" in England are being provided in adult day l~alth centers
here. Robins indicates that the English programs are attempting! to
differentiate between those participants requiring a therapeutic level
of care in the day hospital and those whose need is prima-ily for "social
care":
Admission of patients for primarily social care in day hos-
pitals or maintaining such patients after the need for reha-
bilitation is past is a controversial issue in Great Britain.
In Brocklehrst's view, the t)rOVISIon of Social care may
seen as an extension of the geriatric b;osiptal service into
community and preventive medicine. I-e stronilv recom i-
mends the use of social day centers for naany 'ets dis-
charged from day hospitals. (A pp. 3, p. 63.)
In the United States, the adult day care center under its several
titles has been variously defined as to purpose, function, series
It is a part-time living arrangement for those whose dis-
abilities require s})Dcil! care in wbli(h services are 8(lltQd to
individual need in terms of cocentration of services or dura-
tion of services.

'Aehta, Nitin H., and Mack, Christopher. "Day Care Servicr :An lTr e to TiriPti-
tion-l Care," Journal of the American Geriatrics Society, vol. XXIII, No. 6;, June 1975,
p. 281.


72-82-76, 2







It is a social living arrangement which enables individuals
to remain in contact with others in ways which are normal
and acceptable.
It enables family members to work, to have relief from care
responsibilities-at the same time providing for therapeutic
services without the necessity for multiple treatment visits or
institutionalization.'
These purposes express a strong emphasis on the "living arrange-
ment" which supplements the personal environment and which con-
centrates social and therapeutic services in a single setting.
Another view emphasizes assessment:
The day care setting has as one of its major functions the
assessment of an individual prior to institutionalization; over
a period of time it allows for observation: of physical and
mental functioning, capacities for adaptation, attitudes and
character traits, care needs, and potential capacities.
It provides for necessary tests which lead to assessment of
the whole person and these can be a part of a day care rou-
tine rather than in a fragmented and artificial approach
found when assessment and decisions are made in the physi-
cian's office. When and if placement is made, it can then be
appropriately planned.7
More officially, major stress is placed on the alternative features of
adult day care. The Transcentury study is explicit in its definition:
Within the last few years . a search for alternatives has
been set as a national objective for long term care and re-
search . among them is adult day care envisioned as a
coordinated program of services provided in ambulatory set-
tingsS
And in response to legislation providing for research which would
test the validity of this method,9 a definition has been developed to
serve as a draft regulation to be used in studies of selected day care
centers:
,'Day care" is a program of services provided under health
leadership in an ambulatory care setting for adults who do
not require 24-hour institutional care and yet, due to physical
and/or mental impairment, are not capable of full-time in-
dependent living. Participants in the day care program are
referred to the program by their attending physician or by
some other appropriate source such as an institutional dis-
charge planning program, a welfare agency, et cetera. The
essential elements of a day care program are directed toward
meeting the health maintenance and restoration needs of par-
ticipants. However, there are socialization elements in the
program which, by overcoming the isolation so often associ-
References cited in footnote 3.
7 Theodore Koff, Ed. D. associate professor, P.A., project director, retirement housing
administration, department of public administration. College of Business 'and Public Ad-
ministration, University of Arizona. Interview, May 1975.
8 Reference cited in footnote 4. introduction, p. 1.
9Public Law 92-603, sec. 222(1) (b) (H).






ated with illness in the aged and disabled, are considered vital
for the purposes of fostering and maintaining the maximum
possible state of health and well-being.
This definition allows for a good deal of flexibility of interpreta-
tion as to the service requirements of programs to be admitted to the
study:
Procedures and agreements describing working relat ion-
ships with a hospital and/or a rehabilitation center and a
mental health facility (which provides inpatient or outpa-
tient care) and other health agencies so that participants may
obtain any additional health care services needed.
Personnel policies that specify the educational and experi-
ence qualifications for each position category of the staff of
the day care program.
And as to the definition of individuals considered eligible:
"Impaired adult" means a chronically ill or disabled adult
whose illness or disability may not require 24-hour inpatient
Ca'e but which, in the absence of day care services, may pre-
cipitate admission to or prolong stay in a hospital, nursing
home, or other long-term care facility.0
What is particularly apparent in the draft regulations and in the
definitions which they contain is the stress upon institutional care-
present as much in the expressed desire to avoid it as it might be if it
were emphasized. The threat of increased beds, increased admissions,
increased costs seems to overshadow good intentions, vis-a-vis, the
positive potential of a community based system per se. The search
for "alternatives" seems to narrow the field of eligibles to members
of the endangered species "whose illness or disability in the absence
of day care services may precipitate admission . to an
institution." 11
Such an approach, while it may seem to solve the immediate prob-
lems of continued and costly construction and maintenance of institu-
tional facilities and the prospect of financing care for the increasing
numbers who must be maintained in them. does not focus upon the
needs of those for whom treatment and care of good quality must be
realistically planned. "Care of good quality" is not exclusively bound
up with the avoidance of institutionalization nor is the consideration
of "effectiveness" exclusively tied to considerations of cost.
Care for the population which the day center might potentially
serve is primarily concerned with positive objectives: effective treat-
nent, maximum rehabilitation. physical and social supports to supple-
nent limited function in chronic disease and disability-services
which bring into the "comprehensive care continuum" or into the
4imtainstream of health care" that section of the population for which
the institution is not appropriate. Such care includes, as well, con-
sideration of the possibility that within the continuum the institution
may be eliminated as the sole resource for significant numbers in that
population, to be replaced by services in the community which might
be effective over long periods of time-for some, throughout a lifetime.
:r Draft regulations prepared for use with experiments in day care conducted uider
Pilblhe Lcaw 92-f603, sec. 222.
'a Ibid.







"Cost effectiveness," in the sense that it represents the avoidance of
long-term institutional costs, becomes a byproduct in this context and
the adult day care, treatment, or health improvement center becomes an
essential component in community services.
Such a positive approach places many of our long-term care objec-
tives in a different light. "Rehabilitation" may mean many things. It
may mean protection of a given state of functioning; the arrest, or
at least a retardation, of physical and psychological disability. It may
mean treatment which restores relatively simple but essential self-care
capacities. It may also mean full restoration of those functions which
enable the individual to return to independent living.
Cost alone should not determine whether day care is a
viable alternative to institutional care. More important should
be the issue of the person being served and the ability to keep
him a part of the community as long as possible.
The self-respect of the individual who knows that at the
end of the day he will be returning home is another great fac-
tor in support of day care. Institutionalization for many
means the end of the line. Day care still offers hope.'2

INTERDEPENDENCE OF COMPONENTS
Providers of care in adult day centers are unanimous concerning the
interdependence of all care components. They stress the need for a
systemr'" of care services, a "continuum" in which the effectiveness or
usefulness of any single setting will depend upon the availability of
other services. This, they say, is particularly true of the adult day cen-
ter. The individual in need of the center services will be unable to
make use of them if transportation is not available; the use of the cen-
ter facilities will not be possible unless those services are supplemented
by home delivered meals or home health care for those who live alone
or who do not have family members capable of supplying essential
care in the home; movement in and out of the center to more appro-
priate settings such as nutrition and socialization centers and/or the
multipurpose senior center must be possible when these more closely
meet the need of the consumer (such movement avoids the creation of
a static group fixed in a setting which may become inappropriate to
his needs) ; the availability of acute care treatment and 24-hour facili-
ties increases the usefulness of each of the services in the continuum.
Providers also stress the need in such systems for firm linkages between
care components in order to coordinate and adapt services so that care,
regardless of setting, may be provided in the uninterrupted sequence
which the term "care continuum" implies.

A. TLE ADULT DAY CENTER, GENERAL DESCRIPTION
Broadly described, adult day centers provide for group care during
the day in a ssafe, comfortable environment in which selected thera-
peutic and personal care services, good food, and social opportunity
are offered by professional and paraprofessional staff which has both
12 Lamden, Richard S., director. Handmaker Jewish Nursing Home for the Aged of the
Tucson Jewish Community Council, Tucson, Ariz. ; letter, August 7, 1975.







special training for and special interest in the objectives of this
method of care and in the individuals to whom it is adapted.
A day center for health and related services to adults who have
physical and other limitations utilizes the individual's "own bed" and
sustains his relationship to the environment which he considers his
home. That home may be with a spouse; with renilbers of his family;
with friends or in a group living arrangement: in a place where he is
living alone; and in rarer instances, in a facility which utilizes the
center to provide for transition from an institution to community
living.
Very few of the centers in the U7nited States have been able to niake
use of facilities which have either been intended for such use or which
have been initially well adapted to the needs of the groups they are
serving. The adaptations have been made. fre'quently sil'prisinglv well.
Centers have been established in church halls, in unused school build-
ings, in gymnasiums during "off" hours. in loaned institutional space-
nursing home recreation rooms, hospital waiti-r rooms, rented private
houses. recreation centers-in fact in almost any space which could,
with ingenuity, be adapted to the health and safety of participants
and to the essential services which thev require. Emphasis is placed,
in the selection of sites, upon the availability of emergency medical
care facilities and/or treatment services not available within the center
itself (physical therapy, occupational and speech therapy. access to
recreational therapy). When possible, they have been located in those
districts which have the largest number of potential participants. An
important feature of some centers has been the development of multi-
site centers: centrally administered with sites strategically placed to
meet the needs of various population groups, to adapt to neighborhood
characteristics, and to reduce transportation time. (An advantage in
specialized staff deployment is realized by bringing services to the
center on an itinerant basis rather than by transportin c the participant
to the service.'3)
When possible toilet facilities have been restructured for wheel-
chairs, wheelchair ramps have been installed; some centers have
adapted bathing and shower facilities: centers either prepare hot
meals, rely upon delivered food or combine with available nutrition
centers (title VII of the Older Americans Act). A great deal of atten-
tion is given to light, heat. and whenever possible, access to a garden
or outdoor area. Much of the equipment and most of the furniture
is donated or ingeniously manufactured by the staff. There is great
stress, however, on a general atmosphere of cheerfulness, of comfort,
of safe space which encourages movement: on treatment areas which
protect privacy. Where possible outdoor space is protected and work
space for the pursuit of hobbies and crafts-structured as much as
possible to occupational therapy goals-s provided. The atmosphere is
ursuallv informal and relaxed with structured routines flexibly adapted
to individual participant needs.

THE SERVICES
A tendency, on average, to rive appropriate care is a speci al
strength of adult day programs . programs studied have
13 San Diego Senior Adult Day Care Center; Tucson Senior Health Improvement Programs.







developed an amazingly close match between staff health care
capability and the needs of the participants. Programs with
the most impaired and dependent participants have the high-
est ratio of health care services, especially emphasizing
therapies.14
Conversely it might be stated that when day care programs offer a
Ligh ratio of health care services they will attract and be useful to
larger numbers of impaired and dependent participants-the corol-
lary being that increased numbers of participants might then be en-
abled to continue to use their own beds when a broad range of services
is available for their use in the day center.
Services provided can be classified in general categories, each
utilized in varying amounts and emphasizing aspects of care con-
sidered important in center objectives:
Health care services.-Medical, nursing, diagnostic, pharmacy, psy-
chological, physical therapy, occupational therapy, speech therapy.
Supporting serv,'es.-Social work services, recreation, food, diet
counseling-related paraprofessional services.
8Supportihe enabling services.-Special needs transportation, home
health services, home delivered meals.
Centers differ in the amount of time and staff devoted to specific
health care activities. In 10 programs studied by the Transcentury
group, staff time invested in health care activities ranged from 9.4
percent to 56.6 percent-with an average of 33.4 percent.'5
Some centers are limited because professionals are not always avail-
able to administer medication. Nonprofessional staff can "remind" but
not administer; other centers organize the administration of all medi-
cations with routines parallel to those in well-run institutions.
Services described as "supportive" are related in large part to per-
sonal care, activities of daily living intended to increase the capacity
for self-care, personalized counseling and health education directed
toward maintaining or restoring individual security and a sense of
personal identity; recreation adapted to the interests of the partic-
ipants including organized crafts and the pursuit of hobbies, field
excursions, and social activities. "Adult day care is much more than
simply health care services. . Most programs have a professional
trained staff member in charge of social services and some centers sep-
arate social services and recreation and have a staff member in charge
of each "The cost for supporting health activities in most of
the programs studied is higher than that for health activities," 17 and
this should not be surprising nor should it categorize day centers as
not health oriented. Distinctions concerning what is, or is not, "health
related" are difficult to establish, particularly for the chronically ill,
and many of the services in this category do, in fact, contribute largely
to the health status of the recipient. Direct treatment in acute care
institutions also utilizes a relatively small portion of the time spent
in them and analysis of relative costs might support a similar
conclusion.
Providers of adult day care emphasize the importance of "partic-
ipant centered" services. The program of the center, its staffing pattern,
the relative emphasis upon the use of professional and paraprofes-
1-4 Reference cited in footnoote 4, pp. 9-10.
Reference cited in footnote 4, p. 18; also table 15, appendix 2, p. 61.
a Reference cited in footnote 4, p. 55
:17 Reference cited in footnote 4, p. 63, table 23.







sional stafT, the structure of the activities proirrani are related to the
assessment and related care plans, of the individual i artiipamt. Serv-
ice emphasis within the centers is structured on the concept of the
"care continuum," and the needs of the community itself affect the
service patterns and activities of the center-or centers which serve
the community.
When the capacity for self-care is limited even for short periods of
time, this limitation is one which frequently precipitates the need for
institutional care. "Personal care" services vary from center to center.
Some centers are equipped to provide baths, shampoos, barbering, and
most provide assisted toileting-toilet facilities equipped for wheel-
chairs and with adapted equipment; one at least provides laundry
facilities so that participants may bring laundry to the center. The
capacity of the center to provide such services determines their use-
fulness: Those with the broadest range of services can extend services
to a more disabled group-to those who are chairbound. for ex:,niple.
Tnen there is equipment for bathing and personnel trained in trans-
fer activities, the need for personal cleanliness and comfort, and inci-
dentally skin care, need not be factors which are decisive in making
radical changes in personal living arrangements. A very simple equa-
tion which is related to the concepts of "quality-need" versus "alterna-
tives" is the provision of those services which preserve a personal life
style in an optimum environment.
Food.-Participants in day care invariably receive hot mea-1-. \l-
though there is considerable emphasis on sound nutrition-one center
serving two different ethnic groups provides four special menus: Two
which are ethnic "special diets"; two ethnic "normal" diets-the, atti-
tude toward food is comfortable, sociable. and relaxed. Food appears
to be generally available-for breakfast if it has been missed at home
or a second one is wanted; and hot lunches. Evening meals may be
served or sent home in containers for )articipants who live alone: a
multisite center provides weekend food packages; another combines
with community delivered meals-on-wheels for food service and an-
other with a nearby "nutrition and socialization" center so that there
is an opportunity for a social "mix" at mealtimes. There is a conscious
effort to restore and maintain normal routines with respect to a vital
source of human pleasure.
Social services.-Social services, both formal and informal, are cen-
tral in all day centers. Every staff member is involved in a continuing
effort to provide the psychological support to every participant in
order to make the utilization of the services effective. Psychological
counseling, planned recreation, concern with family relationships,
with housing problems are invariably a part of the services of the cen-
ters. Home visits, attention to continuity of medical care, telephone
contact with participants who are absent for illness or other reasons
are also considered center responsibilities. 'Most centers have estab-
lished firm working relationships with community health and social
agencies and use them effectively. "At every step in the progri-,1. Intel,-
action among participants and among staff and participants i oil-
sidered an important service." "I The emphasis, whether the center- is
Is Reference cited In footnote 4, p. 55.





14


primarily "health oriented" or "socially oriented" is upon a strongly
individualized approach.
Utiliza.tion.-In general, and probably because center objectives
emphasize individualized care, providers tend, both in the United
States and abroad, to stress the small group. The optimum size in rela-
tion to maximum participant benefit and staff utilization has not been
fixed. In general the average daily. attendance ranges from 11 to 47
participants with most centers caring for daily groups of 20 to 25
participants.' There is considerable variation in requirements for fre-
quency of attendance, related to some extent to factors such as service
objectives, transportation, living arrangements-with or without fam-
ilies to assist in interim care.
Eileen Lester 20 reports, both in observations on the Transcentury
study and in the current series of research demonstrations on day
care-homemaker services (Public Law 92-603, section 222) with re-
spect to attendance that:
The chronically ill and physically limited individual is not
invariably capable of meeting a regular day center routine.
There are mornings when, even with help, the task of getting
dressed and out is too much; the transportation becomes a
strain; the time spent in the center seems too long. Intercur-
rent illness, even minor or short term, becomes a barrier to
movement out of the home and the less frequent attendance
rate on the average probably reflects these facts.
She further comments that for these reasons flexible attendance
requirements are important:
The center cannot invariably be the sole effective resource
except for those who are minimally limited and sometimes
even not for them. For those who are more limited, center
services will need additional community care services brought
to the home.
Attendance at least 1 day a week is usually required; some centers
encourage daily attendance. Average attendance, however, is usually
2 to 3 days a week.21
Duration, or length of stay, i.e., "discharge" or discontinuance of
service, appears to be very flexible and long stays for center partici-
pants appear to be a general pattern. In some centers, participants
have continued to participate since the inception of the services,
that is, for several years. If an important criterion in assessment of
the centers is consumer satisfaction this fact could support the con-
clusion that such centers meet a consumer need; other factors also
affect length of stay, the most important being the deemphasis on
rehabilitation or the "maximum usefulness" standard--one which is
sometimes applied in other service organizations as a rationale or
policy governing discharge from service. It is not as reliable as a
standard in long-term care as it is in acute care services.
Certain of the centers provide services on days of nonattendance
and weekends-offering homemaker-home health aide services, meals-
19 Preliminary Analysis of Select Geriatric Day Care Programs, prepared by the Levindale
Geriatric Research Center, funded by the Division of Long-Term Care, Health Resources
Administration, DHEW. June 1974, p. 41.
2W Interview, June 1975.
21 Reference cited in footnote 4, p. 13.







on-wheels, and telephone reassurance services during the intervals.
At least one center program offers the services of a homemaker-home
health aide for assistance to the participant who requires help in
getting dressed and ready for the center program in le imorniug.
Flexibility with respect to days of attendance, supplementary serv-
ices to participants at home and the "open ended" approach to the
utilization of the centers over long periods of time is one of the most
important attributes in planning and delivering effective long-terin
care services. Long-term care, by the very nature of the need, cannot
be defined in terms of arbitrary time limits or arbitrary combintions
of services. The "as needed" approach based upon individualized pro-
fessional assessment is the key factor in the effectiveness of commu-
nity services which have as their focus the most appropriate services
delivered at the time when they are needed in order to avoid the use
of less effective or less appropriate and more costly measures of care.

B. VARIATIONS IN CUIRRENT DAY CENTER OBJECTIVE
In studies which have been made of selected day centers. there
has been a tendency to divide, or describe them in terms of "models,"
depending in part upon whether the objectives of the center are pri-
marily oriented to treatment, to rehabilitation, or physical restora-
tion-the so-called "medical" model-or whether their objectives tend
primarily to emphasize supervision and support-the so-called "social"
model. In the Transcentury report, "Model I" has been described as a
center which has "a high ratio of registered nurses and professional
physical and occupational and speech therapists . ." serving partici-
pants who have recently suffered serious illnesses and need rehabilita-
tion care. An average of 48 percent are paralyzed to some degree. Many
use wheelchairs and most are dependent in three or more activities of
daily living.
"Model II" provides a smaller proportion of professional staff with
greater use of paraprofessionals for those who "suffer the infirmities
of old age and are 1ess apt to be in a rehabilitative stage of chronic ill-
ness. An average of 16 percent are paralyzed to some degree, but most
are dependent in fewer than two activ'ites of daily lZ'q and many
are independent." 22 (Emphasis supplied.)
An earlier study classifies the objectives of day centers in three
ways:
Re.7abi6it ation-orientation referred to programs with a
dominant service leading to rehabilitation and restoration.
because the primary pathological condition of the population
showed the potential for measurable improvement in func-
tional capacities if medical and medically related therapies
were provided on a regular basis.
Maintenav(e-ore ntation referred to programs in which a
dominant service objective was to enhance the ability to main-
tain a person in the community and increase access to recre-
ational stimuli where the target population showed sli2lit pos-
sibility for limited improvement in functional capacities. but
current levels could be contained and unnecessary deteriora-
tion prevented if nursing and social service activities were
provided on a regular basis.
2 Roference cited in footnote 4. p. 9.







Comb ed-orievtation referred to those facilities which con-
sidered the dominant service objective and target population
to include both of the above service goals and types of client
needs.23
In her report on day care centers in the United States, Edith Rob-
ins notes four models of day care:
Each . has certain commonalities such as phychosocial
activities to improve and maintain mental health; health
supervision and supportive services; nutrition services, in-
cluding the noonday meal and snacks, and transportation.
Distinguishing characteristics are two models related to a
time limited therapeutic regimen to acutely ill patients with
the ultimate goal of restoring them to independent living or
to permit them to be transferred to a less intensive form of
care.., and two models which provide long-term mainte-
nance services designed to permit the individual to remain in
the home setting as long as possible ...
The health status of the long-term patient . who has
multiple diseases is subject to frequent change. The necessity
for periodic transfer from one module of care to another can
thus be anticipated. (App. 3, p. 63.)
Such distinctions become difficult to apply, given the current state of
development of the adult day center in the United States. Two very im-
portant trends are prevalent in attitudes toward planning community
based services for the chronically ill and disabled. One is a desire to
define clearly "health related" services in order to provide medical care
and treatment as a health benefit in an insurance program. The second
is a growing concern for large numbers of disabled and chronically ill
adults for whom life in the community becomes an impossibility when
access to health care and the capacity for complete self-care are re-
stricted because both complete mobility and certain of the activities for
daily living are not continuously possible. An individual whose ambu-
lation is somewhat restricted might well have the capacity to continue
to direct his own affairs, to reach needed resources for health and medi-
cal care, to participate in community life and still be unable to manage
three meals a day every day; to achieve enough mobility to have the
kind of social contact and support that is essential for normal life.
The development of centers which set policies and objectives in the
context of treatment and physical restoration may tend to exclude
those in need of some, but not all of these services. For those who are
considered candidates for supervision and socialization, there may be
a tendency to ignore essential health related services. Facilities which
are treatment oriented may also tend to take on institutional charac-
teristics and to make a "patient" of the participant-an aspect of
institutional care which often is counterproductive in terms of the
objectives of treatment. On the other hand, major emphasis on a super-
vision-socialization policy excludes consideration of restoration and
rehabilitation possibilities which may appear to be relatively limited
but are of great importance to the participant and such facilities might
take on the characteristics of current institutions which are "holding
facilities" and ignore essential health needs.
23 Reference cited in footnote 19, p. 5.







,Such d, tUinctos and deftn;twns also becomC ext reinely difieUlt
when they are related to the real needs of the participatrs in day
centers and of services cUr'rmently provided in nmny centers. On paper,
the participants appear to be a group of adults whose major char-
acteristics see/ to be that they are more or les8 dependent. 'his does
not describe chaiprbound particpants who work aggress hely and pain-
fully with intensely inte rested professionals and paraprofes.s ionals to
h',re their wheelchairs for ?,alkere, to leave thceiir walkZrs for canes,
to take their first steps without cssistanee, and who iiaiy ultimately
walk, out of doors to the garden or patio of the center. It does not
describe the willf participation in a set of tedious arm and hand
CeitCPO#ses applied for simple purposes which, may either be ignored in
the socialal" model or overstressed in the "'medical" model.
My major objective is to make every movement useful. If
I can help that woman extend her arm and grasp with her
hand, I'm going to make it possible for her to extend her arm
and grasp a can of beans.
It does not describe the pleasure of a participant at a standing table
((, hr ?aes a M. wa1r,e flowerpot hanger or the total psychological
restoration of a previously profoundly depressed, se erar limited par-
ficipait v'th, cardiac disease as she irorXfl on a hooked rug and chats
iith. members' of the group who work with her, teaching then. a skill
that she has recovered.
There is as yet too little known about the potentials of the groups
with which such centers should be concerned. Fluctuation in physical
and psychological states have not been as carefully examined as they
might be. Understanding of the influence of cultural and social expec-
tation and of sensory stimulation upon these potentials is emerging
but not yet realized. It is probable that a key factor in the success
of day care ,facilities is the very fact that they are "day care"-that
there is a, certain purposefulness in the "coming to" care, and care
services, and that there is, during the hours of a day spent in the
center, a great deal of "care" which is a byproduct of the life activities
of the day, the continuous awareness of both staff and participants
that relationships are based upon mutual trust, interest, concern, and
purpose. These elements have yet to be tested and evaluated adequately.
Other factors related to the practical aspects of day care "models,"
their organization and administration, and their position in the com-
munity are also important in the present stages of their development.
Small communities, districts in larger communities, areas in which
funding is limited, may find in a more flexible approach to services
and objectives a better opportunity to test the needs of the population,
at least at the outset, by offering a broad range of services, both
"health related" and "social" models, allowing for a care continuum
and the possibility of progression or movement between various con-
centrations of service in a single setting. It may be too early in the
history of these centers to establish clear cut and potentially rigid
definitions based upon what is, or is not, a "health related" or a
"social" model.

24 Interview with Sharon Naughton, occupational therapist, Tucson Senior Health
Improvement Programs, May 1975.








FACTORS AFFECTING UTILIZATION
The participant in need of the services of a day care center must
rely upon those who are in the home, upon the center, or upon the
community for the necessary transportation to and from the center.
None of the participants is sufficiently ambulatory to come to the
center without assistance; many are in wheelchairs (in some instances,
50-75 percent) ; others are in walkers; in "most . programs (par-
tially or totally) paralyzed participants make up one-tenth to one-
third of the participants." 23
Such physical limitations and disabilities establish the need for
day care. They also make participation in the day care facility im-
possible unless the services can become accessible. Centers which must
rely on relatives, neighbors, friends, or volunteers to provide trans-
portation cannot assure needed continuity. They must then, limit
their service policies to those who have such resources or offer care
only to those whose disabilities are less severe.

