Report: Shortage of Adult Day Services in Most U.S. Counties

    • January 1, 2004

Are there enough adult day service programs in the United States? Are they financially healthy? What kind of services do they offer? These are a few of the questions raised—and answered—by an RWJF-funded National Study of Adult Day Services, the first of its kind.

A research team directed by Nancy Cox, director of RWJF National Program Partners in Caregiving: The Adult Day Services Program, conducted the study with a $400,000 grant from the Foundation, and $95,000 from the Wake Forest University School of Medicine.

The current number of adult day centers—3,407—falls seriously short of the estimated 8,520 adult day centers needed nationwide, according to researchers.

Service Gap Analysis

The results of this analysis indicate that 56 percent of the 3,141 counties in the United States are underserved (1,770 counties), indicating there is a demand in each of these counties to support at least 1 new adult day center with a capacity of 38 people per day (the average center size as determined by this study). In contrast, 37 percent of the counties (1,171 counties) are in Equilibrium, which means that, based on calculations, they appear to have the appropriate number of centers currently in place to serve the population in need, or the population base cannot support a center at all. And, 7 percent of the counties (200 counties) have more centers than the population in need should be able to support.

Underserved Counties fall into three categories:

  • Counties with no adult day center, but a population base that can support one (or more) centers
  • Counties with existing adult day centers that, overall, are underutilized (i.e., below the national norm of a 66 percent utilization rate as determined by this study), resulting in the need for one (or more) new centers in the county
  • Counties with existing adult day centers that, overall, are utilized (i.e., at or above the national norm of a 66 percent utilization rate), but the population base can still support one (or more) new centers in the county.

The Service Gap Analysis was based on availability gaps and utilization gaps. Calculations factored in an average adult day center size of 38 and an average utilization rate of 66 percent (as determined by this study). Calculations also used the Weiler demand model, which is based on the number of persons in the market area over the age of 65.This research determined that 1.25 percent of the population over the age of 65 is in need and likely to chose adult day services. Compared to three other demand models, the Weiler model (developed specifically for the adult day services field) produced the most conservative estimate of demand. While not a primary reason to use this model, it does provide a defensible, conservative estimate to use to identify new opportunities for the development of adult day centers.

Using this study and the Weiler model, the results of the Service Gap Analysis indicate that the United States needs 5,415 new adult day centers: 35 percent (1,898) are in counties which are underserved/utilized; 34 percent (1,835) are in counties which are underserved/underutilized; and, 31 percent (1,682) are in counties that are underserved/no centers.

Executive Summary

A National Study of Adult Day Services, conducted by Partners in Caregiving: The Adult Day Services Program (with PMD Advisory Services, LLC and the Seniors Research Group of Market Strategies, Inc.), revolved around three major activities:

  • Conducting a census of adult day service providers to determine how many adult day centers exist and where they are located
  • Surveying these providers to determine populations served and services offered
  • Identifying gaps in the current service delivery system.

The assessment of gaps included analysis of utilization gaps (i.e., where centers exist but are underutilized) and availability gaps (i.e., where no centers exist despite a probable need), illustrating counties that are under served, in equilibrium, or have excess capacity.

The study confirmed 3,407 adult day centers in the United States, of which 53 percent are well established, having been open for 11-20 or more years. Individuals being served range in age from 18 to 109, with an average age of 72. The two most prevalent conditions are dementia (52 percent) and 41 percent frail elderly (age 60+ in need of supervision and/or at-risk of social isolation; no dementia). Twenty-four percent (24 percent) are diagnosed with mental retardation/developmental disabilities, 23 percent are physically disabled but cognitively intact, and 14 percent have a chronic mental illness. Forty-three percent (43 percent) of individuals enrolled in an adult day center need assistance with toileting, 37 percent with walking, and 24 percent with eating.

Twenty-one percent (21 percent) of adult day centers are based on the medical model of care, 37 percent are based on the social model of care (with no medical component), and 42 percent are a combination of the two. Adult day centers provide a vast array of services such as: therapeutic activities, health monitoring, social services, personal care services, meals, transportation, nursing services, medication management, caregiver support services, rehabilitation therapy, medical services, overnight care and emergency respite.

Most people attending an adult day center live with an adult child (35 percent) or a spouse (20 percent). The average length of stay at the center is two years, with the number one reason for discharge from the center being placement in a residential setting (such as a long-term care facility). The number two reason for discharge is death.

The study notes that the majority of adult day centers are not-for-profit (78 percent), operate under the umbrella of a large parent organization (70 percent), and are open Monday through Friday, eight or more hours a day. On average, adult day centers serve 25 people per day (with an overall enrollment of 42) at an average cost of $56/day. The average daily fee, however, is $46/day (less than cost). Annual revenue (on average) is $365,208, of which 38 percent comes from third-party public reimbursements (mainly Medicaid Home- and Community-Based Waiver dollars), 35 percent from private pay/out-of-pocket payments, 14 percent from non-operating revenue (such as grants and donations), and 13 percent from other operating revenue (such as private insurance and ancillary services like transportation).

Growth in the adult day services industry is evident, with 26 percent of all adult day centers opening in the last five years. However, growth lags behind the need for the service, with 56 percent of the counties in the United States under served (1,770 counties out of a total of 3,141). The study concludes that the current population base of the United States can support a total of 8,520 adult day centers. With current need not being met, 5,415 new adult day centers are needed nationwide (1,424 in rural areas and 3,991 in urban areas).


The National Study of Adult Day Services, conducted by Partners in Caregiving: The Adult Day Services Program (with PMD Advisory Services, LLC and the Seniors Research Group of Market Strategies, Inc.), provides a wealth of information—a portrait of the field, resulting in valuable planning information for individual adult day centers, and local/state/federal officials, legislators, and policymakers. The information can be used to benchmark centers within their own state, do state-by-state comparisons, and state/national comparisons.

The National Study of Adult Day Services shows a level of sophistication in service delivery of which many people are not aware (in regard to populations served and services offered), dispelling the myth of being just a babysitting service. It shows adult day centers as a viable, cost-effective community-based service option in the long-term care continuum, that helps keep individuals (in need of chronic care) at home, in the community, with family and friends for as long as possible.

The National Study of Adult Day Services shows the need for capacity building at the state level. Based on current service gaps (i.e., availability gaps and utilization gaps), and based on an increase in demand that will occur (due to a projected increase in the disabled elderly population and because centers are now serving a younger population with chronic conditions), capacity building needs to occur at the state level in three areas:

  • Increased public awareness in underutilized areas
  • Increased availability in areas where the service is not currently an option
  • Increased knowledge at the provider level regarding predictors of success (from a marketing and financial management perspective), in order to increase utilization at existing centers and even expand existing centers (when appropriate) to be able to serve more people with chronic care needs.

© 2002 Wake Forest University School of Medicine