Planning and Creating Successful Adult Day Services and Other Home and Community-Based Services

Home , Family caregivers, Home care

A NADSA-AAHSA Whitepaper Planning and Creating Successful Adult Day Services and Other Home and Community-Based Services

By Marilyn Hartle, MSW, LCSW and LaDonna Jensen, RN

Introduction Types of HCBS Programs and Services

Consumer demand is increasing for flexible, respon- For the purposes of this paper, HCBS refer to sive home and community-based services (HCBS), providers of an array of health and support services including adult day services, as options to institu- provided to individuals in their homes or commu- tional care. The growing numbers of elderly, and nities. Most often, HCBS programs provide more federal and state efforts to meet consumer demands than one type of service. For example, adult day and decrease costs of overall long-term care services, providers may also include baths and other person- have led to an expansion of adult day and home al care, and home care providers may include case and community-based service programs. This has management and handyman programs. Types of created opportunities for new and current providers HCBS programs include: to develop or expand services. It has also created a dynamic, changing climate that challenges all long- • Adult day services, medical and/or social (pre- term service providers. Challenges include increased viously termed “adult day care”) competition for consumers and contracts with • Case management (or “care” management) funding sources, more informed and empowered NOTE: Many states use a case management consumers, and changes in rates or availability of system organized through state services or funding. Area Agencies on Aging to become the single point of entry to access all state and federally There are many types of home and community- reimbursed services. based services. Each organization’s approach to serv- • Home care agencies ice delivery is somewhat unique within the business climate of the community in which it exists. To • Home health agencies (Medicare-certified) position themselves for the future, home and com- • Hospice munity-based service providers, including adult day services, must understand their market and be will- • Meals programs: home-delivered and congre- ing to adapt to changing market needs. To be able gate to do this, providers must have good business prac- • PACE (Programs of All-Inclusive Care for the tices to support their mission. Elderly)

This paper provides an overview of factors to con- • Senior centers sider in creating viable adult day services and home • Transportation: para-transit and community and community-based service programs. The aim is to provide a simple yet comprehensive guide to Each service listed above may have a slightly differ- developing an organizational plan of action. Many ent definition based on the funding source(s) of the topics reviewed, such as marketing, leader- accessed. For example, home care is often a generic ship and strategic planning, have had volumes writ- term used to describe care provided in a person’s ten about them. This document highlights essential home. However, Medicare-certified home care agen- information to consider, and suggests additional cies are known as home health agencies, and pro- resources. The basic information presented here is vide Medicare-reimbursed skilled care requiring at directed to all HCBS providers, but is most specific least part-time skilled nursing care or speech/physi- to adult day service (ADS) providers.

NADSA-AAHSA Whitepaper 1 cal/occupational therapies. In contrast, funding for This is partly because advances in medical treat- home care through the Older Americans Act does ment have enabled individuals with developmental not require skilled care; rather, the term “home and intellectual disabilities to live much longer care” is inclusive of other services offered, such as than ever before possible. Some ADS providers have personal care, case management, homemaker and responded to this unmet need by offering special- in-home respite services. ized programming for older adults with mental retardation or developmental disabilities (MR/DD). Adult day service (ADS) programs can be medical/health or social, or a combination. Medical Recent federal and state initiatives have also ADS programs provide the same services as social increased the number of younger persons with dis- models, but include a nurse on staff and offer abilities receiving health and supportive services in health and medication monitoring. Core services their homes and communities. These include per- that most successful ADS offer include therapeutic sons with physical, developmental, cognitive and activities, meals, transportation, social services and psychiatric disabilities. Many of these individuals education. Medical/health adult day service may be best served by a combination of adutl day providers include nursing as a core service. Centers and HCBS programs, while some may need very typically contract with other organizations to pro- specialized services and supports. Attention should vide at least one or more of the core services, partic- be given particularly to staffing and facility set-up ularly transportation and meals. Transportation when multiple target populations are mixed, such services, if provided directly by the center, require a as older adults and younger adults with develop- large financial commitment; however, lack of acces- mental or intellectual disabilities. sible transportation can be a barrier to using the service. If meals are prepared on site, additional Assessing the Market/Community environmental requirements may apply. Optional Understanding the market and community is essen- services an adult day center might consider offering tial to establishing and maintaining an adult day or include baths/showers, hair care, rehabilitation home and community-based service program. A therapies, medical escort, tracheotomy care, injec- community assessment produces a snapshot of criti- tions, etc. cal factors to be considered in estimating the need for and potential utilization of a service or program. It can provide the information you need to develop Persons Adult Day and HCBS or expand a specific service, or help you decide Programs Serve what new service or program would be most successful. Important considerations in this decision Traditional adult day and HCBS target populations process are assessment of the population trends, have been older individuals, age 60 and over, and particularly as that relates to the population you include: serve, and the service environment.