THE PARTICIPANTS
Age as a factor: Although most of the participants in day care pro-
grams recently studied are elderly (the average age in the centers
studied is 71 with approximately one-third over the age of 80 in most
of them and a surprising 7 to 10 percent over age 90 in many of
them 26), it has been stressed that it would not be "wholly accurate to
view day care as a program exclusively for geriatrics. . 27 The
facilities, the services, the approach to care are equally well adapted to
any age group when short- or long-term disability requires this pattern
of care. Disability and dependency in the 40-60 age range present the
same problems, often with greater limitations in resources since in-
surance coverage in general does not extend to long-term services even
when maintenance of existing function or limited but essential restora-
tion of function might be possible, and the social pressures are as
severe (app. 1, p. 45). The current emphasis on services to the elderly
is related largely to the need for ambulatory care services for the
growing numbers of older persons for whom an "intermediate" com-
munity care sequence is not available-a sequence of services which
fills the vacuum between total family or self care at home and long-
term care in an institution.
Although they have a very real potential for services to the dis-
abled in all age groups, centers which have been established have
tended to serve those in the older age ranges, probably because funding
sources have been more available for these groups. Those with a
stronger emphasis upon rehabilitation and physical restoration have
tended to serve a somewhat younger population; 28 a recent study
indicates that "on the average, adult day care participants are about a
decade younger than the 82-year average of nursing home resi-
dents." 29 There are, however, significant numbers of older partici-
pants in the center programs.
2 Reference cited In footnote 4. p. 18.
2 References cited in footnote 19. p. 21 and footnote 4, p. 15.
27 Reference cited in footnote 4, p. 14.
21 Reference cited in footnote 19, p. 21.
2 Reference cited in footnote 4, p. 16.







Feasibility with respect to living arrangements: Day care centers
have demonstrated that such care is possible, whether the participants
live alone or with families (in one of the centers studied, for example,
more than 52 percent of the participants do live alone 30) ; the Trans-
century study notes that "most participants live with someone else,
often a spouse." 31 With respect to the question of feasibility of day
care in relation to living arrangements two comments have been made:
Day care centers are designed to accommodate diverse com-
munity living arrangements. For this large (52 percent) pro-
ortion that lives alone, the supervised, protective setting of
ay care encourages a higher degree of independence. Other
research conducted . established that day care provides an
excellent arrangement for the caretaker. It reduces the con-
stant dependency of an impaired family member when 24-
hour care is the responsibility of the spouse or another family
member. . 2
The day care population is not that different from the
nursing home population. It is not so much whether the par-
ticipants have families or not, as far as using day care is
concerned. It is that neither the family nor the individual
is always capable of knowing what the possibilities for care
in the community might be before making a choice.33
This stress upon the usefulness of day care to those for whom it
is appropriate, rather than upon those whose social, economic, or
living situation impose arbitrary choices, places a heavy responsibility
on the planners, the policymakers, the programers of services-partic-
ularly for disabled or chronically ill older people, who are living alone
or with similarly disabled family members in the same age range. For
them, the accident of a "living arrangement" may restrict options to
a single choice-the institutional choice, in the absence of available
community services.
Disability status: As in the nursing home poulation and the popula-
tion served by home health services, chronic diseases usually in multi-
ples of diagnostic groups are basic problems for the participants in
day care, ranging from an average number of 2.0 to 4.8 per participant
in the various centers studied. (App. 2, p. 58.) The presence of chronic
disease, even when multiple diagnostic problems exist, is not an index
of the need for any of the possible community services for individuals
affected, although it may place them in a "high risk" category. Combi-
nations of diagnostic problems occur in very large numbers of individ-
uals, even in the older age ranges, who continue to work and to function
in the ordinary routines of life. Short-term or long-term limita-
tions in the capacity to function, which may occur as a result of
chronic disease, does demand organized services, and when needed
short- or long-term treatment, supplemented by essential life-support-
ing services, are not available the "high risk" becomes a threat to
recovery and to independence.
The disability status of day care participants when it is viewed
statistically is instructive in terms of what is possible in community
3 Reference cited In footnote 19, p. 19.
31 Reference cited In footnote 4, p. 14.
OReference cited in footnote 19, p. 19.
3 Reference cited in footnote 24.





20


based services. Admission policies and program resources affect ad-
mission with respect to health status:
"Some wheelchair use occurs at every center studied" 34 (an average
of 23 percent of participants) ; partial or total paralysis is present in
23 percent; an average of 28 percent have neurological disorders; 43
percent hypertension. Dependency because of inability to undertake
activities of daily living, while this need does not have a high correla-
tion with medical diagnosis (a fact demonstrated by large numbers of
individuals in the general population who continue with their normal
routines in spite of multiple medical diagnoses), is an important fac-
tor in the need for day care, as in other community services; in all of
the centers,5 dependency related to the ability to undertake activities
of daily living is present in participants, with the need for both assist-
ance by others and assistance of equipment occurring in participants
in a significant number (a factor in arriving at activities of daily
living scores is, as with other characteristics, affected by the capacity
of the center to provide such assistance).
Financial status: Presumably such services can more readily be
procured by those whose incomes make such procurement possible.
Whatever the quality of such care may be, those in the upper income
levels are not predominantly participants in day care services.
Eighty percent of the entire ... group ... have an annual
income of $2,000 or less and 98 percent have incomes under
$6,000. This finding supports the . hypothesis that the
majority being served are poor36
Eight of the programs (studied in a series of 10) have
participant charges. Most are nominal, often only the cost of
a meal. Since most of the programs serve primarily lower in-
come elderly, there is virtually no possibility that this source
could cover more than a fraction of the costs of the programY
The day care participant profile: Participants in day care currently
can be described in terms of several factors: They are in the older age
ranges, although younger, even young individuals with similar needs,
may also be served appropriately by such centers; chronic disease or
situations associated with chronic disease has limited their mobility
and/or self-care capacity, and their access to health care, and may also
have affected the capacity of family members or those associated with
them to provide total care; they may, in spite of limitations in this
capacity, be capable of participating in treatment, of making the
choice to remain in the community, and be capable of directing their
own lives; they may be maintained in day centers for long periods of
time; they may be brought to improved states of functioning; they
may be restored to relatively better levels of self-care; they appear to
be almost invariably poor-although there is no evidence that day cen-
ters could not profitably serve those with similar limitations whose in-
comes are adequate to provide for their needs.
The services provided in centers recently studied are considered
appropriate to individual need although there is variation in services,
14 Reference cited In footnote 4, p. 18.
S-5Reference cited in footnote 4, p. 30.
:1 Reference cited in foof note 19, p. 20.
37 Reference cited in footnote 4, p. 136.







facilities and in the kind and amount of personnel available. This
variation, supported by rationalized policy with respect to prograin
objectives, is largely affected by budgetary considerations. It is af-
fected by related problems such as housing limitations and availability
of equipment and facilities, and by the presence or absence of resources
such as special needs transportation, interim home health and/or
homemaker-home health aide services (since daily attendance is not
the rule and may not even be the most effective pattern of care). Policy
is also affected by the fact that clear definitions of the emphasis needed
in center programs have not yet emerged (app. 8, p. 63) :, tw dis-
tinctions between the several "models" required by the population at
risk and the question of overlapping need; and between a rationale
which separates components of service according to defined eligibility
for both services and funding and one which stresses a more inclusive
approach.
In general, the participant profile both in the centers studied in the
United States and those providing similar services abroad presents a
picture of potentially effective services to chronically ill and disabled
persons, many of them with severe limitations which would make in-
stitutional care a necessity if such services were not available to them.

C. FUNDING SOURCES
Multiple funding is the rule in day care centers as in most other
community services. Three titles of the Older Americans Act (Il1, IV,
VII) have provided funds for some services in some centers through
Federal. State. and local levels of government; three titles (VI and
XVI and more recently XX) of the Social Security Act; Afodel
Cities and revenue-sharing moneys have been tapped; medicare and
medicaid have paid for eligible services; a variety of community or-
ganizations-Untited Way, in some instances private insurors-have
paid for services; and in-kind and volunteer services have been uti-
lized. Participant fees make up a relatively small proportion of rev-
enues. (App. 2, p. 58.)
This roster of funding sources represents an overwhelming burden
in terms of meeting the wide variety of title regulations, grant ai)l)li-
cations, requirements, the proliferation of paperwork, the multiple
reporting and claims presentation, placed upon relatively small adi n-
istrative and professional staffs. The uncertainty with respect to con-
tinuity in employment and the support of service components
considered essential to quality care places pressures upon the center
personnel which make the achievements of the center programs a mi-
raculous combination of devotion, energy expenditure, and
legerdemain.
PROGRAM: COSTS
The per diem or per patient costs vary as widely as policies and
services and are, of course, the result of this variation. Centers which
are classified by the Transcentury report as "Model I," that is. those
stressing "health related" or "rehabilitation" services are about twice
as costly as these in "Model II," which also provide some "health
related" services but with a less intensive approach or a narrower
range of professional services.3s Inclusion in costs of special needs
38 Reference cited in footnote 4, p. 73.





22


transportation when it is available also affects current reporting in
this study which presents a range in programs studied of approxi-
mately $11 to $33 per diem (excluding a day hospital program with
higher costs).
Another report (Levindale 39) which divides programs into three
"models," one of which is a grouping which excludes therapies, placed
the range at approximately $7 to $22 when therapies and special needs
transportation were included. The lowest per diem range without
therapies but including transportation was $3.50 to $13.90. These fig-
ures were based on a study made approximately 2 years earlier than
the publication date including some centers which defined service ob-
jectives differently from those stressed by the Transcentury report.

SUMMARY AND RECOMMENDATIONS
The development of adult day centers as a community service is
relatively new in the United States and has presented a variety of
approaches affected by funding, by what has been seen as the first
priority in community need and by the availability of community re-
sources. Emphasis on treatment or rehabilitation occurs in varying
degrees; "health related" services are variously interpreted as well.
Virtually all centers which have been reviewed formally do, however,
stress effective services which support and maintain the participant
through personalized assessment, interaction in socialization, the pres-
ervation of individual identity, and attention to essential services in
nutrition, hygiene, mobility, and a general approach to health oriented
rather than sickness oriented services. The profile of participants in
almost all centers indicates that individuals whose handicaps are
severe enough to require a variety of coordinated services can be main-
tained in the community-many of them in age ranges and with phys-
ical and psychological limitations which might otherwise require
institutional care which is not as well adapted to their needs, to their
preferences and to the preferences of their families. The effective-
ness of the centers in maintaining such individuals in the community
for long periods of time has been demonstrated in centers recently
studied, and this effectiveness has been achieved in relatively simple
facilities and with efficient utilization of professional and parapro-
fessional staffs. Cost ranges in relation to effectiveness have not been
exorbitant and it is probable that they would not be excessive in long
term care even with the addition of supplementary community serv-
ices which would increase utilization and enhance their potential
usefulness.
The fragmentation of funding sources and in many instances fund-
ing limitations are a serious handicap to the establishment of centers
and to a real exploration of what the center program could do in pro-
viding effective noninstitutional services to that section of the popula-
tion which is at risk because of major chronic disease and disability.
A second handicap is the lack of clarity concerning the most effec-
tive pattern of service, and the methods by which need may be assessed
and met; which groups may best be served by the various combina-
tions of service and how such services may be most effectively devel-
oped, delivered, and related to other necessary community services.
,3 Reference cited In footnote 19, p. 35.







Recommendations for adult day care should involve, first of all, an
affirmation of public policy which supports such programs as a means
of protecting the health and safety of those persons whose disabilities
require the services provided in such ceiters. Implementation of this
policy will involve an investment in furthering the development of
such centers and clarifying their functions and purposes in the follow-
ing ways:
-Through a series of demonstrations adequately funded over suffi-
cient time which will test and evaluate the various service com-
binations and their appropriateness to various population groups
in different geographic and community settings.
-Through an organized approach to the development of adminis-
trative methods, program size, program organization, and pro-
gram policies utilizing the expertise of those who are presently
involved in delivering such services.
-Through research approaches focused upon utilization patterns,
longitudinal studies, and projected costs in various service
combinations.
-Through the provision of organized training opportunities in
adult day care for members of the medical profession and other
health professionals as well as paraprofessionals.
-Through the development of a rational funding pattern which
will eliminate current fragmentation of funding sources and an
initial approach to guidelines which may be developed as man-
dates to States and communities.
-Through the development of materials which 'cill assist com-
munities in the organization of such centers and interpret their
function to the professions and to the public at large.
II. THE "DAY HOSPITAL"
It is impossible to discuss the potential of the day hospital for the
United States without reference to the development of such facilities
in Great Britain where they originated and where they have prolifer-
ated rapidly since 1946 when the first day hospital was established in
London. The British system, however, makes certain distinctions be-
tween the day hospital and the day care center which have not been
applied here. In Great Britain, the day hospital is considered a substi-
tute for inpatient care with emphasis on treatment; the day care cen-
ters "provide social facilities-company, a cooked meal, possibly a
bath and chiropody, but none of the remedial services found in the day
hospital." (Emphasis supplied.) (App. 3, p. 63.)
Certain of the adult day health centers in the United States re-
semble the English day hospital to the extent that their objectives are
primarily related to rehabilitation health care and treatment. Thus,
the sharp distinction made in England between "day centers" and
"day hospitals" is less apparent here and would more accurately de-
scribe the differences between our "health care" oriented adult day
centers and the so-called social model.
Very few facilities for adult day care in the United States call
themselves "day hospitals." One such facility,10 which has designated
40 Burke Day Hospital, White Plains, N.Y.


72-862-76-3





24


its services as day hospital services, has established two levels of care:
the day hospital and the day care center, and makes the distinction in
terms of its relative emphasis on rehabilitation, restoration and indi-
vidualized treat ment on the one hand., and on less concentrated services
which are geared toward maintainance of function with a greater
emphasis on group activity on the other. The programs which approach
the day hospital concept here use admission criteria which more closely
resemble those for inpatient care, place the greatest emphasis on health
care services, accept more severely disabled participants and tend to
serve a younger group of participants. The potential effectiveness of
day hospitals in the United States probably lies in the possibility that
a concentration on treatment might be undertaken without the necessity
for totally altering the living situation of individuals in need of such
treatment, particularly when that need extends beyond periods of acute
illness.
Various estimates have been made in the United States of the per-
centage of time in inpatient facilities devoted to treatment services in
proportion to that which is devoted to hotel aspects of inpatient care,
the need for 24-hour supervision by health professionals is cited as a
major reason for inpatient stay when minimal treatment services are
requi red; the convenience for the physician also carries a good deal of
weight. The facts concerning the true needs of inpatients versus the
use of day-centered treatment services remain to be explored and
evaluated; the English system which uses day hospitals more ex-
tensively has tended to view their usefulness primarily in terms of
rehabilitation and restoration for the older patient.

THE ENGLISH DAY HOSPITAL
Cosin describes the English day hospital and its purposes in the
following way:
The day hospital occupies a median position in continuing
community care, because it can be used by either in- or out-
patients, thus providing services according to patients' chang-
inlg needs and helping to maintain many patients in their own
homes. It is necessary to make quadruple assessment of path-
ological, psychological, social and physical factors . .; these
facilities are available in the day hospital. The purpose of the
day hospital is to treat ... to retrain or teach new skills, to
assist when community and family resources are not avail-
able, and to provide a more humanitarian management ....
Sharing responsibility for the patient facilitates his return
home. .... 41
The day hospitals function:
1. To treat patients .
2. To measure the rate of improvement .
3. To facilitate and assist in an active program of com-
munity care by planning responsibility for that part of the
week for which relatives need to be freed ... or for periods
when community resources (home help, homemaker, health
visitor, voluntary visitor or friends) are not available.
41 Architectural and Functional Planning for a Geriatric Day Hospital, L. Cosin, Interna-
tional Journal of Social Psychiatry, London, 1971, vol. 17, No. 2, pp. 133-40.





25


4. To provide a more huImanitarian management ... than is
otherwise provided by neglect in the coiinimnity> or tie pro-
found demoralization that can follow institutionalization.
A strong case is made by both BrocklehurSt and Cosin for- sill-
stantial financial savings through the use of the patiltis "own bed"
which eliminates financial outlays for new ('onstr uctio l or for r(place-
ment due to obsolescence an d for reduction of total institutional iin-
patient days. Added to this is a reduction of morbidity and mortality 44
assumed to increase in shifts from the accustomed lifestyle to institti-
tional living.
The British concept is positive concerning its theiapeuitic-preventive
objectives in the use of day hospj)tals in long-tenn care and practical
as well, for removing the "hotel element" and1 reserviln thei-apeutio
services to the hospital staff presumably involves a saving in cost,
which has been estimated in 1970 as preventing inpatient adiission in
8 percent of the cases, in a controlled study of patients attending day
hospitals, delaying admissions in 6.7 percent of the cases and enabling
earlier discharge in 11.8 percent of the patients.4r The day hospital is
also credited with expanding overall hospital capacity. The utilization
of day hospital care averages 1.71 days per week per patient: "Because
we reduced the number of tendencies consistent with the patients' cur-
rent needs, which may change . a 1-day hospital place keeps three
people going in the community." 46
The emphasis is upon providing services consistent with consuiner
needs as compared with 24-hour day-in-day-out utilization when serv-
ices are not always consistent with need.
In a nutshell the aim is to dissociate the "hotel" element of
hospital care from the therapeutic content, leaving only the
latter.7
DISTINCTIONS: UT'NITED STATES AND THE BRITISH
One of the distinctions between the British day hospital and the
"health related" adult day centers in the United States is that the
former are frequently annexed to an ordinary hospital and provide
for a full range of treatment and laboratory services. Robins in her
site visit report comments:
In many facilities in which day hospitals are housed it is
customary for the staff and the equipment of the rehabilita-
tion department to be shared by both day hospital patients
and inpatients. Moreover it is a common practice for in-
patients to actively participate in the day hospital prog-rani.
Not only does the opportunity to get away from the wards
boost the morale of the inpatients, but for those patients who
42 The Role of the Geriatric Day Hospital, Dr. L. Cosin, M.A. (Oxon), F.R.C.S., L.R.C.P.,
British Council for Rehabilitation of the Disabled, Tavistock House (South), Tavistock
Square, London, W.C.1.
4 The Geriatric Day Hospital, J. C. Brocklehurst, M.D., F.R.C.P. (Edin.), published
by King Edward's Hospital Fund for London, 1970, p. 13.
Statement by Dr. Lionel Z. Cosin, clinical director, United Oxford Hospitals Geriatric
Unit; and clinical director, Rivermead Unit, United Kingdom, before the Subcommittee on
Long-Term Care of the Special Committee on Aging, U.S. Senate, "Trends In Long-Term
Care," 92d Congress, 1st session, part 14, June 15, 1971. U.S. Government Printing Office,
62-264, pp. 1375-1379.
45 Reference cited in footnote 43, p. 13.
Reference cited in footnote 44.
"9 Reference cited in footnote 43, p. 11.





26
are approaching discharge, participation in the day hospital
program helps to ease the transition from inpatient to out-
patient status. The patient knows that he will be treated in
the same place by the same therapist when he goes home. In
a significant proportion of the patients this practice tends to
reduce the length of inpatient stay. (App. 3, p. 63.)
The distinction between the British day hospitals and centers in
the United States, whether they are treatment oriented day care cen-
ters or more closely resemble the day hospital in objectives is a more
flexible approach in the United States concerning the "mix" in both
admission criteria and in the socialization services which are in-
variably a part of the services offered here.
The British system, focusing primarily upon the relief of geriatric
inpatient beds as well as upon the therapeutic values of the home as a
living situation, tends to emphasize a rehabilitation approach:
Physical rehabilitation was regarded as the. most important
function of the day hospital by most geriatric consultants....
Admission of patients for primarily social care . or
maintaining such patients after the need for rehabilitation is
past is a controversial issue in Great Britain. . Some con-
sultants reluctantly accept social care as a major role for
their day hospitals. They argue that, while they do not re-
gard this as a proper function for a day hospital, if they do
not provide the care, no one else will, and the end result will
be the admission of more inpatients. To a small extent many
day hospitals have some of these patients who require only
social care. (App. 3, p. 63.)
In general, however, the level of treatment in the British day
hospital is more intensive and more closely resembles inpatient care
than that usually provided in adult day care centers here.
Brocklehurst describes the services in the British day hospitals:
They . provide facilities for physiotherapy and occu-
pational therapy, for medical examination and nursing
treatment, and usually for various other activities, including
investigation, speech therapy, dentistry, chiropody, and
hairdressing."
Two of the centers studied in the U.S. Transcentury report which
closely resemble the British day hospital devote more time to treat-
ment and health care than other adult day centers: More than 3 hours
and more than 2 hours, of these two centers respectively, of the par-
ticipant day to the provision of health care services with propor-
tionate emphasis in the use of health professionals-nurses and
therapists '-and correspondingly greater emphasis on health need
in admission criteria.0 Participants in these two centers rank high in
wheelchair use (50 percent and 73 percent), in incidence of partial
or total paralysis (53 percent and 43 percent)51 and in incidence of
stroke (47 percent and 33 percent).5-
In a survey of 90 geriatric day hospitals conducted in 1970
in Great Britain . 30 percent of the patients suffered
'8Ibid.
"Reference cited In footnote 4, p. 43.
50 Reference cited in footnote 4, p. 20.
51 Reference cited in footnote 4, p. 19.
52 Reference cited in footnote 4, p. 23.





9-
-4


from stroke, 30 percent from arthritis, 22 percent from
chronic brain syndrome, and 18 percent from other diseases.
(App. 3, p. 63.)
Like all day care facilities in the United States, British day hos-
pitals stress the absence of special needs transportation as a limiting
factor in utilization and a major factor in cost. A major barrier to
utilization of all day care services in the United States is absent in
the British system. Great stress is placed there upon flexible use of
"home helps' (homemaker-home health aides) which are funded by
Government and are in relatively plentiful supply as are other serv-
ices provided in the home: medical and nursing services and home
delivered meals. (App. 6, p. 107.)
Per diem costs in the day hospitals reviewed by the Transcentury
report in the United States are higher than those in adult day care
centers and reliable experience is not vet available for the costing of
this pattern of care here. As a replacement for inpat" care. the
approach offers interesting possibilities both for the older population
and for those in other age groups whose needs are similar. The British
investment in day hospitals which is substantial (there were 119
geriatric lay hospitals in Great Britain in 1970) (app. 3, p. 63)
would support the conclusion that they are considered cost effec-
tive. Additionally, strong arguments in support of this pattern of
care have been advanced by British clinicians:
The great difference between the usual cold intellectual
study of a patient in hospital and the existential realities of
the patient's problems in a family setting lies in the insuffi-
cientlv considered conclusions in management and care based
on diagnosis obtained from inpatient analytical procedures
which would not necessarily be correct in the community
setting in which the patient, with his long suffering famih"
have to live.
Because the day hospital can be used for inpatients before
discharge or for outpatients. it can adopt a median position
in planning community programmes of continuing care and
help to produce the most warm, empathetic and accurately
tailored milieu for a given environmental position3
This pattern of care is educational for the institutional staff and
must rely upon the development of physicians, nurses. therapists,
and paraprofessionals who are knowledgeable and interested for its
effectiveness.The tendency of health professionals to separate them-
selves from those who are in need of long-term care has been recog-
nized with respect to long-term institutions in the United States.54
Observations of staff attitudes in both adult day care centers and
the day hospital indicate that the hopefulness of the approach. the
difference in milieu, and perhaps most important the experience of
rewarding relationships between personnel and the consumers tends
to replace avoidance witlh re;l interest and to enhance re-ornition,
both of the possibilities for care and the validity of an attitude of
respect for the individual throughout the entire li'fe cycle.
Reference cited in footnote 42.
"Nursing Home Care in the United States: Failure in Public Polic", reports 1 through
9, prepared by the Subcommittee on Long-Term care of the Special Committee on Aging,
U.S. Senate, 1975.






28


SUMMARY AND RECOMMENDATIONS
The concept of a hospital facility which provides needed therapies
,on a regular basis during an 8-hour day for several days each week
without the necessity for 24-hour care has been considered both cost
effective and effective in human terms in Great Britain where it is
being substantially developed primarily for older persons, and in the
United States where it has been demonstrated in a very limited way
as an effective resource for both older persons and for younger persons
as well. It offers possibilities for innovative treatment approaches in
rehabilitation and physical and social restoration, at the same time
maintaining i nlportant ties to normal living patterns. Such possibil-
ities are particularly attractive for those whose disabilities require
either intensive short-term rehabilitation or long-term treatment when
the interruption of a normal lifestyle, which long institutional stays
represent, are considered counterproductive therapeutically. Appro-
priate adaptation of treatment to the precise needs of the individual
might well prove cost effective and the potential for expanding exist-
ing bed utilization is a convincing argument for further exploration of
this method of care.
Recommendations for demonstration of the day hospital in the
United States are similar to those made with respect to the adult day
center. In addition to the funding of demonstrations in order to deter-
mine how and for whom and to what degree such facilities would be
effective, the use of existing hospital facilities in institutions which
do not have full occupancy offers many advantages both in making
good use of what is available and in strengthening institutional ties
to the community and to its resources. The joint use of staff by day
hospital participants as well as the use of such facilities for transitional
purposes for inpatients for whom discharge is planned, appears sound
and also cost effective. Emphasis on such use by those in younger age
groups in need of such services in order to reduce or delay or avoid
inpatient care is as reasonable as it is for the older group. As in the
adult day care centers training opportunities and methods of effective
administration and management will be necessary. Because day
hospital care cannot be effective unless community resources such as
transportation, home health and related inhome services are available,
demonstrations and experiments must necessarily take place where
these are established or simultaneously developed.

