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Key Findings: Data from the National Study of Long-Term Care Providers. In 2012, more than one-third of participants in adult day services centers were younger than 65. A higher percentage of participants in nonprofit centers than in for-profit centers were younger than 65. About one-half of participants in adult day services centers were non-Hispanic white persons. A higher percentage of participants in for-profit centers than in nonprofit centers were Hispanic or were non-Hispanic and of a race other than black or white. Almost one-third of adult day services center participants had Alzheimer's disease or other dementias, and about one-quarter had a developmental disability. A lower percentage of participants in for-profit than in nonprofit centers had Alzheimer's disease or other dementias or a developmental disability. The 4,800 adult day services centers nationwide provide a variety of services to their 273,200 participants, the majority of whom are older adults and women (1). The number of for-profit adult day services centers has grown in recent years (2). The 1,900 for-profit centers, representing 40% of centers nationally, served nearly one-half (47%) of center participants in 2012 (3). Using data from the National Study of Long-Term Care Providers, this report presents selected characteristics of adult day services center participants in 2012 and compares the characteristics of participants in for-profit centers with those in nonprofit centers., (All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.)

This rule adopts as final, without change, an interim final rule amending the Department of Veterans Affairs (VA) regulations governing prioritization of State applications for VA grants for the construction or acquisition of State home facilities that furnish domiciliary, nursing home, or adult day health care to veterans. As amended, the regulation gives preference to State applications that would use grant funds solely or primarily (under certain circumstances) to remedy cited life or safety deficiencies. This rulemaking also makes certain necessary technical amendments to regulations governing State home grants.

This final rule amends Department of Veterans Affairs (VA) medical regulations to incorporate statutory amendments. Certain statutes authorizing VA health care benefits were amended by the Caregivers and Veterans Omnibus Health Services Act of 2010. The statutory amendments affect enrollment in certain health care priority categories and exempt catastrophically disabled veterans from copayment requirements.

Many caregivers of older family members do not realize the need for respite until their own health begins to deteriorate. The mental, emotional, and physical stress of caring for a family member can seem overwhelming. Creative options for respite care are emerging, but there are barriers to effective use of these programs. This article discusses these barriers and proposes suggestions for overcoming them., (Copyright 2009, SLACK Incorporated.)

Background: Few studies on cost of caring for patients with Alzheimer disease (AD) have simultaneously considered multiple dimensions of disease costs and detailed clinical characteristics., Objective: To estimate empirically the incremental effects of patients' clinical characteristics on disease costs., Methods: Data are derived from the baseline visit of 180 patients in the Predictors Study, a large, multicenter cohort of patients with probable AD followed from early stages of the disease. All patients initially lived at home, in retirement homes, or in assisted living facilities. Costs of direct medical care included hospitalizations, outpatient treatment and procedures, assistive devices, and medications. Costs of direct nonmedical care included home health aides, respite care, and adult day care. Indirect costs were measured by caregiving time. Patients' clinical characteristics included cognitive status, functional capacity, psychotic symptoms, behavioral problems, depressive symptoms, extrapyramidal signs, comorbidities, and duration of illness., Results: A 1-point increase in the Blessed Dementia Rating Scale score was associated with a $1,411 increase in direct medical costs and a $2,718 increase in unpaid caregiving costs. Direct medical costs also were $3,777 higher among subjects with depressive symptoms than among those who were not depressed., Conclusions: Medical care costs and unpaid caregiving costs relate differently to patients' clinical characteristics. Poorer functional status is associated with higher medical care costs and unpaid caregiving costs. Interventions may be particularly useful if targeted in the areas of basic and instrumental activities of daily living.

Purpose: The objective of this study is to develop an instrument to evaluate satisfaction with care for older adults in capitated environments. Although satisfaction with care is now widely accepted as an important outcome measure, there are relatively few satisfaction measures developed or validated on older persons. Because many older persons are unable to respond to surveys, separate instruments were developed for individuals and for their families., Design and Methods: There were 402 face-to-face interviews conducted at 11 PACE sites with PACE participants or their family members and a non-PACE group. Scales were constructed by use of factor analysis and were evaluated for internal-consistency reliability, validity, and ability to discriminate., Results: For the participant survey, three factors were identified, but only two exhibited adequate internal consistency (Perceived Access and Perceived Interpersonal Quality). For the family survey, all four identified factors had adequate internal consistency (Perceived Access, Family Pressure, Ease of Access, and Family Involvement). The participant survey discriminated between the PACE sites and the non-PACE sites, but the family-member survey did not., Implications: The PACE Satisfaction Survey appears to have adequate reliability and validity for measuring the satisfaction of older persons and their family members with capitated care. The domains of satisfaction differ between individuals and family members., (Copyright 2004 The Gerontological Society of America)