• Individuals who are physically or cognitively Give careful consideration to each of the following impaired and unable to perform their activi- components in order to reach a realistic and objec- ties of daily living (ADLs) independently tive conclusion: demographics; types of existing and potential services; service trends; needs and • People with chronic health problems who require regular health or medical supervision demands exhibited by documentation and interviews; availability of funding; observations of exist- • Adults newly discharged from an acute care ing programs or services; the competition; the hospital or rehabilitation center strengths and weaknesses of the potential adult day or HCBS provider agency; and risks or threats to New Target Populations providing programs or services. Older persons with disabilities—physical, developmental and cognitive—are needing and using home and community-based services in greater numbers.

NADSA-AAHSA Whitepaper 2 Determining Need and Demand for Services • Veterans Administration There are numerous things you can do to determine • Senior Center providers the need and demand for your services. These include reviewing population and service trends, • Meals on Wheels programs interviewing staff of state and local agencies and • Head trauma groups associations, conducting focus groups and assessing the competition. • State and local provider and consumer agencies, including AAHSA and NADSA state affili- 1. Review population and service trends. ates Understanding current and expected future trends • Local YMCAs/YWCAs in the business on a national, state and local level • Friends, family members, other service users, helps build a project’s foundation. Data that sub- mail carriers and clergy, since they can serve stantiate need for services include: as informal referral sources, as well.

• Demographic information from the national census, available for review at 3. Create a list of pertinent questions to be asked. For www.census.gov interviews or focus groups with potential referral sources, consider the following questions: 2. Conduct interviews. Seek input from a diverse sam- • Are you familiar with the specific service we pling of area agencies and stakeholders. A logical are thinking of providing? (This is particularly place to start is to contact other agencies that deliv- important if dealing with adult day services or er services to the same target population(s), since less familiar services.) they could be primary sources of referrals or potential collaborators. Agencies and providers to consid- • Do you have a general idea of the benefits to er involving in the community needs assessment participants of the service we are suggesting? include, but are not limited to, the following: • Are you aware that the service we are suggesting includes such components as (fill in the • Alzheimer’s Association (local, state or area blank with what is relevant to the service)? agency) For adult day services, this may be bathing, medication and vital signs monitoring, etc.). • Disease-specific associations or caregiver support groups (Parkinson’s, Multiple Sclerosis, • Do you perceive a need for the service in this Muscular Dystrophy, Arthritis, League for the area? Blind, Association for Retarded Citizens, etc.) • Would you refer your clients/family mem- • Area Agencies on Aging bers/friends to this service? • Centers for Independent Living • What would you want the service to look like if your family needed it? • Councils on Aging • What would make the service more accessible • Departments of Social Services (state offices) for your clients/family/friends? • Vocational Rehabilitation providers • Discharge planners and social services profes- If the potential service being considered is adult day sionals of local hospitals or health care facili- services, the following questions could be added to ties the list: • Physicians specializing in geriatrics, family • Do you know someone who needs daytime practice or other specialty groups related to supervision but stays home alone? your target population(s) • Do you have someone in mind you would • Mental health service providers refer to an adult day services center?

