Adult Day Care

Adult day care provides social and physical stimulation to adults who do not require 24-hour institutional care, but who may have some physical or mental impairment that precludes fully independent living. There are currently 120 day care spaces available in Honolulu, 45 of which are financed by the DSSH through Title XX. Based upon the experience of the Task Force members and on phone calls made by HCSCH staff to these adult day care centers, these facilities are usually filled to capacity. There are especially long waiting lists for those persons who are DSSH-eligible and could avail themselves of this service. It is difficult to estimate the number of people on Oahu that might need adult day care but cannot receive it because it is either unavailable or unaffordable.

A significant proportion of Hawaii's elderly live within extended families. The Hawaii Gerontology Center's recent excellent profile of Hawaii's elderly population notes that approximately 83% of Hawaii's population is not living alone, i.e., resides with a spouse, family or non-related others. Families which are providing assistance to persons at risk of becoming functionally dependent gain significant support from adult day care services, especially since many of Hawaii's homemakers are joining the work force to meet the high cost of living, as indicated in the following chart:

More aging parents could live at home with their working children if they could attend a day care facility during work hours.

However,

Adult day care is not available on Oahu west of Kalihi-Palama. during the period in which the Long Term Care Task Force meetings were held, members became aware of the efforts of the Wahiawa Methodist Church and the Central Oahu Community Mental Health Center to establish day care services in Wahiawa. It was estimated that approximately twenty individuals who were at risk of placement in an SNF, or who were currently in an SNF or an ICF, could return home if adult day care were available in Wahiawa. The Wahiawa Methodist Church worked with the Central Oahu Community Mental Health Center to establish such a service. Efforts to obtain start-up funds from federal mental health sources are now in progress. Waipahu has also sought to locate a suitable facility which could be licensed for adult day care.

Financing for adult day care is very limited in Hawaii. DSSH provides financial assistance to qualified individuals under the Title XX program. However, many human service programs also compete for Title XX funds. In view of the federal ceiling for these funds, DSSH officials note that the State cannot expect to substantially increase funding for adult day care from this source.

Home Health Care

According to local providers of home health care, most home health services are readily available. However, this does not mean that there is not a need for an expansion of home health services. Although a majority of home health services are reimbursed by third party payers such as Medicare, Medicaid, Health Maintenance Organizations (HMOs), and private payers, several factors inhibit utilization of home health care. One factor is the lack of understanding and acceptance of home health services by some physicians. A second factor is the myriad of conditions for participation and reimbursement of the different insurers, federal and private. Third, the home health component of in-home care must be supported by a care system within the home such as the family or other crucial caretakers.

Nationally, a number of proposals are currently before Congress to expand home health care services. The Congressional Subcommittee on Health and Long Term Care of the House Select Committee on Aging in a report entitled, "New Perspectives in Health Care for Older Americans," denounced the institutional bias of the federal Medicare and Medicaid laws as a significant cause of the nation's inappropriate focus on institutionalization (U. S. Senate, 1976). There is a growing, yet unsuccessful, effort in Congress to develop a policy to prevent unnecessary institutional care by liberating the Medicare and Medicaid programs to increase and expand home health care services covered by these programs.

There is also the need for reimbursement of support services to provide other kinds of personal assistance for the home health care recipient, such as homemaker and chore services, transportation services, and meals on wheels.

The recent federal Government Accounting Office report entitled, "Home the Need for a National Policy to Better Provide the Elderly," concluded that elimination of:

Health

the limitation on the number of home health visits under Parts A and B of Medicare,

the prior hospitalization requirement under Part A, and

• the homebound requirements under Parts A and B

would allow more home health services to be offered and also reimbursed.

(GAO, 1977).

The expansion of support services in the home health setting will provide greater opportunity for people to receive appropriate care in the least restrictive environment.

