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(A complete list of NCOA publications is available on request.)

MEMBERSHIP

The National Institute on Adult Daycare can maximize service to local agencies and organizations through its association with other NCOA constituent groups that include the National Institute of Senior Centers; National Institute on Community-based Long-term Care; National Voluntary Organizations for Independent Living for the Aging; National Institute of Senior Housing; National Center on Rural Aging plus NCOA's research and public policy components.

You may affiliate with the institute by joining NCOA. Membership benefits include association with the leading professional organization in the field of aging, participation in meetings and conferences at reduced rates, Perspective on Aging, NCOA's bimonthly magazine, and Current Literature on Aging, a quarterly annotated bibliography.

THE NATIONAL COUNCIL ON THE AGING, INC.

600 Maryland Avenue, S.W., West Wing 100, Washington, D.C. 20024 ● (202) 479-1200

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Senator BRADLEY. Then, have you thought of any cost benefit analysis in terms of improved quality of life for the senior or increased productivity for the care giver if the care giver is allowed, because of adult day care, to go back to the job market?

Ms. SHILLINGLAW. We don't have anything other than the studies that we have cited. Again, intuitively, it is there, but it is very difficult to demonstrate and measure quality of life, for example.

Senator BRADLEY. Productivity increase is a little easier to determine.

Ms. SHILLINGLAW. A little easier, yes.

Senator BRADLEY. If somebody is back in the work force as opposed to being forced to stay at home.

What about any of the analyses of the number of people who are now in nursing homes who might actually be able to leave nursing homes if there were adult day care centers?

Ms. SHILLINGLAW. We would not have that kind of analysis, although, clearly, in States that have chosen to do adult day care under the home and community based waiver, to the extent that there are people in institutions in that State who have family who could bring them out and take advantage of those services, one would suppose that they do.

Senator BRADLEY. Thank you very much.

The CHAIRMAN. Thank you very much, Ms. Shillinglaw.

I will now recognize Senator Bradley for introducing the next witness.

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

Our next witness is Ms. Carol Kurland from New Jersey. She is the head of the Office of Home Care Programs at the Department of Human Services. She has a wealth of experience in this area.

I think that New Jersey has really been on the forefront of adult day care services, and I think Mr. Chairman, she might actually address some of the questions that you posed to Ms. Shillinglaw and a number of others based upon the New Jersey experience.

We have worked together on a number of occasions, and I think that Ms. Kurland is really an outstanding public servant. Ms. KURLAND. Thank you.

The CHAIRMAN. Thank you, Senator.

Welcome to the committee, Ms. Kurland. We are delighted to have your testimony.

Ms. KURLAND. Thank you, Senator Melcher, and thank you, Senator Bradley. I am very happy to be here.

STATEMENT OF CAROL H. KURLAND, ADMINISTRATOR, OFFICE OF HOME CARE PROGRAMS, NEW JERSEY DEPARTMENT OF HUMAN SERVICES

Ms. KURLAND. My name is Carol Kurland. I am the Administrator of the Office of Home Care Programs in the New Jersey Department of Human Services, Division of Medical Assistance and Health Services. That is a mouthful; that means New Jersey Medicaid.

My office is responsible for five 2,176 home and community based service waivers reimbursed by Medicaid which include adult day care and also for our statewide medical day care program. I have

been involved in adult day care for over 10 years and served on the National Council on Aging's National Institute on Adult Daycare, NIAD, and its committee which developed the adult day care standards in 1984.

Our department truly appreciates the opportunity to provide testimony in support of adult day health services and to share our experiences in implementing a Medicaid Title XIX funded program in New Jersey. I want to commend you, Senator Melcher, and the committee for scheduling these most important hearings.

New Jersey has been a proponent of adult day health care or medical day care, as it is known in our State, for many years. Medical day care was introduced as a statewide Medicaid service in May of 1977 as an important service in the long-term care continuum. We became the fifth State in the nation to use Medicaid dollars for adult day care.

Adult day care was developed after a study in our State which indicated that 35 percent of our intermediate care facility B patients were inappropriately placed and could be discharged if community based services were provided.

New Jersey's medical day care program was modeled after an informational memorandum issued by the then-United States Department of Health, Education, and Welfare in January of 1976. These Federal guidelines remain the only ones issued in this service area. New Jersey decided to target our Medicaid eligible population to be served in medical day care as the chronically ill elderly or other disabled individuals over the age of 16 who were at the point of discharge from hospital or other acute care facility, or were residing in the community and in crisis, or were residents of nursing homes but inappropriately placed.

Initially, only long-term care facilities, nursing homes, were permitted by New Jersey Medicaid to become providers of medical day care services because of our uncertainty about how large this program would become. However, we realized that sufficient system controls existed to allow for a gradual expansion of these services. In 1980, free-standing, independent clinic type programs were approved, and in 1982, hospital affiliated centers were accepted as medical day care providers.

A center must be approved under a certificate of need process and licensed by our State Department of Health prior to becoming a Medicaid provider.

