This article is one in an occasional series on aging with dignity and public policy that affects the ability of elders to live independently. For a complete archive of the articles, click here.
By Herbert A. Sample
In 2002, Nina Nolcox found her calling. After years as a registered nurse in skilled nursing facilities and hospitals, often on the nightshift, Nolcox started working in an adult day health care center in South Los Angeles. Four years later, she bought the business, Graceful Senescence, with the aid of a small business loan.
Nolcox now employs 26 people and provides health services to about 115 mainly African American and Latino seniors who suffer from diabetes, Alzheimer’s, high blood pressure and other chronic ailments.
Adult Day Health Care is “probably the most logical health care model that I’ve been a part of,” Nolcox said. “I fell in love with it.”
But Nolcox’s clients might soon have to go elsewhere for their care, or get none at all, because the state appears certain to eliminate the three-decades old Adult Day Health Care program in the next few months. More than 35,000 Californians will see their services end, though some as yet undetermined number will be transition to other forms of care.
Paradoxically, the U.S. government is beginning to prod states to establish or expand programs that aim to do what ADHC does in California -– steer seniors and disabled adults away from expensive nursing homes and hospitals, and into community- and home-based care.
“It is a huge disconnect,” said Lydia Missaelides, executive director of the California Association for Adult Day Services, which represents ADHC centers. “At the very moment that the incentive and the public awareness and the rules and the pilot projects and the innovation is coming out from the federal level to the states…here we are in California just taking this huge step backwards and losing an important part of this continuum of care that we need.”
Few really want to kill ADHC, which costs $340 million a year – about $169 million of it in state general funds and the rest from the U.S. treasury. Though the measure passed by state legislators that authorized ADHC’s demise alleged that the program remains vulnerable to fraud, that is rarely invoked as a reason for shutting it down.
Instead, in what has become a refrain for many cuts throughout state government, officials faced with California’s budget crunch admit they have few choices other than to eliminate what is, after all, an optional benefit under federal Medicaid laws.
“We recognize its value and it has served people very well,” Norman Williams, spokesman for the state Department of Health Care Services, said of ADHC. “We have to make some tough choices on what to continue and what to reduce and what to eliminate.”
For poor seniors with chronic illnesses and younger disabled adults, ADHC centers are a ticket out of their residences and into a more socially rich environment where they can receive a number of health-related services – such as physical, occupational and speech therapy, dietary information, and blood pressure and blood sugar monitoring — that is more costly if done in the home by a team of personnel. Centers’ group activities also provide social interaction and physical exercise that leads to healthier emotional lives, Missaelides said.
“People can be just as easily institutionalized in their own homes if they become terribly isolated as they can be by living in an institution,” she added.
The birth of ADHC in the late 1970s was in part a reaction to stories exposing the warehousing of the elderly in nursing homes and other facilities. Other states emulated it; about a dozen authorize similar programs now, according to federal officials.
More than 300 centers operate in California, the bulk of them in Los Angeles County. About 80 percent of the beneficiaries are seniors, and others include younger patients who suffer from traumatic brain injuries, cognitive diseases such as Alzheimer’s, and developmental disabilities.
Nolcox said she observed little coordination between doctors and other care providers in most of her past nursing jobs. But the ADHC program’s requirement for a multi-disciplinary approach to each beneficiary impressed her.
“Now I can deal with all areas that are potentially causing the problems with this person and close the gap,” Nolcox said. “We do it in a team fashion….It was the first place that I had been that I was able to feel like I was having an impact in actually decreasing health care costs and improving quality of life.”
As beneficial and cost-effective as ADHC may be, federal rules consider it voluntary for states while more expensive nursing home care are mandatory. That’s why twice before in recent budget struggles, California officials have tried to eliminate the program. Though reluctantly, they appear to have succeeded this time.
