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What’s on the Horizon for Adult Day Health Care?

Office manager Katie Breeze is walking through the many empty rooms of the Robertson Adult Day Health Center in East Sacramento.

It has been two weeks since the official close of Robertson, and now there are no cars in the big parking lot out front, except for the pest control van, and most of the rooms in the building have been cleared out.

“It’s all winding down now,” Breeze said. “I’m pretty much the only one here right now.”

That’s not entirely correct. In what used to be the rec room, a few volunteers are busy loading up brown grocery bags. “They’re packing up art supplies to take to participants,” Breeze said. “It just made sense, rather than just getting rid of all the art supplies.”

A sign on the far wall reads, “Love is like a garden. It grows.” Out back in the patio area, what seems to be growing is a collection of walkers and whirlpool tubs that crowds the backyard paths.

Robertson Center is one of 11 adult day health care centers shutting their doors across the state. Those 11 likely will be joined by others.

The state is eliminating adult day health care in California. There is hope that a new, smaller program will take up many of those ADHC patients. That potential program has been dubbed KAFI, or Keeping Adults Free from Institutions, and the Assembly and the Senate have approved $85 million for it.

But that program is far from reality. The Legislature and Gov. Jerry Brown (D) took the first big step by including it as part of the budget package. After official approval, the KAFI program would have to go through a long waiver-application process with the federal government. That means a narrow window of about two months before the state eliminates ADHC. The deadline for closure is Sept. 1.

What is ADHC?

A common misconception about adult day health care is that it’s day care for seniors. “It’s an unfortunate name,” Lydia Missaelides of Adult Day Health Services said.

Roughly 300 ADHC centers in California provide nursing home-type services — from physical therapy to medical services to transportation — during the day, allowing seniors and people with disabilities to live and remain functional at home. That keeps them out of expensive nursing homes, and they live better lives because they’re still home, Missaelides said.

In fact, the whole concept of ADHC was designed to save money, she said. That’s why it’s so difficult for her to understand why the state is trying to eliminate it as a cost-saving measure.

“This is not a logical process,” she said. “Adult day health saves the state millions of dollars. Maybe hundreds of millions. And at the same time provides better care for 35,000 Californians. Why would you want to cut that?”

According to Norman Williams, a deputy director at the state Department of Health Care Services, the answer is simple.

“Medi-Cal is the second-largest general fund expenditure. Federal laws require us to maintain certain programs and benefits,” Williams said. “One of the few areas we can touch is the optional benefits, and adult day health care is one of those optional benefits.”

Eliminating the program completely, he said, clears $169 million off the books for California.

If the Legislature keeps about half of that for KAFI in the budget — right now pegged at $85 million — and if the governor signs that program into law, Williams said his department will immediately start working on a waiver plan to submit to CMS. Until that time, though, the department has a different directive.

“Right now we’re putting together a transition plan,” Williams said, to identify the needs of people who have been getting ADHC services and to try to place them in some other existing program.

“Various programs in the mental health department, in aging, in rehabilitation, they all touch ADHC in some manner. We’re assessing and seeing what they need to stay out of the nursing home setting.”

‘What Do We Do Now?’

The state plans to work on structuring the KAFI program as it eliminates ADHC as a program by Sept. 1. That means shuttering about 300 more centers around the state.

Sue Barnett, a patient at an ADHC center in Sonora that closed in April, suffered a major stroke and has extremely limited mobility, and yet she managed just fine, she said, with help from her local ADHC center.

“I can’t drive, it’s tough to get around,” Barnett said, “but I manage to keep myself going. I take care of myself.”

That may change now that the Sonora center closed, she said. “Without their help, I wouldn’t be where I am,” she said. “And really, there’s nothing to replace ADHC. I don’t get any physical therapy now, I don’t get to see any of my friends, I don’t really leave the house now. I sit in my recliner and watch TV most of the day.”

Barnett said that the scariest part of it, to her, is not her own troubles.

“There are people who are much worse than me, and they are in real trouble,” Barnett said. “They are down to the bare bones. How is anyone going to take up that slack? What do we do now? Who’s going to help all of those people?”

Lawsuit Time

The KAFI program has a number of worrisome issues. At half the budget of the original program, KAFI will need to focus help on those individuals who are most at risk for entering a nursing home — the ones who are sickest and require the most expensive care.

That means that half of the budget won’t support half of the patients. It is likely that the new KAFI program will have a much smaller patient base, and the directors of existing ADHC centers have said they can’t run a program with such a limited number of people needing such specialized care.

Speculation in the ADHC world is that there will be many fewer centers in California, mostly serving acute care patients. So most of the 35,000 patients currently using ADHC services will need to go elsewhere, even if the KAFI program is approved and implemented.

“With half the funding and the direction to serve the most needy, the centers will close,” according to Carmen Reimer, former director of the Sonora center. “One cannot have a financially viable model with half the funding. [Centers] will have to decide which patients we serve will be left standing, and which patients will have to be left in the cold.”

Timing is also critical. Lyndsey Roush, former program director of the Robertson center in Sacramento, said that if all centers have to close in September and there’s a gap of months before the KAFI program can start up, it will be tremendously difficult to re-open those centers, she said.

“They will have a hard time making a comeback,” Roush said. “Once the building is gone, once the vans are sold, the equipment is sold, the barrier to startup is pretty high.”

All of that rankles Elissa Gershon of Disability Rights California, which filed a lawsuit challenging the elimination of ADHC services in the first place.

Even if the KAFI program is realized, Gershon said, most of the current ADHC patients will have nowhere to go. The state’s hope to move some of them into existing programs such as In-Home Supportive Services is really just false hope.

“They don’t have the first idea how they’re going to do this [elimination process],” Gershon said.

As for the KAFI idea, “There isn’t a clear answer in a waiver program, just how to make a waiver work,” Gershon said. “Programs say they need a balance of participants to make it work, cost-wise. As a practical matter, I just don’t see how any of them are going to stay open.”

Eliminating the whole ADHC program, she said, is not only the wrong thing to do — both in terms of saving money and saving lives — but it’s also illegal.

Final briefs must be filed by July 12, and a judge’s decision should come within a week or so after that, Gershon said.

In the meantime, ADHC advocates are stuck just waiting.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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