The CHAIRMAN. Thank you.

Don, the non-profit American Association of Homes for the Aging-and I stress every word of that, non-profit homes for the aging-is it true that there are over 3,200 homes for the aging in that association?

Mr. PETERSON. That is right. They represent nursing homes, housing programs, continuing care retirement communities, and some community service providers.

The CHAIRMAN. And you are a director of that association?

Mr. PETERSON. I am a former board member. I am presently on the House of Delegates for that organization.

The CHAIRMAN. How much experience have you had personally at St. John's?

Mr. PETERSON. I have been there over 15 years, Senator.

The CHAIRMAN. Over 15 years.

Mr. PETERSON. That is right.

The CHAIRMAN. And was adult day care a part of St. John's when you started 15 years ago?

Mr. PETERSON. No, it was not. We have had our adult day care program for about four years.

The CHAIRMAN. How many of the membership-or do you know of the American Association of Homes for the Aging, the non-profits, how many of those 3,200 have adult day care centers?

Mr. PETERSON. There are over 300 of them that now have adult day care programs, and that has roughly doubled in the last four

years.

The CHAIRMAN. Then, I conclude it is your experience that in nursing homes, this is a part of most of them or should be a part of most of them or all of them?

Mr. PETERSON. Well, it is roughly 10 percent right now.

The CHAIRMAN. Yes, I understand that, but the trend seems to be upward. Should it be part of most or all?

Mr. PETERSON. It certainly is a trend. I think that is an individual decision that will be made by each of these facilities depending on a number of factors.

We happened to have some space in our facility and a demand in our community that makes a program possible. There were no other adult day care programs, and we felt that there was a need. By expanding our program, that is adding an adult day care program to our comprehensive service package at St. John's, we are able to meet this need.

Obviously, that is not going to work at every facility, because they won't have the space or programs that they can expand.

The CHAIRMAN. Ms. Larmer, you said this is grassroots and that the cost of providing it is sort of scattered between local and donations and States-do any of the States provide any help?

Ms. LARMER. Some States do. Some States provide start-up money for programs. Some States provide funding through Title XX, the matched grant moneys. Some States provide separate special allocations every year for scholarships for certain programs, but not the majority of States, no.

The CHAIRMAN. Last year when we were considering what could become a help in catastrophic coverage, in visiting with HHS, I found that a number of people in nursing homes throughout the

country, 1.5 or 1.3 million or whatever figure one chooses to take, was about tripled or more by the number of people who were identified as older Americans who had to have home health care.

I am beginning to believe that perhaps adult day care centers are the place to start on home health care. Am I beginning to look at this in the right perspective? What is your judgment on this?

I notice you have not only a degree in nursing but also a master's in family and community development.

Is it your opinion that this is the place to start with adult day care centers for helping older Americans who need health care at home?

Ms. LARMER. I believe that we need to look at the whole longterm care system. It is almost a package, and we need to identify what services someone needs to be as independent as possible.

As Mr. Glakas referred to, he comes to the day care center three times a week, he utilizes home care several other times a week, and I feel that it can be a combination of services that someone needs. Some people will need to come to adult day care five days a week and require additional services on the weekends.

Some people, really, if it is just for respite care for the care giver, may require just two days a week at the day care center and require no home care.

What is happening at our day care centers in Fairfax County is we are designing our centers to include a functioning clinic with bathing facilities for handicapped people. So, we are providing a lot of the personal care that used to be provided in home care.

However, what we found was that when someone had to stay home just for that bath and just to receive that service, then they missed the entire day of adult day care. So, we are starting to add services in our county.

The CHAIRMAN. What is your relationship with the adult day care center that Mr. Glakas participates in?

Ms. LARMER. I started in that center back in 1979 as the director of that program, and I have seen it expand. When they first opened that center-Fairfax County financially supports that program-it was a program to see if, in fact, it was a needed service, and we opened in January of 1980. Since May of 1980, we have had a long waiting list.