III. "AFTER-CARE" 55
. the problems of the homebound ill patient persist and
grow and, indeed, may have become exacerbated. The home-
bound patient with multiple sclerosis or a stroke or a pul-
monary or cardiac cripple, is probably less likely to get a
doctor to visit him at home now than a couple of decades
ago. . Moreover, it has been estimated that from 12 to 14
percent of all elderly persons are ill or disabled and thereby
homebound . a homebound contingent of some 1.7 million

5 This program has been called "after-care" because of its initial applicability to post-
hospital care. The potential of the services extends beyond post-hospital care to a variety
of other uses.





29


individuals is the largest single subgroup in the geriatric
population . a vast group of parents and grandparents
disabled and in need of personal care services. Their unmet
needs are obviously extensive . there are many hundreds
of thousands under 65 who face the same problems ..
These are the facts of life that call for new approaches .... 06
The pattern of organized "after-care" has been developed out of a
hospital-based home care program. In New York City, the Montefiore
home care program, more than 25 years ago, initiated the delivery of
coordinated health care services to the homes of patients who might
otherwise have remained inpatients for protracted periods, and sub-
sequent home health services adapted the pattern in various ways: a
significant number remain hospital based; free standing programs
have also been developed and have been considered effective in many
communities, although the extent of these programs in terms of range,
duration, and population coverage have been limited in the United
States.
The "after-care" concept at Montefiore grew out of a recognition
that several factors have limited the full effective use of home care
for the homebound individual, among them a limited availability of
primary care physicians for home visits; a shortage of skilled thera-
pists; decreased availability of visiting nurses; and, in the urban com-
munity at least, problems of security for personnel. After-care was
therefore seen as an "alternative" to home care and "instead of treating
patients in their homes . provides services to patients, who though
homebound, are well enough to be picked up, delivered to the hospital
for an afternoon of therapy and social activity, and later returned to
their homes." 57 In the course of a single visit all of their essential
treatment and health care needs are met. Usually groups of six are
selected with composition of the group based upon common treatment
needs.
During the course of a 3-hour stay they receive physical,
occupational, and recreational therapies, access to doctor,
nurse, and social worker as well as to such other institutional
facilities as library, laboratory, X-ray. . An interesting
and well received feature has been a group social hour con-
ducted by the social worker, which has had great impact on
these isolated and lonely patientsB
These visits are usually scheduled once a week although more fre-
quent visits may be planned when necessary. The resources of the home
care program from which patients are selected are available as needed.
Coordination of care, responsibility for treatment plans, interim home
care as needed and the professional "backup" remains the responsi-
bility of the home care service at Montefiore.
Although this has obvious advantages, it is also apparent
that an after-care program need in ot necessarily have a home
care backup service.59
5 The Montefiore After-Care Program, Rossman, Isidore, M.D., the Nursing Outlook,
vol. 22. No. 5, May 1974, pp. 325-326.
57 Ibid.
58Alternatives to Institutional Care, Rossman, Isidore. M.D., bulletin of the New York
Academy of Medicine, second series, vol. 49, No. 12. pp. 1084-1092, December 1973.
59 The After Care Project: A Viable Alternative to Home Care, Rossman, Isidore, Ph. D.,
M.D., Medical Care, June 1974, vol. XII, No. 6.







In this context the "viability" of after-care need not necessarily
be seen in its relationship to home care nor does it necessarily remain
an "alternative." It becomes a supplement to other community-based
resources for treatment and care; its potential value is inherent in the
combination of planned, coordinated utilization of treatment resources
with a minimum of stress for the consumer.
Basic to the protection of quality is the assumption that if the back-
up does not necessarily reside in the home care program, the responsi-
bility must still be placed and when services are needed in the home
they must still be available. If simple administrative arrangements
could be made in such services as home health care, health maintenance
organizations, and even in private practice, the after-care approach
could offer consumers of these services a more rational resource. Those
who are limited in mobility could then have available comprehen-
sively planned care services either as after-care or as coordinated treat-
ment without the necessity for multiple visits which now occurs.
An example of the difficulties encountered by consumers with
limited mobility is best illustrated in a review which was recently
undertaken by one of the home health programs in an urban com-
munity. Records were kept of all prescribed medical supervisory, lab-
oratory, and related appointments. Those who were unable to meet
their appointments independently or with the help of family or
friends, were assigned a homemaker-home health aide to accompany
them, using taxis for transportation. The consumer (and the aide, who
necessarily remained with the consumer) spent an average of more
than 2 hours per visit. Almost one-third of the group were in the offices
of providers (private physicians, clinics) for from 2 to more than 5
hours.60 No facilities were available for food, rest, transfer from curb-
side, to the site of care, or for return. The cost of paraprofessional time
equaled one full-time attendant for 9 months. It might have been said
that members of the study group were too ill to be living at home. This
was not the case, however. The struggle with public transportation or
taxi, with stairs and corridors, the hours without food, are a challenge
for almost any convalescent or for any individual with physical limita-
tions. The study emphasizes the need for more sensible provider ar-
rangements; for treatment plans arranged around the needs of the
consumer rather than in the context of provider convenience.

PROBLEM: SUSTAINED PHYSICIAN CARE
A major problem for all chronically ill and/or disabled individuals
is related to continuity of physician care, except within the hospital
or extended care facility:
The British or Russian practitioner is accustomed to devot-
ing up to half of his working day to house calls. In contrast
here the house call seems to be phased out in favor of other
approaches. The alternatives, some of which one may regard
as medical ploymanship, are to invite the patient, even if
febrile, weak, or incapacitated, to come to the emergency room
or to the office on the grounds that diagnostic resources are
better in those settings. The fact is that many medical
0 San Francisco Home Health Service, study of field service worker visits; medical visits
by type and time required, January-September 1969.







events . are not generally difficult to diagnose in the
home setting. . Perhaps the basic issue is whether one is
willing to accommodate himself to the patient or insists on
61
the reverse.
Long-term inpatient institutions report that continuity in medical
supervision and treatment services are difficult to achieve. "With the
exception of a small minority, doctors are infrequent visitors to nurs-
ing homes," 62 and many long-term institutions have neither the equip-
ment nor the personnel to provide for continuity of medical super-
vision and treatment. The more responsible institutions for group
living transport patients to diagnostic and therapeutic facilities but
such arrangements encounter the same problems of physical strain,
uncoordination and dissatisfaction as those experienced by the indi-
vidual who relies on family or friends or on the resources of the home
health personnel. Adaptations in programing care must, in order to
be effective, be those which place the needs of the consumer in a health-
related frame of reference.

ASSESSMENT OF ADVANTAGES
Advantages which are stressed by the Montefiore after-care person-
nel are a greater economy in the use of staff, particularly professional
staff, since group care in the therapies and in counseling is possible.
The group "modules" may be multiplied and during the period of
each scheduled half -day virtually all treatment needs, including podia-
try, delivery of prescriptions, consultant visits, and an opportunity
to discuss problems in a therapeutic setting are provided. Other fac-
tors which are economically advantageous are the saving in travel-
time for home care personnel and, in the urban area where the after-
care program has been developed, increased safety for visiting staff
is a consideration. During periods of intercurrent illness the home
care program provides the needed services in the home. For consumers
who are too ill to leave their homes, home care is available.
The "costing out" of the after-care program by its director pin-
points group transportation as a major cost factor, as it is in all other
community programs for those whose mobility is limited. The cost
of chartering a specially equipped van for each six patients brought
to after-care is high even when it is compared with six solo trips by
taxi which would not, for these patients, be feasible. It is less than
the ambulance services which are sometimes used in British day hos-
pitals and by institutional facilities here.
Against this major cost is a saving of physicians' time, estimated at
11/2 hours saved; six-sevenths of the therapist's time, the group de-
livery of other needed services and the elimination of time and costs
for drug delivery. This program was considered feasible as an adjunct
to a home care program aid as a means of supplementing that pro-
gram with needed services in a hospital setting. The growth in group
practice programs makes this method an interesting possibility in
other patterns as well and might well provide a pattern of care for
the solo practitioners whose patients are usually referred to a single
f Reference cited In footnote 58. p. 5,16.
02 urslng Home Care in the United States: Failure in Public Policy, Supporting paper
No. 6, p. XVII. Prepared by the Subcommittee on Long-Term Care of the Special Com-
mittee on Aging, U.S. Senate, September 1975.





32


institution for diagnostic and treatment appointments, particularly
when the private practitioner can be available for planned after-care
groups.
The advantages stressed in the Montefiore after-care program
might well be demonstrated in arrangements where the source of
medical supervision is adapted to such coordination-particularly for
consumers whose physical limitations make frequent individual visits
extremely difficult to plan and exact a high cost in energy. Efforts to
insure continuity of care are particularly important for this group
and lapses in care cannot always be attributed to the indifference of
the consumer. The tendency to lapse is more often related to consider-
ations which outweigh the value of continuity.

COMI"ENT
Administrative adjustments adapted to groups such as these might
greatly ease the problems of reaching health supervision and treat-
ment. The advantages of planned, coordinated medical care and re-
lated treatment services made available on a "one visit" basis rather
than in multiple uncoordinated visits is one which offers a solution to
the problem of continuity for those in nursing homes, in congregate
living facilities as well as for the individual in his own home who may
be receiving home care as well as for the consumer who is limited in his
capacity to arrange for medical supervision and related therapeutic
services independently.
IV. SENIOR GROUP PROG RAMS (SENIOR CENTERS AND
SENIOR CLUBS)
The senior center movement which began in the United States more
than 30 years ago was one of the first of the community-based services
to develop in response to the needs of older persons. Public and pri-
vate social, educational and recreation agencies, church groups, and
fraternal organizations became aware early of the increased isolation
of older persons, particularly those who were economically disadvan-
taged, limited by chronic illness, suffering from changes in living re-
quirements because of emerging new patterns in American family life.
Initially developed to provide opportunities for social activities, the
senior center movement has been singularly responsive to a wide range
of needs in its membership; socialization, while still a central activity,
has become only one of many services offered by a substantial number
of senior group centers:
The rapid growth of senior centers over the last three
decades in this country has been impressive . it has been
a self-help grassroots, bootstrap operation from the
start 63
Passage of the Older Americans Act in 1965 has, however, provided
a substantial stimulus to the development of such centers. A national
directory published in 1966 listed a total of 400 centers in the United
States. A similar directory published in 1974 lists nearly 5,000 senior
centers and clubs. As in the adult day health center movement, there is
6s Statement of Pothier. William, member of the Board of Directors, the National Council
on the Aging; president, National Institute of Senior Centers; and director, San Francisco
Senior Center, before the Select Committee on Aging, U.S. House of Representatives, Hear-
ings on "Problems Affecting the Elderly (Senior Centers)."





33


some overlapping in the objectives, activities, and general terminology
used by the various organized community centers for older people. Al-
though they may be classified as clubs, senior centers. multipuiripose
centers, nutrition. and socialization centers (tie result of title VII
funding), sharp distinctions are not established. Services and act ivi-
ties vary considerably:
Senior centers have developed over the past three decades
to meet, initially, the recognized needs of older individuals-
socially enriching experiences that help to preserve human
dignity and enhance feelings of self worth-and then, a, the
senior center movement expanded, to assist them in continu-
ing personal growth and maintaining viable lifestyles. Sen-
ior centers perform a unique community function; they are
the focal point (or physical place) to which older persons
and their families may come for services and from which
services reach out to the isolated and homebound elderly.
Community residents seeking information about aging find
it at senior centers, where they also can tap the talent and
skills of their retired citizenry. Senior centers are the visible
statement of how communities value their senior citizens.64
The support and maintenance of normal social and community ac-
tivities for older persons is as essential as it is for all age groups. Such
"normal" participation, however, is conditioned by a number of fac-
tors which affect the lives of individuals who are limited by changed
circumstances of living: by reduced income, by physical limitations,
by restricted opportunities in work life, by narrowed opportunities
for intimacy, by fear or concern that the resources necessary to main-
tain personal integrity will not be available. Sensitivity to these fac-
tors has been reflected in the senior center movement as it has devel-
oped over the years.

FIN-DINGS FROMI RECEN-T STUDIES
Although flexibility has been evident in the variety of approaches
based on local need, recent studies of senior group programs have
stressed aspects of their activity which imply that definitions of pur-
pose and function are emerging.
Criteria for subjects in studies of the senior group movement are in
themselves a form of definition:
-That they were directed to older adults; a requirement which as-
sures the participant that the central focus of interest is in the
specific needs of his group. This might be less essential in a more
inclusive social structure. Given the categorized organization of
our society this emphasis has probably been the most influential
in the growth of the senior group movement;
-That they were regularly scheduled to meet at least once a week
throughout the year; a requirement which defines continuity and
the assurance of continuitv as a key element in the programs: and
-Tiat they procide .aome iad of educatioital, recreational, or so-
cial activities; a requiremen-t broad enough to include those serv-
64 Directory of Senior Centers and Clubs. A National Resouree; prepared by the Natilonwl
Institute of Senior Centers for the Administration on Aging of the U.S. DHEW under
grant No. 93-P-575441/3-01, December 1974, Introduction, p. iii.





34


ices and/or activities best suited to the groups served-but stress-
ing reliable content and related to the expressed needs of the
group and the community.
In the directory of such centers 65 released in January 1974, 4,870
did meet the three requirements considered basic.
Detailed findings describe the center programs more vividly.
The majority of all the senior programs were located in
cities. Though rural areas often have high percentages of
older persons they have many fewer programs to meet their
needs.66
Overall, however, there has been an increase in the range of services
offered by senior group programs. "Multipurpose" centers may offer,
n addition to the required minimum of three services, such activities
as friendly visiting and other useful volunteer services provided by
participants as a community service; transportation, and special
:services to the handicapped. Even before the implementation of the
title VII nutrition program, approximately 487 multipurpose centers
were serving a hot noon meal daily; current data is not available but
it is logical to assume that senior group centers participate signifi-
cantly as locations for the 4,112 congregate meal sites funded by the
nutrition program.
Another development of significance has been the provision of
selected health services in senior group programs. The availability of
health information, health counseling and referral to health care;
transportation to health care and appropriate direct health services
is among the major needs of older persons, particularly those with
limited incomes. Early discovery and treatment of potential or actual
high-risk problems is an important advantage to the individual and
his family; its importance for the community at large as a measure of
morbidity control is as great. Some form of health related service is
provided by more than half the senior programs-with major em-
phasis placed on health related information and referral, health educa-
tion, transportation to health resources, health screening, in that
order.67
CHARACTERISTICS OF PARTICIPANTS
The characteristics of those attending centers resemble in some ways
those who utilize other community based resources. Generally greater
use of the centers is made by those over 65 in low-income groups rather
than by the more affluent. Of all of the community services stressing
older consumers, the center movement is impressive in its appeal to
those below age 65. The 55-65 age group, while representing a rela-
tively small percent of participants, does provide evidence that such
services can appeal to younger adults whose use of the services may
offer protection in later years.68
Those with lower incomes are also limited in their ability to take
advantage of the services by transportation problems and the location
convenience of the centers.69 Location has been largely influenced by
5 Ibid.
6 Pothier. William, interview, November 1975.
6 Challenge for Tomorrow, a report on research findings of a study of senior group pro-
grams. Sara B. Wagner, Ed. D., senior research associate, the National Council on Aging,
Inc., present at the Western Gerontological Society Conference, San Francisco, Calif.,
April 28, 1975, table S.
6q Ibid, p. 15.
69 Ibid, p. 14.






35


funding: Like so many of the adult day centers many of the senior
group centers have been forced to use "found" housing, tlen inade-
quate to program needs." Funding has also limited the availability of
paid staff. The centers do have an impressive record in participant vol-
unteer activity but the reliable leadership and energy in program de-
velopment which full time paid stafl provides is sharply limited by
funding limitations. As in other cominunity services for older persons
the money problem is paramount. Reliance on multiple funding and
the constant pressure to obtain funds for continuity. for population
coverage, for service development to meet expressed need, for adequate
housing of the center program siphons oil valuable energ-V which should
and could become an investment in the service progrram. Of those
queried who "would like" to attend a senior group program a signifi-
cantly high number were in the low-income group, 39 percent were
black and problems of availability and transportation ranked among
the barriers to participation.7
SUMMARY AND _RECOMM1fENDATIONS
The senior group center movement which developed as the result of
concern in public and private organizations for older persons who are
isolated and frequently disadvantaged economically owes its astonish-
ing growth as well as its flexible response to the needs of participants
in large part to the energy and activity of its own membership and to
the efforts of public and vountary organizations developed nationally
and at State and local levels. It primary imtus i the cognition
triat it is an essential resource. a center for the support of older persons.
It has provided a wide variety of services and activities but has been
limited in its potential usefulness by the absence of funding for ex-
panded geographic coverage, for adequate housing, for paid staff, and
for transportation especially adapted to the needs of participants. As
in all other community services, reliance upon multiple funding sources
has limited the capacity of the movement to meet expressed need bv
potential participants who would willingly utilize such programs. The
activities and services provided are more than a social luxury. They
become a necessity for increasing numbers of persons who, deprived of
normal participation in community life. are exposed to the risks which
isolation produces-risks which involve the destructive and costly se-
quels to such isolation.
Recommendations for the extems'o ard expa on of tlese Centers
have been made by program1 representatives:
First.-Fnding 72 of mzdtiplrpose senior centers at a rniimu m in
e.ach plar: ;: q and sr~iee area (,ndir t~tle TV of the Older Amereans
Act) from which area aqe -Ps on aa;g could cooidin ate fhe deh ery,
of Usrvwe. Use of conmut development fund. prad, to meet
felt need in local communit es, particularly for facilities development
wi.here centers do not havre adequate hws'2ng.
Second.-Grahts to ass~t W 7flhI~t :iifinq tenpter aetiz'ities and to
subsidize expansion of ,aftiritie.-specfrally dire etcd (to ward inct'eas-
ing the number of multipurpose centers.

Leanse, Joyce, report to the board of directors, National Council on Aging. Sept. 2';,
1975.
"' Reference cited In footnote 67.
.'2 Pothier, William, interview, November 1975.








Third.-Funding assistaitce to nonprofit centers a well as to those
which are publicly supported with emphasis on support of centers
in the community development program.
Fourth.-Support for the development of contractual arrangements
between area agencies on aging and senior centers in order to insure
more comprehensive community services.
Fi fth.-Support for the development of standards which encourage
and protect the quality of the centers and the services which they
offer.73
V. HOME HEALTH SERVICES
The reiterated emphasis on home health services as a possible alter-
native to institutional care tends to exclude consideration of their
potential value as a resource for the noninstitutionalized consumer who
must rely on inhome services in order to use the centers and facilities
described in this report. If maintenance in the community is an objec-
tive, the extension of treatment and supportive care into the home is a
.necessity for many of the disabled and chronically ill persons who are
unable. to be totally self-sustaining at home and who do not have
family or others in the home capable of providing this support.
u,,e of the mattisite day centers, for example, reports that of 541
participants in day care, about one-half were also using home health
services. Slightly more than half of these participants were living
a lone; approximately one-fourth with a spouse "--and given the age
range of the participants it is not likely that essential supportive care,
health supervision and continuous treatment routines could be pro-
vided on days of nonattendance.
For effective participation in noninstitutional programs it is evi-
dent that home health services are needed in order to provide the on-
going support necessary to make utilization of other community serv-
ices a real possibility. When they are not available, or when they
are too limited to serve as an enabling service, the "network" aspects
of the community program cannot be realized and it is not possible to
envisage the future development of day care, the day hospital, after-
care, nutrition and socialization centers, the senior group center, and
related services without them.
"AN ABSENCE OF ACTION"
Since the inception of medicare and medicaid, however, the spate
of discussion, argument, reporting, and recommendation concerning
home health services has been equaled only by the absence of action
on all levels.
There has been no significant effort to test the value of the services
as a reliable health resource by removing artificial barriers to their
use, by stimulating population coverage and by supporting expansion
of their service range in order to make them viable and thereby to
demonstrate their real usefulness. Although there have been two re-
Ts Pothier. William, interview, November 1975.
74 Parks. Carol S., project director, Senior Health Improvement Centers, Tucson, Ariz.,
,preliminary report, June 3, 1975.






37


ports by the General Accounting Office' recommending such stimula-
tion, with concurrent reports from the Senate Special Committee on
Aging," and numerous recommendations by a wide variety of Federal,
State, and local committees, connnissions, and study groups, all of
them recommending the development of such services as "alterna-
tives" to institutional care; as "humane" in terms of the provision of
the opportunity for choice; as "appropriate" in a wide variety of
acute and long-term need situations; as a possible preventive resource
which might control morbidity and thereby reduce utilization of acute
and long-term care institutions-there has been no visible change with
respect to increased availability of these services.
Expenditures for home health services peaked in medicaid in 1971
to 0.48 percent of total expenditures and had decreased by 1973 to
0.28 percent of total expenditures. In medicare, expenditures for home
health services peaked in 1969 to 1.1 percent of total expenditures and
had decreased by 1973 to 0.7 percent of total expenditures.77 "GAO
recommendations were, in short, to encourage expansion of the under-
standing and use of the benefits." "I Encouragement of understanding
ha-s not, however, been an effective measure.
Factors which discourage use are more tangible. These have been
described in previous Senate reports and in hearings and, more re-
cently, in a department background paper.79 Restricted use and de-
velopment of the services are related to restrictions: The "home-
bound" but not "custodial" description; the nature of the services
reimbursed the "posthospital" requirement; the need for "skilled",
that is, treatment-nursing services; the interpretation of "part-time,
intermittent" need, and limitations in the use of the homemaker-home
health aide with respect to essential life supporting services; exclu-
sion of services which are not "condition-related," and to reimburse-
ment problems which confuse medicare parts A and B and differ-
ences and similarities and discrepancies between medicare and medic-
aid provisions, some real, some related to general misunderstanding:
Providers contend that the enormous administrative over-
head required to submit and collect on claims have had the
effect of increasing administrative costs and the smaller
agencies curtailing services. . Policies governing medic-
aid's home health program have further dampened the ex-
pansion of home health services. Medicaid's reimbursement
policies permit States to set a flat rate that is unrelated to
costs and charges.80
The situation with respect to expansion of home health services
remains essentially the same, or perhaps somewhat less encouraging,
than it was 5 years ago:
5 Study of Health Facilities Construction Costs, enclosure C. report to the Congress by
the Comptroller General of the United States, 1973; "Home Health Care Benefits Under
Medicare and Medicaid, July 1974."
7 Home Health Services in the United Statea, a report to the Special Committee on
Acing. U.S. Senate. April 1972: Home Health Services in the United States, A Working
Paper on Current Status, July 1973.
7 Callender, Marie, and LaVor, Judy, Home Health Care Developments, Problems and
Potential, Office of Social Services and Human Development, Office of the Assistant
Secretary for Planning and Evaluation, U.S. Department of Health, Education, and Wel-
fare, app. 2, table III.
78 Ibid, Introduction.
Ibid, p. 47.
90 Ibid, p. 27.