Objective: The purpose of this study was to estimate the outcomes and costs of day hospital and nonmedical community-based day treatment for chemical dependency., Method: A community sample of 271 adults (179 men) dependent on alcohol and/or drugs was recruited and randomized to either a hospital-based (medical) day treatment program or to a community-based (nonmedical) day treatment program. The day hospital (DH) program lasted for 3 weeks. One community-based program (CP2) lasted for 4 weeks, and the other (CP1) lasted for 6 weeks but with shorter treatment days and more criminal justice clients. Because of our concerns regarding treatment fidelity, we replaced CP1 with CP2 as the randomization site for the nonmedical, community-based arm of the trial halfway through the study., Results: Abstinence rates were similar between DH and CP2 subjects, with 53% and 60% of each group, respectively, reporting no drinking for the 30 days preceding both follow-up interviews. DH subjects were less likely than those in either of the nonmedical programs to report medical problems at both follow-ups. Average episode costs per client were significantly (p < .01) lower at CP1 (dollars 526) than at DH (dollars 1,274) or CP2 (dollars 1,163). A pattern of weaker effects was observed at the less costly problematic community program (CP1), including less abstinence than was reported at CP2 (only 40% of CP1 subjects were alcohol free at both follow-ups) and worse psychiatric, family/friend and employment outcomes than were reported at DH or CP2., Conclusions: Our results not only demonstrate the clinical diversity that exists between nonmedical, community-based day treatment programs but also show that nonmedical programs can compete with DH treatment in cost as well as in most outcomes.

The Program of All-Inclusive Care for the Elderly (PACE), is a three-way partnership among providers, state government, and the federal government. Most participants are able to live at home while receiving a wide array of services at day care centers. Because the focus is on preventive care, hospitalizations and ED visits have been cut dramatically.

Objectives: To assess outcomes and satisfaction among frail elderly day care clients and their informal caregivers and the impact of adult day care on the cost of health services., Methods: One-hundred eight elderly participants were randomly assigned to the experimental group (immediate admission to an adult day care center) and 104 participants to the control group (3 months on a waiting list)., Results: Participants' and caregivers' subjective perceptions of the day center's effects were positive. However, using standard research instruments, there was no evidence of an effect of day center attendance on the client's anxiety, depression, or functional status; on caregiver burden; or on the cost of health services., Discussion: It is difficult to demonstrate objectively the benefits of programs and interventions that are perceived by clients, caregivers, and staff to have positive effects. In future studies, maintenance of high levels of participation should be incorporated as an explicit program goal.

This document establishes regulations regarding grants to States for the construction or acquisition of State homes for furnishing domiciliary and nursing home care to veterans, or for the expansion, remodeling, or alteration of existing State homes for furnishing domiciliary, nursing home, or adult day health care to veterans. This is necessary to update the regulations and to implement statutory provisions, including provisions of the Veterans Millennium Health Care and Benefits Act.

Programs of All-inclusive Care for the Elderly (PACE) have been in existence for nearly three decades but have only recently become an established part of the Medicare program. In this brief we explore the PACE model: what it is, how it works, who is enrolled and the challenges it faces in the future.

The objective of this paper is to summarize and critically review the most recent literature on economic evaluation of alcohol treatment services, identify information gaps, and suggest a research agenda for the future. The focus of the review is research published after 1995, although some of the earlier economic studies are also included. Research findings in the literature provide evidence for the following. First, for many alcoholics, day hospital treatment or even less intensive outpatient services are cost-effective alternatives to inpatient treatment. Second, alcoholism treatment often results in declining health care costs for alcoholics who are covered by private health insurance. Third, though the use of alcoholics anonymous (AA) as an alternative to more structured alcohol treatment services may be cost-effective, substance abuse outcomes from AA are sometimes less favorable and the risk of relapse is higher. Fourth, methods have recently been developed to estimate the dollar value of alcohol treatment outcomes such as avoided absenteeism, increased productivity, improved health, and avoided crime. Based on these findings and developments, new treatment approaches and changes in service delivery systems require a fresh perspective on the costs and benefits of alternative treatment services. The findings from economic evaluation studies must be reported in clear and nontechnical terms to an audience of clinicians and politicians so that they can be used in the process of decision making.

A transition to a new Medicare outpatient prospective payment system (PPS) will begin in July 2000, affecting many of the outpatient services provided by hospitals that participate in the Medicare program. The outpatient PPS will rely on ambulatory payment classifications (APCs) to classify outpatient services. Hospitals should anticipate that discounts and other factors will affect APC payments and take into account the impact that the new system will have on their revenue.