So, the county has opened its second program and is in the planning phase of two more programs.

Now, we are very lucky to live in Fairfax County, because they do financially support the program. We have Title XX funds, and we receive Title III Older American Act funds for the meal component of the program, but the remaining amount is financed through Fairfax County.

The CHAIRMAN. When Mr. Glakas, on the sliding scale that you have in Fairfax County, pays $8 each day he goes, how much of that is subsidized by Fairfax County?

Ms. LARMER. The charge for the participants who pay full fee is $24 dollars. It is going to be increased to $26 this summer.

However, if you include all in-kind services, for example, Fairfax County has renovated elementary schools that were closed, but we pay no rent for that-if you include everything that is in-kind from the county, the cost would be, if we established ourselves as a non

profit organization that wanted to break even, it would be $37 a day.

The CHAIRMAN. And Senator Burdick asked Mr. and Mrs. Glakas what the professionals are in that particular center.

Ms. LARMER. Yes. We have 1.5 registered nurses, and we have a recreation therapist. We have physical therapy, occupational therapy, and speech therapy available as a consultant for those that need it.

For example, if we had someone come to our center who required physical therapy, it would just be a matter of our picking up the phone and getting them to come in and do an evaluation and provide the care. They are not on-site, but they are an ancillary service, as is podiatry and a variety of other health services, dental services, and so forth.

The CHAIRMAN. All right, the full cost is $37 a day, and there are professionals to assist in each phase from nursing to physical therapy and speech therapy, et cetera. Given that, you have to prioritize this. After all, you are speaking for the National Council on the Aging.

Should this be a major concern, the major concern, given what Congress always has to do is to prioritize what goes on with Medicare and what is available under Medicare. Should this be the number one priority, adult day care centers?

Ms. LARMER. For long-term care? In the whole system of longterm care? If I had to choose?

The CHAIRMAN. Well, consider our position in having to prioritize what Medicare can cover. Is this the number one priority now?

Ms. LARMER. Well, I would like to back up a second, Senator, and talk about CBO's estimates, because I really firmly believe that they do not look at cost off-setting information and that if they did, then I believe that we could look at the whole spectrum of services that are required and, with cost off-setting, be able to see that with adult day care when appropriate, with home care when appropriate, with respite care when appropriate, we would with those packages still provide services at less cost than institutional care.

Now, I know there are lots of people who don't agree with me, but I have difficulty in saying adult day care is the number one priority for NCOA. From a day care director's perspective, I can say that easily, but I think when you look at the broader picture, we need to look at what is best for the older person and their family, and the only way to do that is to provide options for them and to allow them some choices based on their personal needs.

Now, adult day care meets a lot of those needs, and that may be one place to start to develop an in-home care system as well, but some people need in-home care as well. Some people need just respite care. The family just needs four hours a night to get out and be able to do something, but they need to get out of their own

home.

There is a variety. I would hope, given the country that we live in, that we can look at this kind of long-term care system and find ways so that our people in our nation have the ability to choose rather than favoring just-I think we have long favored institutional care. I hope we don't do that now with home care or something else. I hope we offer the options that are needed.

The CHAIRMAN. Well, then, perhaps you would like the two or link the three, home care, respite care, and day care. You would link them all together as being the step needed?

Ms. LARMER. As separate services. I think what has happened in some of the bills

The CHAIRMAN. Yes, I understand, but become part of Medicare. Ms. LARMER. Yes, and required services.

The CHAIRMAN. And required services?

Ms. LARMER. And they are required services in order to enable someone to stay in their home and community.

The CHAIRMAN. Yes, home health care.

Now, you mentioned three insurance carriers have recognized this as part of what they would provide to their policy holders? Ms. LARMER. That is correct. They are Prudential through the AARP insurance long-term care plan, Aetna, and Travelers. The CHAIRMAN. Three of the large ones, then.