The problem of availability of home health services, and
the benefit provisions under medicare and medicaid have a
circular cause-effect relationship. There is a maldistribution
of certified home health agenices (54 percent of the Nation's
counties have no certified home health agency) to provide
covered services under medicare and medicaid. Of the 46
percent of the counties covered, the coverage may not in-
clude the entire county. This lack of coverage is primarily
because these certified agencies are one- or two-nurse agencies
and cannot cover the entire area. Counties without certified
agencies (the 54 percent) are primarily rural. Medicare
and medicaid were expected in 1965 to produce the needed
support, but it is agreed that their increasingly restrictive
benefit interpretations slowed and then stopped the expan-
sion of home health agencies. Most of the private insurance
plans offering home health benefits adhere to the medicare
provider standards. Thus, the benefit is not universally avail-
able and it is argued that the services and the number of pro-
viders has dropped since 1971 after the initial rise from
1966 to 1971. It is further argued that the administrative
complexities of medicare and medicaid, and the small trade-
off in numbers of clients, have encouraged providers to stay
out of the programs.
The number of home health agencies grew from 1,850 to
2,350-a growth rate of slightly over 20 percent-from 1966
to 1970.
In 1972 there were approximately 2,222 and by 1974 2,248
home health agencies-a substantial drop in growth rate.
Number of participating home health agencies, 1966-1974;
all areas:
Year: Number
1966 -------------------------------------1, 850
1967 -------------------------------------2,111
1968 -------------------------------------2,164
1969 -------------------------------------2,209
1970 -------------------------------------2,350
1971 -------------------------------------2,284
1972 -------------------------------------2,-22
1973 ------------------------------------- 2,211
1974 -----------------------------------82,248
The value of noninstitutional community services has been recog-
nized in other countries: along with day care, which relies on inhome
supports, the Callender-La-Vor paper comments: 82
Forty-seven foreign countries provided constant attendance
allowances for both work-related and nonwork-related dis-
ability. The allowances are payable under the disability pro-
visions of old-age, survivors, and invalidity insurance pro-
grams. Seventy-six nations provide the allowances on their
workers' compensation programs. The major developments

Sl Ibid., p. 28.
2 Ibid., pp. 45-46.







have occurred since 1961, and are generally meant to provide
in-home services when voluntary services are not available,
or to offset rising costs of institutional care.8-' J"he criterion
for the allowance is invalidity, regardless of cause, and the
need for constant attendance. The allowance may provide for
a friend or family member to stay home to care for the belle-
ficiary, or may be used to purchase services outside.
In addition to the allowances provided through invalidity
insurance and workers' compensation. most industrialized
nations (except the United States) provide both home health
and home help services. The home help services are designed
to assist disabled and handicapped persons with various
chores and food activities. The services are viewed as a means
of keeping people independently at home and out of high-
priced institutions. Voluntary as well as official govern-
mental agencies provide home help services and are usually
paid for out of public funds. These funds may be health
programs, disability and social insurance, or social services.
The uncertainty concerning potential costs if viable home health
services were to be developed is frequently cited as an obstacle to
their development, along with difficulties encountered in comparing
home health costs with institutional costs. A sensible approach might
be the analysis of those programs which provide a broad range of
services, or which, even to a limited extent. extend their services to
the long-term consumer in order to determine costs over a period of
time rather than in the framework of the present acute care-episodic-
unit-cost estimates. Cost studies and utilization projections should
not be insurmountable and, while frightening enough, the cost prob-
lem has not yet stemmed the tide in the institutional construction-
utilization areas of the health care system.
THE MAJOR OBSTACLE
The major obstacle in home health services development appears to
be more accurately described by the HIBAC report:
Despite the demonstrated value of home health services,
priority continues to be given by third-party payors and cur-
rent legislation to the present institutionally oriented system
of health care.84
This tendency or characteristic in the planning of care services will,
if continued, affect not only expenditures-it will limit innovative and
creative development in other noninstitutional approaches as well and
will continue to offer to a growing segment of our population a sad
choice-either the institution or possible isolation and neglect at home.
Recommendations made by HIBAC and by the Special Committee
on Aging in previous reports have yet to be implemented. They in-
elude development of broad range home health services: expanded
population coverage; manpower training, and access provisions which
are rational in order to encourage expansion of understanding and
appropriate use of the services.
3 Social Security Bulletin, "Constant Attendance Allowances for Nonwork-Related Dis-
ability," November 1974.
11 RePort from the Health Insurance Benefits Advisory Council, on Home Health Care.
September, 1974.
72--'2-76-4







VI. "SPECIAL NEEDS" TRANSPORTATION
Limited mobility is a major obstacle in almost every aspect of daily
life. The loss of the ability to walk, to get in and out of a bus, to
move about freely, which most people take for granted is an imprison-
ing handicap. Access to treatment, to recreation, to the pursuit of
personal interests is destroyed, and the simplest undertakings con-
stitute an overwhelming problem requiring elaborate and frustrating
planning and effort which discourage the attempt. In all of the
centers and facilities, the availabilty of transportation-for the
semiambulatory, for the frail and for those who are wheelchair-
bound-is stressed as a key factor in the success of the program.
It is also a major cost factor. One of the centers reports that almost
one-half of the daily cost is invested in contracted "special needs"
transportation. A multisite center reports that it is unable to fund
such transportation and must limit acceptance to those participants
who have family or friends able to provide transportation. Centers
which purchase their own buses emphasize the cost of purchase and
maintenance and the cost of idle periods when the transportation per-
sonnel "have nothing to do."
Limited access is reported as a major obstacle by the senior group
centers. Home health services report that both the cost and the time
spent Jn planning for or providing assisted transportation to medical
and other health care resources are a serious problem, since medical
supervision in the home is a rare occurrence. Many of the day centers
contract with "for-profit" commercial transportation companies with
a high cost-plus-profit charge-particularly for chair-bound partici-
pants and this is a cost which siphons off a sizable proportion of
limited funds.
Transportation is the "biggest problem" . It is trouble-
some for all day care programs . It is probably essen-
tial . Where it wasn't provided, staff members often had
to use their personal cars to provide it on an ad hoc basis.
Some participants were probably left out of the program
for lack of transportation.85
"Special needs" transportation is transportation specifically de-
signed for handicapped individuals; usually minibuses equipped with
wheelchair hoists and stabilizing locks; optimally with specially
trained staff accustomed to transfer activities and sensitive to the
needs and fears of the disabled or fragile individual.
THE TUCSON EXPERIENCE
One community has faced this need and solved it sensibly. The city
of Tucson, which offers a multisite day care program, an extensive
senior group program, a multisite nutrition and socialization program,
a mobile meals program, and home health services has integrated "spe-
cial needs" transportation into its public transportation system. It
considers all transportation a public utility:
The handicapped have as much right to public transporta-
tion services as any other member of the population . if
5 Reference cited In footnote 4, p. 56.







the city will handle this type of transportation for everybody
who has special needs it will be a lot less costly to Govern-
ment.86
(Government cost in this context is intended to mean the overall
cost-not just a narrow cost concern in a single communityy) It owns
24 specially equipped buses, employs well trained drivers described
as "orderlies on wheels," who are capable of meeting emergencies. It
operates the system 5 days each week from 7 o'clock in the morning to
10 o'clock at night, serves "low-income" handicapped persons, provid-
ing door-to-door or "care-to-care" transportation, emphasizing health-
related need, although a part of its services meet recreational needs as
well (center outings and picnics are served) and offers individual
shopping service in the evenings and on Saturdays.
Approximately 1,179 to 1,765 rides are provided each month, most
of them to clinics, physicians' offices, hospitals, and the community
center programs. In May of 1975, about 1,000 handicapped individuals
were provided special needs transportation-85 percent of them aged,
30 percent requiring transportation for medical reasons. Center par-
ticipants are regularly served and the relationship between drivers
and participants is striking-friendship, concern, understanding, and
trust are evident. Both wheelchair and frail ambulatory or semi-
ambulatory persons are served at a cost to the community of about
$500,000 a year (1975).87
The service is in addition to the community's free transportation
program for the elderly and low-income groups able to use the regular
public transportation facilities. The average cost per ride is lower than
taxi service or commercial special needs transportation, and while this
has been a subject of concern in some quarters the rationale is sound.
Consumers of this service are being provided tax supported health
services usually nonprofit, and the addition of transportation to the
cost of care on a nonprofit basis as well, is a sensible approach, leaving
aside the question of the rights of individuals to public transporta-
tion facilities and the injustice of discrimination against the handi-
capped by denying them this access.
The addition of mobility-of the means of moving out of the home
and into the community-restores more than the "right" to a public
facility. It reduces or eliminates many of the destructive problems
which ultimately affect the individual and the community: Limited
access to care, services and social life creates new problems and new
problems trouble the conscience of the community; they involve in-
creased costs as well.
A public policy with associated funding which support.f8 s'eh trarn.-
portation would not, as in other services, be supporting an "inno-
vative" or "demonstration" approach. It would restore equity in public
service to a group which hAs been deprived.
86 Interview with Carl W. Anderson. special needs transportation superintendent, depart-
ment of transportation, city of Tucson, May 1975.
7 Ibid.












PART 3

THE COMMUNITY NETWORK

The interdependence of community service components for effec-
tive, total quality must be self-evident. The absence of reliable trans-
portation services cuts off access to the services for those who are most
in need. The absence of health supervision and essential supports in
activities of daily living in the home makes utilization of out-of-home
center services impossible. Inadequate income and poor housing de-
stroy the value of even the highest quality in center services. Unless
there is geographic coverage and efficient organization and coordina-
tion of the services, they become unusable. Unless those who need any
one or all of the services are aware that they exist and are enabled to
make appropriate use of them, they become elite symbols of com-
munity intention rather than examples of action-oriented community
efforts to control morbidity and humanize the existence of population
groups which have been variously disadvantaged and ignored.
In discussing day care, Theodore Koff emphasized the key to effec-
tiveness in all of the services:
The primary essential is that [they] be a part of a sequence
of services so that the individual can move in and out of the
various service settings. . The extent to which there is a
community support system which insures appropriate choice;
awareness of health needs; central intake; coordination in
planning and placement; transportation, and other such serv-
ices. insures the success of each section of the sequence... the
centers are a part of a system; they are not the entire system.
Their use must be very flexible, depending on community per-
ception of need. There is no single approach but the princi-
ples and standards must provide for quality-in professional
services, in training-and for flexibility-for movement out
as well as in.88
In its report on the planning and organization of geriatric serv-
ices, a World Health Organization expert committee formulates the
aims of health care for the elderly and aged in the following way:
The spectrum of services:
(1) To sustain them in independence, comfort, and content-
ment in their own homes, and when independence begins to
wane, to support them by all necessary means for as long as
possible;
(2) To offer alternative residential accommodation to those

8 Koff, Theodore H., Ed. D., associate professor, retirement housing administration,
department of public administration, University of Arizona, interview, May 1975, Tucson,
Ariz.


(42)







who by reason of infirmity, lack of a proper home, or other
circumstances are in need of care and attention;
(3) To provide hospital accommodation for those who by
reason of physical or mental ill health are in need of full
medical assessment, therapy, rehabilitation, or long-term
skilled medical and/or nursing care.9
The community network whi;h encompasses the services described
in this report (but does not exclude related community resources) is
directed toward tle first of these aims and stresses organized services
which are the "iecessary means" essential for life in the home and com-
munity for vulnerable high-risk groups.

COST
The projection of cost for the population which might benefit from
the services and programs described in this report could not at present
be made with any degree of precision. Some of the services must be
considered "innovative" for the United States and have not had a long
enough period of trial here; for others, the effort to analyze existing
data has not been made. and would, in any case, be affected by the limi-
tations which have been imposed upon their delivery, with the result
that their full usefulness has not yet been demonstrated, particularly
in relation to key factors which might affect cost savings througTh
control of morbidity and arrest of deterioration which ultimately
affects total cost in long-term care. (In this sense "preventive" care
should be, but generally is not, considered "health related" in our
present system which inappropriately emphasizes acute care services
for a population group which has a major need for long-term services.)
The use of "dollar expense" in a context which uses a simple mul-
tiplication system, that is, unit cost or per diem cost in a given program
or service multiplied by estimated utilization by a group of potential
consumers, is an approach which frequently does not take into account
the fluctuating need in long-term care: Many consumers do not need
or use all of the services all of the time: many do not need or use any
single service or combination of services continuously and there may
be long periods when no services or only limited services are required.
Dollar figures also ignore outcomes in another context:
... The outcomes or values one does consider are largely
noneconomic . life satisfaction, independence, physical
functioning, and so forth.90
Data provided for a research plan of a cross national comparison
between selected areas in the UTnite(d States and Enland indicate that
both the percentage of expenditures in the gross national product for
health services, as well as the rate of increase, are higher in the United
States, although health services, and specifically services considered
"innovative" in the United States. are freely available in the United
Kingdom.9' (This data is not lrcise concerning differences in defini-
8 World Health Organization, technical report series, report of a WHO expert committee,
"Planning and Organization of Geriatric Services," Geneva 1974.
90 Doherty, Neville J. G., Ph. ).. and Hicks, Barbara C.. MSSW, The Use of Cost Effec-
tiveness in Geriatric Day Care, paper presented at the 27th annual scientific meeting (f the
Gerontological Society, Portland, Oreg., October 2S-November 1, 1974. (Supported by HEW
Contract #O-73-196.)
91 Gurland, Barry, and Zubin, Joseph, A Feasibility Study of a Cross National Comnari-
son of the Institutional Elderly Including the Cost Effectiveness of their Long Term
Care. (HEW, Office of the Assistant Secretary for Planning and Evaluation.)





44


tion of health services or in the quality of the services delivered.) A
general approach to the question of health needs in the aging pop-
ulation, moreover, is emerging in the international field which pro-
vides a less stereotyped approach to the "condition" of aging and
for costs and values in the social structure:
Persons with specific chronic diseases often regard them-
selves as being in good health because they can independently
and satisfactorily engage in their usual daily living activities.
This is particularly true in old age . ..2
While it must be admitted that many of these conditions
are chronic in type and hence not amenable to complete cure,
many, if not all, are capable of amelioration, some to a very
considerable degree 93
Pathology of many chronic diseases remains irreversible.
This does not mean, however, that the physical, emotional,
social, and vocational sequence of these diseases must 'remain
irreversible . Experience has shown that ... much of the
undesirable sequence of chronic diseases and disabilities can
be minimized, alleviated, or even eliminated. Thus, rehabili-
tation constitutes the essential part of so-called "tertiary pre-
vention," in terms of preventing the development of adverse
persistent effects of diseases leading to permanent disability.94
* it is also true that a strong case can be made economi-
cally for rehabilitating an increasing number of older dis-
abled people . Their rehabilitation often pays a maximum
return on public funds invested and it always achieves social
and personal gains that are beyond measurement in economic
Values.95
The impact of insufficient, inadequate or poorly organized services
upon those who are particularly vulnerable to neglect does, however,
measurably affect dependency, and increased dependency where it is
avoidable will measurably affect dollar outlays. The interdependence
between adequate health services and cost control, ,hile it is difficult
to project precisely, must be considered in all planning and dollar
investment in community programs and services, in order that short-
range economies do not result in long-range costs.
92 United Nations Department of Economic and Social Affairs, The Aging: Trends and
Policies, U.N., New York, 1975, p. 90.
93 ibid., p. 91.
94 bid., p. 93.
95 Ibid.











APPENDIXES


Appendix 1
ISSUES IN LONG-TERM CARE FOR PERSONS DISABLED
EARLY IN LIFE; BY ELIZABETH M. BOGGS,* PH. D.
(Performed through a cost-sharing arrangement with the Division of
Long-Term Care, National Center for Health Service Research,
Health Resources Administration, DHEW, and the Office of Long-
Term Care Standards Enforcement, DHEW Region IX)
IMPACT OF AGE ON LONG-TERM: CARE NEEDS
Clearly the age of an individual needing any service is a relevant
factor. In social terms, impairment of function must be seen in rela-
tion to role expectations for people in our society of comparable age.
For the elderly, capacity for self-care and self-direction are normative
values, more so than economic productivity; for those of work age
(18-65) economic self-support is highly valued, and incapacity in that
dimension constitutes deviance; for a child, schooling is the indicator
task, but maturation, the development of physical, intellectual and so-
cial competence, is the underlying expectation. In the early years, self-
direction is not assumed, and potential impairment is therefore often
masked, at least in the legal sense that minority subsumes a need for
protection.
DEMOGRAPHIC FACTORS IN- LONG-TERMA CARE
The National Center for Vital Statistics, through its household
interview surveys of the noninstitutionalized civilian population finds
that about one person in eight of the population at large has an
activity limitation due to a chronic condition: of these about three-
fourths (9.3 percent of the population or about 19 million people)
are limited in their major activity. Major activity refers to ability
to work, keep house, or engage in school or preschool activities. Of
these persons with major activity limitations onlv 71/ million, or less
than 40 percent are age 65 or over. Even when these figures are com-
bined with the population of institutions housing long-term residents,
age balance is not reversed. Moreover, there is reason to believe that
the household interview technique under-enumerates younger people
with mental handicaps who are outside of institutions. Program data
(such as social security, disability allowances) consistently turn up
mental retardation (in children and young adults) and mental illness
*Addenda to final report of task force (June 1975), Institutes on Health Care and
Health Care Delivery, "Human Factors in Long-Term Care," National Conference on Social
Welfare, San Francisco, Calif., May 1975.
(45)





46


in young and young middle-aged adults as a primary cause disability,
even among the noninstitutionalized, although such is not reflected in
National Center for Vital Statistics data.
The last decade has seen a spectacular increase in nursing home
populations and a spectacular but not comparable decrease in mental
hospital population. Partly as a result, it is difficult to assemble data,
even on the institutional populations, which clearly describe compa-
rable population bases. It appears, however, that in the population at
large there are approximately 1.7 million persons in long-term institu-
tional care because of mental or physical handicaps of whom about
700,000 are under age 65. The latter figure includes at least 150,000
children.
LONG-TERM CARE NEEDS OF THE NEWBORN
Although estimates, vary, 5 percent is a substantiable figure for
"significant" abnormalities present at birth in liveborn infants. (Some
authorities go as high as 10 percent.) Although mortality by age 5 is
about 50 percent, it is offset, statistically, by the identification process
which continues through the preschool and early school years. It is
important to note that among those with predictably fatal disorders,
the needs for sustained medical and social support for both patients
and families is not dissimilar to those among the very old. Indeed the
thanatologist, Dr. Elisabeth Kubler-Ross, has devoted much of her
time to the study of dying children and their needs.
For infants with major birth defects who survive beyond age 5,
the prognosis is most likely for long-term care reaching at least into
early adulthood. Among the specific conditions with long-term care
implications for which prevalence is increasing (due to increased
survivorship) are: spina bifida (3 per 1,000), Down's syndrome (pres-
ent in 1 out of 600 live births but frequently not immediately identi-
fied), hydrocephalus, and cardiac malformations (about 2 and 4 per
1,000 respectively). Mental retardation is a frequent concomitant
of all these conditions.
Other important conditions calling for long-term care beginning
in infancy are cerebral palsy, epilepsy, and autism. Prevalence of
cerebral palsy in childhood is now estimated at about 0.5 percent.
Manifestation of a tendency to recurring seizures can occur at any
age but, usually begins in childhood; in 30 percent of all cases, epilepsy
first appears in those under 5.

LONG-TERM CARE NEEDS IN CHILDHOOD AND YOUTH
The National Center for Vital Statistics data on noninstitutional-
ized children identify over 1 million under 17, or about 1.6 percent,
with major activity limitation. Of these one in eight (0.2 percent of
child population) is "unable to carry on major activity," i.e., go to
school. These figures must be regarded as conservative indicators of
the long-term care needs of the child population inasmuch as there are
over 3 million children actually enrolled in school programs for the
education of the handicapped which are themselves "sustained" serv-
ices. If one excludes those children classed as "speech impaired" (a
relatively transitory disorder, as a rule) there remains over 11/2 million
children actually identified as chronically impaired in the "major







activity" of their age group. Of these over half are mentally retarded.
Moreover, State vocational rehabilitation agencies annually accept
over 100,000 youths (under 21) about three-fourths of whom are
"rehabilitated" (i.e., prepared for gainful employment). Such youth
are, by definition, "impaired" in their major activity, i.e., work. Again,
mental retardation and mental illness are major contributors to the
total, with orthopedic and sensory handicaps also significantly repre-
sented. Although only one-fourth of those accepted are not "success-
fully rehabilitated"-i.e., prepared for appropriate gainful activity,
it is increasingly recognized that even those who are placed in employ-
ment are in many cases in need of continuing supportive service-i.e.,
long-term care, within the Brody* definition.
ADULTS OF WORKING AGE AT RISK FOR Lo,--T:nt CARE
The National Center for Vital Statistics' "limitation in major activ-
ity" classes include 2.7 million persons of working age who are unable
to work in addition to over 8 million whose ability to work is limited
in kind or amount as of 1972. Persons over 44 predominated in both
groups, but more so in the totally disabled segment. These figures can
be compared with program data from the Social Security Administra-
tion, which, in 1974, was paying current benefits to 2.6 million adults
age 18 to 64 who were severely disabled to the extent that they were
"unable to engage in substantial gainful employment." Of these. 1.8
million were disabled workers (mostly men) currently under 6i and
328.000 were adults who had been disabled in and since childhood. In
addition some 80,000 disabled widows and widowers over 50 received
benefits under a special clause. This grand total of nearly 2.7 million
individually identified beneficiaries includes some who are in institu-
tions but excludes disabled individuals not covered by social security
such as certain government employees, railroad workers, housewives,
and others without an extended earnings record in covered
employment.
Annual data on the characteristics of these disabled persons at the
time first found eligible for social security benefits are relevant. Among
workers who became disabled prior to age 40, schizophrenia was the
leading diagnosis; after that age, heart disease takes the lead in all
age groups, with schizophrenia in second place, gradually giving way
to emphysema and arthritis in those over 55. n
By contrast, in the smaller group representing those whose disabili-
ties originated before age 18, mental retardation is the major cause,
followed by cerebral palsy, mental illness, and epilepsy.

I31PACT OF AGE AT ONSET OF DISABILITY
Although the age of a person at the time service is needed and re-
ceived is an important determinant of the social as well as medical need,
there are, because of the age-related social and economic roles and ex-
pectations of our society, equally important effects attributable to past
and prospective duration and age at onset. For example, although the
11 percent or so of nursing home residents who are under 65 are on the
*Brody, Elaine M., "Long-Term Care: The Decisionmaking Process," in "Human Factors
in Long-Term Care," Institutes on Health and Health Care Delivery, National Conference
on Social Welfare, San Francisco, CtI if., May 1975.





48


whole less impaired than older residents, their average length of stay
is longer. There are, moreover, cumulative effects both direct and in-
direct, for those whose disability originates early. For the young adult,
upward social and economic mobility is denied, often soon after he or
she has assumed new family responsibilities and roles. Multiple scle-
rosis typically creates such problems. Tremendous emotional adjust-
me-nts to revised aspirations at this age may be accompanied by intense
indignation.
For the person disabled in early childhood, there is an even more
fundamental deprivation, since normal growth and development may
be significantly suppressed. With it the entire life experience becomes
atypical. Not to have experienced normality (in vision, hearing, intel-
lectual functioning, social relationships. or mobility) sets the affected
individual apart from peers, and even from those with like disabil-
ities or later orioin, as is the case with the congenitally deaf or blind.
Moreover, the seriously developmentally disabled person is, even with
the best available programing, unlikely to achieve the economic en-
titlenients and family status which are taken for granted by and for
those who remain active until their declining years.
This is evidenced in a variety of ways. Persons severely disabled
in childhood are less likely to be married during the period of adult
disability than are persons who become disabled after marrying, and
are thus more likely to be dependent for social, if not economic. sup-
port on older family members (parents), who themselves are becom-
ing" more vulnerable. Among identified noninstitutionalized adults (age
18 through 64) who were severely disabled before age 18, 48 percent
were found to be "functionally dependent" as compared with 27 per-
cent of those with later onset. Among members of the same age group
in mental institutions for whom aoe at onset was known, 47 percent
had been disabled since childhood. Even among those over 65 in the
same institutions, 8 percent had been disabled prior to age 18.
Among adults receiving disability assistance in 1970, and for whom
age-at-onset data was reported, more than 30 percent were disabled
before maturity: few of these recipients were in institutions. This
figure is likely to be increased when data become available on disabled
recipients of supplemental security income under the federalized pro-
gram which went into effect in January 1974.
Tlese figures strongly suggest that disability originating early in
childhood is a significant component of all adult disability. However,
they are not entirely consistent with the results of the survey of non-
institutionalized disabled adults conducted in 1966 by the Social Se-
cUrity Administration. That survey found only one out of six severely
disabled persons to have experienced onset in childhood. Again the
survey method appears to have resulted in under-representation of the
mentally handicapped. The contribution of childhood disability to
4dut (isability probably lies between one-sixth and one-third.

ECONOrIC FACTORS
All data point to a greater prevalence of disability among low in-
come people. The differences are more pronounced in the working
years, since during this period disability is a cause as well as an effect
of marginal economic status. Again age-at-onset of disability differen-
tiates among members of the same age cohort. Those disabled in child-





49


hood do not have the same compensations as disabledd vorlker"s with a
history of participation in the work force: in addition, as just men-
tioned, they are less likely to be married and thls do not have the
support of an able bodied spouse. At the same time half a million
AFDC families have one incapacitated parent. There are 37,000 fani-
ilies with young children in which both parents are disabled.
Berkowitz has pointed out that public transfer programs are more
likely to replace adequately income losses due to disability which is
not severe than to replace the losses of those who experience severe
disability during the years which are usually income producing. The
entire family unit is affected by a reduction in the standard of livin.
Berkowitz has also studied trends in the economics of long-terin care
as part of the total costs of disability. Counting the costs of income
maintenance or replacement transfers and medical costs, he estimates
the 1967 losses at $15 billion and the projected 1990 rate as .170 bil-
lion. of which somewhat more than half is attributed to medical costs.
He does not estimate social service costs. The rate of growth of long-
term costs thus estimated will exceed the rate of growth of the GNP
and also the growth in costs of short-ter.ln disabilitv. These projections
do not include costs of long-term care of the elderly. They also exclude
dollar data reflective of the "human factors" implicit in the impact on
dependents and survivors of the premature disability and death of an
adult of working age. although Berkowitz also made estimates of these
effects as well.
PROGRA-M IMTPLICATIONS OF EARLY "ON--SET OF DISABILITY"
Clearly servicess integration" for di -.abled children reaches beyond
1he medical-social continuum to involve education as a major com-
ponent. Moreover, the value system of our society. as, well as practical
considerations, leads to the emphasis on some form of work activity
for the adult under 65 as a constructive objective, even when economic
self-support is not feasible. The person who experiences disability
before he has fully matured does have developmental potential even
if expectations are altered, and his social and emotional growth must
be fostered despite impediments. The service goal is to foster such
growth. not merely to slow down decline.
At the present time. litigation and some lecrislation is leading to an
extended concept of the public school responsibility to the severely
handicapped. No longer is the classification of "unable to benefit from
Pducation" being permitted to justify exclusion from school programs.
Courts have responded to expert opinions holding that every human
beinz has potential for growth and chan.oe, especially dilrin the so-
Palled developmental period. and that it is the duty of schools to educe
1his potential even when maior impairments are present.
The "developmental model" addressed the wholee chil!" in a way
which requires concurrent attention to physical, social and iTtellectimal
growth.
BARRIERS TO EFFECTIVE LONG-TERM CARE
Almost everything that Brahna Trager* says about Jeinstititionali-
zation, dehumanization. "community alternative<' "individul asess-
*Tracer. Brahna. 'The Community In Lonz-Term Care." In "Hupman Faetorf In Long-
Term Care," National Conference on Social Welfare, San Francisco, Calif., May 1975.