NADSA-AAHSA Whitepaper 3 • How familiar are you with adult day services Determine what is unique about how the competition provides services and what your organization • What specific services would your clients need would do differently. to have access to while at the adult day center, e.g. bathing, wound care, injections, blood sugar level monitoring, medication 8. Assess risks and/or threats. Identify factors, such as administration, support group, counseling, competition or size of the target population, that therapeutic activities, life skills training/main- may jeopardize the project’s success. Consider the tenance, or other? availability, accessibility and volatility of funding, both private and public, to support the services. 4. Conduct focus groups. Focus groups can provide Defining Your Target Population valuable information and insights about the com- The consumer market must be large enough to sus- munity. A successful focus group usually is a group tain your home and community-based service pro- of 10 to 15 people who are not acquainted with one gram. Adult day services and HCBS agencies often another and have different backgrounds. Consider serve multiple groups based on community needs, using a qualified outside facilitator to run the agency mission and available funding to support group. This tends to foster unbiased and accurate services for these groups. Target populations directly feedback from group members. If possible, offer a influence programming, staffing and marketing meal, snacks or small stipend to motivate increased efforts. For example, there are many adult day serv- attendance. Invite attendees with a personal letter ice centers that target their markets to reach certain of invitation that describes the purpose of the high density areas of ethnic groups (Russian immi- group, date, time and location. Consider audio-tap- grants, Asian immigrants, Native Americans, et al). ing the session but be sure to get signatures for per- Other centers define their market niche by serving mission to do so from each group member. Honor younger adults with physical disabilities. the original time parameters to be respectful of the time commitments of participants. Follow up atten- Defining your target population is essential. For dance at the group promptly with a thank you Adult day services and HCBS providers of long-term note. care services, this is usually the older adult population, which is generally thought of as the popula- 5. Summarize the responses from the group and respon- tion aged 65 and over. However, programs and fun- dents. Record the responses from interviews and ders differ on the minimum age of eligible individu- focus group. This provides a source of information als. For example, Medicare uses a minimum age of for development of marketing and program materi- 65, but also provides benefits for qualified younger als, as well as for future reference in writing busi- adults with disabilities. Older Americans Act pro- ness plans to attract funding for the service. grams use a minimum age of 60. Medicaid provides reimbursement for long-term home and community 6. Observe existing programs and services. Visit other based services, particularly personal care, to eligible organizations already providing the proposed pro- individuals of any age. So, in defining your target grams or services, whether locally or in nearby population, you need to know area demographics as counties or states. Observe the programs or services well as what funding sources are available. in action. This is particularly important if adult day services are being considered. Every center is differ- Some providers may choose niche markets or diag- ent, even multiple centers managed by the same nosis-specific markets, such as persons with company. Remember, policy and procedure manuals Alzheimer’s disease or other dementias, multiple do not give adult day services their personality; the sclerosis, HIV/AIDS or developmental disabilities; people do. frail elderly with no dementia; persons who are chronically mentally ill; those with physical disabil- 7. Consider the competition. Identify all the home ities but no cognitive deficits; persons with traumat- and community-based service providers in your ic brain injury, etc. area. Review their services and markets to determine The challenge in targeting one or two specific diag- if they are competitors or potential collaborators.

NADSA-AAHSA Whitepaper 4 nostic groups is filling the roster to attain maxi- Some Start-Up Basics mum financial viability. Diagnosis-specific ADS cen- Once you have decided to pursue development or ters located in large metropolitan areas often thrive expansion of an adult day or home and communi- if there is a stable funding stream for the targeted ty-based service, there are numerous things to population. Also, some states have consistent, stable decide and prepare for. These include basic start-up funding to support care for people with psychiatric needs such as review and preparation for licensure disabilities, developmental disabilities, profound or certification; decisions about tax and affiliation physical disabilities or other specific, identified status; the location and geographic boundaries for needs. These state-funded initiatives create opportu- your services; and a good financial analysis and nities for providers willing to look beyond their tra- understanding of the unit cost of services. ditional markets. Licensure and Certification Assessing Availability of Funding Sources HCBS agencies must explore federal, state and local Funding for adult day and HCBS is nearly as varied requirements for licensure and certification of each as the types of services offered. It is important to type of service to be provided. These requirements identify the types of funding sources that exist for often are different state to state. Specific informa- your services, and how available these are. For tion can be found within state health departments, example, the Older Americans Act reimburses a health and human services departments or state range of home and community-based services health care licensing bureaus. State HCBS member including adult day care, but to receive Older associations may be helpful in identifying state Americans Act funding, you need to have a contract requirements. There are often additional require- with an Area Agency on Aging. Consequently, you ments and certifications to be met for specific fund- need to know when and how to apply. Under ing sources such as Medicaid and Medicare Medicaid, most home and community-based services are funded through Medicaid HCBS 1915(c) Some states continue to use a “certificate of need” waivers. Besides becoming a Medicaid-certified as a criterion for adult day services start-up. Most provider, you need to know if there is a waiver that states have guidelines for operating an ADS center, covers the population you want to serve, and if even if they do not require licensure or certifica- there are available slots or a waiting list. tion. Many states have fees associated with licensure or certification. If the state does not have current Diversified funding is a necessity since there are so operating standards and guidelines, consider order- many types of funders, and all have specific require- ing the National Adult Day Services Association’s ments and limits for reimbursing for services. For (NADSA) Standards and Guidelines for Adult Day example, the Veterans Administration reimburses Services (order information available at adult day services, but may limit coverage to two www.nadsa.org) or the CARF (Commission on days a week. Fee for service (private pay) continues Accreditation of Rehabilitation Facilities) Adult Day to be a primary revenue source for adult day and Services Standards Manual (order information avail- home and community-based providers. Private able at www.carf.org). insurance is a growing source of funding. Tax Status An overview of potential funding sources is dis- A major decision for a new business is how to struc- cussed below under the “Revenue Streams” heading. ture the organization. A business should expect to More in-depth information on funding sources and pay taxes on all profits unless approval has been revenue streams is available in the AAHSA technical granted by the Internal Revenue Service (IRS) to assistance brief titled Funding Home and establish the organization as a not-for-profit. The Community Based Services: The Building Blocks majority of adult day service centers are private, and How to Assemble Them. It is available on the not-for-profit (79%), a status that has given these AAHSA Web site at centers access to grants and foundation project dol- http://www.aahsa.org/pubs_resources/papers_arti- lars. The primary differences in not-for-profits and cles/default.asp. for-profits relate to governance, the ability of not-

