key: cord-0781832-j7y5ibjl
authors: Gaugler, Joseph E.; Marx, Katherine; Dabelko-Schoeny, Holly; Parker, Lauren; Anderson, Keith A.; Albers, Elizabeth; Gitlin, Laura N.
title: COVID-19 and the Need for Adult Day Services
date: 2021-05-07
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.04.025
sha: 00847902e6b7ebbbe7f088b5202a0934cfb051ef
doc_id: 781832
cord_uid: j7y5ibjl

COVID-19 has shone a harsh light on the inequities of healthcare in the U.S., particularly in how we care for older people. We summarize some of the effects of lockdown orders on clients, family caregivers, and staff of adult day service programs throughout the U.S., which may serve as a counterpoint to scientific evidence suggesting a lack of efficacy of these programs. Given the ramifications of state lockdown orders for users and staff of the long-term services and support system, we provide recommendations to better support community-based programs and those they serve. Specifically: 1) adult day programs should be classified as essential; 2) a focus on the value of adult day and similar programs is needed; and 3) an exploration of new ways to finance home and community-based services is warranted. Such advances in policy and science would help to integrate adult day services more effectively into the broader healthcare landscape.

Prior systematic reviews of the efficacy and cost-effectiveness of adult day services 79 generally conclude that, when subjected to randomized controlled evaluations, these programs do 80 not reduce older persons' nursing home admission or other healthcare costs nor do they alleviate 81 family caregiver distress. Most randomized controlled evaluations of adult day service programs 82 were conducted from the late 1970s through the 1980s, and the lack of effect of these programs 83 in early research demonstrations led to various recommendations including improved "targeting" 84 of such services to those at the greatest risk of nursing home admission or other high needs. 15-20 85 Research conducted on adult day services since the 1990s has raised concerns that the use 86 of randomized controlled designs when evaluating adult day services may not capture how and 87 why these programs may exert benefits for users. For example, challenges in creating tightly 88 controlled treatment and comparison conditions, differential attrition across treatment and 89 control groups, inadequate operationalization of the treatment under study, and lack of insight as 90 to mechanisms of benefit have led to some criticism as to whether a randomized controlled trial 91 strategy that over-emphasizes internal validity is appropriate (i.e., achieving internally valid In some respects, the COVID-19 pandemic has created a tragic, natural experiment to 100 consider the "controversy" as to whether these community-based service options are effective or 101 not. For example, we are currently conducting a national study involving <blinded> adult day 102 service programs funded by the National Institutes of Health (<blinded>). Referred to as the 103 <blinded>, we are evaluating whether training staff to provide dementia education, non-104 pharmacological strategies, and care management support to family caregivers who utilize adult 105 day programs results in improved outcomes for older clients with dementia and their 106 caregivers. 19 We were in the midst of the trial when, in March 2020, states across the U.S. made 107 the decision to shut down adult day services to contain the spread of SARS-CoV-2. Since then 108 we have heard first hand an outpouring of anguish, grief, confusion, and anger from families 109 whose relatives can no longer access programs as well as from staff and directors who are 110 struggling to meet the needs of clients and family caregivers.

In August 2020, we reached out to 30 of the adult day programs active in our study to due to an Ohio Department of Health executive order. During this same period, 83% of program 142 directors reported participants had to move to higher and more expensive levels of care such as 143 nursing homes and assisted living facilities. 20 One Ohio program director stated "We believe this 

COVID-19 and the Need for Adult Day Services 18

Table 1. The "Controversy" of Adult Day Services and Their Effectiveness