Homemaker and Chore Services

Homemaker and chore services are frequently essential for maintaining people at home, especially if they are without a live-in family support system. A good portion of State Homemaker and Chore Services is covered under Title XX through DSSH.

According to DSSH, recipients eligible for homemaker services receive these light personal care services from DSSH staff. DSSH recipients in need of more extensive homemaking assistance than DSSH staff can provide, receive money from DSSH to locate, hire and pay a person to give the necessary assistance. This second program of services is called chore services.

According to a private homemaker and chore services providers, homemakers come into the home to assist with personal care of the client and with light housekeeping. Homemaker services include shopping and meal preparation, dishwashing, and routine cleaning and laundry. Chore or housekeeper service tasks include heavier chores and seasonal cleaning. Some homemaker services are provided by Catholic Social Service and some can be purchased from commercial home care service providers.

SERVICE GAPS FOR LONG TERM CARE IN HAWAII

The Long Term Care Task Force has identified the following support

services which are either not currently available in Hawaii or are inadequate in meeting long term care needs. We recommend that all segments of the community work together to see that demonstration models of these services be

developed in the near future.

Congregate housing, sheltered housing.

Respite services for families who are caring for chronically ill persons. These services are designed to provide a break or a vacation for families. A few nursing homes in Hawaii maintain beds which can be used for this purpose. Some mainland communities have developed a home sitting service so that families can enjoy a free evening, weekend or series of vacation days as a break from caring for disabled family members.

They are

Foster care services for the partially dependent elderly in Hawaii. This service places frail elderly persons in community homes with volunteer foster families, one elderly person per family. There are two demonstration programs in existence on the mainland. supported by grant funds as pilot projects. One program through Johns Hopkins University reimburses each foster family between $300-$400 a month to provide intermediate level care and support in activities of daily living to a frail elderly person who comes to live in the family's home. Queen's Medical Center has committed some program funds to develop a similar program in Honolulu.

Red Cross nursing courses to accommodate the training of family members to cope and provide assistance to disabled family members. Care home operators and senior project managers should be provided with an ongoing training and sensitizing program, perhaps through a college of continuing education.

Counseling for families caring for long term care family members. Although DSSH provides some counseling during the intake service process and through their adult services units, public and private efforts should be directed towards the establishment of more and varied kinds of family counseling and information and referral services for families who are caring for the frail elderly.

More home outreach assistance. The programs to train gerontology aides should be expanded and further developed by community colleges throughout the State. DSSH is watching with interest the development of federal legislation which would allocate funds to train AFDS (Aid to Families with Dependent Children) mothers to become qualified home health aides. The Long Term Care Task Force believes that the State should not reject this idea if the federal legislation does not succeed. If this training were developed as part of a package to expand the delivery of services in the home setting, federal funds might be available from the Administration on Aging, given the new emphasis on programs to assist the frail elderly.

Other local sources of funding (for example, the United Way or trusts and foundations) should be sought to assist a small cohort of AFDC mothers or other interested individuals to become home aides for those persons with chronic illnesses.

Consideration should also be given to the development of curriculum and recruitment of trainees that will expand the utility of outreach services to frail individuals within the various ethnic cultures of Hawaii. Day Hospital/Day Health Center. Day health facilities operating on the mainland (for example, On Lok in San Francisco, California) provide restorative services, medical monitoring and social casework in a day care setting. Participants are elderly people who are less independent than users of adult day care, but who are still functioning enough to return to their families at night. Services provided include physical and occupational therapy and social activities which are at the same level as those in regular adult day care settings.

Except for some day hospital programs for mental patients, these kinds of health facilities do not yet exist in Hawaii. The establishment of a day health project would be beneficial to the community. Since a day health center would be considered a medical facility rather than a social facility, Title XIX funds could be applied to new day hospital projects and to add a medical component to existing Title XX sponsored programs. Some states have been successful in using Title XIX money for day care and multi-service centers as well as day hospitals by applying for federal waivers to specific Title XIX regulations.