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VOL 1, NO1
CONGREGATIONS AND ADULT DAY CARE
Problem: Less-than-satisfactory performance by some established care providers, and the general graying of the American population, are generating demand for alternatives in senior care.
Solution: A small though growing number of congregations have established adult day care programs to provide part-time senior care in a safe environment.
Adult day care began in Russia in the 1920s and �30s, proliferated in England at mid-century, and moved to the United States in the 1970s, where it grew rapidly. Twice as many adult day care centers were started in the first five years of the 1980s as in the last five years of the 1970s.
There is no fixed definition of adult day care. Programs have grown up largely unregulated and vary widely in practice. In general, adult day care offers seniors a structured program of social activities � and sometimes health services � in a safe environment. Usually limited to normal business hours, it often involves provision of a meal and one or two snacks during the day. Some programs also provide transportation for their clients.
Programs generally follow one of two models � social or medical. In the social model, the center concentrates primarily on providing activities and meals for seniors. The staff may also administer prescribed medication. A center operating under the medical model provides sophisticated health care. At minimum, there is a registered nurse on staff, and the center may offer services such as physical therapy. The social model is by far the more common of the two.
Religious organizations have never been a major factor in adult day care. A 1985 report published by the Indiana State Board of Health found that there were nineteen adult day centers in Indiana. Of these, only two were in a religious facility. The numbers have not changed significantly since then. This does not mean that congregations are not interested in adult day care. Anecdotal evidence suggests that several have tried to start programs, but most of these have closed soon after opening.
Perhaps it is the simplicity of the concept that leads to trouble. To pursue the social model of adult day care requires only some space, a director and volunteers, and provisions for food and activities. But the frequent failures suggest that it is not for the faint of heart and ill-prepared. Most often, a center has no more than one or two clients for its first few months of operation, and this situation can quickly strain a center�s finances. If done the right way, an adult day care service can serve important needs in both the congregation and community. But a congregation considering opening an adult day care should first consider the pitfalls and the necessity of adequate preparation and backing.
Americans are turning away from traditional senior care, searching for something more effective and humane. As the baby-boom generation retires and enters old age during the next few decades, that search will only intensify.
ADULT DAY CARE CENTERS IN INDIANANAPOLIS: TWO EXAMPLES
Catholic Social Services (CSS) sponsors the oldest existing church-based program in the city, in operation since 1980 at Holy Trinity Place, 907 N. Holmes Ave. Catholic Social Services is funded by Catholic churches in the archdiocese and encompasses 16 distinct programs, ranging in target population from infants to the elderly. Each program has its own professional staff. Lula Baxter is the program director of adult day care for CSS; A Caring Place and Holy Trinity Place each has a site manager under Baxter�s general oversight. Site managers tend to the administrative details of their individual programs, while Baxter�s job is to find funding sources for them.
In 1990, CSS agreed to manage a second adult day care program at Fairview Presbyterian Church, 4609 N. Capitol Ave. A survey sponsored by Fairview and other local churches indicated that elder care was an important concern for residents of the area. The churches invited Catholic Social Services � which by this time had ten years of experience in running Holy Trinity Place � to manage an adult day care program using space in Fairview�s building. After two years of startup effort, the churches could no longer afford to sustain the program, and CSS assumed administrative and financial responsibility for A Caring Place.
Catholic Social Services/A Caring Place
Earlier this year, Lula Baxter met with several other staff members and discussed how to better publicize their adult day care programs. From one perspective, things were going well. In 1998, A Caring Place served a total of 48 families, averaging between 10 and 20 participants each day. (The number served varies from day to day, as does the number enrolled at any given time, due to the high mortality rate and the fact that many seniors go south during the winter months.) The situation had improved dramatically since the program�s debut in 1990.
"Our first six months, we might have one participant one day and zero the next, maybe two the third, none the next," said Susan Dinnin, site manager of A Caring Place. "For the first six or seven months, there was very little income."
The distance they had come from that point was cause for celebration. A Caring Place had not only survived but had achieved stability and respectability. Yet based on its staffing and space capacity, A Caring Place was far from operating at its potential � for no apparent reason. There were seniors who could use the service living in the area, but reaching and convincing them (and their loved ones) remained a problem.
Adult day care exists in the borderland between independent living and the full-time care that nursing homes provide. Adult day care is an alternative to the nursing home for only a small percentage of the nursing home population. Nursing home residents tend to be significantly older and in much worse health than adult day care participants. Adult day care centers typically do not offer the kind of intensive care that nursing home residents require.
The target population for adult day care is people who retain some measure of mobility and independence. They may resist the idea of entering a nursing home, and because adult day care is a halfway step toward the nursing home, they resist that as well. Often, by the time people agree to adult day care, their condition has deteriorated too much for an adult day center to help them.
"The problems we face here are the same all over the country," Baxter said. "Usually, people don�t seek out adult day care until it�s too late. That�s unfortunate. A lot of people decide they�ll try it, but by then they are beyond the capacity of our people to take care of them."
Arguments for adult day care are difficult to make in the abstract. The only advertising that has really worked for A Caring Place is word-of-mouth. Actual participation in the program convinces many to keep coming back.
