Home health and adult day services come together to provide care

CMS project could result in expanded reimbursement requirements

While the results of the Medical Adult Day Care Services Demonstration will not be presented to Congress by the Centers for Medicare & Medicaid Services (CMS) until 2009, home health managers and adult day care service managers are looking forward to a report that is positive for both types of health care organizations, as well as Medicare patients.

"It makes sense that adult day care services and home health agencies work together to provide the best care for a patient, because it ensures a continuum of care in the community," says Judith A. Bellome, RN, BSN, MSEd, CEO of Douglas County VNA and Hospice in Lawrence, KS. The demonstration project is evaluating whether providing medical adult day care to Medicare recipients as part of the home health service improves outcomes. Care provided in a day care setting has not qualified for Medicare reimbursement because of the "homebound" definition required for home health reimbursement.

"Home health agencies focus upon acute episodes that require care, while adult day services are designed as long-term care," says Nancy Brundy, MSW, director of external affairs for the Institute on Aging, a community organization in San Francisco that provides a range of services to senior citizens, including adult day services. There is a role for each organization, and if a relationship, formal or informal, is developed, it will benefit both organizations, she points out.

"There are home health and adult day services staff and managers who feel that they are in competition with each other, but we are not seeing the same patients," Bellome says. In reality, home health and adult day care services can be excellent sources of referrals for each other, she says. Also, the continued supervision and observation of the patient in the adult day setting can mean earlier intervention if problems arise, she adds. "This can mean better outcomes and fewer rehospitalizations," she points out.

Although it will be three years before any reimbursement for combined home health and adult day services, there are steps that home health managers should now take to position their agencies to move forward, Bellome suggests. "The first agencies to set up day service programs, or partner with existing programs, will have the edge in the market," she adds.

The first step is to learn about adult day services, says Brundy. "There is a lot of misunderstanding about day services and what services can be provided," she says. Ask a local center if you can meet with them to learn more about day services, and then plan to spend at least one-half a day to observe the staff and participants at the center, she suggests.

"It's important to realize that if the adult day program provides nursing or therapy, the staff members work together as a team, meeting each morning to discuss who is coming that day and what services they may need. This is similar to home health's team approach to patient care," Brundy explains.

Two types of adult day services

Be aware that there are two types of adult day services that may exist in your community, Bellome says. "The first model is a medical model in which an RN is on staff to dispense medications if needed, check blood pressure, evaluate symptoms the patient may experience, and offer health education," she explains. "Some programs that are medically designed also offer occupational and physical therapy."

The other model for adult day services is designed more as a respite for the family care-giver, points out Bellome. There is no nurse on staff, but patients can come to the center with their medications for the day and staff members will remind them to take them. "These programs are usually geared toward the cognitively impaired who do not need medical supervision and they offer a safe environment for patients to socialize with other people while their family member gets a break," she explains.

"No matter which type of model is used, it is important to remember that 50% of adult day service clients are cognitively impaired," Bellome points out.

After educating yourself, survey your community for adult day service programs. Find out what types of programs are offered, whether or not they are affiliated with a hospital or home health program, and how many participants they have in their program. "Once you know what is already available, you can evaluate the feasibility of setting up an adult day service program, or partnering with an existing program," says Bellome.

Setting up an adult day service program makes sense for hospital-owned home health agencies, as a natural progression in the continuum of care, she says. "This is not a program that will become a big profit center for the organization because most clients pay out of their pocket. In some cases, they do have coverage from long-term care insurance policies; but most don't," she says.

Fees must be kept reasonable, with typical costs ranging between $50 and $60 for an eight-hour day. Ideally, you should plan on about 20 people per day once you are established, with staff members who can run the activities, monitor medications and, if you are offering medical services, make therapy available, she says.

While such a program won't represent a large profit, it will be one more way to keep patients loyal to the hospital, home health agency, and the hospital's physicians, Bellome points out. If patients can receive every type of care they need, even ongoing community-based care such as adult day services, they are less likely to look elsewhere for a physician, hospital or home health care, she explains.

"You must offer two different types of activity throughout the day to fit the needs of different clients," says Bellome. "One activity might be reading the newspaper and talking about the news to reorient the participants; the other activity might be more active or more challenging, such as a craft project." Both activities should be designed to promote interaction among participants, she says.

Cross-train staff to offer options

The best person to run an adult day program is a nurse, social worker, or someone with a degree in therapeutic activities, suggests Bellome. "Whatever the director's background may be, look for a creative individual who understands that adult day services is not a baby-sitting program." All staff members must enjoy working with geriatric patients, she adds.

If the home health agency and the adult day service program are in the same organization, there is also the opportunity to cross-train staff, says Brundy. Not only does cross-training improve understanding of both types of service, but it offers new opportunities to each staff member and could help with recruitment and retention of employees for both programs, she adds.

Because most adult day service clients are private-pay, it is important to make sure that the center is attractive and that activities are varied and interesting, says Bellome. "Clients want to know that they are going to see friends and that they will be comfortable, safe, and busy throughout the day," she says, pointing out that setting up an adult day service program is different from state to state. "Some states require licensure for any program, others require it only for medical model programs, and others don't require any license." She suggests checking your state's requirements carefully before beginning.

If it's feasible …

If your feasibility study shows that there already are plenty of well-established programs in the area that would make it difficult to set up a successful program, look at partnering with an existing program, Bellome says. If your partnership is a formal one, it will allow both programs to share patient information more easily, thus providing more consistent care, she says.

"This will be beneficial if the patient is receiving home health care and going to adult day services at the same time," she says. Be sure to double-check your organization's privacy policies and HIPAA regulations if you do share information, she warns.

Another option, if your agency wants to add adult day services to the organization, is to purchase an existing program, says Bellome. "This has happened in some locations, and it can be a good way to enhance your services."

Informal partnerships in which both organizations share information about services and programs and refer patients to each other when appropriate also are beneficial, says Bellome. Being able to refer patients to another organization that offers high-quality care and shares the same goals of improving outcomes enhances your ability to ensure your patient gets the care or follow up that is needed, she explains. It also is helpful to family members who may need the extra help but do not know where to find it, she adds.

Brundy looks forward to more home health and adult day service programs working together. "There is a real synergy in the type of care that home health and adult day services offers. This is a win-win for everyone — home health, adult day services, and patients."


For more information about home health and adult day services, contact:

  • Judith A. Bellome, RN, MSEd, CEO, Douglas County VNA and Hospice, 200 Maine St., Suite C, Lawrence, KS 66049. Phone: (888) 295-2273 or (785) 843-3738. Fax: (785) 843-0757. E-mail: judyb@vna.lawrence.ks.us.
  • Nancy Brundy, MSW, Director of External Affairs, Institute on Aging, 3330 Geary Boulevard, San Francisco, CA 94118. Phone: (415) 750-4180, ext. 102. E-mail: nbrundy@ioaging.org.
  • National Adult Day Services Association, 2519 Connecticut Ave., N.W., Washington, DC 20008. Phone: (800) 558-5301 or (202) 508-9492. Fax: (202) 783-2255. E-mail: info@nadsa.org.

An article that describes how to conduct a feasibility study and identifies issues to address when setting up an adult day services program can be found on the association's web site: www.nadsa.org. On the home page, choose "Starting an adult day service" under the "More things to do" section in the right-hand column.