NADSA-AAHSA Whitepaper 5 for-profits to attract money from grants and foun- center’s success. dations, and how profits are used or disbursed. Affiliation Governing Body Affiliating with a larger “parent” organization such Structuring the governing body differs in for-profit, as the American Red Cross, National Easter Seals, not-for-profit and public agencies. In a private, for- Salvation Army or a faith community can provide profit organization, the responsibility for manage- resources that might otherwise not be available. For ment may lie with either a single owner or a board example, affiliating with an established organiza- of directors. Private, not-for-profit organizations tion should produce a more immediate audience for must have a board of directors, based on the pro- promoting services, since those organizations likely gram’s status as a 501(c)(3) organization as defined have established relationships in the community. by the IRS. Public agencies have a board that governs the organization, although administration for While affiliation should mean gaining support, it some programs or services may be delegated to an also means losing some control in decision making. advisory board. When an organization is governed An example would be if a parent organization limits by a board, the overall responsibility of the board the age of clients served to 60+, while an adult day generally will be the same regardless of the pro- service intends to serve people 18+. Approximately gram’s size, location or other attributes. two-thirds of existing adult day services in the United States are affiliated with larger organizations. Not-for-profit boards have two fundamental responsibilities: governance and support. Acting as the for- Geographic Boundaries mal representative of the public, the board governs Geographic boundaries for programs and services and provides oversight to the organization. At the are often defined by transportation time. For exam- same time, board members as individuals support ple, home care services may be determined by dis- the organization by volunteering, raising money tance in miles or the length of time a worker may and advising. Successful private, for-profit organiza- spend to travel to a client. For adult day services tions establish advisory boards. An advisory board’s centers, consideration should be given to a reason- responsibilities are more loosely defined. The advi- able travel distance for the adult day participants. sory board usually does not have any legal authori- Rural communities might expect the distance trav- ty over the organization unless board members are eled to be greater while the commute time may be co-owners of the business. less than that in urban areas. It is not unusual for county lines to be crossed so services can be A dynamic board or governing body is the organiza- accessed. Adult day services industry standards sug- tion’s link to the outside community. gest that travel time for participants should not Responsibilities of a board of directors may include, exceed one hour. but are not necessarily limited to, hiring and evalu- ating the performance of the executive director; Location of Facility or Service Site establishing operating policies; approving operating Location differs in importance among providers. For procedures or defining a line of authority that programs such as home care or home health, in allows executive staff to define procedures that which the service comes to the client, the location implement policies; reviewing and overseeing finan- is less important. For services such as adult day or cial affairs; ensuring compliance with all relevant senior center programs, in which the participant laws and regulations governing the organization; comes to the service, the site is more important. and overseeing a quality assurance plan. The location of the building strongly influences Today’s board culture has changed as leadership accessibility, as well as potential service users. expectations have changed. Board leadership is not An outdoor area accessible to participants enhances about “command and control” but about facilitat- the therapeutic value of the program. Major consid- ing, coaching, modeling, teaching and providing eration must be given to the safety of the surround- stewardship. The hands-on board may be key to the ings (traffic, crime) and the reputation of the build-