"Many of our participants are reluctant in the beginning to come," Baxter said. "But after they�ve been here they look forward to coming, just like they�re going to church or a job."
A Caring Place provides a structured day. The first two hours, beginning at 7 a.m., are left open for naps, watching the news, and general socializing. From 9 to 10, participants have coffee and tea while a staff member reads the newspaper aloud, and they discuss it together. At 11, they have a devotional and singing. Lunch is served at 11:30. From noon to 1 p.m., participants watch the news or nap. The next two hours are set aside for games, arts and crafts, or sessions of reminiscing. At 3:30, a staff member reads to them while they engage in armchair exercises. The rest of the day is left open for listening to music, reading, or watching the news. A Caring Place closes at 5:30 p.m.
The regular cost for the service is $17 for half a day and $33 for a full day, but A Caring Place offers a sliding fee scale based on the income of the participant and his or her spouse. Daily fees on the sliding scale range from $5 to $21.
The pricing structure presents complications. Adult day care centers, unlike child care centers, bill only for the days that the service is used; participants are not obligated to pay weekly or monthly rates that apply regardless of whether they show up on a given day. Consequently, the centers have no guaranteed stream of income, and a stretch of bad weather can wreak havoc on their budget.
Church-based centers often cannot charge participants enough to cover their costs. For-profit centers usually can depend on economies of scale. In a nursing home, for example, facilities are in place, there is a staff on hand, and the home prepares several dozen meals a day; adding a few more meals incurs little extra expense. Congregations starting from scratch have none of these advantages except perhaps available space. Their overhead costs are higher, and charging enough to cover them would turn away most potential customers.
Congregations must either plan to subsidize adult day care with money from their budget or find funding from outside sources. Catholic Social Services has received grants from an array of organizations, including the Veterans Administration, the Marion County Board of Health, and the United Way. (These organizations also serve, albeit indirectly, a regulatory function. Adult day care centers are not formally regulated or licensed by a state agency in Indiana. But most funding sources stipulate that the adult day care centers they support be in compliance with the standards set by the Indiana Association of Adult Day Services.)
Because of the paperwork involved, even the smallest of adult day centers requires at least two staff members � one who tends to the administrative details, and one devoted to working with the seniors. The latter might work on a volunteer basis, but the administrator�s job will likely be a paid position.
Employee costs can escalate quickly as the program grows. A Caring Place, for instance, has a full-time activity coordinator, a part-time social worker, a part-time activity director, a part-time art and music therapist, a part-time kitchen aide, and five part-time "senior companions" to assist with activities, feeding people, and other needs.
Finding enough competent people should be the single most important concern for any congregation considering adult day care. In addition to its paid staff, A Caring Place makes extensive use of volunteers. But whether paid or volunteer, all staff should meet certain criteria.
"The main thing is a compassion for the elderly, the ability to listen, the ability to plan challenging and meaningful activity for the participants, and flexibility," Dinnin said. "A Caring Place and Holy Trinity Place are a ministry to families and the elderly. It�s not just a place to come and collect a paycheck. It�s about creating a loving environment for these participants."
Southport Presbyterian Adult Day Center
While few congregations have a CSS-type organization to support their program, the challenges to be overcome are similar with any adult day care startup. Southport Presbyterian, which operates the other adult day care center considered here, demonstrates how a congregation can go about starting a program while drawing on the expertise of existing programs.
Prior to opening its centers for adult day care and child care in 1997, Southport Presbyterian had informally discussed the idea for years, and spent two years in the planning and preparations stages.
Students from nearby University of Indianapolis had already done a research project focused on the demographics of the area, to determine whether there was sufficient need for an adult day care program. As well, Southport Presbyterian could draw on the work of Catholic Social Services, with its two church-based programs already in operation.
Southport Presbyterian�s members formed a committee to explore adult day care. They joined the state�s adult day care association, visited A Caring Place and other centers around town, attended national conferences on the subject, and tried to take into account all the seemingly minor things � such as transportation � that turn into major concerns once a program is up and running.
"I still have a three- or four-inch binder full of committee minutes and notes about whether this would be feasible," said Julie Feagans, director of the program. "People even used their own money in doing the research, so there was a real commitment made by committee members before they committed the church to it."
Despite all this preparation, the center faced problems when it opened in September, 1997. The most daunting was a lack of participants.
"It was very slow going," Feagans said. "Our first two months, we were doing well if we had a participant a day. And that can be very scary if there�s not a committed majority of the church behind a ministry. The church has to help spread the word, too. You need members to open the door for you so you can do the work. But it takes a while to get a client base."
Southport Presbyterian charges $40 per full day and $25 per half day. These rates are not enough to cover the cost of the program, but the church cannot set its prices much higher and remain competitive. And, unlike Catholic Social Services, it does not receive grants from outside sources, so any difference between costs and participant fees must be covered by the church.
The child-care model of a flat weekly or monthly fee is usually not accepted in adult day care. According to Feagans, other centers have tried it and lost their participants. But the pay-for-use billing system, fair as it may seem to customers, poses real problems for providers.