Objectives: The analyses presented here are intended to provide empirical guidance to two questions faced by researchers performing clinical trials which include a cost component: Which health care services should we track? Should we use facility specific costs or national average costs for individual services in estimating total costs?, Methods: We reanalyzed cost data from the Department of Veterans Affairs (VA) multisite clinical trial which compared Adult Day Health Care (ADHC) to Customary Care for patients at high risk for nursing home care. The data presented here compares the original analysis (a combination of local and national costs) to an analysis based on purely facility-specific costs and to an analysis based upon purely VA national costs. Costs for hospital, clinic, nursing home, ADHC, hospital based home care, rehabilitation, pharmacy, and laboratory were included., Results: Hospital, nursing home, clinic, and ADHC in combination account for 98% of the variation in total cost per patient. Including only hospital, clinic, nursing home, ADHC, and hospital-based home care in total cost per patient closely replicated the findings for total cost when all services were included. The originally reported analysis and the 2 new analyses, using respectively facility specific costs and national average costs, did differ substantially in the magnitude of the difference between the total cost per patient of ADHC and Customary Care. They did differ with regard to statistical significance as the P values were either slightly above or below 0.05., Conclusions: Ideally all health care costs should be included in the analysis. When this is not feasible, one should determine utilization and cost for the intervention itself, costly services (usually hospital, nursing home, and clinic care), and lower cost services that are likely to be affected by the intervention. Sensitivity analysis should be performed to determine if different methods of costing (eg, facility specific versus national costs) materially affect the conclusions of the study.

This final rule amends the Child and Adult Care Food Program regulations governing reimbursement for meals served in family day care homes by incorporating changes resulting from the Department's review of comments received on a January 7, 1997, interim rule. These changes and clarifications involve: The appropriate use of school and census data for making tier I day care home determinations; documentation requirements for tier I classifications; tier II day care home options for reimbursement, including use of child care vouchers; calculating claiming percentages/blended rates using attendance and enrollment lists; and procedures for verifying household applications of children enrolled in day care homes. This final rule also amends the National School Lunch Program regulations to facilitate tier I day care home determinations by requiring school food authorities to provide elementary school attendance area information to sponsoring organizations. These revisions implement in final form the provisions of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 to target higher CACFP reimbursements to low-income children and providers.

Objective: This study proposes a model with five criteria for evaluating the effectiveness of intensive outpatient behavioral health care programs and applies this model to a brief partial hospital-crisis stabilization program. The five criteria are client selection, program attendance, service utilization and focus of treatment, client improvement, and cost-effectiveness., Methods: The program evaluation model was tested with a sample of 285 adults with severe mental illness who were admitted for or were receiving outpatient treatment at a state-funded community mental health center. Evaluation data included pre- and postprogram ratings by clinical staff of clients' symptoms, level of functioning, and treatment readiness; current and retrospective reports of clients' symptoms based on interviews with clients; and clients' service and financial records. Clients and clinicians also provided data about the problems addressed during treatment sessions., Results: Program dropouts used significant facility resources before dropping out. Clients who participated in the partial hospital-crisis stabilization program showed reduced symptoms, improved daily functioning, and improved treatment readiness. Clients who showed more improvement cost less to treat., Conclusions: The evaluation model produced the information necessary for demonstrating program effectiveness. The results support the belief that clinical effectiveness and cost-effectiveness are positively related.

This article presents findings from a recently completed Health Insurance Association of America-sponsored survey that sought to measure the extent to which long-term care insurers paid for newer, long-term care alternatives. The focus of the survey was on payment for three services: adult day care, board and care homes, and assisted living facilities. The survey also collected information on companies offering reimbursement for these services under an alternate care benefit (i.e., a plan of nonconventional care and services that can serve as an alternative to more costly inpatient nursing home care). Survey data showed that long-term care insurance sold in employer markets reimburses a richer set of alternative long-term care benefits than policies sold in individual markets. In addition, the majority of employer market companies reimburse for alternatives under their base policy, recognizing the importance of payment for noninstitutional, long-term care alternatives.

This rule sets forth the coverage criteria and payment methodology for partial hospitalization services in community mental health centers. The purpose of this rule is to establish regulations governing this coverage under the provisions of section 4162 of the Omnibus Budget Reconciliation Act of 1990.

In 1987 The Robert Wood Johnson Foundation announced the creation of the Dementia Care and Respite Services Program (DCRSP), the first national demonstration project to focus on day center and respite services for persons with dementia. The intent of $5.1 million, 4-year (1988-1992) program was to demonstrate that nonprofit day centers could provide financially viable programs and services needed by people with dementia and their caregivers. Seventeen grantees in 13 states, representing 21 different organizations and operating 24 day centers, participated in the project throughout the entire 4 years. The DCRSP has provided the first overview of dementia-specific day programs in the United States, with specific insight as to who is being served (e.g., participant and caregiver characteristics), types of assistance needed in relation to activities of daily living, and the most common behavior problems being exhibited. In addition, results of the 4-year project support the fact that community-based day centers can effectively care for people with dementia, a demand for these services does exist, and families consider these services of sufficient value that they are willing to pay for them out-of-pocket. Results also show that nonprofit day centers can become financially viable programs if attention is given to factors such as providing consumer-responsive services, charging what services actually cost, and having a high level of community visibility. The net result is increased net operating revenue with improved financial performance and enhanced long-term stability.

