JAG33210.1177/0733464812460431 460431Journal of Applied GerontologyBrown et al. Article Journal of Applied Gerontology 2014, Vol. 33(2) 189 –206 Use of Adult Day Care © The Author(s) 2012 Reprints and permissions: Service Centers in sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464812460431 an Ethnically Diverse jag.sagepub.com Sample of Older Adults Ellen L. Brown1, Marie-Luise Friedemann,1 and Ana C. Mauro1 Abstract Our nation is aging and unprepared to meet the needs of community-dwelling seniors and their caregivers. This study explored the perceived need for and use of adult day care services (ADS) in a low-income population. A random sample of 537 patient–caregiver dyads were recruited in home care agencies, and separate in- home surveys were conducted. Patients and caregivers were primarily women and 50.2% were of Hispanic origin. Although half (n = 267/537, 49.7%) of the caregivers had a perceived need for using ADS, only 19.1% of these caregivers used these services, mostly in the context of severe patient cognitive impairment. There were no racial or ethnic differences among ADS users and nonusers. The overall low use of ADS in a growing ethnically diverse senior population with a perceived need for services warrants further investigation and action as states seek to decrease nurs- ing home placement and find solutions for our looming caregiving crisis. Keywords adult day care, home- and community-based services, caregiver Manuscript received: February 03, 2012; final revision received: June 11, 2012; accepted: August 10, 2012. 1Florida International University, Miami, FL, USA Corresponding Author: Ellen L. Brown, College of Nursing and Health Sciences, Florida International University, 11200 SW 8th Street, ACH-3, Office 226, Miami, FL 33199, USA. Email: [email protected] Downloaded from jag.sagepub.com at OHIO STATE UNIVERSITY LIBRARY on March 6, 2015 190 Journal of Applied Gerontology 33(2) Whereas approximately 1.4 million older adults live in nursing homes in the United States (National Center for Health Statistics, 2012), it is estimated that by 2050, 19 million Americans (almost doubling from the present day) will receive long-term care services, many within the home and in community-based settings, and many older adults will be eligible for Medicaid assistance to pay for this care (USDHHS, 2011). Supporting the choice to live in the community and in one’s own home is clearly the preference of many older adults and their families and is a focus of the 2010 Affordable Care Act. There is evidence that meeting the needs of a growing low-income disabled older adult population through provision of Medicaid home and community-based services can be cost-saving for states by keeping seniors from entering a nursing home (Felix, Mays, Stewarts, Cottoms, & Olson, 2011). In these times of fiscal constraints, improving the efficiency of home- and community-based care delivery for a growing, culturally diverse, dis- abled Medicaid-eligible older adult population is vital for state Medicaid pro- grams and Waiver Programs (Henry J.Kaiser Family Foundation, 2007). One home- and community-based service option is Adult Day Health Care Service(s) (ADS); in general, ADS are designed to provide therapeutic social programs and some health services to adults and respite for caregivers. An intended goal of ADS is to extend the participants’ stay at their homes as well as maintain and restore cognitive and physical functioning (U.S. Department of Health & Human Services [USDHHS; Office of Disability, Aging and Long-Term Care Policy (DALTCP)], 2006). Overall, there has been growth in home- and community-based services spurred by states, including ADS, in their Medicaid state plan. In recent years, adult day care programs have increased from 2,000 in the year 1989 to more than 4,600 in 2009 servicing more than 260,000 participants and their families (Metropolitan Life Insurance Company [MetLife] & Mature Market Institute [MMI], 2010), but this growth has not kept pace with the increas- ing number of older adults with a potential need. Furthermore, public funding for ADS is limited and providers are concerned about their future financial viability (Anderson, Dabelko-Schoeny, & Tarrant, 2012). ADS can be divided into three models of care, each focusing on different aspects of the caring spectrum (MetLife & MMI, 2010). The social model focuses on providing preventive services as well as social activities created to enhance the care recipients’ experience. Facilities operating under the medical model offer assessment, treatment, and rehabilitation services. Combined models offer both social and medical services as outlined above. Nevertheless, the distinction between these different approaches to ADS is often ambiguous, as there has been an increasing emphasis on offering care that is congruent with both the social and medical models (MetLife & MMI, 2010). Downloaded from jag.sagepub.com at OHIO STATE UNIVERSITY LIBRARY on March 6, 2015 Brown et al. 191 According to a 2001-2002 national survey of 3,493 ADS centers, conducted by Wake Forest University