50


meant" and other catch words of the seventies are applicable in spades
to children and adults disabled early in life with long-term prospects
for long-term care. Means tests present a special problem, since, if
parents are self supporting the child is often ineligible for means-
tested programs. SSI is beginning to breach this inequity but the in-
come cutout level for children under 18 is still very low, especially in
States where medicaid is available only to actual recipients.
Private medical insurance (and even federally aided crippled chil-
dren's programs) still cover little long-term care for children, espe-
cially after "maximum therapeutic benefit" has been exhausted; NHI
offers poor prospects for remedying the situation. "Catastrophic" is
still measured in major episodes, rather than cumulative drawdown
of resources. Exclusion from school places additional social and finan-
cial burdens on parents, as well as accentuating their sense of their
own rejection by society.
When the economic and social pressures, and the needs of other
family members, become too destructive, the residential institution
may be seen as the only alternative option, drastic as it may be. For
those who are well-to-do, there are good and bad private facilities; for
those for whom an annual continuing cost of $6,000 to $18,000 a year
seems stiff, there are waiting lists for both good and bad State oper-
ated or State subsidized facilities. Unfortunately in a significant num-
ber of both public and private facilities, "premature functional death"
begins early and lasts a very long time.
The economic and social burdens experienced by families of disabled
children and young adults are not only immediate and direct, but in-
direct and sometimes subtle. The prospects of long-term care without
end for a young family member have a debilitating effect on even the
most courageous parents. Richardson and his colleagues found in their
longitudinal studies in Aberdeen that the presence of a mentally
handicapped child was inversely correlated with upward social mo-
bility of the parents, when social class factors were otherwise con-
trolled. Career decisions by parents may be modified when choice of
locale has to take into account special resources needed by a disabled
child. If long-term care were more evenly accessible this social price
could be avoided. Clearly the need for long-term care in the form of
sustained social supports is even more urgent where ripple effects, for
better or worse, are so important.
Sustained support requires a core of continuity, preferably through
the instrumentality of an informed and client oriented advocate. Case
closure is antithetical to long-term care, yet open-ended casework is
seen by many professionals as unsatisfying. Fortunately there are
some intimations that both professional values and accountability
measures may increasingly favor the model of long-term prescriptive
support services with continuity provided by an individual client pro-
gram coordinator who works among, as well as within, systems.

Th-END AND PRO5PECTS
Of greatest significance are changing concepts of the structure of
the service systems. For example, in 1970, Federal legislation (Public
Law 91-517) was addressed to "developmental disabilities" (originat-
ing before 18, of indefinite duration, and "substantially" handicap-







pin.). It dealt implicitly and explicitly with the need to replace the
monolithic "institutional" model, with a coordinative but pluralistic
approach both to planning and to clinical case management. It recog-
nized the right of the severely disabled to participate prescriptively in
the major generic delivery systems-health, social services, rehabili-
tation, education, recreation, as well as income maintenance where
necessary, and the obligation of those systems to be responsive to
special needs, each within its own sphere of competence.
Because the developmentally disabled person usually requires some
special services, as well as a more-than-average amount of adapted
generic services, and because he is himself impaired in his ability to
"work the system," he, even more than others who are, or once were,
competent, needs both an advocate and a skilled case manager. As this
is written, the U.S. Senate has drafted an extension to the 1970 legis-
lation which will require the setting-in-place of a truly comprehensive
system for assessing and tracking the individual progress of develop-
mentally disabled children and adults in accordance with "an individ-
ual written habilitation plan." The evaluation model assumes that the
plan will draw on all relevant components of the human services sys-
tems as delineated above. It is a bold new approach, all right, and
blows the mind. Its precursors are already being set up, however, on a
demonstration basis, in response to concepts embodied in standards
enunciated by the Accreditation Council on Facilities for the Mentally
Retarded. ACF/MR is a unique interdisciplinary body, in which con-
sumer and provider organizations have joined. The individual pro-
gram plan, whether in the residential or community setting, and the
client case coordinator, are key concepts.
The former Vocational Rehabilitation Act was extensively rewrit-
ten in the early 1970's to embody some of the same concepts, albeit in
a more limited time frame. The intent of Congress was made clear that
more severely disabled persons be served both, more intensively and
for more extended periods, and more prescriptively, with more par-
ticipation in decisionmaking by the client.
An even more promising event for the severely disabled was the
passage, early in 1975, of the Social Services Amendments, creating
the new title XX to the Social Security Act. Although it is likely that
in many States the disabled, both children and adults, may be short-
changed once again in the short run, two trends may eventually
reverse the tide. First there are States which have demonstrated effec-
tively how social service funding can "put it all together" for plural-
istic community programing for the disabled. Such demonstrations
can be catching. Second, the concepts of the act itself call for better
prescriptive packaging of health, rehabilitation, education, and in-
come maintenance components, using social services as the matrix. For
the first time institutional residents are perceived as part of the con-
tinuum of care, rather than a population apart. Moreover, the goal
structure on which the legislation is predicated speaks directly to the
spectrum of functional needs of the child and adult requiring long-
term care. Their goals are:
(A) Achieving or maintaining economic self-support to prevent,
reduce, or eliminate dependency,
(B) Achieving or maintaining self-sufficiency, including reduction
or prevention of dependency,






52


(C) Preventing or remedying nerlect, abuse, or exploitation of chil-
dren and adults unable to protect their own interests, or preserving,
rehabilitating or reuniting families,
(D) Preventing or reducing inappropriate institutional care by pro-
viding for community-based care, bome-based care, or other forms of
less intensive care, or
(E) Securing referral or admission for institutional care when other
forms of care are not appropriate, or providing services to individuals
in institutions.
Although the social services reporting requirements being developed
for use with title XX once again tend to stress "closures" based on
achievement of goals through time-limited delivery of services, the use,
in the act, of the terms "maintaining" in relation to self sufficiency
and "reducing," as well as "preventing," dependency provide a statu-
tory base on which advocates for those at risk in long-term care of all
ages can construct delivery systems which include extended case man-
agement leading to sequenced services "on a sustained basis," as called
for in the Brody definition.
REFERENCES
(1) Berkowitz, M., Cost Burden of Disability and Effects of Federal Program
Expenditures, Final Report, Bureau of Economic Research, Rutgers University,
New Brunswick, N.J. (HEW-OS-141) 1974.
(2) Boggs, E. M., "Some Issues Related to Long-Term Disability: A Position
Paper," in Schreiber, M. (ed.) Social Work and Mental Retardation, John Day
Co., New York, 1970, p. 244.
(3) Boggs, E. M., "The Need for Protective Services for the Mentally Retarded
and Others With Serious Long-Term Disabilities," ibid., p. 593.
(4) Dempsey, J. J., "Congenital Malformations and Long-Term Care: Epide-
miology, Service Utilization and Costs, A Preliminary Appraisal of the Litera-
ture," working paper No. 1, DHEW, Office of Assistant Secretary for Planning
and Evaluation, October 1974.
(5) Dempsey, J. J., "Cerebral Palsy: Epidemiology and Implications for Long-
Term Care, A Preliminary Appraisal of the Literature," working paper No. 2,
DHEW, Office of Assistant Secretary for Planning and Evaluation, November
1974.
(6) Office of Management and Budget, Executive Office of the President,
Social Indicators, 1973, Washington, D.C., U.S. Government Printing Office,
1973.
(7) Franklin, P. A. "The Disabled Widow," Social Security Bulletin, 38: 20-27
(1975).
(8) Frohlich, P., The 1967 National Survey of Institutionalized Adults-Resi-
dents of Long-Term Medical Care Institutions. DHEW Publications (SSA) 75-
11803, Washington, D.C., U.S. Government Printing Office, 1974.
(9) Kakilak, J. S. et al., Services for Handicapped Youth: A Program Over-
view, Rand Corporation, Santa Monica, Calif., (R-1220-HEW) May 1973.
(10) Kakilak, J. S. et al., Improving Services to Handicapped Children, Rand
Corporation, Santa Monica, Calif., (R-1420-HEW) May 1974.
(11) Lazar, I. et al., Cornell Studies of P.L. 92-603, 6 volumes, Community
Services Laboratory, Cornell University, Ithaca, N.Y., 1974.
(12) National Center for Health Statistics, Health Resources Statistics-
Health Manpower and Health Facilities, 1974, U.S. Public Health Service, Rock-
ville, Md.
(13) National Center for Health Statistics, Series 10, No. 87, Impairments due
to Injury, United States 1971, DHEW Pub. No. (HRS) 74-1514, 1973, U.S. Public
Health Service, Rockville, Md., 1973.
(14) National Center for Health Statistics, Series 10, No. 96, Limitation of
Activity and Mobility Due to Chronic Conditions-United States 1972, DHEW
Pub. No. 75-1523, U.S. Public Health Service, Rockville, Md., 1974.
(15) National Center for Health Statistics, Series 12, No. 19, Characteristics
of Residents in Nursing and Personal Care Homes-United States, June-August









1969, DHEW Pub. No. (HSM) 73-1704, U.S. Public Health Serviee, Ro-kville.
Md.
(16) National Center for Health Statistics, Series 12, No. 22, Chroic Crondi-
tions and Impairments of Nursing Home Residcnts-United States 1969 DHEW
Pub. No. (HRS) 74-17017, U.S. Public Health Service, Rockville, ld.
(17) National Center for Social Statistics, Findings of the 1970 APTD Study:
Part I, Demographic and Program Characteristie DHEW Pub. No. (SRS) 733-
03853, Social and Rehabilitation Service. Washington. D.C.. September 1972.
(18) Haber, L. D.. "Epidemiological Factors in Disability: Major l)isablii_
Conditions," No. 6 of Reports from Social Sceurity Survy of the Disabied: 1966,
Washington, D.C.. Office of Research and Statistics, 1969.
(19) Brehm, H., "The Disabled on Public Assistance," No. 9 of Reports from
Social Security Survey of the Disabled: 1966, Washington, D.C., Office of Re-
search and Statistics, 1970.
(20) Haber, L. D., "The Measurement of Functilonal Capacity Limilations."
No. 10 of Reports from Social Security Survey of the Disabled: 1966, Washing-
ton, D.C., Office of Research and Statistics. 1R70.
(21) Treitel, R., "Onset of Disability," No. 18 of Reports from Social Security
Survey of the Disabled: 1966, Washington, D.C., Office of Research and Statistics,
1972.
(22) Office of Research and Statistics, Monthly Benefit Statistics., April 30,
1975, DHEW Pub. No. (SSA) 75-11703, Social Security Administration, Wash-
ington, D.C.
(23) Rice, D. B. (ed.), Critical Issues Involved in Rehabilitation of the
Severely Handicapped, Report of a Study Group, Arkansas Rehabilitari,-n Re-
search and Training Center, University of Arkansas, 1974.
(24) Rosen, B. M., Kramer, M., Redick, R. and Willner, S., Utilization of
Psychiatric Facilities by Children: Current Status, 7-rends, Implications, Report
Series on Mental Health Statistics, Series B, No. 1, National Institute of Mental
Health, Rockville, Md. 1968.
(25) Stephenson, D.. McWilliams, S. and Fisher. I. L.. Handicapping Condi-
tions: A Resource Book, Office for Handicapped Individuals, Office of the Secre-
tary, DHEW, Washington, D.C. (in press).

TABLE 1.-TOTAL POPULATION AND NUMBER AND PERCENT DISTRIBUTION BY ACTIVITY LIMITATION STATUS
DUE TO CHRONIC CONDITIONS, FAMILY INCOME, AND AGE: UNITED STATES, 1972
[Number of persons in thousands and percent distribution

With limita- With limita-
tion, but tion in Unable to
not in amount or carry on
Total Per- major Per- kind of major Per- major Per-
Family income and age population cent activity I cent activity I cent activity I cent

ALL INCOMES
All ages---------- 204, 149 100 6, 279 3. 1 13, 557 6. 6 6, 032 3.0
Under 17 years --------------64,865 100 884 1.4 906 1.4 131 .2
17 to 44 years- ...77,131 100 2,410 3.1 3,242 4.2 755 1.0
45 to 64 years -------------- 42,229 100 1,929 4.6 5,097 12.1 1, 90,) 4.5
65 years and over ------------19, 924 100 1,056 5.3 4, 312 21.6 3, 246 16. 3


LESS THAN $3,000
All ages
U.der 17 years_-_
17 to 44 years
45 to 64 years-_
65 years and over -----------
$3,000 TO $4,999
All ages
Under 17 years-.
17 to 44 years --------------
45 to 64 years --------------
65 years and over


19,674 100 931 4.7 3, C83 15.7 1,951 10.0
4,304 100 52 1.2 83 1.9
5,611 100 272 4.8 359 6.4 209 3.7
3,615 100 222 6.1 969 26.8 606 16.8
6,144 100 385 6.3 1,672 27.2 1,136 18.5


21,162 100 805 3.8 2,227 10.5 1,398 6.7
6,167 100 90 1.5 125 2.0 --------------------
6,457 109 224 3.5 424 6.6 158 2.4
3,913 100 210 5.4 677 17.3 433 11.1
4,625 100 281 6.1 1,001 21.6 807 17.4







54


TABLE 1.-TOTAL POPULATION AND NUMBER AND PERCENT DISTRIBUTION BY ACTIVITY LIMITATION STATUS
DUE TO CHRONIC CONDITIONS, FAMILY INCOME, AND AGE: UNITED STATES, 1972-Continued
[Number of persons in thousands and percent distribution]

With limita- With limita-
tion, but tion in Unable to
not in amount or carry on
Total Per- major Per- kind of major Per- major Per-
Family income and age population cent activity I cent activity I ceot activityI cent

$5,000 TO $6,999
All ages -------------- 24, 513 100 712 2.9 1,814 7.4 809 3.4
Under 17 years ------------- 7,864 100 109 1.4 123 1.6 --------------------
17 to 44 years -------------- 9,136 100 314 3.4 455 5.0 108 1.2
45 to 64 -------------------- 4,844 100 189 3.9 706 14.6 287 5.9
65 years and over ------------ 2,669 100 100 3.7 530 19.9 414 15.5
$7,000 TO $9,999
All ages -------------- 34,620 100 884 2.6 1,944 5.6 646 1.9
Under 17 years ------------- 11,754 100 160 1.4 173 1.5 ------------------
17 to 44 years -------------- 14,061 100 369 2.6 572 4.1 113 .8
45 to 64 years -------------- 6,894 100 287 4.2 840 12.2 240 3.5
65 years and over ----------- 1,911 100 68 3.6 359 18.8 293 15.3
$10,000 TO $14,999
All ages -------------- 51,073 100 1, 403 2.7 2, 160 4.2 464 1.0
Under 17 years ------------- 18, 277 100 252 1.4 233 1.3
17 to 44 years -------------- 21,253 100 637 3.0 743 3.5 76 .4
45 to 64 years -------------- 10,001 100 452 4.5 932 9.3 173 1.7
65 years and over ----------- 1,542 100 62 4.0 252 16.3 215 13.9
$15,000 OR MORE
All ages -------------- 40,984 100 1,256 3.1 1,629 4.0 346 .8
Under 17 years ------------- 12,782 100 182 1.4 135 1.1 -------------------
17 to 44 years -------------- 16,715 100 515 3.1 540 3.2 47 .3
45 to 64 years -------------- 9,988 100 474 4.7 712 7.1 88 .9
65 years and over ----------- 1,499 100 85 5.7 242 16.1 191 12.7


I Major activity refers to ability to work, keep house,
s Includes unknown income.


or engage in school or preschool activities.


Source of data: The information for table 1 was derived from data in the National Center for Health Statistics publica-
tion titled "Limitation of Activity and Mobility Due to Chronic Conditions," series 10, No. 96.
Data notes: The health interview survey of the civilian, noninstitutionalized population began in 1957. The information
is obtained in household interviews in a continuing nationwide survey conducted by trained personnel of the U.S. Bureau
of the Census. During 1972, the sample was composed of about 44,000 households, containing about 134,000 persons. A
description of the survey design methods used in estimation, limitations of the data and definitions of terms are presented
in the appendixes of the publications. During 1972, an estimated 12.7 percent of the population or 23,868,000 persons in
the civilian noninstitutionalized population were reported to be limited to some extent in activity due to chronic disease
or impairment. About 3 percent of the population or 6,031,000 persons were unable to carry on their major activity (work-
ing, keeping house, going to school). About 6.6 percent were limited in the amount or kind of major activity, and 3.1 per-
cent or 6,279,000 persons were limited in other activities such as recreational, church or civic activities. Over the 15 years
of the survey, the percentages of the population in each degree of activity limitation have been quite stable. As age increases
and income decreases, the proportions of persons with limitations of activity and mobility rose regardless of sex or race.
This information is important in estimating the present and future population in need of long-term care.







TABLE 2.-LONG-TERM CARE RESOURCES BY STATE AND REGION


Total
nursing
centers and Certified Certified JCAH Institute
Home personal intermediate skilled accredited for
Senior Homemaker health care care nursing nursing Certified mentally Psychiatric General
centers programs agencies facilities facilities I facilities I homes ICMR retarded hospital hospital


3 1,611


42,286


117


5 22,004


2,054


48, 789


4 7,384


e 1, 592


4 1,258 5 1,236


5 497


56,491


1, 101


Connecticut...
Maine__--
Massachusetts----
New Hampshire .....
Rhode Island
Vermont....
Region II ------------


N ew Jersey --- -- -- ---------
New York
Puerto Rico ---------------
Virgin Islands
Region III -----------


867 178 188 1,644 262 816 197 0 62 59 448


548
1,096


222 36
589 156
5 5


586 201 303 1,514 428 594 124 0


20 14 111
42 45 337
-----------------------83----70-----526---
83 70 526


Delaware -------------------
District of Columbia-........
Maryland-..
Pennsylvania---------------
West Virginia
Region IV ------------


Region IV 2,521


Alabama ...................- 49 23 69 192 166 165 15
Florida --------------- 90 34 47 373 97 258 26
Georgia ------------------ 46 10 15 283 327 248 25
Kentucky-.....-............. 41 29 41 344 80 84 27
Mississippi .................- 6 29 88 134 16 96 13
North Carolina..-------------- 128 68 53 843 83 164 21
South Carolina....36 27 18 118 59 79 18
Tennessee ------------------ 48 22 92 234 206 43 26


1, 143


0 3 5 136
1 24 14 206
7 5 11 183
3 4 6 117
1 2 2 122
4 12 7 144
4 2 5 89
0 12 9 146


Total-. .


Region I


24, 769


331


1,034


1,157


2,521












TABLE 2.-LONG-TERM CARE RESOURCES BY STATE AND REGION-Continued


Total
nursing
centers and Certified Certified JCAH Institute
Home personal intermediate skilled accredited for
Senior Homemaker health care care nursing nursing Certified mentally Psychiatric General
centers programs agencies facilities facilities I facilities I homes ICMR retarded hospital hospital


Region V
Illinois .. ...................
Indiana_
Michigan.. . . . .
Minnesota ...
O hio_. . . . . .
W isconsin ------------------
Region VI ------------
Arkansas -------------------
Louisiana -----------------
New Mexico ----------------
Oklahoma ------------------
Texas ----------------------
Region VII ------------
Iowa ......................
Kansas ---------------------
M issouri -------------------
Nebraska -------------------
Region VIII ----------


1,116


4,404


2,343


1,652


232 54 84 1,046 87 Z
87 58 28 522 391 1
165 32 48 562 285 3
210 79 63 593 354 2
278 87 101 1,191 661 3
144 95 67 490 565 2


1,838


1,616


85 94
20 38
38 115
76 81 1'
46 61
87 91
66 77


265 115 134 1,974 1,205 240 96 1


1,153


976 C;


5 1 99
13 5 149
7 3 59
9 6 142
32 17 527
51 28 574


250 102 89 753 415 379 63 25 42 13 356


Colorado ------------------- 48 21
Montana ------------------- 50 24
North Dakota --------------- 47 33
South Dakota --------------- 59 20
Utah .----------------------- 32 4
Wyoming ----------------- 14 --------------
Region IX ------------- 473 111


103 4,534 144


149 18
74 7
52 16
56 10
37 4
11 8
1,241 193


17 23 7 88
6 5 -------------- 72
0 2 1 61
2 2 2 66
0 8 1 39
0 2 2 30
1 601 42 699


v





American Samoa ----------------------------------------------------------------------------------------------------------------------------------------------------------------------
Ari7ona -------------------- 56 13 10 82 -------------- 17 12 -------------- 9 3 81
California ------------------- 347 86 85 4,277 133 1,191 165 0 569 36 572
Guam--------------------------------------------1----- I ------------------------- 1I
Hawaii --------------------- 57 6 4 132 11 15 11 1 22 1 22
Nevada -------------------- 13 6 3 43 --------------- 17 5 ------------- 1 2 24
Trust territory ------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Region X ------------- 163 58 59 768 241 402 60 4 30 13 282
Alaska --------------------- 8 1 1 8 1 8 1 0 1 1 26
Idaho ---------------------- 38 6 9 64 6 50 8 0 1 2 49
Oregon --------------------- 40 15 26 311 155 59 14 4 6 4 86
Washington ----------------- 77 36 23 385 79 285 37 0 22 6 121


I The numbers of certified skilled and intermediate care facilities are not mutually exclusive because
some facilities have dual certification. This applies to approximately 1/3 of the certified facilities
and varies from State-to-State dramatically. The data for certified intermediate care facilities and
intermediate care facilities for mental retardation only includes those facilities reported to Social
Security by May 1975. Because a new set of regulations are being applied, many States will have many
more or less facilities later this year pending outcome of the application of waivers. In some States,
nursing homes are serving as intermediate care facilities for the mentally retarded and therefore,
are certified as ICMR's but are not counted, by the National Center for Health Statistics as insti-
tutions for the mentally retarded.
1he variation of resources available for long term, as well as, acute care from region to region
and State-to-State is most important in providing appropriate service. Region V has more resources
of all types per citizen than any other area of the country. Numbers alone do not tell the story but


they do give an indication of the distribution and potential quantity of service available to meet
peoples needs.
2 Directory of Senior Centers and Clubs-A National Resource by the National Institute of Senior
Centers under grant number 93-P-575441/3 01 from the Administration on Aging, 1974.
s Unpublished data from survey conducted by National Council for Homemaker-Home Health
Aide Services, Inc., for the Public Health Service under Contract No. HSM 110-72-260, June 1974.
4 Unpublished data from Management Information System, Social Security Administration, May
1975.
6 "Health Resources Statistics," National Center for Health Statistics, 1974.
6 "Long Term Care Fact Book," American Health Care Asscciation, 1974.

















Appendix 2


SELECTED TABLES-ADULT DAY CARE IN THE UNITED STATES-A COMPARATIVE STUDY

(Prepared by the TransCentury Corp. in accordance with provisions of contract, awarded by the National Center
for Health Services Research, Health Resources Administration, PHS, DIIEW)


TABLE 1.-COMPARISON OF SELECTED PROGRAM CHARACTERISTICS OF ADULT DAY CARE PROGRAMS, RANK ORDERED BY AVERAGE DAILY ATTENDANCE

Average Length of Days per
daily Principal funding operation week in
attendance source (months) Affiliation operation Geographic location

Tucson senior health improvement programs ------------------------ 115 Model Cities -------- 92 Nursing home, hospital ----------- 5 Tucson, Ariz.
San Diego senior adult day care program --------------------------- 52 Revenue sharing --- 20 Social service organization -------- 5 San Diego, Calif.
On Lok senior health services center ------------------------------- 47 Title IV, OAA ------- 27 Free standing ------------------- 7 San Francisco, Calif.
Burke Day Hospital --------------------------------------------- 40 do ------------- 27 Rehabilitation center ------------- 5 White Plains, N.Y.
Lexington-Center for Creative Living ------------------------------ 29 Title VI, SSA ------- 25 County health department -------- 5 Lexington, Ky.
Mosholu-Montefiore Geriatric Day Care program --------------------- 28 Title IV, OAA ------- 26 YMHA-YWHA, hospital ----------- 5 Bronx, N.Y.
Levindale adult day treatment program ---------------------------- 25 Medicaid ----------- 60 Geriatric center------------------ 5 Baltimore, Md.
St. Camillus health care by the day program--------------------------18-do-.............-34 Skilled nursing facility 5 Syracuse, N.Y.
Athens-Brightwood Day Care Center ------------------------------- 11 Title VI, SSA -------- 36 Social service organization -------- 5 Athens, Ga.
St. Otto's day care programs ------------------------------------ 11 Medicaid ----------- 79 Nursing home ------------------ 5 Little Falls, Minn.
Average ------------------------------------------------- 37.6 42.6

Source: Average daily attendance reflects TransCentury findings from a count of actual attendance onsite visit days and program records of lunches consumed in sample months. Tucson program officials
disagree with figures for their program. Their estimate is 143.








59


TABLE 2.-SELECTED DEMOGRAPHIC


CHARACTERISTICS OF ADULT DAY
BY AVERAGE AGE


CARE PARTICIPANTS; RANK ORDERED


Precent of Percent of
Partic- partic- partic-
ipants pants ipants
average Percent Percent who are living Percentage of ethnic
age under 65 over 85 female alone orientation

Montefire--------------77 10 20 80 53 Jewish, 63.
Lexington ------------ 76 13 27 70 30 Black, 52.
On Lok-------------.. -76 10 17 33 50 Oriental, 87.
San Diego ------------ 76 20 10 70 27 White, 73.
Athens-----------------75 23 27 63 40 Black, 63.
Levindale- ...........75 17 20 53 23 Jewish, 68.
Burke---------- 71 33 14 73 20 White, 64.
Tucson --------------- 69 27 7 57 20 White, 53.
Spanish surnames, 33.
St. Callus 65 36 3 67 13 White, 83.
St. Otto's ............ -54 70 3 67 33 White, 100.

Average -------- 71 26 15 63 31

Source: TransCentury sample of 30 participants' records selected randomly from active files.

TABLE 3.-COMPARISON OF INCIDENCE OF PARALYSIS AMONG PARTICIPANTS IN ADULT DAY CARE
PROGRAMS, IN RANK ORDER

Proportion
with partial
or total
paralysis
(percent) Rank

Burke- ------------------------------------------------------------53 1.0
St. Camilluus ------------------------------------------------------------------ 43 2.0
Tucson- ..........................................33 3.0
On Lok ----------------------------------------------------------------------- 30 4.0
Lexington --------------------------------------------------------------------- 20 5.5
San Diego --------------------------------------------------------------------- 20 5.5
Athens- ------------------------------------------------------------10 8.0
Levindale------------------------------------------------------------10 8.0
Montefiore -------------------------------------------------------------------- 10 8.0
St. Otto's------------------------------------------------------------3 10.0
Average- ------------------------------------------------------23 -----------

Source: TransCentury participant sample of 30 participants randomly selected at each program.

