Adult day services provide health care and social connection to older adults and adults with disabilities, along with crucial respite for the growing number of family caregivers in Vermont. But the industry faces challenges. Five adult day programs have closed in the state since 2020, and policy changes at the federal level are hampering new programs that were in the works.
Medicare, the federal insurance program for people 65 and older, doesn’t cover adult day programs, which in Vermont can cost more than $26 an hour. According to the Centers for Disease Control and Prevention, 79% of Americans who use adult day services rely on Medicaid to pay for it.
Program administrators say historically, Medicaid’s reimbursement rates have not kept up with the rising costs to provide these services. Now that Congress has approved more than $900 billion in cuts to Medicaid over the next decade, concerns are mounting.
“Well, I’m not sure where the ax is going to fall,” said Kristin Bolton, executive director of Elderly Services Inc. The nonprofit operates an adult day program in Middlebury that serves about 125 clients directly and also provides caregiver support services
“I’ve been assured by the people who manage the funding at the state level that we shouldn't worry for this fiscal year, which has already started for us, so that’s a huge relief, Bolton said. “But I think there’s going to be a lot of deliberations at the state level about how to take a shrunken pot of money and provide it for all the services needed throughout the state, of which adult day gets some portion.”
The uncertainty comes as some programs in Vermont were already struggling.
Potential new programs hit roadblocks
“Adult day programs are one of the toughest business models to make work,” said Jane Catton, CEO of Age Well, one of five Area Agencies on Aging that serve older adults in Vermont.
The work is physically and emotionally demanding, and traditionally, wages have been low.
Loryn Hamilton, who directed InterAge, an adult day program that operated for many years in Rutland, said funding and staffing challenges exacerbated by the coronavirus pandemic forced her to close in 2020. Four other programs have also shut their doors since 2020, including ones in Barre, Newbury, Colchester and Essex. There are now 11 adult day programs operating around the state.
Earlier this year, state officials were optimistic about three new programs that were in the planning stages in Mendon, Colchester and central Vermont. But none will be opening anytime soon, if at all.
Recent changes to immigration policy are posing challenges for one program that was planned for Mendon.
Luis Marin, executive director of Vista Senior Living in Mendon said they had hoped to open an adult day program this year. It would have expanded their existing assisted living and memory care residential services and filled a crucial void in Rutland County.
But Marin told Vermont Public that staffing challenges had forced him to put those plans on hold. New immigration policies have exacerbated the already short supply of workers, he said, so now it's unclear when or if he’ll be able to resume his adult day plans.
A 2023 Kaiser Family Foundation report found nationally, immigrants make up 28% of the overall direct care workforce for long-term care services. In comparison, foreign-born workers account for about 19% of the entire U.S. civilian labor force.
An effort to create a new intergenerational day care service in central Vermont has also hit roadblocks.
The nonprofit Generations Vermont has been trying to create a combination child and adult day care center in the Barre-Montpelier area. They were planning to open it in 2027, according to Executive Director Erin Clark, but a start date now remains elusive.
“Like with everything with this, there are a lot of unknowns,” she said.
While Clark said cuts to Medicaid will create challenges down the road, she said they’re more concerned with cuts to federal funds they hoped would help them with start-up building costs.
Finding a space that can accommodate children and adults has been harder than expected, said Clark.
“When we started this effort we were looking at HUD’s Community Development Block Grant and USDA funding for the Community Facilities, Direct Loan and Grant Program,” she said. “Historically, those would have been available for a community build project like this; but both are looking a lot sketchier now,” she added.
The Trump administration had proposed eliminating the Community Development Block Grant program. Congress voted to maintain it, but funding levels have not kept up with inflation.
There are some grant opportunities Clark remains hopeful about and she said they plan to do a capital campaign.
“But the more I get into this work and in the realm of health care, it’s turning very grassroots," Clark said. "Like we need to rely on ourselves to help ourselves in times like this. And it’s challenging in a small state like Vermont.”
Plans for a new adult day program in Colchester also appear to have stalled. Rebecca Silbernagel, with Vermont’s Department of Disabilities, Aging and Independent Living, which oversees adult day programs in the state, said they recently heard the applicant was seeking a new location. But no other updates were provided.
Some groups are working to fill gaps
Still, there are some bright spots as some organizations take matters into their own hands to expand access to care.
Project Independence, the adult day program in Middlebury that Kristin Bolton oversees, is currently serving 75% of the number of clients they had before the pandemic. Bolton recognized an opportunity to fill the gap.
“That got me thinking, maybe we could use our vans to bring clients from nearby underserved areas.”
This summer, they began a pilot program to bring a small number of clients from Burlington, which is about an hour drive away. The group is also in the process of hiring a driver to bring clients to and from Rutland, and Bolton said that if the effort is successful, they’ll be able to bring 10 or 11 people from each direction.
“It feels good to be serving families and participants who don't have those resources on hand, who can't just go to the local adult day center because it's a long way away,” she said.
A transportation charge is included in the bill for anyone who pays for their services privately, said Bolton, while Medicaid and the Veterans Administration cover transportation in their funding.
“So to cover this new service, all we have to do is provide a driver and try to break even,” she added.
Cathedral Square, a nonprofit affordable housing agency in Chittenden County, is also trying to expand respite services.
The agency plans to use a $125,000 innovation grant from the Alzheimer's Association to offer day respite services for people with dementia at the Allen Brook Memory Care community they operate in Williston. The facility currently has 14 full-time residents. The grant money will help Cathedral Square hire an extra staff person, add furniture and expand activities at Allen Brook to accommodate additional clients for daytime services, according to Executive Director Kim Fitzgerald.
The group aims to launch a pilot program this fall serving one to three people per week, with the potential to expand to 10 daily, she said.
“We know that more than 13,000 Vermonters over the age of 65 have Alzheimer's, and we know that 20,000 are providing unpaid care to loved ones with dementia so they can stay home,” Fitzgerald said. “And we want to support that because we know how difficult it is to get into long-term care.”
Because they plan to offer only four hours of respite care a day, which is less than traditional adult day services, Fitzgerald said they need a waiver from the state to bill Medicaid for the services. But she’s optimistic that will happen.
Allen Brook is the state’s only nonprofit memory care community exclusively for low-income Vermonters on Medicaid. Revenue generated by the clients that come between 10 a.m. and 2 p.m. would help sustain services for the full-time residents, Fitzgerald said, so it could be a win-win.
These initiatives may only benefit a small number of Vermonters in the short term, admits Kristin Bolton. But if it makes a difference for the families who can take part, she said it’s worth it.
