Day hospitals and daycare programmes

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Over the past few decades, adult day centres have become one of the mainstays of community-based care for demented individuals in most of the world's developed nations. These centres first developed out of the need to provide respite for caregivers, and have evolved to include full-time 5 day a week programmes (in some cases offering evening and weekend hours as well) that offer a wide range of options for individuals with varying degrees of cognitive impairment.

In the United Kingdom, adult day centres are an integral component of geriatric services, being built into the package of old age services in each health-care district. There is debate in the United Kingdom as to whether a day-hospital format, with greater availability of health-care services, is superior to a more socially oriented approach/5) Sweden has also been a leader in the development of adult day centres. Studies there have shown that it costs less to care for individuals enrolled in these centres than to care for individuals in a waiting-list control group (US $55 versus US $63 respectively). (21> In addition, better outcomes were obtained on some behavioural and activity of daily living measures, such as cheerfulness and the ability to dress oneself. (21>

As of 1998, the United States had over 4000 adult day centres. However, unlike the developed nations of western Europe where they are part of a government-funded national programme of care for the elderly, adult day centres in the United States have been set up as local initiatives, often by community-minded individuals. The largest United States initiative in providing adult day services was Partners in Caregiving. This comprised two consecutive national demonstration programs between 1987 and 1998 funded by the Robert Wood Johnson Foundation: the first included 19 sites (22> and the second 50.(23) The intent was to demonstrate that adult day centres could care for individuals across the entire spectrum of dementia, and that they could be financially viable. (This is a much more complex issue in the United States, where there is considerable state-by-state variability in service coverage and means-testing than in countries with a single payor system for all health-care services.) Results showed that adult day centres were able to take care of individuals with all degrees of dementia, from mild to severe, and that with careful attention to business aspects (such as making sure the fee covered the actual costs) these centres could, on average, meet over 80 per cent of their expenses through fee-for-service revenue (i.e. out-of-pocket payments and Medicaid), thus having to rely less on subsidization.

Studies from industrialized nations show that a typical adult day centre provides services for 20 to 30 individuals each day; average attendance is about 2 days a week, although those with full-time working caregivers may attend for 5 days. The average Folstein Mini-Mental State score (range 0-30) is usually in the mid to low teens. In the United States, an emerging trend in adult day centres is the concept of programming tracks, where participants are grouped by their degree of dementia and engage in activities suitable for their degree of impairment.

Adult day centres have become an important component in the continuum of care for demented elderly, and along with in-home care and day hospitals offer valuable alternatives to the two classical alternatives of the full-time family caregiver or the nursing home. Other options are also likely to be developed, one example being the group-living sites in Sweden where between six and eight cognitively impaired older adults live together. (24)

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