NADSA-AAHSA Whitepaper 6 ing and the area. For example, locating in a former past several years. Developing diverse funding funeral home may cause marketing problems for sources requires vision, creativity and knowledge of natives of the area. Locating in an upper-class the field. neighborhood may create the perception that serv- Financing should reflect diversified funding sources ices are restricted or costly. Locating in a nursing that include operating and non-operating revenue. home could heighten the anxiety of people who While grants or loans may help get a center or service fear they will be moved there permanently. started, the objective in successful business practice is to increase the amount of money generated by oper- Co-location, on the other hand, may bring ating revenue, such as participant fees, and reduce the economies of scale, thus reducing the cost of facili- amount of non-operating revenue, such as grants and ties or staffing. For example, sharing space, emer- loans. Operating revenue should generate at least gency equipment, office equipment, etc., may save two-thirds of the organization’s budget. on overhead costs. The traditional array of funding options for operat- Hours and Days of Operation ing revenue includes but is not limited to: To succeed, organizations must establish hours and days of operation that meet the needs of their cus- • Medicare (most commonly for home health tomers. Consider the results of a market/communi- and therapy services) ty assessment when establishing hours and days of • Medicaid waiver programs, including personal operation. A 2002 survey of adult day service cen- care services ters found that one indicator of success was having operating hours earlier and/or later than normal • Private pay/out of pocket business hours. Factors to consider in determining • Older Americans Act (Title III) hours and days of operation include the following: • Social Services Block Grants (Title XX) • Hours most commonly needed by working • Child and Adult Care Food Programs (CACFP, caregivers USDA) • Commuting times • Veterans Administration • Shifts at most commonly worked companies • Budgeted state-specific funding programs • Holidays most often worked by working care- • County tax levies givers • Days of the week most often worked by work- More recent developments in funding mechanisms ing caregivers include such sources as: • Interest of family caregivers in using evening and weekend services • Family caregiver support from the Older Americans Act (Title III E) Revenue Streams • Long-term care insurance plans Diversification of funding in home and communi- • Asset protection long-term care plans ty-based programs is essential because of the wide range of funding sources for these programs and • Managed care programs services, and because revenue streams can change. Diversifying revenue protects the organization if Common non-operating revenue options include there are sudden shifts in the market or a funding grants, foundation funding and United Way. The source diminishes. For example, some states have availability, accessibility, regulation and scope of all reduced state funds for ADS, as well as cut Medicaid funding sources can vary significantly, affecting a rates and funding for many home and community- client’s care and the organization’s financial plan. based services, due to fiscal crises experienced in the Limitations imposed on funding by public payers, such as limiting the number of days per week and

NADSA-AAHSA Whitepaper 7 maximum hours per day that a client can receive Contractual Arrangements for Services services, is further reason for diversifying funding. It is not always necessary for an organization to This fragmentation of revenue streams requires per- provide all the services directly in order to meet the sistence to understand and creativity to establish needs of its customers. At times it is more efficient both an acceptable plan of care for clients and an to provide services through collaborative efforts equitable funding stream for the service provider. with other community agencies, and in some cases Thus, it becomes necessary for some clients to that allows for additional services that may attract receive care based on a mix of payers, such as pri- new customers and maintain existing ones. The vate pay and state-specific funding programs. On most frequently contracted services among adult average, ADS centers report 38% of all revenue com- day service centers include transportation, meals, ing from third-party public reimbursement. The therapies such as physical, occupational and speech, most commonly reported sources of revenue for and hair care. third-party public reimbursement were Medicaid home and community-based waivers; state or local Adult day services that are equipped to provide programs; and USDA/CACFP. their own transportation might consider offering medical escort services for reimbursement through Unit Costs federal transportation grants. Group homes, adult Understanding unit costs for home and communi- care homes or nursing homes might be interested in ty-based services is increasingly important in today’s contracting with adult day services to allow some of market. It is necessary for setting adequate rates for their higher functioning residents to participate in services, developing proposals and contracts for stimulating activities. funding, and controlling costs. It is also important for planning and accessing credit when needed. Agencies to consider approaching to enhance client Depending on the type of home and community- care include YMCAs, YWCAs, senior centers, nurs- based service, the unit cost could be a trip, or an ing homes, rehabilitation centers, churches, com- amount of time. This should be tailored to reim- munity centers, mental health centers, group bursement practices. For example, many funders of homes, public health clinics, parks and recreation adult day services reimburse for a day or half day of departments, the local Alzheimer’s Association or service per individual. For ADS providers, therefore, other diagnosis-specific groups, and colleges, uni- the unit cost should be per participant per day or versities and trade schools. half day of service.

The simple formula for calculating unit cost Developing Strategic and Business requires three steps based on basic arithmetic: (1) Plans identify expenses, (2) define units, and (3) divide the expenses by service units. For example, if your No matter what type of program or service you transportation costs for the year were $21,000, and operate or want to start, developing good business you make 2,500 trips, your unit or per trip cost practices is essential. Developing strategic and busi- would be $8.40, or $21,000/2,500 = $8.40. ness plans provides the foundation and details for Calculating costs includes identifying all costs, both what your particular service is, what is needed to variable and fixed. This total is divided by operating make it successful, and how it will operate. days, and then by the number of expected participants. A strategic plan is a roadmap for the organization’s evolution. It reflects core values, philosophy, vision There are two ways to decrease unit cost: either and mission. It defines the possibilities for excel- decrease expenses or increase units. Factors that can lence in service provision, forecasts probable decrease expenses include decreasing staffing during achievement of these goals and delineates the steps off-peak hours, increasing utilization of services and necessary to ensure success. Historically, five-year sharing expenses, such as accounting, with other strategic plans were the norm. Three-year plans are organizations. becoming more widely used due to today’s rapid