School of Medicine, the average age of participant is 72 years, who suffer from dementia or other disabling conditions (Partners in Caregiving, 2002). Most ADS program participants live in the home of their adult child (35%) or with a spouse (20%) (Partners in Caregiving, 2002). The survey at the centers indicated that more than half of the participants used respite services due to cognitive impairments, and almost 25% of the participants were diagnosed with mental retardation or other developmental disabilities. According to the sur- vey, specific services are provided as follows in the available programs: therapeu- tic activities (97%), personal assistance (96%), meals (84%), social services (82%), health-related services (74%), medication management (70%), transpor- tation (68%), personal care services (64%), caregiver support groups (64%), and rehabilitation therapy (28%). The USDHHS (DALTCP) study (2006) finds ADS centers often assist participants with Activities of Daily Living (ADL) tasks and medication management as well as health education and monitoring. There are two significant differences between ADS and other home- and community-based services. ADS are provided “outside of the home” and in a “group setting” (Biegel, Bass, Schulz, & Morzycz, 1993; Conrad, Hughes, & Wang, 1992). These factors may affect the use of ADS by caregivers, and consideration should be given to examining “in-home” and “out-of -home services” separately (Gill, Hinrichsen, & DiGiuseppe, 1998). There is a dearth of research examining the impact of ADS services on the care recipient. ADS have been associated with an improved quality of life for participants (Schmitt, Sands, Weiss, Dowling, & Covinsky, 2010) as well as a decrease in caregiver burden and stress for caregivers (Gitlin, Reever, Dennis, Mathieu, & Hauck, 2006; Zarit et al., 2011), but other studies failed to find a positive impact (Baumgarten, Lebel, Laprise, Leclerc, & Quinn, 2002; Gottlieb & Johnson, 2000; Zank & Schacke, 2002). There is no established best approach to identifying when a care recipient or caregiver (i.e., respite) will benefit from the use of ADS and how ADS should be used in combination with other home- and community-based services and infor- mal caregiving. Participation in ADS has been found to be associated with less use of other home care services (Skarupski et al., 2008) without threatening the participants’ staying at their home. In another study, the use of ADS in a frail older adult population significantly increased, when case managers knowledge- able about home and community services were integrated into the primary care setting (Parsons et al., 2012). The present study builds on previous research by examining the use of ADS in a racially and ethnically diverse older adult population that includes Cuban Americans, the largest older adult Hispanic group in the United States (U.S. Downloaded from jag.sagepub.com at OHIO STATE UNIVERSITY LIBRARY on March 6, 2015 192 Journal of Applied Gerontology 33(2) Census Bureau, 2007). In the United States, Hispanic caregivers may face differ- ent barriers to accessing and using community- and home-based services (Whittier, Scharlach, & Dal Santo, 2005) compared to non-Hispanics. Nevertheless, Scharlach, Giunta, Chun-Chung Chow, and Lehning (2008) found in a telephone survey of California caregivers that neither race nor ethnicity affected caregiver service utilization, and another research team found that Hispanic caregivers used more ADS and respite services than White non-Hispanics and African American caregivers (Kosloski, Schaefer, Allwardt, Montgomery, & Karner, 2002). To shed more light on the issue of ADS use, this study examined (a) the per- ceived need and use of ADS in a primarily minority, low-income, older adult caregiving population, and (b) patient and caregiver factors associated with per- ceived need and use of ADS. These data are needed and timely as the Medicare Adult Day Services Act of 2009 is currently under revision (Anderson et al., 2012). The Medicare Adult Day Services Act of 2009 (H.R. 3043) proposes to amend title XVIII of the Social Security Act to provide for coverage of ADS under the Medicare Program. Policy makers and advocates concerned about dis- parities in the use of ADS will benefit from having current information about use of ADS in an understudied growing diverse U.S. population. In this study, we selected variables from the “Behavioral Model of Health Services Use” to organize and inform the study (Andersen & Newman, 1973). The model originally was used to understand predictors of family health service use and has been used to understand variations in caregiver support services (Gill et al., 1998; Robinson, Buckwalter, & Reed, 2005; Scharlach et al., 2008). The model purports that population predisposing factors (i.e., age, gender, race, edu- cation, occupation, social structure, health beliefs), enabling factors (i.e., income, insurance status, availability, and accessibility of services), and need factors (i.e., level of illness and emotional distress) are central to predicting health service use.