Ms. LARMER. Yes. They are currently providing adult day care. The CHAIRMAN. Thank you.

Senator Bradley.

Senator BRADLEY. Thank you very much, Mr. Chairman.

I would just like to ask Mr. Peterson what he thinks is the standard that providers of adult day care should follow. We are very interested in quality in addition to providing the service.

Do you have any thoughts for the committee on standards that providers of adult day care should adhere to?

Mr. PETERSON. We used NIAD standards to develop our program, and we believe they have come a long way in the development of good standards, and certainly think they could represent a basis for national standards that ensure quality services. Senator BRADLEY. Ms. Larmer.

Ms. LARMER. The NIAD standards were developed back in 1984 as a result of the fact that there were no standards at all for adult day care. We are in the process now of revising those standards to address the more specialized programs that we see developing in our country, for example, programs that serve only Alzheimers, programs that serve head injured, programs that serve mentally disabled individuals.

We also will accompany these revised standards with a self-assessment tool, but we feel that this is just one step towards quality programs. We would eventually like to see certification be implemented so that programs were certified to be quality programs. Senator BRADLEY. Certified by?

Ms. LARMER. Well, we would like to see Medicare cover adult day care and then certification would come accompanying the Medi

care.

Senator BRADLEY. Thank you.

The CHAIRMAN. Thank you, Senator.

On the standards, when would NIAD have completed this revision of standards?

Ms. LARMER. Well, right now, we are looking for funding to help us with these standards revisions. We have the proposal that we have submitted to-actually, we submitted to the State agencies on aging to help us fund it, and at this point, we don't know exactly

when, but this is our number one priority for this year, and we hope to have it done within a year or so if funds can be obtained. The CHAIRMAN. Thank you. Thank you both for giving us some excellent testimony and good background.

Mr. PETERSON. Thank you.

The CHAIRMAN. The next witness is Ellen Shillinglaw, Director of the Office of Legislation and Policy for the Health Care Financing Administration.

STATEMENT OF ELLEN SHILLINGLAW, DIRECTOR, OFFICE OF LEGISLATION AND POLICY, HEALTH CARE FINANCING ADMINISTRATION

Ms. SHILLINGLAW. My name is Ellen Shillinglaw, and I am the Director of the Office of Legislation and Policy for the Health Care Financing Administration.

I am pleased to be here this morning to discuss with you the issue of day care for non-institutionalized adults. There are thousands of young as well as elderly adults with serious health impairments being cared for at home who benefit from the extra assistance provided by an adult day care center.

Adult day care centers are designed to afford relief for family care givers, allowing the family members to continue working and attending to the needs of children and other family members.

The Department of Health and Human Services has a key role in funding adult day health care. My statement will focus on a profile of our experience with community based care, including adult day health, and the cost effectiveness of this care.

I will go into some detail later in my testimony about cost effectiveness, but would like to indicate that adult day health care should be viewed, by and large, as additional services to additional clients and not as a substitute for nursing home care.

I would like to begin by offering some background on the clientele and services of adult day care centers.

Adult day care centers vary a great deal in the services they provide to their clientele, but there are similarities in the programs and populations served. The most comprehensive analysis of adult day care is from a 1985 National Council on Aging survey of adult day care centers that found 50,000 Americans are served in some 1,200 adult day care centers.

Most clients of these centers are elderly and physically disabled, and many clients are developmentally disabled, mentally retarded, or mentally ill. The average participant in adult day care is a 73year-old, white female with a monthly income of $478. She lives with a spouse, relatives, or friends, and she attends the center for 6 hours 2 to 3 days a week.

The typical center is open Monday through Friday for 8 or more hours a day and has 37 participants. It provides a variety of services such as nursing, nutritional services, counseling, and transportation.

The largest single funding source of adult day care is the Medicaid program, but centers do rely on a variety of funding mechanisms. Medicaid permits coverage of these services primarily through home and community based waiver programs. However,