"I may have four people scheduled to come five days a week, and two of those may only make it in three days a week," Feagans said. "That�s all the income I get from those two people, yet I still have to maintain staffing in case they show up those other days. The flat rate would make it easier to plan staffing. But that�s not possible at this point, and it creates a real management problem."
After slow going in the first few months, Southport Presbyterian�s numbers picked up. After the first year of operation, it was averaging ten participants per day � as high as some operations that have been open for several years, Feagans noted. (The average drops to about eight after the holidays, when many seniors head to warmer climates.)
Southport Presbyterian�s support for the program has never wavered. The congregation went into adult day car having done its homework, and was committed to the program as a ministry. Like other ministries, the program was not expected to turn a profit � on the contrary, it would likely lose money. From that perspective, attracting more participants isn�t so urgent a concern as serving the participants who are already involved.
"It�s a very expensive ministry," Feagans said. "Many churcheshave called me to talk about it. I tell them it�s a matter of prioritizing � what do they define as their key ministry? You can�t do everything.
"This church has undertaken a great risk. It really stepped out on a limb, totally through faith. The leadership of the church is really the only reason that faith step was taken, because they believed so strongly. They keep reminding the congregation that if we do it for the glory of God � and that is the purpose for doing it � then our needs will be met."
WHAT IS REQUIREDWhat is clear is that adult day care, despite the pitfalls, can be done successfully, provided there is a strong desire backed with sufficient preparation. Initial resources matter less than the sense of mission driving the ministry.
Adult day care is not currently covered by the federal government�s Medicare program. (Some state aid is available, but the impact is insignificant.) Given the unregulated nature of adult day care, the programs vary too widely in quality to receive the federal endorsement that Medicare coverage implies.
Early in 1999, the National Adult Day Services Association released official guidelines setting forth the standards expected from adult day care providers. Its goal was to begin certifying programs later in the year. The certification will be costly (an estimated $4,000 to $6,000), and there is no requirement that a program be certified, so participants will likely be scarce for the first few years.
Even so, these developments signal important changes in the adult day care industry. The field is professionalizing. Programs that continue to operate beyond the reach of inspection by outside authorities or governing bodies will become increasingly marginal.
Adult day care may one day be covered by Medicare, which would create a substantial increase in its use. On the other hand, Medicare might choose to cover only those programs that operate according to the medical model � providing extensive health care services. That would exclude most church-based programs.
Any congregation interested in adult day care should begin by surveying the area it hopes to serve to determine whether there is a need for the service.
Gaining the solid support of the congregation is the second critical ingredient in starting an adult day care. Both Catholic Social Services and Southport Presbyterian reported that traditional advertising simply does not work. If church members are behind the program, their efforts in getting the news out will likely be the best advertising.
Finally, expect to spend at least several months in the planning stages. Conduct a survey of the area, try to build support in the congregation, and talk with potential participants and their families. Visit as many programs as possible to see how they operate. The programs discussed here would be good places to begin; both have indicated a willingness to share their expertise in helping startups get on their feet. "We aren�t in competition," Feagans said. "We�ll do everything we can to help others get started and help them succeed."
POINTS TO REMEMBER:
- Commit to research and preparation before beginning a program.
- Providing a qualified staff will be the biggest expense and should be the highest priority; don't skimp on paid staff, but make appropriate use of volunteer help, too.
- Expect to attract few participants in the first few months of the program.
- Word of mouth is the best form of advertising for adult day care programs, but be aware that some people may be reluctant to use a program connected to their congregation.
- Because of its unregulated nature, adult day care is not covered by Medicare; though the field is now professionalizing, future coverage by Medicare is not guaranteed.
- No matter how successful in terms of the people served, an adult day care is almost certain to be a financial drain.
- A strong financial and ministry commitment by the host congregation is crucial.
- Make use of the experience of other congregations involved in adult day care.
CONTACTS & RESOURCES:Catholic Social Services
1400 N. Meridian St.
Indianapolis, IN 46202
(317) 236-1527A Caring Place
4609 N. Capitol Ave.
Indianapolis, IN 46208
(317) 466-0015National Adult Day Services Association
409 Third St. SW, Suite 200
Washington, D.C. 20024
(202) 479-0735The association's web site at http://www.ncoa.org/nadsa offers new general information about adult day care, publications for providers, news of conferences, and links to other sites of interest.
Southport Presbyterian Adult Day Center
1427 Southview Dr.
Indianapolis, IN 46227
(317) 788-5935This center is open from 7:30 a.m. to 5:30 p.m. The program is still in its infancy, so observing it should give you a good idea of the problems facing any adult day care startup. The church drew heavily on the experience of others in starting its own program; in turn, the staff seems especially open to helping others in the same way.
Indiana Association of Adult Day Services
2236 E. 10th St.
Indianapolis, IN
(317) 633-8220The 50-plus members of IAADS include both for-profit and not-for-profit centers, as well as individuals and organizations that are interested in adult day care. IAADS works to increase awareness about adult day care, and conducts ongoing educational efforts for its members. For any congregation interested in starting an adult day care program, membership in IAADS is a good starting point.