Each person entering a medical day care center is certified by an attending physician as needing this care and an individualized plan of care prepared by the medical day care staff is performed initially and every 90 days to 6 months. The plan of care which has multi-disciplinary input is submitted to a Medicaid district office, and we have an office in 16 of our 21 counties in the State. It is submitted for review and authorization by a Medicaid medical evaluation team prior to the provision of services by the center.

This same team prior-authorizes home health and nursing home services. So, they are fully aware of the total care needs of an individual.

A Medicaid medical review team comprised of a physician, nurse, social worker, and pharmacist also visits each center several times during the year to monitor and evaluate the programs.

Against this background of a health care service developed to meet an identified need for community based care, medical day care in New Jersey has slowly grown over the past 11 years to a very visible needed option. Currently, there are 48 nonprofit and proprietary centers in the State, 23 nursing home based, 18 freestanding, and 7 affiliated with hospitals serving an average of 800 participants a month at a cost of $3.6 million of Federal and State monies in State fiscal year 1987.

By the way, our newest medical day care center is in Paterson, North Jersey serving persons with AIDS and ARC; I believe it is the first in the nation.

Since medical day care began as a nursing home based program, reimbursement has been related to the cost of nursing home care. Currently, Medicaid pays 55 percent of the intermediate care facility B, that is the ICFB rate—we have three levels of care in New Jersey-which averages $31 per day.

In New Jersey, Medicaid's annual net cost of an ICFB nursing home patient is $14,664.

Since medical day care services are provided on an average of three days a week, a participant who resides in the community with comparable needs to an ICFB patient costs Medicaid in New Jersey approximately $4,800 per year, a considerable savings to our program.

Data was recently compiled on 1,083 Medicaid clients in 38 centers. This is on a computer base in my office and will be a continuing informational source for our program.

Centers ranged in size from 6 to 109 participants with a median census of 33 and a mean daily attendance of 24.5 per center. Sixty percent of the individuals served were 65 or older, 18.6 were 55 to 64, and 21 percent were under 55. Ages actually ranged from 20 to 101.

Most participants were female, 75 percent. Racial characteristics were 44 percent black, 43 percent white, and 11 percent Hispanic, and over 88 percent were not married. Of these, 41 percent were widowed and 30 percent never married.

Most individuals live alone or with adult children or parents or in a boarding home situation. Over 33 percent had no primary caregiver, but for 20 percent, the adult child was the primary caregiver.

The most common significant diagnoses were cardiovascular disease and musculoskeletal disorders, but there were also significant numbers of clients with diabetes, eye disorders, mental illness, and retardation, miscellaneous neurosensory, nutritional, and metabolic disorders, and Alzheimers disease, diagnoses not dissimilar to those found in nursing home patients.

We see them as the same individuals, not as an additional group, as indicated by Ms. Shillinglaw.

Individuals attended the program because of their chronic physical health problems, recent deterioration of medical status, increased dependency, social isolation, and their care givers' need for relief.

The overwhelming majority, 93 percent, lived in the community and were considered at risk. Participants required health monitoring, therapeutic recreation and nutrition, social services, supervi

sion or administration of medication. Few required physical, speech, or occupational therapy.

It is my understanding that you are also interested in hearing about some specific cases served in medical day care. Three actual cases illustrate the value of this service.

One is John, a 76-year-old widower who has lived alone since his wife's death four years ago. He was depressed, neglected himself, and used alcohol excessively. He was diagnosed as having epidermal cancer with involvement of lymph nodes under one arm.

After hospital treatment, he was admitted to a nursing home. He discharged himself from the nursing home, returned to his own home, and enrolled in medical day care for the necessary shortterm health care monitoring.

He gained weight, emerged as a leader at the center, and developed a positive attitude. Although he is no longer enrolled at the center, he visits regularly and has become quite outgoing and social in his community.

The second situation is Mary, an 80-year-old diagnosed as hypertensive, demented, and hypothyroid, was admitted to a medical day care center. She was unresponsive with a flat affect, needed intensive prompting to walk and socialize.

The center provided medical and nutritional monitoring. The family was educated about her medical needs as well as her need for changes in the home environment.

Her blood pressure medication soon was no longer needed. She now eats independently, and incontinence is managed by frequent toileting.

She has become social, is known for a good sense of humor, and enjoys singing. The family states that medical day care was their last hope before nursing home placement and are delighted with the changes that have enabled her to remain home.

Finally, Catherine, an 83-year-old with a diagnosis of probable progressive dementia, Alzheimer type, had a history of visiting the local emergency room-a very expensive service to Medicaid, by the way-three or four times a week with numerous complaints. She also called her daughter constantly at her job.

The center provided counseling to the family in crisis. Staff taught the family expected behaviors and furnished resources for additional help.

As a result of her attendance at the center, the client's complaints diminished, and the emergency room visits became a thing of the past.

Families of participants are particularly laudatory about medical day care. They state that their loved ones are less depressed, have fewer outbursts of temper, are more cooperative at home, and, in general, there is improved family functioning. One son even stated that his mother's participation made it possible for him to cope with the stress of his own family's problems dealing with a bulemic

son.

Our service providers also inform us that because of the serious shortage of home health aides in New Jersey, at times, the only health care option is medical day care. Although covered under both Medicare and Medicaid, home health services may be inaccessible and unavailable. If a person needs nursing and personal care

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