NADSA-AAHSA Whitepaper 8 pace of change. Effective plans break the project sources, radio or newspaper ads, Web into stages to make the process more manageable resources, etc.) and achievable. • Describes the governing body, membership of A well-designed business plan will appeal to poten- the board of directors and the board’s role. tial funders and donors, and satisfy a new board of Will the board be involved in activities such directors, or a board looking to expand the services as strategic planning, marketing, fundraising? the organization already offers. The plan can be key Are there bylaws and officers? Resumes of to arranging alliances or collaborative efforts for the board members should be available. organization. A business plan can be developed in • Includes a management and staffing overview many forms but every plan has common elements. with expected staff numbers and qualifica- A business plan: tions, job descriptions, standards for hiring and training staff and management, and per- • Identifies the organization, what is special about sonnel policies and how these will be commu- its services, and its current funding sources. nicated. • Describes the organization, including the year • Lists facility and equipment requirements needed started or proposed start date, type of busi- to conduct the business of the organization ness, philosophy, structure of the organization and plans for securing the equipment – lease, and location. purchase or donations.

• Provides a market analysis that summarizes the • Has a written financial plan that delineates community (market) and how this supports pricing of services and sources of projected the start-up or expansion of the program. revenue. The financial plan should demon- Specific data includes population and trends, strate where potential resources are expected other services in the area, funding sources, to come from (revenue) and how they will be barriers identified and ways to overcome spent (expenses). them, community support, major competitors, etc. This information should be correlat- ed with the program’s expected target popula- As noted earlier, it is important to understand and tion and geographic boundaries. use unit costs in preparing budget forecasts and financial statements, setting fees for program servic- • Includes an operations plan that explains how es and requesting adequate reimbursement from services will be provided and how specific payers. It is critical to note that if the reimburse- goals will be met. A goal is a very general ment from any funding source is less than the actu- statement such as, “We will provide the best dementia care possible.” An objective defines al cost to provide the service, that difference must the specific results to be achieved, for be made up through other means. Identify what instance, “We will offer home and communi- funds will cover any shortfalls, such as discounts or ty-based respite services to our community.” public reimbursement that falls short of actual To accomplish objectives, specific actions are costs. In adult day services, it is a rare center that described such as, “Utilizing space at the local achieves full census within a year unless a strong senior center, we will provide trained staff to third-party reimbursement stream, such as targeted facilitate respite care once a week.” Medicaid waiver dollars, exists. A time span of 24 to • Describes core services and optional (ancillary) 36 months to attain financial stability is more real- services. Since it is common for adult day pro- istic for ADS. The plan should clearly state what grams to offer basic, core services initially, financing the organization is seeking. plans for additional, anticipated services, such as baths/showers, hair care, rehabilitation therapies, medical escort, tracheotomy care, Developing, Refining and Improving injections, etc., should be included. Quality • Has a marketing plan that identifies your targeted participants and how you will advertise To accomplish their missions, providers are depend- your services (flyers to potential referral ent upon the public’s confidence and support.

NADSA-AAHSA Whitepaper 9 Support comes from consumers who use the servic- Customer Satisfaction es, funders and community organizations with Customer satisfaction is a core quality measure. which providers collaborate. Successful providers, Defining and measuring it can be complex, and like all other businesses, earn this confidence and includes determining who your customers are, what support by providing quality programs and services. their expectations are, and how best to measure Learning how to measure, demonstrate and this. Options might include surveys (post-enroll- improve quality is essential. ment, annual or exit surveys) and focus groups. Defining customers can be a challenge. Possible There are many different ways to define and meas- groups include: ure quality. These range from simple customer satisfaction surveys to full program accreditation. All • Employees: Employee satisfaction not only these include knowing who your customers are, as increases quality, but several studies have well as what they and others perceive as quality. For shown that it increases recruitment and reten- example, quality is often equated with person-cen- tion. tered/directed services. It is important to use this • Current clients/participants and family and/or information to show how your organization paid caregivers: If you can survey only one changes over time and compares to others in the group, participants and family caregivers are community. Some resources and tools to measure the most important group. They should be and create a continuous quality improvement pro- surveyed both during their participation, and gram follow. after leaving your program. It is particularly important to include family members in sur- Accreditation veys if participants have substantial cognitive Accreditation is one way to define, promote and impairments. This group is also important advertise quality in your program. CARF because of the emphasis on person-centered (Commission on Accreditation of Rehabilitation planning and services. Facilities) has a specific accreditation program for adult day services programs. Though voluntary, this • Informal referral sources: These include other accreditation process is considered a best-practice family members, neighbors, clergy, and formal standard in the field, and some states recognize the referral sources such as doctors, discharge accreditation, especially if the state has no licensure planners, bank trust officers, care managers, requirements. For more details about the CARF stan- home health workers, etc. Surveying these dards and guidelines for adult day services go to groups helps to assess how you are perceived www.carf.org. This is not a free service, so providers in the community. need to weigh the cost benefit of becoming accred- ited. A simple survey form is often the best method to gather information. It is generally best to allow Quality First responders to do this anonymously to encourage The AAHSA Quality First initiative is part of a honest feedback. Rating your services from “excel- national effort to evaluate the quality of aging serv- lent” to “needs improvement” is an easy format to ices; identify factors influencing the ability to use. While many of the surveys will have similar improve quality of care nationally; and make rec- questions, it is important to tailor them to each ommendations about national efforts that could “customer” group. lead to sustainable quality improvement. The program helps service providers assess and demonstrate The following simple survey may be a helpful their commitment to quality. It includes 10 ele- example in thinking about what information you ments of quality and steps and tools to use to wish to gather from current clients or family care- achieve ongoing quality assurance. Information on givers. It can be used with cognitively intact partici- this program is at: http://www.aahsa.org/quality- pants or family caregivers. first/guides/default.asp.

