National Adult Day Services Association Research Agenda

Research Positioning Statement

This report was prepared by the Research Committee (formerly the Research Task Force) of the National Adult Day Services Association (NADSA), the nonprofit trade association of adult day services providers operating in the U.S. NADSA advances the national development, recognition and use of Adult Day Services. The NADSA Research Committee is an ad hoc committee of researchers, providers, and other stakeholders who are committed to facilitating the development, utilization and dissemination of research to improve the delivery of adult day services and the quality of life of adult day participants and their caregivers. In June 2011, NADSA’s Research Committee convened with the intent to discuss recent research-related efforts focused on adult day services and make recommendations about future research endeavors that might support furthering the mission and goals of NADSA, expanding the successes of its member organizations, enhancing the quality of care of adult day participants, and improving the quality of life of participants and their caregivers. The purpose of this report is to outline the recommended approach of NADSA with respect to how research in the field of adult day services (ADS) should be positioned and developed in the coming years.

A research agenda is defined as “a set of properly selected themes or topics that have been prioritized for research purposes” (Msuya, 2002, p. 251). For a scientific field, such an agenda provides a framework for organizing the constellation of research studies conducted by independently operating research funders and researchers. The NADSA Research committee sees research as a crucial element in increasing awareness of adult day services among key stakeholders in elder and dementia care. Research produces the demonstrated impacts that raise awareness. In recent years, there has been a surge in adult day service research-related activities, including:

  • Board membership of researchers interested in the topic of adult day services (2008)
  • Strategic planning meeting in Wisconsin, which included the topic of research (2008)
  • Incorporation on the NADSA website (2008)
  • Hosting of a research breakfast at the annual meeting of the Gerontological Society of America (2008)
  • MetLife National Study of Adult Day Services (2010)
  • UWM Next Steps Think Tank (2010)
  • NADSA’s Managing Director knowledge/commitment to research (2011)
  • National Study of Long Term Care Providers (2012)
  • National Study of Long Term Care Providers (2014)

To meet the demands of their consumers, adult day services are providing increasingly more comprehensive skilled health care, chronic disease management, and care for persons with Alzheimer’s disease and other dementias (MetLife, 2010). Indeed, nearly 80% of adult day centers have a nursing professional on staff, and roughly 60% offer case management services (MetLife, 2010). Awareness of adult day services can be raised by positioning adult day services as an alternative health care provider in relation to the better-known options in the elder care spectrum, e.g., assisted living facilities, nursing homes, and home health, and by extension, health care providers, such as hospitals, physicians, health plans, and hospice.

NADSA leverages the momentum in research and the provision of health care services and has aligned its research agenda with the leading framework in health care quality assessment, the Institute of Medicine’s Six Domains of Health Care Quality. As defined by the Institute of Medicine (IOM), health care quality is “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (1990, p. 21).

Six Domains of Health Care Quality

The IOM refers to itself as the health “arm” of the National Academy of Sciences. The IOM is an independent, nonprofit organization that seeks to provide unbiased and authoritative advice on health issues, health research, health policy, and health care services to decision makers in government and private sector.

In its landmark report, Crossing the Quality Chasm (2001), the IOM called for all health care providers to commit to a shared vision of improving health care across six domains. In the IOM model, quality health care is safe, effective, patient-centered, timely, efficient, and equitable (Table 1).

Table 1: IOM Six Domains of Health Care Quality

Safe Safe health care means avoiding injuries to patients from the care that is intended to help them.
Effective Effective health care entails providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.
Patient-centered Patient-centered health care means providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
Timely Timely health care refers to reducing waits and sometimes harmful delays for both those who receive and those who give care.
Efficient Efficient health care means avoiding waste, including waste of equipment, supplies, ideas, and energy.
Equitable Equitable health care refers to providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

 

Operationalizing the Six Domains of Health Care Quality

The Agency for Healthcare Quality (AHRQ) offers direction with regard to operationalizing the six domains of health care quality for a variety of health care providers, including hospitals, health plans, physicians, nursing homes, home health agencies, and hospice (AHRQ, n.d.). The Research Task Force notes the absence of adult day services, doubtless due to the general lack of awareness of adult day services as an emerging health care provider. It is the intent of this initiative to have adult day services recognized as a credible setting for the provision of health care.

For each of the recognized health care providers, AHRQ describes examples of quality measures that are indicators of each of the six domains of quality. For example, measures of the domain of patient safety that are indicators of hospital quality include:

  • “Percentage of surgery patients with surgical complications or postoperative infection.
  • Rates at which patients fall and incur injury during a hospital stay.
  • Use of electronic systems for entering medication orders.
  • Patient mortality rates by type of condition (e.g., heart attack, hip fracture, pneumonia) or by type of procedure (e.g., coronary artery bypass graft surgeries, valve surgeries, hip replacement)” (AHRQ, n.d.).