TABLE 4.-COMPARISON OF THE INCIDENCE OF WHEELCHAIR USE AMONG PARTICIPANTS IN ADULT DAY CARE
PROGRAMS, IN RANK ORDER

Proportion
using
wheelchairs
(percent) Rank

St. Camillus ------------------------------------------------------------------- 73 1.0
Burke-- .........................................50 2.0
Tucson I- --------------------------------------------------------- 27 3.0
Levindale- -------------------------------------------------------- 23 4.0
Lexington --------------------------------------------------------------------- 13 5.5
On Lok -------------------------------------------------------------- 13 5.5
Athens 2_ ..... ..... ..... .... ..... ..... .... ..... ..... .... ..... .....-10 7.5
San Diego3 ..................-.................................................. 10 7.5
St. Otto's --------------------------------------------------------------------- 3 9.5
Montefiore- ......................................3 9.5
Average ----------.---------------------------------------------------- 23

I The number of wheelchair participants at 3 of the 6 centers in the Tucson program is limited by the lack of specially-
equipped bathroom facilities.
S The Athens program cannot accommodate more than 4 participants using wheelchairs per day because of restricted
space.
3 Because of fire regulations, the San Diego program will not accept participants who are wheelchair-bound.








60

TABLE 6.-COMPARISON OF THE INCIDENCE OF STROKE AMONG PARTICIPANTS IN ADULT DAY CARE PROGRAMS
IN RANK ORDER


Proportion who
have suffered
stroke (percent)


Rank


Burke ------------------------------------------------------------------------ 47 1.0
On Lok ----------------------------------------------------------------------- 40 2.0
St. Camillus ------------------------------------------------------------------- 33 3.5
Tucson ---------------------------------------------------------------------- 33 3. 5
Athens ----------------------------------------------------------------------- 20 6.0
Lexington --------------------------------------------------------------------- 20 6.0
San Diego --------------------------------------------------------------------- 20 6.0
Montefiore ------------------------------------------------------------------ 13 8. 0
Levindale ---------------------------------------------------------------------- 10 9.0
SL Otto's --------------------------------------------------------------------- 3 10.0
Average ---------------------------------------------------------------- 24 ----------

Source: TransCentury participant sample.

TABLE 11.-COMPARISON OF AVERAGE NUMBER OF DIAGNOSED CHRONIC CONDITIONS AFFLICTING PARTICI-
PANTS IN ADULT DAY CARE PROGRAMS, IN RANK ORDER

Average number
of conditions
per participant Rank

Burke ------------------------------------------------------------------------ 4.8 1.0
Montefiore -------------------------------------------------------------------- 3.9 2.0
On Lok ----------------------------------------------------------------------- 3.5 3.0
Lexington ----------- : ----------------------------------------------------------- 3.3 4.0
St. Camillus ------------------------------------------------------------------- 3.0 5. 5
Tucson -------..--------------------------------------------------------------- 3.0 5.5
Levindale --------------------------------------------------------------------- 2.9 7.0
Athens ----------------------------------------------------------------------- 2.7 8.0
San Diego --------------------------------------------------------------------- 2.1 9.0
St. Otto's --------------------------------------------------------------------- 2.0 10.0
Average ---------------------------------------------------------------- 3. 1 ........

Source: TransCentury participant sample.

TABLE 12.-COMPARISON OF MEAN ADL SCORES I FOR PARTICIPANTS IN ADULT DAY CARE PROGRAMS, IN RANK
ORDER

Mean ADL score Rank

St. Camillus ------------------------------------------------------------------- 3.8 1
Burke ------------------------------------------------------------------------ 2.8 2
On Lok ----------------------------------------------------------------------- 1.8 3
Tucson ----------------------------------------------------------------------- 1.4 4
Levindale --------------------------------------------------------------------- 1.1 5
San Diego --------------------------------------------------------------------- 1.1 6
Lexington ---------------------------------------------------------------------. 8 7
Athens ----------------------------------------------------------------------- .5 8
Montefiore -------------------------------------------------------------------- .5 9
St. Otto's --------------------------------------------------------------------. 1 10

1 An ADL score is an index computed to express dependency in activities of daily living. The score reflects both the
number of activities in which a participant is dependent, and weighting for extent of dependency. Activities of daily living
include: walking, wheeling, eating, and toileting. Weighting is assigned as follows: 1-requires assistance of equipment;
2-requires assistance of a person; 3-requires assistance of both equipment and a person.
Source: Computations using TransCentury participant sample.








61

TABLE 13.-COMPARISON OF RATIO OF PARTICIPANTS TO TOTAL STAFF IN ADULT DAY CARE PROGR AMS, IN RANK
ORDER

Number of
participants Average Total
per staff daily FTE I
member attendance staff Rank

Burke --------------------------------------------1.3 40 31.41 1
Athens-------------------------------- 1.5 11 7.13 2
St. Camillus ------------------------------------- 1.9 18.3 9.71 3
San Diego ------------------------------ 2.0 52.1 26.53 4
,OnLok ........2.2 47 21.65 5
Montefiore...-2.5 28 11.41 6
Lexington--------------------------------------2.5 29 11.51 7
Tucson ---------------------------------------- 2.8 115 41.54 8
1.evindale ----------------------------------------- 3. 2 25 7.72 9
St Otto's- .......4.8 11 2.29 10

Average-----------------------------------2. 5 37. 6 17.09...........

I The term full-time equivalent(FTE) may be confusing. It simply means total full-time and part-time hours worked per
day, divided by the number of hours in the program's work day-usually 8, but for some programs, 7Y2.
Source: TransCentury estimates computed by dividing average daily attendance by number of full-time equivalent
ttaff (FTE).


'TABLE 15.-COMPARISON OF EMPHASIS ON HEALTH CARE SERVICES
ORDER


IN ADULT DAY CARE PROGRAMS, IN RANK


Proportion of Minutes in
staff time in health care
health care services per
services participant-
(percent) day I Rank,

Burke ---------------------------------------------------------- 56.6 108.6 1
St. Camillus ----------------------------------------------------- 43.7 85.0 2
'St. Otto's ----------------------------------------- -------------- 42.1 32.8 3
San Diego ------------------------------------------------ 41.5 70.6 4
,Montefiore ------------------------------------------------------ 33.2 30.4 5
Levindale ------------------------------------------------------- 29.3 15.7 6
Lexington ------------------------------------------------ 27.4 31.0 7
Tucson --------------------------------------------------------- 25.8 35.6 8
VOn Lok --------------------------------------------------------- 24.5 28.4 9
Athens ---------------------------------------------------------- 9.4 20.5 10
Average --------------------------------------------------- 33.4 45. 9

I Does not include time of therapies received on referral, if any, except Tucson.
Source: TransCentury computations.








62

TABLE 29.-COMPARISON OF PRINCIPAL CHARACTERISTICS OF 2 MODELS OF ADULT DAY CARE


Model I


Model It


Participant characteristics:
A verage age ----------------------------------------------------------------
Living alone (percent) -------------------------------------------------------
Incidence of paralysis (percent)--
Incidence of wheelchair use (percent) ...............................
Incidence of fractures (percent)
Incidence of stroke (percent) ------------------------------------
Incidence of neurological disorders (percent)
Incidence of mental disorders (percent)
Incidence of hypertension (percent)
Incidence of blindness (percent)
Average number of diagnosed medical conditions_
Mean ADL score-....
Staffing patterns:
Participants per staff member
Participants per health professional_-
Percent of staff time in health care services
Minutes of probable health care services per participant day
Minutes of physical therapy per participant day provided by a professional physical
therapist
Minutes of occupational therapy per participant day provided by a professional
occupational therapist --------------------------------------
Minutes of speech therapy per participant day provided by a professional speech
therapist
Minutes of nursing services per participant day provided by a registered nurse -----
Minutes of nursing services per participant day provided by a licensed practical
n u rse -- -- -- -- ---- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --
Program costs:
Per diem, total .......
Health care services ---------------------------------------------------------
Supporting health activities ---------------------------------------------------
Transportation services ..........


68. 0
16.7
48. 3
61.7
23. 3
40. 0
25. 0
20. 0
55. 0
6.7
3.9
3.3


72. 3
34. 6,
17. 1
12.9
9.1
20. 0
28.8-
28. 0
40. 0
2.5
2.9
.9


1.6 2.7
5.9 21.8
50.1 29.2-
29.5 12.6
15.1 1.2
10.7 1.1
7.3 .3
(1) 3.8
(1) 3. 2
$43. 09 $20. 5&
17.60 5.38
19.60 11.82'
5. 89 3. 36


I Not significant,











Appendix 3


REPORT ON DAY HOSPITALS IN ISRAEL AND GREAT
BRITAIN; BY EDITH G. ROBINS'

CARE OF TM ELDERLY IN ISRAEL
As a framework for the following observations, a brief overview of
the health care system in Israel will be helpful.
Primary health care and arrangements for hospital care are provided
to most employed workers and their families as well as to retirees
through the Kupat Holim. the medical arm of the Israeli Federa-
tion of Labor (Histadritth). The Ministry of Health provides coin-
prehensive health services to the medically indigent and to immigrants
and their families who are not members of Kupat Ilolim. Private
health care is available on a limited basis to those who wish to pay for
services.
The Ministry of Health operates the majority of hospitals (includ-
ing day, hospitals), and Kupat Holim members may receive their care
in these facilities, with the Kupat Holim paying for a portion of such
,care and the government making up the difference.
There are no government-operated nursing homes, but the govern-
ment, through the Department of Social Welfare, does operate a few
homes for the aged; other homes for the aged are operated by volun-
tary organizations. Only one home for the aged has a well equipped
medical component.
A report entitled "The Organizational Structure of the Kupat Ho-
lim Services According to Regionalization and Integration" describes
the move currently underway to merge the current 15 health districts
into 8 health regions and 1 centralized medical center. Also included
in the report is a description of the proposal for services to the aged
and chronically ill to be conducted by the Kupat Holim that was ap-
proved in 1972. Efforts are currently being directed by the labor or-
Tanization to implement these recommendations.
To obtain the information in the following report, conversations
were held with the following:
Dr. Jacob -Menczel, Director-General. Ministry of Health.
Dr. Joseph Silberstein, Director, Chronic Illness and Aging, Israel
Ministry of Health.
Dr. Marian Rabinowitch. Chief, Department of Geriatric Rehabilita-
tion, Tel Hashomer Hospital, Tel Aviv, Israel.
Dr. Daniel Kindler, Director of Day Hospital, Tel Hashomer Hospital,
Tel Aviv, Israel.
Ms. Hassida Guaryahu. Director of the Unit for the Aged and Health,
Municipality of Jerusalem.
"Ms. Robins Is Deputy Director, Division of Long-Term Care, National Center for Health
'Services Research, HRA, DHEW.
(63)






In reading the following discussion, these facts should be kept in
mind:
(1) Until recently, there was little in the way of outreach services
for the elderly; although a few programs recently have been under-
taken, it is widely acknowledged by Israeli health and social welfare
authorities that much more is needed.
(2) Very little is currently being undertaken in research on health
services.
(3) There are no government-operated nursing homes, and for the
most part the privately owned nursing homes are considered by Israel's,
health and social welfare authorities to be of very poor quality.
(4) While the proportion of elderly in Israel is currently relatively
small, a marked shift in the makeup of the population is anticipated,
resulting from the large numbers of elderly persons migrating to Israel.
Estimates for 1980 forecast a doubling of the number of persons over
65 years of age.
(5) A high priority is being given to the development of home health,
services and day hospitals.
(6) High priority is also placed on increased development of pre-
ventive services and on creation of comprehensive health centers, coin-
bining Kupat Holim and government resources.
(7) Action is just getting underway to develop sheltered housing,
based on models developed in Scotland and England.

DAY HOSPITALS
Currently there are four day hospitals in Israel, and it is anticipated
that there will be five more in operation by the end of the year. These
day hospitals are based on the British model. Great interest was shown
by Dr. Silberstein in the writer's paper presented at the Congress pro-
posing four distinct modules of day care, including the module serving
as a substitute for inpatient hospital care, the module providing time-
limited restorative care, the module providing long-term maintenance
care, and the module providing psychosocial care (see "Operational
Research in Geriatric Day Care in the United States," p. 82.)
In Israel (as in England and the United States), there is an urgent
need for day care for the socially isolated frail elderly, and this serv-
ice calls for a different staffing from that in programs providing re-
storative and maintenance care. Dr. Silberstein noted that many of
the Israeli day hospital participants remain in the program after the
restorative goal is reached because of lack of other alternatives in
the community. Where the patient is to go after discharge from the
day hospital is the key problem, he emphasized.
The four existing day care programs are Shaarej Zedek, Tel Hash-
omer, Assaf Harofeh, and Pardess Katz. With the exception of the
Tel Hashomer Day Hospital, each of these models is located directly
in or on the grounds of the parent hospital that operates the program.
The Tel Hashomer model is housed in what was formerly a private
residence located in close proximity to the hospital.
No documentation on costs has as yet been obtained from these
programs, but the need to obtain such data is recognized by Israeli
health officials.







According to Dr. Silberstein, the day hospital has as its major
objectives the shortening of hospital stay by providing treatment with-
out the. hotel services, and the prevention or postponement of inpatient
care. In some instances, the day hospital also provides diagnostic
work-ups.
Dr. Menczel was of the opinion that the day hospital should be used
for more than the elderly, that it should be utilized for all age groups
in need of protective long-term care. He also emphasized the need to
have the day hospital located in a general hospital to provide easy ac-
cess to all specified facilities required for therapy.
SHAAREJ ZEDE K DAY HOSPITAL, JERUSALEM; PROF. DAVID NEIRX
DIRECTOR
Started 1 year ago, this day hospital is housed in two rooms in an
old building on the grounds of the Shaarej Zedek Hospital, a general
hospital that contains a 22-bed geriatric department and sponsors a
home care program. The program started with three patients dis-
charged from the geriatric ward; 6 weeks later there were 20 patients.
Currently the program serves 15 persons daily, most of whom attend
twice a week.
In addition to the more traditional reasons for acceptance into the
program, the day hospital accepts patients for observation and for
diagnostic tests.
Referral sources are as follows: Home care program, 12 percent;
emergency room, 25 percent; out-patient department, 30 percent; hos-
pital discharge, 33 percent.
The observation was made that women have a shorter length of stay
because they want to return to their homemaker responsibilities; men
have a longer length of stay because when they are ill, they become
a burden to their wives, particularly among the more elderly. Average
attendance is 15 days.
TEL HASHOMER DAY HOSPITAL, TEL AVIV; DR. MARIAN RABINOWITCH,
CHIEF OF DEPARTMENT OF GERIATRIC REHABILITATION; DR. DANIEL
KINDER, DIRECTOR OF DAY HOSPITAL
This was the first day hospital in Israel, opened in February 1974.
It is located in a rented house located a few minutes ride from the
hospital, and contains two three-bed rooms for treatment of cancer
patients. The program has a census of 55 participants and serves ap-
proximately 15 patients a day, with attendance three times a week,
twice a week or once a week, as medically indicated. The average stay
is approximately 3 or 4 months. Ambulance transportation is pro-
vided. The house in which the program was located contained several
small rooms and lacked a sizable general purpose room.

SUMMARY ON DAY HOSPITALS IN ISRAEL
Day hospitals are regarded in Israel as a vital aspect of care, but the
two programs visited indicate that these are still in the formative
stages.







Data gathering to document costs, utilization, diagnostic categories,
etc., is rudimentary or nonexistent.
Transportation and programs to serve patients after discharge are
the two most critical problems cited by all who are involved in these
activities.
Dr. Joseph Silberstein, director of chronic illness and aging of the
Ministry of Health, a dedicated physician who has a deep feeling
about the health needs of the aged, is an ardent advocate of this form
of care. As evidence, an excerpt from a letter to Robins from him
after her visit reports: ". . We go ahead with day hospitals. In
fact there is a consensus that this is the field on which we must con-
centrate for the next few years. Staff shortages, rocketing hospital
costs, and last, but by no means least, the needs of the patients dictate
this course to us."
REHABILITATION
Information in this section-some of the ideas quite provocative-is
based on an interview with Dr. Rabinowitch, chief, department of
geriatric rehabilitation, Tel Hashomer Hospital in Tel Aviv. Dr.
Rabinowitch trained for 9 years at Rancho Los Amigos is California,
and is dedicated to the creation of an innovative and effective geriatric
rehabilitation program.
(1) Rehabilitation should be highly selective, and is not for all
patients. If the patient can't be rehabilitated, the physician should be
strong enough to be honest and make appropriate referral. In rehabili-
tation, functional assessment is of greater importance than medical
diagnosis.
(2) Any medical system without adequate emphasis on discharge
planning is a failure.
(3) The same team (physician and allied professionals) providing
treatment in hospital should provide care following discharge. (It
takes about 3 years of working together to create maximum team effec-
tiveness.) Most of the care in total course of treatment will be pro-
vided to an individual as an outpatient.
(4) Long admissions should be avoided. The goal of rehabilitation
is to limit inpatient stays to no longer than 4 or 5 weeks, with dis-
charge as soon as it is feasible to provide treatment out of the hos-
pital. (After 6 to 7 weeks of hospitalization, the patient develops
"hospital syndrome," and after experiencing freedom from care of
patient for a protracted period, the family has a tendency to resist
assuming responsibility for care in the home setting.)
(5) High turnover of patients can help to maintain morale of staff
(professionals and paraprofessionals) by providing new challenges.
(6) Preadmission assessment should be made by a team (doctor,
nurse, social worker) and include outcome planning. Periodic reassess-
ments following hospital discharge should be made by same team.
(7) The goal of rehabilitation should be to enable the individual to
live a productive life through maximum restoration of function. For
some, the goal may be limited to improvement of the quality of life
at home.
(8) Rehabilitation to improve the quality of life should apply to the
terminally ill. "There can be no death with dignity in a hospital."








FAMILY SESSIONS
As a means of obtaining maximum family involvement and cooper-
ation in treatment and discharge planning for inpatients in tlhe (eri-
atric Rehabilitation Service, Dr. Rabinowitch biweekly sponsors a
social encounter held during evening hours. A multidisciplinary team
attends this session, at which a lecture is presented on a speci i. prob-
lem. A question-and-answer period follows the presentation, and time
is allotted for informal conferences of the family with team members.
Some of these sessions are on subjects of interest to all of the famni-
lies, and in other instances the sessions are devoted to a particular
medical problem. For example, a recent meeting was directed to faini-
lies of patients suffering cerebral vascular accidents. Other more gen-
eral sessions, such as those dealing with psychological aspects of long-
term care, bring together as many as 100 family members.
Dr. Rabinowitch reported that this program has been well received
by the participating families and has given valuable insights to the
professional staff members who care for the patients.
THE REHABILITATION CLUB-AN INNOVATIVE APPROACH
An innovative approach, the rehabilitation club, has been developed
by Dr. Rabinowitch for patients discharged from the Tel Hashomer
Day Hospital who need less intensive but continuing health super-
vision and psychosocial activities geared to their needs. An open door
policy for admissions will be maintained for those discharged from
the hospital directly to the community, or for those living in the com-
munity who could benefit from the services. The rehabilitation club is
located in Ramat Gan, a town about 15 minutes ride from the hospital,
and will become operative early in September 1975.
According to present plans. an assessment on each participant will
be made bv a Rehabilitation club team comprised of a physician. nurse,
physical therapist, occupational therapist. recreational therapist. and
medical social worker. A noondav meal will be provided, and emphasis
will be on resocialization. Referrals will be made for homemaker serv-
ice or health supportive services as required., but Dr. Rabinowitch
emphasized that the greatest thrust of the program will be on provi-
sion of social rather than medical services.
It is anticipated that in addition to the paid staff, services will be
provided by community volunteers, and that financial support will
also be provided through the health insurance program and the
municipality.
TERMINAL ILLNESS
Although the resources are not vet available for developing a pro-
gram specifically designed for the terminally ill. Dr. Rabinowitc' is
making preliminary plans for such an activity in the future. He feels
strongly that it is necessary to break the medical concept that the
death of a patient should be viewed as a medical failure; instead, he
asserts that care of the terminally ill should be made a positive part
of the care plan.
Because Dr. Rabinowitch feels that it is not possible to have death
with dignity in a hospital setting, he strongly recommends that when-






68


ever possible, the terminally ill patient should receive care in the home
setting, and that hospital admission should be made only when sup-
portive services in the home are no longer practical. For those who do
not have the family resources for care in the home, he advocates serv-
ice in a facility especially designed to serve the physical and psycho-
social needs of such patients (based on the British model of the
"hospice"). He points out that such a facility should not be utilized
for patients in a "vegetative coma."

HOME HEALTH AND HOMEMAKER SERVICES
HOME HEALTH SERVICES
Home health services are highly regarded in Israel as an alternative
to institutional care. Seven distinct programs currently exist; three
are hospital based, three are home based; and one program, still in
the developmental stages, emanates from a Kupat Jiolim health center.
Dr. Rabinowitch described the following criteria utilized by Tel
Hashomer Hospital for eligibility for home health services:
(1) There must be a rehabilitation potential.
(2) The home setting must provide proper physical and emo-
tional environment.
(3) Patient is not eligible for coverage from any other agency.
(4) Patient must be homebound or bedbound.
(5) Patient does not have "welfare mentality." (If it is judged
that this attitude exists, referral is made to welfare agency.)
Generally, from three to four months of home care is provided with
the aim of enabling the patient to be able to receive any additional
care in an ambulatory care setting, with ambulance service provided
if necessary to bring the patient from the home to the outpatient clinic.

HOMEMAKER SERVICES
Homemaker service was started in Israel by retired social workers in
1967. Workers receive 3 months of on-the-job training, work a maxi-
mum of 5 hours a day.
A program now underway involves the use of a homemaker to visit
the isolated aged who have poor living conditions. A weekly visit is
made to change linens, check on medications, and do essential errands.
The homemaker also serves as liaison with the individual's social
worker and physician. Twenty-two homemakers have been able to
serve a caseload of 200 elderly in this program.
The Kupat Holim health program initially provided only home
health care, but these services are currently being broadened to include
homemaker services.
GERIATRIC DAY HOSPITALS IN GREAT BRITAIN
Because of the widespread demand for information on day care and
day hospitals by health, welfare, and planning authorities in the
United States, this report will present background information to
assist the reader as well as highlights of observations and conversations
with staff members of these programs and with the above-mentioned






69


authorities. The background information is based primarily on a book
ent itled The Geriatric Day Hospital, written by Professor Brockle-
hurst that focuses on a national survey of geriatric day hospitals
(1969-70), an in-depth survey of five day hospitals, and a 6-year
survey of Lennard Day Hospital in Bromley.
Throughout Great Britain, the geriatric day hospital has been
accepted by health and social welfare authorities as well as by the
public as a valuable modality of care for the elderly and for physically
disabled younger persons who could benefit from such care.
The day hospital was originally conceived as a means of providing
care and therapy for patients whose disability did not justify admis-
sion to a hospital bed, but necessitated continuous supervision through-
out the day when the rest of household was out at work. The need for
this form of care stemmed from the increasing shortage of psychiatric
beds for the elderly mentally frail.
In 1945. the Malborough Day Hospital, associated with the psy-
chiatric unit of the parent hospital, was created as the first operational
program to serve psychiatric patients. In 1952, the principle was more
broadly applied to geriatric patients who needed care primarily for
physical rather than mental disabilities, and the Cowley Road Day
Hospital in Oxford established by Dr. Lionel Z. Cosin served as a
model.
The program proved so successful that by the end of 1970 there were
119 geriatric day hospitals in Great Britain. Increasingly, additional
day hospitals are being established, usually in existing hospitals, but
'often in free standing facilities constructed and designed specifically
for this purpose. The ultimate goal is to have a program in each of the
200 geriatric units in the nation.
A significant fact to be kept in mind by the reader is that there is
no e,:tablished set of crteria for day hospitals in Great Britain, and
m'ninai data is available on costs. Many variations exist in terms of
size," prog am staffing and patient characteristics. Communications
between the various day hospitals take place on an informal basis,
with a few individuals taking the initiative for the development of
structured meetings and workshops. At the time of my visit, a day
hospital conference was being planned for September 1975 by Pro-
fessor R. E. Irvine, consultant physician to the Hastings geriatric
unit and a recognized leader in the field.
I had the privilege of visiting five of the outstanding day
hospitals in Great Britain (Withington Day Hospital in the Uni-
versity Hospital of South Manchester; Hastings Day Hospital; Bex-
hill Day Hospital; Leinard Day Hospital in Bromley, Kent; St.
Pancras Day Hospital in London). More importantly, I had the in-
valuable opportunity of having in-depth discussions with the geriatric
consultants of these programs who are acknowledged leaders of the
day hospital movement in Great Britain-Professor J. C. Brockle-
hurst (South Manchester), R. E. Irvine (Hastings and Bexhill), and
A.N. Exton-Smith (London). Enhancing this experience was the
opportunity to visit King George VI Memorial Club, a social day
center for the physically handicapped elderly. This organization pro-
vides a vitally needed level of care not commonly addressed in the
United States-is much less health-service oriented than the day hospi-
tal. (Note: this may well be the type of care that is now reimbursable
under the new title XX of the Social Security Act.)