NADSA-AAHSA Whitepaper 10 Referral Sources Caregiving.) Design the survey form to gauge the satisfaction of referral sources slightly differently. Keep the form Evaluation and Quality Assurance simple and easy to use. Using the same format as Evaluation is important in developing and support- the client and caregiver survey may keep the ing quality assurance. It involves gathering both process more manageable. A sample of one such quantitative and qualitative data. The process must survey follows as adapted from the work of Greg be clear about what is to be measured and why. Newton for the Partners In Caregiving: Dementia Quantitative data provides numeric values to gauge Care and Respite Services Program. achievement of goals, helps identify trends or (See http://www.rwjf.org/reports/npreports/part- problem areas, and suggests baselines for compari- nerse.htm for information about Partners In son of performance. Satisfaction surveys are the

Sample Survey for Current Clients or Family Caregivers How Are We Doing? We want to provide the best possible services for you and your clients. We would appreciate any comments or suggestions if you will take a few minutes to share your opinions about our performance. We value your input as we strive to provide excellent service to meet your needs. Please check the box that best describes your rating of the following service aspects:

Needs Don’t Excellent Good Improvement know Do we respond to your referrals in a timely manner? Do you find our staff courteous and professional? Are the hours and days of operation convenient for your clients? Do your clients find our facility pleasing and attractive? Do the services we offer meet the needs of your clients? etc. How are we doing in helping your clients meet their goals through using our services?

Value for the price

How are we doing in helping you meet your goals through using our services?

What do you feel is the most important thing we need to improve to be the best we can be?

What other suggestions do you have to help improve our services and/or our facility?

Thank you! If you would like to speak with our director, please list your phone number and the best time to call.

Optional: Name

NADSA-AAHSA Whitepaper 11 most common tools for gathering qualitative data. ing a quality assurance program is to try to track But, gathered data is meaningless unless it is used to too many things at once. Too much information validate, eliminate or otherwise effect changes to can be paralyzing. programs or services. Data collection and evaluation may seem complex, Quantitative data is often gathered from established but need not be if the process is kept simple and agency record keeping or other tracking mecha- focused. The most frequent mistake when develop- nisms. For example, records of service utilization

Sample Survey for Referral Sources

How Are We Doing? We want to provide the best possible services for you. We would appreciate any comments or suggestions if you will take a few minutes to share your opinions about our performance. We value your input as we strive to provide excellent service to meet your needs. Please check the box that best describes your rating of each of the following services:

Needs Don’t Excellent Good Improvement know

Staff assistance

Activities and program

Facility: Clean, attractive, pleasant, safe

Meals, food service

Services: Health, bathing, transportation, etc.

Hours and days of operation

Value for the price

How are we doing in helping you meet your goals through using our services?

What do you feel is the most important thing we need to improve to be the best we can be?

What other suggestions do you have to help improve our services and/or our facility? Thank you! If you would like to speak with our director, please list your phone number and the best time to call.