As an additional example, measures of the quality domain of effectiveness in nursing homes include:

  • “Percentage of residents who lost too much weight.
  • Percentage of residents whose need for help with daily activities has increased.
  • Percentage of recently hospitalized patients with symptoms of delirium” (AHRQ, n.d.).

Frequencies of Measures of Quality in Nursing Homes, Home Health Agencies, and Hospice.

The website of AHRQ describes examples of “measures of agency characteristics and activities” as these measures relate to the domains of quality for nursing homes, home health agencies, and hospice. While the number of measures of quality in the six domains is inconsistent across the settings of nursing homes, home health agencies, and hospice (see Table 2) on AHRQ’s website, presumably there are other measures of quality for the different settings, the results of which are made available to consumers in one way or another. Furthermore, in addition to the six domains, there is a category of “Descriptive Measures,” with the following explanation: “While not associated with any particular IOM domain, descriptive measures can convey the (aging services provider) capacity for providing quality of care and service.” These additional “descriptive measures” of nursing home quality, for example, include:

  • What programs (Medicare, Medicaid) the nursing home participates in
  • Total number of residents.
  • The ownership of the nursing home (e.g., for-profit, not-for-profit, government).
  • Whether the facility has resident councils, family councils, or both.
  • The number of hours per day that each patient receives care from all licensed nursing staff, including Registered Nurses (RNs), Licensed Vocational Nurses (LVNs) or Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs).

Table 2: Frequencies of Specified Measures of Quality Posted on the AHRQ Website

Measures

Nursing Home

Home Health

Hospice

Patient Safety

3

2

0

Effectiveness

3

1

3

Patient-centeredness

4

2

3

Timeliness

2

0

1

Efficiency

0

1

0

Equity

0

0

0

Descriptive

5

3

6

Linking ADS with the Six Domains of Health Care Quality

The Research Task Force recognizes the applicability of these domains to adult day services with minor adjustments, e.g., substituting “person-centered care” for “patient-centered care” for the reason described in the next two paragraphs:

While the trend among adult day services is to provide an increasing amount of health care services, there is a simultaneous movement among a growing number of long-term care providers toward “culture change.” Culture change refers to the shift away from a “medical model” culture in long-term care in which individuals are treated as “patients” and characterized in terms of diagnoses and deficiencies, and toward a more holistic, humanistic approach to elder and dementia care.

One of the most promising modes of culture change is person-centered care. Person-centered care is built on the philosophy of personhood in dementia. Personhood is a holistic concept that honors the individual and his or her relationships with others, and views the person as a unique individual with a rich life full of preferences, interests, and experiences that can still be enacted. Among long-term care providers, the distinction between “patient” and “person” is comparatively more elemental to adult day services given that the majority of participants reside in the community rather than in residential facilities.

It should be noted that aligning the research priorities of ADS with the IOM Domains of Health Care Quality does not reflect a bias toward the medical services offered through ADS. In this application, the term “health” refers to the physical, emotional, and social wellbeing of ADS participants and their family members. Reflective of recent legislation on parity between physical and mental health (Mental Health Parity and Addiction Equity Act, 2008), the Research Task Force views the social services and benefits (e.g., caregiver respite, emotional support, social engagement, job training) as equally important as the medical services offered through ADS. Given this stance, we remain confident that the expansive scope of the IOM Domains framework makes it an applicable and useful format for evaluating the broad range of services provided by ADS.

Thus, it is proposed that the six domains of quality for adult day services be: safe, effective, person-centered, timely, efficient, and equitable. The domains and their descriptions within the context of adult day services are summarized in Table 3.

Table 3: Proposed Six Domains of Quality for Adult Day Services

Safe Adult day services should be safe in that they protect participants from injury from the care that is intended to help them.
Effective Adult day services should be effective in that they provide services based on scientific knowledge and best practices to all who can benefit.
Person-centered Adult day services should be person-centered in that the main focus is on enhancing the quality of life of the individual and her/his engagement, which is facilitated through the incorporation of her/his life preferences, interests, and experiences into programming.
Timely Adult day services should be timely in that waits and delays of all types are avoided.
Efficient Adult day services should be efficient in that waste of all types (equipment, supplies, ideas, energy) is avoided
Equitable Adult day services should be equitable in that the provision of care does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

Operationalizing the Domains of Quality for Adult Day Services

The Research Task Force proposes that the six domains of quality for ADS be operationalized using measures and indicators that are specific to adult day services. A further level of organization is suggested that differentiates among the key constituencies of ADS: program participants, family caregivers, professional caregiving staff, and provider organizations. The following (Table 4) is a rough sketch of ADS-relevant outcomes and indicators that might be considered elements of quality of care:

Table 4: Examples of Potential Quality Outcomes and Indicators for Adult Day Services

Measures Participant Family Caregiver Staff Provider Organization
Safety
  • Reduced depression
  • Fewer falls
Effectiveness
  • Managed weight gain/loss
  • Managed diabetes care
  • Reduced UTIs
  • Managed chronic Illness
  • Reduced caregiver burden
  • Increased days of usage
  • Job satisfaction
  • Consistent assignments
  • Increased census
Person-centeredness
  • Increased engagement
  • Presence of person-centered care practices in the facility
  • Reduced anxiety over caregiver concern
  • Positive interactions with participants
  • Diversify payor mix
Timeliness
  • Postponed institutionalization
  • Consideration of nursing home placement
Efficiency
  • Number of ER visits post hospitalization
  • Number of hospital admits post hospitalization
  • Reduced missed days
  • Days of missed work
  • Reduced missed work days
  • Staff turnover
Equity
  • Participant diversity
  • Staff diversity
Descriptive
  • Expenses to revenue ratio
  • Accreditation or licensure
  • Membership in NADSA

Conclusion

This report was prepared by NADSA’s Research Task Force, which was convened with intent to review and discuss recent research-related efforts and trends in adult day services with an eye toward developing future research endeavors to support furthering the mission and goals of NADSA and its member ADS providers. The Task Force recommends that NADSA leverage the momentum in research and the increased provision of health care services and align its research agenda with the leading framework in health care quality assessment, the IOM’s Six Domains of Health Care Quality. As an emerging provider of health care services, these six domains are correspondingly relevant to ADS, with the substitution of the concept of “person-centered” for “patient-centered” in recognition of the movement in long-term care away from a medical model of care and toward a more holistic, humanistic approach to elder and dementia care. Therefore, it is proposed that the six domains of quality for adult day services be: safe, effective, person-centered, timely, efficient, and equitable. These six domains of quality should be operationalized for ADS using measures and indicators that are specific to adult day services, and which address the diversity of needs among stakeholders in ADS, including program participants, family caregivers, professional caregiving staff, and provider organizations.

Next Steps

The Research Task Force requests that the Board of Directors grant their approval of this research positioning statement. Following board approval, the Task Force will produce a “mini-marketing plan” (see Appendix for draft plan) for the research positioning statement that will identify different target markets who will be interested in learning about the research position for ADS and the respective communication strategies for each market. Further, it is anticipated that one of the first strategies will involve reaching out to key contacts at AHRQ to assess their interest in collaborating with Research Task Force members to further develop measures and indicators specific to ADS within each of the IOM six domains of quality.

NADSA Research Task Force Members

  • Keith Anderson, Ph.D., Assistant Professor and Hartford Faculty Scholar, School of Social Work, Ohio State University, Columbus, OH
  • Holly Dabelko-Schoeny, M.S.W, Ph.D., Assistant Professor and Hartford Geriatric Scholar, School of Social Work, Ohio State University, Columbus, OH
  • Joe Gaugler, Ph.D., Associate Professor and McKnight Presidential Fellow, School of Nursing, University of Minnesota, Minneapolis, MN
  • Lyn Geboy, Ph.D., Independent Research and Planning Consultant, Milwaukee, WI
  • Rick Greene, M.S.W., Veterans Administration, Washington, DC
  • Teresa Johnson, National Adult Day Services Association, Fairfax, VA
  • Beth Meyer-Arnold, R.N., M.S., Luther Manor Adult Day Services, Wauwatosa, WI
  • Ned Morgens, M.B.A., SarahCare Adult Day Services, Johns Creek, GA
  • Lisa Peters-Beumer, M.P.H, Adult and Senior Services, Easter Seals Headquarters, Chicago, IL

References

Agency for Healthcare Research and Quality (AHRQ) (n.d..). Measures of quality in nursing homes, home health agencies, and hospice.

http://www.qualitymeasures.ahrq.gov/

Institute of Medicine. (IOM) (2001). Crossing the Quality Chasm. Washington: National Academies Press.

Institute of Medicine. (IOM) (1990, May). Medicare: A strategy for quality assurance. Vol. 1. Washington: National Academies Press.

Mental Health Parity and Addiction Equity Act, 45 C.F.R. 146 (2008).

Msuya, J. (2002, December). Developing a library research agenda at the University of Dar es Salaam. Information Development, 18 (4), 251-256.

US Department of Health and Human Services. (2006). Adult day services: A key community service for older adults. http://aspe.hhs.gov/daltcp/reports/2006/keyADS.pdf