70


BACKGROUND INFORMATION
Professor Brocklehurst defines the geriatric day hospital as follows:
"A day hospital is a building to which patients may come, or be
brought, in the morning, where they may spend several hours in
therapeutic activity and whence they return subsequently on the same
day to their own homes. The building is generally, although not
always, within the curtilage of an ordinary hospital. It may be not
more than a single room specially adapted, or a whole purpose-built
structure of many varied rooms. Geriatric day hospitals provide
facilities for physiotherapy and occupational therapy, for medical
examination and nursing treatment, and usually for various other
activities including investigation, speech therapy, dentistry, chirop-
ody, and hairdressing. The building and its facilities may be used
entirely for day patients coming from their homes, or it may be used
by inpatients as well, who come over from the wards in the morning
and return in the afternoon.
"Geriatric day patients are almost always brought by special trans-
port and thus make moderate demands on the ambulance service, the
cost of which may well be the most expensive element in day hospital
treatment. Usually between 4 and 8 hours are spent every day in the
day hospital. This long period of time differentiates day patients froni
those attending for short periods of treatment in physical medicine
departments. The prolonged period is necessary for elderly people.
Though the pace must be slow, the activity must be as continuous as
possible. Everything the patient does-walking along corridors, hav-
ing lunch, taking part in remedial exercises or in group projects-
involves a therapeutic activity designed to improve his health and
overcome his disabilities. Geriatric day hospitals may also be used
to prevent breakdown in health, both in patients and in their families.
In a nutshell, the aim is to dissociate the "hotel" element of hospital
care from the therapeutic, leaving only the latter."
In many hospitals in which day hospitals are housed, it is customary
for the staff and the equipment of the rehabilitation department to be
shared by both the day hospital patients and the inpatients. This is
considered to be economic use of staff and facilities. Moreover, it is a
common practice for inpatients to actively participate in the day
hospital program. Not only does the opportunity to get away from the
wards boost the morale of the inpatients, but for those patients who
are approaching discharge, participation in the day hospital program
helps to ease the change from inpatient to outpatient status. The
patient knows he will continue to be treated in the same place by the
same therapist when he goes home. In a significant proportion of the
patients, this practice tends to reduce the length of inpatient stay.
Transportation appears to be a crucial problem that has yet to be
fully resolved. Most of the patients come by ambulance, and for the
most part, 8- or 10-seater vehicles with hydraulic lifts are used;
in some areas, taxis and hospital sitting cars bring patients. In gen-
eral, most of the patients travel 5 miles or less to reach the day
hospital, with the first patients arriving between 9 and 10 o'clock
in the morning and the last patients leaving between 3 and 5 o'clock
in the afternoon.








Brocklehurst stresses that there are many advantages to liavin,_
special ambulance crews assigned to this task. crews that are aware
of the need for special assistance required by elderly passengers, ail ,
who can be depended upon to report cries or mishaps that arise at
home. According to Brocklehurst, whether or not a patient eives ill)
day hospital treatment in the first week or two may depend largely
on the quality and understanding of the ambulance crew.
Some day hospitals serve a very limited nuin-ier of patients (fo wer
than 10 a day), while others are much larger serving 50 or more daily.
Of the programs surveyed by Brocklehurst. one-thIird were sTnall. 1a v-
ing fewer than 20 places a day, and only 24 percent llad more t!han 40
places daily. The survey findings indicated that day hospitals with i0
or fewer pla(s were overfille(d, with patient, atten(ding in exce s of t1-e
real capacity of the program. According to Brocklehurst. the m'+-t
popular size of day hospitals-20 to 40 places a day-would serve a
target population of 60.000 to 180.000 of average age structure, Tie
warns that an excessively large day hospital capacity could discourage
discharge and interfere with proper function of the program.
Great variations in staffing patterns exist among day hospitals in
Great Britain. However, the average 30-place day hospital has ti.e
service equivalent of 10 full-time workers. with 5.7 full-time eqivi-
lents of occupational therapists. Physical therapists. speech therauz i.
and aides. and 4.2. full-time equivalents in all (ra(des of nurses. The
proportion of different types of staff utilized varies with the patient
needs. Tn general. there are four ancillary workers for every three
nurses (including aides).
The consultant geriatrician and his junior medical staff spen(i 1c-
tween 7 and 141/ hours a week in the day hospital. The consultant
,eriatrician saw patients at the day hospital at least 1 day a week in
80 percent of the facilities surveyed, and the dav-to-day care was pro-
viclecl by the other medical staff. In 15 of the 90 programs surveve3.
consultants other than geriatricians visited the day hospital patient
(psychiatrist in eight, physical medicine specialist in four. general
physician in two. and orthopedic surgeon in one).
More than half of the patients were over 74 years old: less than one-
fifth were under 65. About one-fourth of the patients could walk alone.
and 13 percent were wheelchair patients. Although 20 percent of tio
men and 8 percent of the women lad some rinaIr incontnene. in
only 2 percent of the patients was this the major reason for attendne.
A survey of the 90 existing geriatric day hospitals ondeted in
1970 indicated that. the majority of these programs provided services
on a 5-dav-n-week basis, and had places for between 20 and 40 percons
each day. The survey further revealed that 57 percent of the patippt:
attended oee a week. 28 percent twice weekly, 10 percent three times
a week. and 5 percent attended either four or five times week. Almost
40 percent of the patients ,attended for longer tlhin 1 year. and tlioze
attending for social reasons or for stroke rehabilitation attended for
the most prolonged periods of time.
In the day hospital surveyed. 30 percent of the patients suffered
from stroke. A0 nereent from' arthritis. Q perce-nt from chronic brain
svndrome and 18 percent from other diseases. The prineinal rpasons
for attendance were physical maintenance (49 percent). rehabilitation
(97 percent). ana czociql rea ons (26 percent). Five nercent came for
other reasons, primarily medical and nursing procedures.
72-862-76------6






72


Physical rehabilitation was regarded as the most important func-
tion of the day hospital by most geriatric consultants; physical main-
tenance therapy came second. Medical and nursing procedures pro-
vided in the day hospital were considered by the consultants to be of
lesser importance. According to Professor Brocklehurst, this may be
an indication of the fact that relatively few patients can benefit from
such services in the day hospital, rather than a reflection of a feeling
that the service itself is not important.
The day hospital has an important staff education function. Eighty-
three of the proo'ams had an arrangement for regularly scheduled
case conferences attended by doctors, nurses, ancillary, and social
workers or for a review clinic run by doctors and nurses only. In some
,case conferences, patients are discussed but not seen, and in others,
patients are first discussed and then each brought in to meet the group,
discuss progress, and demonstrate what has been achieved. Brockle-
hurst stresses that the case conference not only provides an oppor-
tunity for the geriatric rehabilitation team to exchange ideas, but
serves as an excellent medium for teaching students of all disciplines.
Admiss;ion of patients for primarily social care in day hospitals or
maintaining such patients after the need for rehabilitation is past is a
controversial issue in Great Britain. Brocklehurst reports:
Some consultants reluctantly accept social care as a major role for
their day hospitals. They argue that, while they do not regard this as a
proper function of a day hospital, if they do not provide such care, no
one else will. and the end result will be the admission of more in-
patients. To a small extent many day hospitals have some of these
patients who require only social care."
In general, those coming for social care in Great Britain are not
coming to allow relatives to go out to work, but more often attend the
day hospital to give relatives a breather once a week. Another im-
portant reason for social care is to combat the patient's social isolation.
>Some authorities recommend as beneficial a mix of the mentally dis-
oriented with other patients in the therapeutic environment. On the
other hand, the geriatric consultants in day hosiptals surveyed by
Brocklehurst considered social care of the mentally confused to be of
little value as a day hospital service.
iroldehurst calls for a more positive approach to this problem
than has been given to date, and points to the need for experiments to
det rmine whether mentally confused patients could best be cared for
in .e Vritr"c or psychiatric day hospitals or in social day centers.
In Brocklehurst's view, the provision of social care may be seen as
an extension of the geriatric hospital service into community and pre-
ventive medicine. He strongly recommends the use of social day centers
for many patients discharged from day hospitals (see section on social
day centers).

'VX ITITIN.GTON DAY HOSPITAL, UNIVERSITY HOSPITAL OF SOUTH MAN-
CHESTER, PROF. J. C. BROCKLEHURST, GERIATRIC CONSULTANT
The program is housed in a single story building forming a config-
uration of the. letter "E". One wing is primarily for administrative
offices; one for occupational therapy, including a demonstration
kitchen, bath areas and an X-ray room; one wing is for physiotherapy,
and also contains consulting rooms, nursing treatment rooms, and a






73


soundproof room for speech therapy. Specially designred toilet areas
have been provided for men and women. An open area outside of the
building is utilized as a raised garden tendled by the patients during
the summer. A large o-eneral activity area and a well-eqilipped gym -
nasinmn are also provided, along with a section for admin istrative
oitices. The facility is well equipped. spaciolls, and attractive.
The prime emphasis in this comprehensive (ay hospital is relabilita-
tion. Maintenance, medical, and social problems are also dealt with,
but to a lesser degree. For all patients, the program contains activities
designed to promote resocialization and reorientation to living in the
community and to maximize ability for independent living.
The day hospital currently serves approximately 70 patients daily,
including 45 participants from the community and 25 inpatients. It is
planned to gradually increase the number served to achieve a daily
census of 120, comprised of 60 community participants and 60
inpatients.
Transportation is primarily by ambulance, with taxi service used
to a limited extent fox' participants livinI outside of Manchester.
Four ambulances bring participants from the community, while porter
service and internal ambulance service is used for participating in-
patients. Transportation was identified as the biggrest problem; lack of
additional transportation was given as the main factor preventing
pro('ram expansion.
The program day is from 8 a.m. to 5 p.m., with patients attendincr
from one to five times a week, depending on need. The majority of
patients come two to three times a week: early strokes come daily. The
averanre length of attendance is from 13 to 16 days over a 2- to 3-month
period.
The team consists of doctors, nurses, occupational therapists,
physiotherapists, speech therapists, dietitian, medical social workers,
podiatrist, aides, and administrative personnel. Unit meetings of al
(lay hospital staff are held periodically to encourage interaction
between the disciplines.
The patients' physical conditions cover a wide range, with strokes
pre,'loininating. Age range is from 50 to over 90 years.
An impressive array of equipment for physical and occupational
therapy is provided. Included is an experimental rowing machine
desig~ied by Professor Blocklehurst for muscle strengthening.
An innovative board that is centrally located identifies the daily
activities for each patient. Magnetic symbols of various colors and
shapes are used to indicate the specific activities and services. This
insures each patient Iparticipating in each service prescribed, and
prevents the need for waiting for services.
The care plan is developed by a multidisciplinary team from the
day hospital. The physician is not part of the team, but his recon-
iiendations are incorporated into the plan. Case review clinics are held
at which each patient is reviewed at least once a month, and more often
if medically indicated.
I had the opportunity of attending a case review session., chaired
by P'ofcssor Brocklehurst and attended by the day hospital profes-
sional staff as well as a group of medical students. The p 1oce;11re
consisted of a discussion of an individual case by Professor Brockle-






74


hurst, with professional staff contributing pertinent information..
Discussion concerned not only the medical but the social aspects of the
case. (This provided the medical students with knowledge about such
community resources as meals on wheels, home help aides, home
nursing, etc.) Following the discussion, the patient was brought to the
room, and progress and problems were discussed by the patient and
Professor Brocklehurst. Significantly, the patient was made part of
the process by Professor Brocklehurst, and his attitude permitted the
patient to feel completely at ease.
Varied problems were presented for discussion. In one case, the
patient fell frequently in his home, and a decision was reached to,
supply a wheelchair to be used in the home as a preventive measure.
In another instance, during the discussion period prior to the patient's
appearance, the problem of decreasing mental capacity was discussed,
and retesting for mental acuity was recommended. The students had
the opportunity to observe the patient when he was brought into the
room. In still another case, Professor Brocklehurst called attention
to an ill-fitting brace, and ordered the appliance to be adjusted.
In each case presented, the schedule for day hospital participation
was discussed with the patient. For some, changed schedules (either
increase or decrease in participation) were discussed and mutual
agreement was reached on proposed changes.
During the course of the case reviews, Professor Brocklehurst very
adroitly questioned the students for their opinions, and the resulting
dialogue was teaching in action. It would appear that with skillful
leadership such as that provided by Professor Brocklehurst, this-
approach could be adapted in U.S. day care programs to provide
effective teaching programs in the medical and social aspects of care-
for the elderly not only for medical students but for students of social
work, nursing, and the various therapies.
Social care in day hospitals is provided for patients with physical
or mental disability, including many who use wheelchairs and some
who are incontinent. Many of the patients suffer from chronic brain.
syndrome, and to a lesser extent, day hospitals serve younger patients
with chronic neurological disorders. In most instances, such patients
could not be managed at social day centers.
In his excellent report, Professor Brocklehurst suggests that patient
needs should be taken into consideration in planning the physical
facility. He points to the fact that since 13 percent of the patients are
in wheelchairs, and an additional 59 percent use walking aids, proper
allowance must be made in constructing day hospital buildings. This
would call for wide corridors, with access to lavatories around baffle
walls and not through doors which have to be opened.

HASTINGS DAY HOSPITAL, ST. HELEN'S HOSPITAL, HASTINGS,
PROF. R. E. IRVINE, GERIATRIC CONSULTANT
Hastings is a popular area for retirement, with approximately 25
percent of the population aged 65 and older, and a sizable segment of
this group in the 75 and older age category.
While the day hospital places emphasis on short-term rehabilitation
to permit the patient to return to independent living, the majority of





75


the patients attend for maintenance or for purely social reasons. Pro-
fessor Irvine underscores the fact that this indicates "the need, at pres-
fnt not catered for, for a day center run by the local authority. Were
day care not available many of these people would need inpatient or
residential care, probably for long periods."
Irvine holds firmly to the concept that the occupational therapist
is the most effective director of the day hospital. In a report on day
hospital, he said:
"Day units may be oriented to nursing or to rehabilitation. In my
view, the proper orientation is to rehabilitation, and the proper person
to be in charge is the occupational therapist. She understands best how
,creative work brings reablement of mind and body. sustains morale,
and restores to the patient, however infirm, a sense of his unique value
as a human being."
Hastings Day Hospital provides diagnostic workups, functional
assessment, short-term rehabilitation, long-term rehabilitation, serv-
ices to prevent deterioration, and support for relations caring for
participants.
Providing 30 places a day. the facility is located in a purpose-built
building that also serves as the occupational therapy department for
the hospital. Most of the long-term patients attend once or twice a
week, although a lesser number, including those receiving short-term
rehabilitation, attend more often.
A study carried out in the first 2 years after the day hospital started
in 1965 revealed that approxnnatelv two-thirds of the 3,28 patients
served were over 70; 15 were under 50, with the youngest a spastic girl,
23. The average a'e was 75.
Approximately half of the patients have cerebrovascular disease, and
many of these suffered mental as well as physical impairment. In 75
patients. the principal diagnosis was arthritis. Other forms of neuro-
logical disease, principally multiple sclerosis, cervical spondylosis with
mvelonathy. Parkinsonism and motor neiiron e disease, accounted for
a further 37. Fourteen patients had recent fractures, mainly of the
femur, and there were nine recent amputees. Among the remaining 30
were a wide variety of diagnoses, including diabetes, bronchitis, and
heart disease. In most of the patients, psychological and social factors
were as important as the medical factors in determining the need for
day care. Forty-nine. or one in seven, lived alone.
Referrals are made by family physicians and by the hospi+al de-
partments of physical medicine. orthopedics and psychiatry. Sli ,rhtly
less than one-third of the participants were former hosinital patients
who needed continuing care and rehabilitation after discharge from
the hospital.
Only two of the day' hospital patients in the 12-year study rernired
care in lonfg-term beds. and accordingr to Irvine, this is probably the
mo4t significant fact to come out of the study.
Irvine is concerned with the problem of the growin y number of those
who need long-term protected care, and how this will affect the day
hospital. He proposes two courses of action that may be taken: (1) to
expand existing day hospital programs, and (2) to have the local au-
thorities establish sufficient social day centers to serve those in need of
preventive services.





76


BEXuIILL GERIATRIC UNIT AND DAY HOSPITAL, PROF. R. E. IRVINE,
GERLATmIC CONSULTANT
The Bexhill Day Hospital is housed in a bright modern facility, and
serves the surrounding community that, like Hastings, is composed of
a high proportion of retirees.
_At this facility, I had the privilege of attending a case review ses-
sion that is a weekly occurence, following a working luncheon. Chaired
by Professor Irvine, participants in the program include the multi-
disciplinary staff of the geriatric unit and day hospital; the local
physicians whose patients are to be reviewed are also invited to par-
ticipate. Five physicians attended the review session, and this was
considered an excellent turnout. Apparently, it is not easy for the-
physicians to find the time for regular attendance.
Of the 52 cases reviewed, 19 were day hospital participants and the
remainder were inpatients of the geriatric unit.
Some of the cases were dispensed with in short order; other required
more detailed discussion by social workers, nurses, therapists and/or
the physicians in attendance. This appeared to be a valuable educa-
tional experience for all concerned, and decisions were made by con-
sensus of the total group. Irvine very skillfully conducted the review
process.

LE N-.ARD DAY HOSPITAL, BRZO-MLEY, PROF. IR. NAYLOR)
GERIATRIG CONSULTANT
Established in 1962, Lennard Day Hospital was the first nonpsychi-
atric geriatic day hospital in Great Britain. Professor Brocklehurst
was the first director of the program, and continued in that role until
his transfer to Manchester several years ago.
Most of the facility in which it is housed was built specifically for
use of the day hospital. The new portion is comprised of three sides of
a square, with the fourth side of the square the existing hospital. In
the center of the day hospital is a beautiful garden-courtyard, and the
glass walls lining the three corridors of the new part of the structure
provide an unencumbered view of the garden-courtyard, giving a
cheerful touch to the environment.
The physiotherapy department is located in a bright and well-
equipped gymnasium. Occupational therapy is administered in three
smaller patient activity rooms. A dining room that seats 36 is located
in the facility and two seatings are made at lunch.
Inpatients also participate in the day hospital program; approxi-
mately 36 day hospital patients and an equal number of inpatients are
served daily.
Day patients are transferred in four 10-seater ambulances of the
Greater London Council ambulance service, each of which has a hy-
draulic lift.
An outreach team goes to the general hospital for referrals, and
most of the admissions are for rehabilitation therapy from the surgi-
cal ward of the general hospital.
Because the program has been ongoing for 13 years, the local physi-
cians know about it and also refer patients. However, Professor Nay-







lor pointed out that a large proportion of physician refeirals are
inappropriate for day hospital care. Ile also reported tlat in rialINy
instances, it is difficult to get good cooperation from the fainiilv phYvsi-
cian after the patient is enrolled in the day hospital. Naylor sipecu-
lated that the reason for this attitude may be that, in creneral, lhysi-
cians know about the rehabilitation of young patients but are not
very knowledgeable about rehabilitation of the elderly.
Naylor said that the program at one time was much larger. a'o-, -
modating 110 participants. In his view, this prograin wa iiot
successful because with the larger numbers, services became deper-
sonalized, the area needed to accommodate the program was so Ia r~e
that the therapists got fatigued. The program was then cut back to
its present size.
On the first day of enrollment, the patient is seen by the geri atric
registrar for assessment and examination, and a care plan is de-
veloped. The geriatric registrar attends the pro- ram daily, an, pro-
vides continuing medical supervision to those patients needin (,y It aml
cares for any participants who might be unwell. Ile maintains con-
taets with the family physician. Regular (ase eonferenc-s are 1)e1d
at which treatments are reviewed and social problems diseiis.-'d. A
review is carried out for each patient at least once a month.
The primary aims of the program are physical rehi,,i)itation and
maintenance, and the ultimate goal is to discha.ge the patient when-
ever feasible. Naylor is of the firm opinion that day hospitals should
be direc-ted by a nurse rather than an occupational therapist, as some
others in Great Britain recommend.

FIVE-DAY WARD
An innovative program, the first of its kind, has recently been es-
tablished by Naylor in conjunction with the day hospital. I'he .5-day
ward has 16 beds and is used for patients suffering from strokes., frac-
tures, and Parkinson's disease. Patients arrive on M\ondav morning
and are returned to their homes on Friday afternoon. The ratioiiale
behind this is the difficulty in getting staff to work on weekends. le-
search is planned to determine the reaction of family phvziiaT to
this new form of care. At the time of my visit, the ward with its
16 beds had no visible patients; they were all involved in thera) y or
activities.
Supportive services as needed during the weekend are proviId by
the community. Dr. Naylor indicated that another unique feature of
this program is the sharing of responsibility bv the conimunitv and
the hospital for the patient who needs hospital care.

ST. PANcRAS DAY HOSPITAL, ST. PANCRAS HOSPITAL. LONDON,
PROF. A. N. EXTONx-SM.ITTI, GERIATRIC CONSULTANT
Located in an innercity area., St. Pancras Day Hospital haq a target
population of 130,000 and serves 35 participants daily. Staff consists
of one nurse, two nurse-trainees, two nurse aides, one part-time physi-
cal therapist, one part-time occupational therapist, and one speech





78


therapist twice a week. (The feeling was expressed that the ideal
arrangement would be to have the services of a speech therapist avail-
able on a 5-day a week basis.) The facility is spacious and well
equipped, and a stroke rehabilitation unit is being established. Of
particular interest is the day hospital bathroom area, with toilets
and washbasins specially designed to easily accommodate wheelchair
patients. (The writer has photographs of this equipment.)
Professor Exton-Smith is actively involved in furthering the day
hospital program in Great Britain. and has collaborated with Profes-
sor Irvine in planning a day hospital conference in September 1975.
Dr. John P. Keet, clinical lecturer and senior registrar of the day
hospital, is a bright young physician who is carrying out collabora-
tive research with Baylor University (Texas) for the development
of psychometric instruments for objective measurements of the effect
of Behavior modifying drugs.
Approximately 25 percent of the total participants are stroke pa-
tients; 5 percent have Parkinsonism. The largest group suffer from
inniobility of some sort, including a significant proportion suffering
from arthritis. Very few senile patients are admitted, and continence
in such patients is a requirement.
Half of the participants attend one or two days a week: the re-
mainder attend more often. Post-hospital stroke patients attend two
to three times a week until it is feasible to reduce attendance to once
a week, followed by once a month. When indicated, following dis-
charge, the participant is discharged to a social day center.
Oral medications are not customarily administered by staff. Periodic
checks are made on intake of medications through surprise visits to the
home by day hospital staff at which time remaining pills are counted to
makn e sure the medications have been taken as prescribed.
Transportation is by ambulance manned by a driver and an aide,
with the target popula-tion residincr in a 5-square-mile area. Two ambu-
lances and two crews are provided for this program.
The following problems were identified by staff :
(1) Transportation-having the ambulances arrive promptly,
and having sufficient ambuflances to do the job.
(2) Discharge-preventing a bottleneck between the day hos-
pital and the social day center. Approximately 20 percent of the
participants participate in the day hospital on an indefinite basis;
jmany could be discharged to the social day center if they could be
accommodated in this program.
(3) Communication between general practitioners and day hos-
pital physicians could be improved.
(4) Nonattendance at day hospital by participants.
(5) Need for a psvchogoeriatric program; this is the only service
needed by approximately one-eighth of day hospital participants.
StalT members agreed that in general, the overriding problem is the
lack of policy decision on whether the day hospital should be purely a
medical operation, or whether the program should also serve those
whose primary need is social. They are aware of the fact that, in many
instances, if such social needs are not addressed, these problems de-
generate into medical problems that require long-term inpatient care.






79


SOCIAL DAY CENTERS
For the physically and/or mentally handicapped elderly, social day
centers provide personal care in a protected social setting-conipaiiy,
a cooked meal, and in some cases bathing ald podiatry services, but do
not provide the therapeutic services found in the day hospital. These
centers are usually run by local authorities or voluntary bodies, aiid
frequently both groups are involved with their work coorditiated
through the old people's welfare committee. In accordance with the
1968 Health Services and Public Health Act, transportation must be
provided in these programs. Referral is usually made by the family
physicians or the social worker.
In The Geriatric Day Ilospitul, Brocklehurst repeatedly called for
the creation of more social day centers that would serve as appendages
to geriatric day hospitals.
Discussing the problem in the introductory chapter, Brockleluirst
wrote:
"Almost all papers written about day hospitals stress the importance
of developing complementary social day centers in the community for
those whose needs are social rather than medical. AV, oodford-W jllIaiiis
and Alvarez went further and suggested the need for four coniplemen-
tary day establishments within the geriatric service-a day club. a
workshop for the elderly, a day ward, and a day hospital."
Of the 119 day hospitals in operation or expected to be in operation
in 1970, 76 reported that social day centers with supporting transpor-
tation services were already available.
Brocklehurst regards social day centers as essential to the proper
functioning of day hospitals, and emphasizes that when such centers
do not exist, discharge from the day hospitals is adversely affected.
The following excerpts relating to social day centers were contained
in the report of the survey of 5-day hospitals:

LENNARD DAY HOSPITAL, BROMILEY
The neighborhood has three social day centers with their own trin n-
port, and more are planned. Their use is limited largely by insufficient
transport, and at present not everyone who would be suitable can be
transferred to a social day center.
DAY HOSPITAL AT JOYCE GREEN HOSPITALi DARTFORD
A somewhat ruthless policy of discharging patients as soon as 1;ef,,1
therapy is completed has been the rule since the day hospital opened.
We are fortunate in having several social day centres run by the old
people's welfare committees in our area to which we can refer somP of
our patients on discharge. A return to isolation and inactivity is thus
avoided, but despite this we find some patients no longer require active
therapy who, if not attending the day hospital once a week. put them-
selves to bed at once on return home. Sometimes they have to be ad-
mitted as inpatients, later to be mobilized. We have. therefore. to keep
this group of perhaps 20 patients attending at least once a week. They
tend to get in the way of patients undergoing active therapy, and addi-
tional space where they can be accommodated and kept occupied is
badly needed.






80


WESTBROOK DAY HOSPITAL MARGATE
The statutory and voluntary agencies must develop day centres and
dubs in the area to cope with the demands of healthy, but socially iso-
lated, elderly people.