Optional: Name

NADSA-AAHSA Whitepaper 12 (days and times used). at least from board members, clients and their fami- Examples of questions eliciting quantitative data ly members, referral sources and funders. At a mini- are: mum, the program’s mission, goals and objectives should be reviewed. For example, review an adult • How many clients were served in a defined day services center’s plan of operation with the time period? Taking it a step further, examine CARF national standards and guidelines (updated the client mix of the people served with biannually) in mind. Does the center meet all of regard to race, funding sources, etc. these guidelines? Remember to compare your out- • How many infections or falls have occurred comes to other providers from year to year. This is with the clients in a defined time frame? referred to as benchmarking and allows you to assess your program and quality assurance measures • How many complaints have been registered in the context of other community organizations. within a certain time period? What was the Participant numbers and quality indicators may be nature of the complaints? How quick were available from state associations of adult day servic- the responses? es, state associations of homes and services for the • How many hours of service or number of vis- aging, home and hospice care associations or state- its were provided in a specific period of time? defined standards as part of the licensure or certification process for providers. Some questions to Start with one or two questions that need to be facilitate your evaluation process include: answered to further develop, enhance or improve your services. For example: Are our hours conven- • How do our current services relate to the orga- ient for your family? What services do you need nization’s mission? that we don’t provide? Decide the easiest way to • Are we in compliance with all legal, regulato- get the information/measurement you want and ry and financial reporting requirements? implement the process. It may be useful to collect information periodically, annually or even monthly. • Whom are we serving? That will provide information on how the organiza- • Are we meeting the needs of our target popu- tion is changing or meeting goals over time. lation? • What are the benchmarks of quality attained Comparing numbers of inquiries for a service to the by industry peers? actual number of enrollments for the service identifies a conversion rate. If an agency received 20 • Is our organization comparing favorably using inquiries but only enrolled five people in the serv- those benchmarks of quality? ice, the conversion rate would be 25 percent. (5 ÷ • Is the program compatible with the needs of 20 = .25) This number may offer clues about how the referral sources’ clients? well barriers are being overcome to mobilize people to use the service. On the other hand, if the per- • What will help the center be where we want centage rate is low for falls, that is a good thing. If a to be in three years? Five years? particular challenge has been identified, special • Do improvements need to be made to the tracking processes may be developed to monitor physical facility? Inspect your facility. patterns, trends or progress towards goals. An exam- • Does the adult day services programming we ple is closely tracking statistics of the client mix offer engage the participants? after a targeted marketing campaign to attract a certain population. • Are the program participants showing signs of well being? Program Evaluation and Benchmarking An evaluation of the entire program should be con- • Are records, inspections and paperwork current? ducted at least annually to review successes and to identify areas that need improvement. It should • Are the center’s outcomes what we expected involve soliciting feedback about program operation and planned for?

NADSA-AAHSA Whitepaper 13 The outcomes of the program evaluation need to be Some providers respond to these frequent changes by results-focused, impartial, unbiased measures. becoming fearful or immobilized. The hope is that Perhaps one area of needed improvement is the area the information shared here will stimulate thought of falls prevention. The plan developed should note about how to be proactive in creating a desired future. a desired goal, methods of tracking, industry benchmarks (if available) for comparison and over what The demographics of our aging society speak to the length of time data will be gathered. Review of the continued need to expand these vital services with- data will look for trends in precipitators of falls, in our communities. They must be expanded, how- including environmental factors, physical health ever, with great sensitivity to the vast economic indicators of participants, or certain staffing pat- implications that additional services bring. Care terns present. Once patterns or other critical indica- costs. Creativity is needed to ensure that care needs tors are noted, a plan of corrective action should be are met humanely, yet cost-effectively. The goal of developed and implemented. Staff can be valuable creating viable home and community-based service in this process, often providing solutions to include programs is achievable with commitment, careful in action plans. planningsuch as adult day services, and ongoing evaluation. Financial evaluation is also essential. This is perhaps most easily accomplished with an external auditing agency. Financial audits may be mandated by some Marilyn Hartle, MSW, LCSW, has 25 years of experience in work- funding sources. If not, a periodic external audit is ing with older adult issues. LaDonna Jensen, RN, is a registered nurse of 40 years. Hartle and Jensen are partners in Jentle Harts healthy for any organization. Consulting, Indianapolis, Ind. Dedicated to enhancing the lives of frail and memory-impaired adults, the firm provides educational Last but certainly not least of the evaluation com- programs for personal and professional caregivers, environmental ponents is community evaluation. Consider con- assessments for personal homes and facilities, and staff develop- ducting a periodic focus group as described in the ment through team building and leadership skills. “Assessing the Market/Community” section of this document. Also, send a survey by mail to new or potential referral sources to gather community information that is useful in goal setting and provides a marketing tool. Stay abreast of the competition within the community. Know what services they provide, and always be prepared to state posi- tively what your organization does differently.

Conclusion

This document has discussed many of the aspects of service development for consideration when start- ing a new home and community-based service including adult day services or expanding an existing program. It is not meant to be an exhaustive resource but rather a prompt for further research into areas of concern for service start-up. The resources available for home and community-based services are increasing daily as the environment of nadsa social services and health care changes dramatically. National Adult Day Services Association

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