The Legislature authorized ADHC’s end earlier this year, and the federal Centers for Medicare and Medicaid Services has until mid-August to act on the Brown Administration’s proposal, according to a CMS official who did not want to be identified. CMS is examining the state’s plans to transition at least some ADHC beneficiaries into other services, but the agency is expected to go along with ending the program – if for no other reason than the state is not required to maintain it.
At the same time, the federal government has begun to push a goal – voiced in, for example, a little-noticed part of last year’s health care reform law – that states steer seniors into home- and community-based services, and classify more costly nursing homes and other institutions as a “fall-back option.”
The health care reform law funded two such programs: The Money Follows the Person Demonstration, which was originally authorized in 2005, and the newer Community First Choice Medicaid Option. Thirteen states, though not California, were awarded $45 million in February to implement their MFP programs.
Regulations for CFCO are due later this year, and it will not be implemented before October. Some estimates suggest California could receive about $125 million annually from it. But federal officials said CFCO money is aimed at home supportive services – such as cooking, cleaning, bathing and transportation to doctors’ offices – and not the more directly health-related services ADHC provides.
The seeming incongruity of the federal goals and California’s elimination of ADHC is not lost on federal officials.
“States struggle with that,” the CMS official said. “They can’t eliminate the nursing homes benefits. They can’t eliminate the hospital benefits….And if they need to make a cut in their budget, they need to look at where they can cut, and they have the ability to cut an optional service.”
Advocates for ADHC worry that the guts of a program will be difficult to replicate once California’s economy and budget stabilizes.
“It ain’t coming back,” Casey Young, a lobbyist for AARP California. “These are businesses that are going to close, and the infrastructure will be gone.”
Nolcox’ because the state appears certain to eliminate the three decade-old Adult Day Health Care program in the next few months.
Graceful Senescence could be one of them, Nolcox said. Her entire business, personal finances and employees are now in danger.
“I might be forced to lay off 26 people and claim personal bankruptcy,” she said. “Remember, I have an SBA loan.”
Similarly, the non-profit Yolo Adult Day Health Center in Woodland may have to close if there is no seamless transition from ADHC to another program, said Dawn Myers Purkey, the center’s program manager and immediate past president of CAADS.
“We could bear at most several months worth of support as we slowly work toward completely closing our doors. There’s no pretending for us that we’re going to survive,” said Purkey, whose center provides services to 80 beneficiaries and employs 17 workers.
Missaelides said CAADS is working with center owners to diversify by attracting patients who can pay themselves or through private insurance. “It’s really hard right now to say what will happen,” she said.
It’s also difficult to predict the future of beneficiaries who aren’t transferred to other programs. Advocates complain the state has offered few concrete answers, and they suggest a significant number of former ADHC patients will end up in emergency rooms, hospitals and nursing homes – at a higher government cost and exactly counter to the approach the U.S. is emphasizing.
State legislators have signaled support for a new program called Keeping Adults Free From Institutions, into which the former ADHC beneficiaries with the worst conditions would transition. It would cost about $170 million, with the state and federal governments sharing the burden. But KAFI has not yet won final approval, and Department of Health Care Services officials say they won’t start working on it until it does.
There’s a bigger, longer-term worry, said Gary Passmore, director of the Congress of California Seniors: The number of California’s senior citizens will rise from 4½ million to 10 million in about 20 years.
“It is ironic and tragic that in the face of this projected demand, the State of California is actually cutting back,” he said. “We have…put our heads in the sand, and (are) in denial that millions of people are going to need services and care.”
State officials say they understand the demographics, even as they grapple in the here and now with extremely tight bottom lines. The demise of ADHC is going to force some efficiencies into the mix of services the state offers, while the health care reform law will provide funds and guidance to eventually do more, Williams said.
“We are looking at all of these with an eye to the future to provide to all segments of the Medi-Cal population,” he added, “including and most urgently, in terms of time, the seniors.”
Herbert A. Sample is a freelance writer in Los Angeles. He can be reached at firstname.lastname@example.org.