LINTON DAY HOSPITAL, MAIDSTONE
. Some of these social cases could be discharged if there were
suitable day centres in the town.
HASTINGS DAY HOSPITAL
. Many more (than for short term rehabilitation). come for main-
tenance and for purely social reasons. The last reason is an indication
of the need, at present not catered to, for a day centre run by the local
authority.
Often the main difficulty is transportation. Without this essential
service, social day centers simply became luncheon clubs for the able-
bodied, excluding those whose needs are greatest.
The concluding chapter of Brocklehurst's report indicates that pro-
vision of social day centers seems to follow a year or two after the
opening of a day hospital. He warns that if social day centers are not
developed, a sizable number of patients coming for social reason only
tend to accumulate in the day hospital.
RING GEORGE VI MEMORIAL CLUB (SOCIAL DAY CENTER) CAMBERWELL,
MRS. ANN DARSELY, DEPUTY WARDEN
This social day center is unique in that it is not run by the local
authority, but rather is a voluntary effort, supported by contributions
with limited input from the government. The program is designed
specifically for the disabled and handicapped, and does not admit those
whose only problem is social isolation.
The program is carried out in a free standing facility, and includes
a cheerful, spacious general purpose room, a small administrative office,
a kitchen and bathing and toilet facilities.
Ambulance service is provided, with three pickups a day, the first
pickvn starting at 9 in the morning and arriving at the center at 9:45
a.m. The earliest arrivals are the first to leave in the afternoon, and
those who don't arrive until 11:30 a.m. leave at 5 in the evening.
A total of 250 are enrolled. The program could accommodate 300, but
limited ambulance capacity to transport wheelchair participants is
the restricting factor. Between 45 and 50 attend daily, the majority
coming once a week. Where the need is indicated, a limited number
is permitted to attend twice a week. Participants suffer from arthritis,
multiple sclerosis, stroke, cardiovascular disease (a number of whom
have pacemakers). The age range is from 70 to 90, with one par-
ticipant age 96. At the time of my visit, I observed that a large pro-
portion were in wheelchairs or used walking aids. Primary sources of
referrals are day hospitals and health visitors.
Staffing is as follows: three administrative personnel (warden,
deputy warden. secretary) ; full-time occupational therapist (paid by
the government); hairdresser (3 days one week, 2 days the next);








chiropodist (1 week a month) ; hall orderly (male--assists in bath-
ing male participants) ; bathing attendant (bathing is done using
a special shower seat) ; and two escorts for ambulance services. With
the exception of the occupational therapist, the remainder of the staff
is paid from funds raised through voluntary efforts in the community.
Manv volunteers participate in the program, both in the center itself
an(d through helping participants shop Ior groceries.
Participants pay a minimal amount (8 pence) for lunch, tuppence
for tea and thruppence for coffee and a sweet, and the borough helps
to make up the deficit for food cost. Except for diabetics, no special
diets are provided.
The warden and deputy warden are nondezree social workers, and
except for the occupational therapist, there are no professionals work-
ing in the center.
As I observed the program. I could stnse a happy and relaxed feel-
ing on the part of the staff as well as the participants. Undoubtedly,
much of this can be attributed to the leadership. Although the warden
was not present on the day of my visit, the deputy warden, Mrs. Dars-
1ev. is an outgoing person who relates easily to the participants and
who bring-s a spirit of gaiety to the program. From my observations in
the United States as well as in England, it is this intangible quality
hy the leadership of combining an attitude of caring with a spirit of
lightheartedness that positively affects the response of participants
to the program.
In essence, the program provides occupational therapy, personal
grooming (including bathing), podiatry, lunch and snacks, and so-
cialization. Through the borough. the social service program provides
funds (11/ pounds per participant) to supplement the recreational
activities. MNrs. Darslev told me that although in the past. a, yearly
holiday involving a week at a resort area was planned, this practice
has been discontinued. Considered a huge success by those who at-
tended, wheelchair patients had to be excluded from the activity. and
this did not seem fair. Therefore, starting with this year, the week-
lone holiday has been replaced by more frequent dav-lonz outings at
which all can participate. (Participants contribute 50 pence each for
every outing.)
Mrs. Darsley pointed out that although the social day center pro-
Zrmam of the King George VI Memorial Club is not unique exceptt
for the fact that it is supported primarily through voluntary rather
than governmental effort). there are in fact a very limited number of
prozramrs in Great Britain that are designed exclusively for the dis-
abled and handicapped.

REFLECTIONS ON VISITS TO DAY HOSPITALS IN
GREAT BRITAIN AND ISRAEL
Tn Israel. where day hospitals are a fairly recent innovation, the
concept appears to be enthusiastically accepted in the ongoin pro-
,aras. wh;le other physicians in the nation have mixed feelings-
some anxious to initiate the program in their facilities, others con-
cerned about starting a program because of lack of avilsble sTace,
4qraff. etc. However, the health authorities T talked with. Dr. Jacob
'Menezel, director-general of the Ministry of Health, and Dr. Joseph






82


Silberstein, director of chronic illness and aging, feel strongly that
sufficient programs should be developed so that all who could benefit
from such services should have access to day hospitals.
In Great Britain, day hospitals are an accepted module of care in
the health delivery system, with resources provided by the govern-
ment. (The writer was particularly impressed in London at the sight
of a large building being constructed next to a hospital, with a large
sign in front indicating that this was to be a day hospital.)
No regulations pertaining to day hospitals are in effect in Great
Britain and thus many models have evolved. To my knowledge, how-
ever, no research has been undertaken to determine the relative effec-
tiveness of the various models with respect to costs, quality of care,.
size, program content, location, staffing, and physical facilities.
Despite the fact that ambulance transportation is provided through
the health system, transportation was mentioned as one of the most
serious problems in each of the programs visited. In some cases, pro-
gram expansion is limited by the number of ambulances available. In
other instances, the problem of having day hospital ambulances di-
verted for emergency use was identified.
The urgent need to have a lower level of care (social day center) to
which day hospital participants could be discharged was repeatedly
emphasized.
In the United States, many health and social welfare authorities
feel that efforts should be concentrated upon the practitioners of the
future-doctors, social workers, therapists, nurses, nutritionists-
those who are now receiving their training. The experience in Great
Britain demonstrates that properly conducted case review conferences
in the day care programs can be a valuable educational experience for
sensitizing the future health practitioners to the multifaceted and
closely interwoven health and health-related problems of the elderly.
The experience of visiting the program in Great Britain and Israel
was exceedingly valuable to me, and I am deeply grateful for the op-
portunity to have made the trip, and to the various health authorities
and program staff personnel who gave so generously of their time
in sharing ideas.
OPERATIONAL RESEARCH IN GERIATRIC DAY CARE IN
THE UNITED STATES'
In recent years, sharply accelerated interest has been focused on the
potentials of geriatric day care and day hospital care as modalities
of care for shortening, delaying or preventing the need for institu-
tionalization, especially for the long-term patient. In a concerted effort
to determine whether such modalities could be effectively integrated
into the health care system, operational research in geriatric day care
is currently being supported by the U.S. Department of Health, Edu-
cation, and Welfare. This paper will describe experiments designed
to provide guidelines for future policy decisions.
'Preqentd at the 10th Tnternational Congress on Gerontology In Jerugalem, Israel
(June 22-27, 1975). by Edith G. Robins. Deputy Director. Division of Long-Term Care,
National Center for HI.9lth Services Researeh, Health Resources Administration, U.S.
Department of Health, Education, and Welfare.





83


Because of differences in nomenclature used to identify similar
forms of ambulatory care in other countries, I would like to describe
four modules of such care in the United States. Let me hasten to point
out that these modules do not represent categories established by Fed-
eral regulation. They have been developed by me to help clarify the
:subject under discussion.
Each of these four modules has certain commonalities, such as: psy-
chosocial activities to improve and maintain mental health; health
-supervision and supportive services; nutrition services, including the
noonday meal and snacks; and transportation. Modules I and II de-
scribe programs that provide a time-limited therapeutic regimen to
acutely ill patients with the ultimate goal of restoring them to inde-
pendent living or to permit them to be transferred to a less intensive
form of care. In contrast. Modules III and IV provide long-term main-
tenance services designed to permit the individual to remain in the
home setting as long as possible. The experiments discussed in this
paper are based on services described in Modules II and III.

MODULE I
Module I provides intensive restorative medical and health suppor-
tive services to individuals who otherwise would have remained as in-
patients had this form of care not been available.
Such patients are brought to the facility and receive the full range of
medical services along with the health supportive services during the
dav, and are returned to their homes evenings and weekends. When
indicated, transportation is in the form of ambulance service. A vital
aspect of this program is training of family members to assume limited
responsibility for honie care; and any needed supplemental home health
services are provided by public health nurses, home health aides, or
physical or speech therapists.
This model of care does not now exist in the United States, but
Federal support has been provided for an experimental model to be
established for research purposes in a highly sophisticated rehabili-
tation center in New York. It is anticipated that the findings of this
experiment will indicate whether or not this is a feasible, cost-effective
form of care that is acceptable by the patient and his family in lieu of
inpatient rehabilitation services.

MODULE II
Module II provides time-limited, intensive restorative services to
the post-hospital or post-nursing home patient.
A major difference between Modules I and I is that in Module IT,
physician services are not provided directly by the program as in
Module I. Rather. continuing medical care is the responsibility of the
pa".tient's personal physician and is provided in a setting other than
Module II. The personal physician makes recommendations for care
that are incorporated into the care plan developed by the module's
multidisciplinary team.
The physician on the Module II staff serves as the leader of the multi-
disciplinary team, and also plays a major role in policy development,
sta t traininr, a]l provision of staff consultation to insure the delivery
of high quality care.




84


MODULE III
Module III provides long-term health maintenance services to a
high risk population who either are eligible for institutional care or
could reasonably be expected to be eligible for such care in the near
future if continuous health monitoring and supportive services were
not provided. This form of care often provides the essential physical
relief to family members in their efforts to maintain the individual
in the home setting, or provides the essential supervision during the
hours when family members are at work and there is no one in the
home to give the needed care. The majority of Module III participants
live with family members or others who can provide health super-
vision and needed services in the home setting; in some instances, addi-
tional supportive services in the home are required.
Depending on individual circumstances, the possibility exists for
an individual to receive intensive care from Modules I or II for a
portion of a week, and receive the less intensive form of care from
Module III for the remainder of the week.
MODULE IV
Module IV provides preventive care for the frail elderly who pri-
marily require psychosocial activities in a protected environment. In
this module, there is far less need for health services and therapies.
Primary emphasis is placed on socialization and the maintenance of
proper nutrition in order to prevent or to decelerate the mental and
physical deterioration that is a frequent by-product of the aging
process and is accentuated by social isolation.
INTERCHANGE BETWEEN MNIODALITIES
The health status of the long-term patient, particularly the elderly
patient who has multiple diseases, is subject to frequent change. The
necessity for periodic transfer from one module of care to another
can thus be anticipated.

RELATED M'ODALITIES OF CARE
Psychiatric day hospitals have long played an important role in
treatment plans for psychiatric patients. Increasing attention is cur-
rently being directed at the potential for highly specialized day care
programs for cancer patients, the mentally retarded, etc. Such cate-
gorical approaches to day care are not included in the experiments to
be described in this paper.

EXPERIMENTS IN GERIATRIC DAY CARE
As early as 1963, the Federal Government provided support for day
care experiments. More recently, legislation was passed specifically
requiring additional research. Public Law 92-603 (Social Security
Amendments of 1972) mandated that experimental programs be de-
veloped to provide day care services for individuals eligible under the
medicare and medicaid provisions of the Social Security Act. Under
this authority, seven experimental research studies are being developed.




85


Two of the programs are being conducted in inpatient rehabilitation
centers, two in medical centers with fully developed reliabilitatio
services, one in a skilled nursing facility, and two in free standing
facilities.
The research plan and methodology for these experiments were
developed by a DHEW Interagency Task Force. Random allocation
of eligible patients to either experimental or control groups is an
underlying requisite in each demonstration study. Moreover, for pur-
poses of comparability of data, the following working definitions of
the therapeutic model of day care were developed:
Day care is a program of services provided under health
leadership in an ambulatory care setting for adults who do 1not;
require 24-hour institutional care and yet, due to physical and /or
mental impairment, are not capable of full-time independent
living. Participants in the day care program are referred to the
program by their attending physician or by some other appro-
priate source such as an institutional discharge planning Pl10-
gram, a welfare agency, etc. The essential elements of a day-care
program are directed toward meeting the health maintenance
and restoration needs of participants. However, there are social-
ization elements in the program which, by overcoming the isola-
tion so often associated with illness in the aged and disabled,
are considered vital for the purposes of fostering and maintain-
ing the maximum possible state of health and well-being.
Impaired adult is a chronically ill or disabled individual whose
illness or disability may not require 24-hour inpatient care but
which, in the absence of day care services, may precipitate admis-
sion to or prolong stay in a hospital, nursing home, or other long-
term care facility.

PURPOsE OF EXPERIMENTAL PROGRAMS
The purpose of the experimental programs is to provide ambulatory
care services to impaired adults who are capable o~f only marginal
self-care. Such care, provided on a short-term basis, serves as a tran-
sition from an acute care hospital, long-term care institution, or home
health care program to personal independence. When provided on a
long-term basis, such care serves as an alternative to institutionali-
zation in a nursing home or other long-term care facility. As men-
tioned earlier, programs to be tested are comparable to those described
in Modules and II and III.

STANDARDIZED INSTRUMENTS USED IN EACI STUDY
Referral sources include individuals, institutions, and agencies who
have agreed to refer patient to the demonstration.
Through the use of a presumptive screening form, the referral
source alerts the program to patients meeting basic eligibility criteria.
This presumptive screening form includes patient identification d'ita-
diagnostic information, and a statement of reasons why the patient
was referred. An informed consent form is used to obtain the patient'-
agreement to become a participant in the demonstration project.




86


A patient status instrument, developed especially for these experi-
ments, is the major source of data on the patient's health and func-
tional status, including psychological, social, economic, and demo-
graphic characteristics. At the first assessment, this instrument is
used to determine whether or not a patient is a suitable candidate for
the demonstration, and to provide information for the development
of patient care plans.
The demonstrations will accept patients judged to be suitable for
the experimental services and will randomly assign patients into two
groups. Patients in the "expanded benefits" group will be covered for
the cost of authorized day care; patients in the control group will not
have this additional coverage.
The assessment team care plan is a form on which the assessment
team records its "ideal" plan of treatment for the patient and its prog-
nosis for patient outcomes. This plan, when completed, is not shown
to the patient's attending physician or to other health services pro-
viders, but is used to compare prescription patterns actually followed
with those the assessment team regards as "ideal," and to compare
predicted patient outcomes with actual outcomes.

EVALUATION OF EACH STUDY
Evaluation will be addressed to the major policy issue of whether
,day care services ought to be routinely provided as benefits under the
medicare and medicaid programs. The evaluation will provide esti-
mates of the effectiveness and costs of these "experimental" services
as compared with traditional service modes, and on some of the poten-
tia] consequences in terms of patient outcomes. Information will be
analyzed on patient and family satisfaction with this form of care.
Appropriateness of placement decisions and care planning will be
evaluated. Attention will also be directed to the role of the experi-
mental services in the total health services system in terms of linkages
between referral sources and providers.

SPECIAL CHALLENGES OF DAY CARE EXPERIMENTS
The research I have described is being carried out to test the effec-
tiveness of a new concept of care that realistically is still in an evolu-
tionary stage, and this presents a very special challenge. For maximum
effe-tiveness of these experiments, answers are needed to very basic
questions such as: What mix of patients is most effective? What is
the optimal staffing pattern? How does the setting (hospital, nursing
home, rehabilitation center, free standing facility) affect the services
that could or should be offered? What pattern of fee schedules should
be developed (fee for service, inclusive fee, fee for modality of care
provided) ? And for meaningful communication, a very urgent need
exists for the development of a standardized nomenclature for the
various modalities of geriatric day care.

DAY CARE PROGRAMING IN THE UNITED STATES
The day care experiments are just now becoming operational, and
findings will therefore not be available for at least a year and a half.





87


At the State and local levels, however, authorities are not waiting
for the final word.
A flurry of activity has taken PIla(e ill ,'io, lllnities throughout the
Nation (irecte(l toward the (levelolp)ilent of '-Criatri( dav cae pro-
grains. A few States have seized tie initial i V an iid sslte( I. il (VI1
(rglidelines, anl ill a veryw limited u 1 e11 1' cases are alra(l pro-
vidin g re i lursemient for such care tmedl )I iicaid.
To assist the States iii their efforts. .111(1 to) lOv iIde fill effe'ti ye
forum for excllange ()f iieas, it is anlici)ate(d ita t a i'( Icerall v
sponsored National (onference on I)av (Care will ibe held in \Vaii1inti-
ton, I).C.. in tle fall. We 1Impw that those ()f \)n\ wh()are iivo()l\Ned withI
this new modality of care will be able to join us at that tinge.


72-862 0-76-7











Appendix 4


MATERIALS SELE TED I ROM HOME HEALTH CARE DE-
V ELO MENT IPR()BLEMS,, ANI) POTEN TIAL: BY MARIE
CALLENIDAR, AND JUDY LAVOR
REP RT FROM Ti' 1E IJEALTI INSURANCE BENEFITS ADVISORY COUNCIL
ON 1IOMNE HEALTH' CARE, SEPTEMBER 10 1974
BACKGROUND
The recommendations in this report are made in the belief that home
health care is a basic component of any comprehensive health pro-
gyran. Properly utilized, in-home health services cani provide a pre-
ferred means of restoring and maintaining the health of individuals
and fan ilies, as well as reduce or prevent hospitalization or long-term
institutional care. Furthermiore. studies indicate that the majority of
older persons prefer to remain in their own homes. The familiar inti-
macy of the, home setting meets a unique and vital health need: con-
valescence is faster, more complete.
The home health care benefits currently available under the medi-
care and medicaid programs as well as from other third party payers
are far from ineetinc the full range of patients' health care needs.
Home health care currently accounts for less than 1 percent of medi-
care Oxpenditures anid an est inated 0.4 l .)e1'ent of Federal/State ex-
penditures under medicaid. Increased ut ilization may follow the recent
elimination of beneficiary coinsurance pay-ment for home health care
under the medical insurance portion of medicare: however, further
changes are needed before home health care can reach its full poten-
tial as an important contributor to the Nation's health care delivery
system.
The present low utilization of home health care benefits can be attrib-
uted to a variety of factors. These include the medicare statutory
requirement for "skilled nursing care": the absence of coverao'e under
the medicare law for hiomiemaker services: the lack of recognition on
the part of plhvsicians, other providers and patients of the available
benefits or of the services of local aoemcies: the reluctance of some
physicians to prescribe home care: and the absence of home health
care services in rural or remote areas. From the consumer standpoint,
home health services of quality are not a valid resource in terms of
availability and accessibility. About half of all the counties in the Na-
tion had no home health agencies as of July 1973.
The report of the Special Seenate Committee on Aging, "Home
Health Services in the United States"" (April 1972). identifies con-
vincigtflv the problems which home health agencies are encountering"
in their endeavor to provide vitally needed services to home bound
Office of -oeial Services and Hunman Development, Office of the Assistant Secretary for
Planning and Evaluation, HEW.
(88)





89

patients l1der illedilicare Or Illi icaid 1roralls. Tile Sle il ( olitllil-
tee oil Ail feels Ihlt i ItI leri>Iati ve ilstl1 1 1i l Ilat l'iA lv li tiiS I he
delivery of ll&lIle lirail care. Ill addit loll, partiipak;s iill Ill e l ;'ll S
befot te i ecial eniat e ( 'iit Iit I )ee m I AiiiK iIdel ilie(d lvst i't i\ e
administi ati e lIr()I C0 i ro11)1 ex yeInl I V'elieit j) 13 ru I 111 Hi>. iial113 v
interpretation of tile law, ain(1 limited covert_ a> Sr I' s10I> i m1-k
to the develol)lent of additi )olal loille lwaltll (Iervices.
This is re in lo(red )v he ( A) reoi)()t o(f I (l)v 1971. 'I I loe I Heal It
Cale BIenefits Under i le(icae and Me(dicald. which (')niplia izes I he
saime prol)lenis ald makes specific 'ric(iilileiidat iolls I() itItl)1)T)Ve lit i-
t111 and assure Ilioeeni, e and linitlorli ilt erpret at iol of -,i i isti i
benefits.
While hioiie (ca.re c.ai norilllally )e pro\' ided at a tirziction cI inl(, t(, i
of inpatieit c"re. tlle e aVe I() e lieilitli\ye nlaionial co)>t fi ,ll'es. TII te
GAO report cites the fact that several studies hlave l)otited Out' I hat
loie health cae !(.a 1 cot si lei'al less (' Xl)el Isi\ye l 11i 'a e iIl a
fl(,It ry I I h t 't-I
hospital or skilled nriiisilnX facility. Ilie roltilt(e lieve> tlhat it wvilI
prove to be move cost e flect ye to utilize Ihole llelaltl care :er\xices ilI-
stead of institittfioli for tle loni-teim care patient. It li r(es i lie ece-
tarv to continue the special studies authori zed 1)v section 222 of IPuld)in
Lawxv 92-( 18 in order to 1lro'aden the existing l1ase of kllowle(loe abou)lt
home health care.
There is ample documentary evidence that bome health services rep-
resent a lorical, humane. and ecolnimical means of maintaili ,,2," a
quality of life a(l of fovestalligo ov shortening i flstitltional care. Tile
restrictive laws now iin eleet (to not recognize tie value of plreN1 1ti\e.
supportive, and counseling" services in health mainltenailce. Tie
chronic diseases to which tile ag-ing, are Prone demand sustained at-
tention to preNent health care crises requirmno instit ti ionalizat ion.
Home health ('are Is als-o )referrl-ed for tlloe who require only part-
time or intermittent health services. A home health aide can frequently
make it possible for an ailing person who lives alone. or with a spouse
too frail to provide care. to remai at bome.
Despite the demonstrated value of home health services. priority
contiliues to be given by thir'd-pavtv payers an(Il curr)ient le(,,-.l ation ito
the present institutionallv oriented sv:-tenm of boalth Irare. Bevei'silr
this priority would make'it p)ossihle for hone lheadtlh care to elneroe as
a major national healtl- resource andot to take its riglitfill pla-e in ally
comprehensive healt]l insigrnce prramn that 11 av 1)e eiac'te(.
There iP a broad conce stus aIid Incrr-easill2fr ativitv o1'1a rding thte
need to expand the breadth. scope. and reimbursement of hone health
services, subject to ap)rop)viate ultilizatihm >afe 'li. twi'it eXl)(al-
sin could be ancon pl I hed by reviin2" or elinli) natila" restrnetve (l-
minrisrative an( stalzttorv req(uirenentt: eml)arkIIg on a ro)rrall to
developp an aifi rnilative attiti(le towar'1 lole Iltea1111 : elwwes ) N tlii H(I-
party pavers. hIysicia1s an( others in th le healt Ini C ('otuuifltIIlitNV.
and cos1>1111,w k i11(1 prov i(liii- 2t112' ,F(,de ral s1)1)( )t I')v tile ((,-
veoplnlelit of c()mprehens~ive lionle imaith i services t1,01'1 olit lie
Nation.
IREC( NI)ATIoINS ]iEIATINo TO 'MEDICAlRE
Although tbe coiltnittee believes that a number of a(illillistrative
and legislative change> would be desirable il the medicare home health





90


b)enefit. it has agreed that the recommen(lations below should be given
li-hest p)riority. Tie adlinistratiVe recInlediilations are considered
b)v the committee as having potential for innediate implementation.
Ilie legislative revonlmeiindations lave longer range implications and
st ii 1be, considered essential to any development of new health legis-
lat ion or lodification of existing benefits defined by statute.

ADMINISTRATIVE ACTIONS
(1) The term "iome health aide" should identify an individual who
could render a )road range of services addressed to health and health
related needs. current t iiistiictions are interpreted unevenly and, as
a result, limit home health aide services to those which are only inci-
dental and which are needed to protect the health and safety of the
f)atient. Withoiit a broad range of supportive services. aged persons
wlho live alone may be forced from their own homes into an institu-
tion earlier than necessary. Since these supportive services are so
often essential to the care and continued independence of the ailing
elderly, it is reconuniended that efforts are made to uniformly interpret
Itlese services so that they become an integral part of the overall
services.
('0) The adequate utilization of home health services requires knowl-
edoe and understanding" by both the consumer and the health profes-
sional. It is recoinmeil(led that the Department embark on a strong
lumblic informat ion prooyramn to fully acquaint families, patients. phy-
sicians, hospitals, home health agencies and other health organiza-
tions witl home health services currently available in the community.

LEGISLATIVE ACTIONS
(1) The words "skilled nursino- care" in the physician certification
reqinireme nts of the statute, and the words "skilled nursing services"
in the conditions of participation for home health agencies, should
be replaced by the words "nursing" care," or "nursing services," omit-
ting" the word "skilled." The "skilled" irsing- re(fuireflent has been
onie of the main barriers to the provision of needed home care to the
elderly since it lias limited benefits to those who are acutely ill and need
rehabilitation, while denving" needed benefits to patients whose condi-
tion lias stabilized or who re(quire a somewhat lower level of care than
that defined as "skilled."
(2) At present, in order for a beneficiary to be eligible for any home
health benefits, a physician must certify that the beneficiary needs
either skilled nursing care or physical or speech therapy. Once this
qualification is net, other covered services such as occupational ther-
apy, medical social services, home health aide services, etc., are then
covered. The physician certification requirelnent should be changed
to provide tlat the need for any one of the covered services would
q a tiif the )person for lome lhealtl benefits, provided the services are
based on nedi,'al need and rendered as part of a written care plan ap-
proved by a physician.