This report presents data collection measures and methods for the evaluation of Adult Day Health Care (ADHC) in the Department of Veterans Affairs (VA). Measures of patient health were survival, the Sickness Impact Profile, self-rated health, the Mini-Mental State Exam, Psychological Distress Scale, Social Support Scale, and Problem Behaviors Scale. Measures of health for the care giver were: Activities of Daily Living, Instrumental Activities of Daily Living, health perceptions, Psychological Distress Scale, life satisfaction, Social Support Scale, and Caregiver Burden Scale. We also assessed patient and care giver satisfaction with the care received by the patient. Measures of health status and outcomes were assessed primarily through patient and care giver interview at study enrollment, 6 months, and 12 months. Utilization and cost both within and outside VA were assessed for hospital, ambulatory care, nursing home, ADHC, home care, pharmacy, laboratory, and other forms of health care. Sources of utilization data included VA's computerized patient database, VA medical records, patient questionnaires, care giver questionnaires, and health care providers outside VA. Costs were obtained from VA's cost accounting system, VA Central Office, VA's contracts with outside providers, and directly from outside providers. Utilization and cost were assessed for each patient for a period of 1 year after entry into the study.

Although Adult Day Health Care (ADHC) is increasingly prominent in the continuum of long-term care services, the results from previous studies of the effects of ADHC are mixed. The objectives of the ADHC Evaluation Study were to determine the effect of ADHC on health status, utilization, and cost of care. The first phase was a randomized controlled trial evaluating ADHC provided directly by the VA. Patients at four medical centers (n = 826) were randomly assigned to receive either ADHC or customary care, and outcomes were compared for the two groups. The second phase was a prospective cohort study evaluating ADHC provided under contract to community agencies in which patients at four additional medical centers (n = 163) were assigned to contract ADHC programs. Outcomes were compared with those of similar patients in the randomized trial. Patients and care givers were assessed at intake and 6 and 12 months after intake. To be admitted to the study, patients must have met one of the following criteria: residence in a nursing home; dependence in ambulation, dressing, or toileting; bowel incontinence; or significant cognitive impairment. Patients at intake demonstrated major impairment in function and high levels of prior use of health care services.

This article summarizes the study results and presents an evaluative summary of the implementation of study methods designed to provide guidance in the degree of confidence with which the results may be accepted and generalized to other situations. Patients who were offered VA-ADHC services in the first phase of this study had significantly higher VA health care costs on average than patients assigned to customary care, with no apparent incremental health benefit to themselves or their care givers. One can have a high level of confidence in these results. The ADHC clinical services were implemented as planned, the randomized controlled trial was implemented successfully, and such threats to validity as insufficient numbers of patients and differential attrition were not present. Certain subgroups of patients assigned to VA-ADHC had VA costs of care that were not significantly higher than those assigned to customary care, although these results must be interpreted with caution. The findings of the second phase of the study evaluating contract ADHC provide no support for choosing to provide either contract ADHC or VA-ADHC over the other. The nonrandomized design and smaller sample size suggest that inferences from the contract ADHC evaluation should be drawn with more caution than those from the VA-ADHC evaluation.

This final rule establishes a CHAMPUS benefit for partial hospitalization and makes corrections and clarifications on other mental health issues resulting from implementation of recent legislative changes. The partial hospitalization benefit is being added at the request of Congress to improve the availability of mental health services under CHAMPUS. The intent is to provide a needed service at a lower cost than the full hospitalization rate, and allow more efficient use of resources for needed mental health care. Facilities must be certified and enter into a participation agreement with CHAMPUS and obtain the required preauthorization prior to admitting CHAMPUS patients. Applications for facility approval may be obtained from the Director, OCHAMPUS, or a designee.

The innovative model of capitated acute and chronic care for nursing-home-eligible elderly persons, which was developed at On Lok in San Francisco's Chinatown and stresses using community care in lieu of institutional care, has been replicated at eight sites around the country. The early experience in developing these sites tests the extent to which the principles of this approach, based on day health care, can be reproduced in a variety of other settings. Four of the eight sites have begun formal capitated care; enrollment has been less active than anticipated, apparently due to reluctance to change physicians and resistance to day care.

Every day more than 5,600 people in the United States celebrate their 65th birthday. Parent care, like child care, is increasingly becoming a business issue.