U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

NCHS reports can be downloaded from: https://www.cdc.gov/nchs/products/index.htm.

NATIONAL CENTER FOR HEALTH STATISTICS

Vital and Health Statistics

98.1 (0.93)

99.5 (0.26)

98.7 (0.75)

99.3 (0.73)

98.4 (1.49)

98.4 (1.58)

94.7 (1.95)

98.6 (1.30)

92.4 (2.88)

92.5 (2.46)

96.7 (2.48)

91.8 (3.61)

17.0 (0.46)

16.7 (0.55)

16.8 (1.01)

11.8 (2.48)

20.0 (1.88)

12.9 (1.13)

8.7 (1.26)

7.3 (2.20)

17.1 (4.43)

14.5 (3.05)

7.7 (2.11) 

3.8 (0.64) 

4.7 (1.03)

*2.4 (1.00)

84.5 (7.72)

*8.3 (3.48)

13.6 (2.00)

*3.9 (1.52)

17.5 (2.81)

*19.2 (7.52)

*18.5 (6.70)

*17.1 (4.85)

96.9 (0.21)

97.0 (0.24)

97.2 (0.44)

96.8 (1.27)

95.2 (0.88)

96.7 (0.78)

99.3 (0.29)

94.8 (1.66)

95.6 (1.39)

97.5 (1.40)

93.1 (2.60)

98.1 (0.93)

99.5 (0.26)

98.7 (0.75)

99.3 (0.73)

98.4 (1.49)

98.4 (1.58)

94.7 (1.95)

98.6 (1.30)

92.4 (2.88)

92.5 (2.46)

96.7 (2.48)

91.8 (3.61)

7.0 (0.24)

7.2 (0.44)

6.8 (1.27)

5.2 (0.88)

6.7 (0.78)

9.3 (0.29)

4.8 (1.66)

5.6 (1.39)

7.5 (1.40)

3.1 (2.60)

8.1 (0.93)

9.5 (0.26)

8.7 (0.75)

9.3 (0.73)

8.4 (1.49)

8.4 (1.58)

4.7 (1.95)

8.6 (1.30)

2.4 (2.88)

2.5 (2.46)

6.7 (2.48)

1.8 (3.61)

NATIONAL CENTER FOR HEALTH STATISTICS

Vital and Health Statistics

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

NCHS reports can be downloaded from: https://www.cdc.gov/nchs/products/index.htm.

Series 3, Number 45 October 2020

Differences in Characteristics of 

Adult Day Services Centers, by Level 

of Medical Service Provision

Analytical and Epidemiological Studies
Copyright information

All material appearing in this report is in the public domain and may be reproduced or 

copied without permission; citation as to source, however, is appreciated.

Suggested citation

Rome V, Lendon JP, Harris-Kojetin L. Differences in characteristics of adult day services 

centers, by level of medical service provision. National Center for Health Statistics. Vital 

Health Stat 3(45). 2020.

For sale by the U.S. Government Publishing Office 

Superintendent of Documents 

Mail Stop: SSOP 

Washington, DC 20401–0001 

Printed on acid-free paper.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Hyattsville, Maryland

October 2020

Differences in Characteristics of 

Adult Day Services Centers, by 

Level of Medical Service Provision

Analytical and Epidemiological Studies

NATIONAL CENTER FOR HEALTH STATISTICS

Vital and Health Statistics

Series 3, Number 45 October 2020

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Hyattsville, Maryland

October 2020
National Center for Health Statistics

Brian C. Moyer, Ph.D., Director

Amy M. Branum, Ph.D., Acting Associate Director for Science

Division of Health Care Statistics

Carol J. DeFrances, Ph.D., Acting Director

Alexander Strashny, Ph.D., Associate Director for Science
Series 3, Number 45 iii NATIONAL CENTER FOR HEALTH STATISTICS 

Contents

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Data Source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

National Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Organizational Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Distribution of Participant Characteristics at the Center Level (Case-Mix) . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Geographic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Organizational Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Distribution of Participant Characteristics at the Center Level (Case-Mix) . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Geographic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Appendix. Technical Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Text Figures

1. Average capacity and average daily attendance of adult day services center participants, overall and by

level of medical service provision: United States, 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

2. Percentage of adult day services centers by Medicaid licensure and for-profit ownership, overall and by

level of medical service provision: United States, 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

3. Average staff hours per participant per day, overall and by level of medical service provision:

United States, 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

4. Percentage of revenue from paid participant fees, overall and by level of medical service provision:

United States, 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

5. Percentage of adult day services centers that used electronic health records and health information

exchange, overall and by level of medical service provision: United States, 2016 . . . . . . . . . . . . . . . . . . . . . . .9

6. Percentage of specialized adult day services centers by specialization, overall and by level of medical

service provision: United States, 2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

7. Percentage of adult day services centers that provided selected services, overall and by level of medical

service provision: United States, 2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

8. Percentage of participants in adult day services centers by age, overall and by level of medical service

provision: United States, 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

9. Percentage of participants in adult day services centers by race and Hispanic origin, overall and by level

of medical service provision: United States, 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

10. Percentage of participants in adult day services centers diagnosed with selected conditions, overall and

by level of medical service provision: United States, 2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
NATIONAL CENTER FOR HEALTH STATISTICS iv Series 3, Number 45

Contents—Con.

11. Percentage of participants in adult day services centers needing any assistance with activities of daily 

living, overall and by level of medical service provision: United States, 2016 . . . . . . . . . . . . . . . . . . . . . . . . 15

12. Percentage of participants in adult day services centers among selected living arrangements, overall and 

by level of medical service provision: United States, 2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

13. Percentage of participants in adult day services centers with falls, emergency department visits, and 

overnight hospitalizations in the last 90 days, overall and by level of medical service provision:

United States, 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

14. Percentage of adult day services centers among U.S. Census regions, overall and by level of medical 

service provision: United States, 2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

15. Percentage of adult day services centers according to metropolitan statistical area status, overall and by 

level of medical service provision: United States, 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

16. Percentage of moderate and high medical adult day services centers, by state: United States, 2016 . . . . . . . . . . . 19

Detailed Tables

1. Weighted number and percentage of adult day services centers and participants, by level of medical 

service provision: United States, 2016. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

2. Organizational, participant case-mix, and geographic characteristics of adult day services centers, overall 

and by level of medical service provision: United States, 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Series 3, Number 45 v NATIONAL CENTER FOR HEALTH STATISTICS 

This report is dedicated to Lauren Harris-Kojetin, Ph.D.

August 19, 1963–January 29, 2020

Dedication

Lauren Harris-Kojetin was Chief of the Division 

of Health Care Statistics’ Long-Term Care 

Statistics Branch for 14 years. During this time, 

she led four national survey waves of the 

National Study of Long-Term Care Providers 

and spearheaded multiple innovative 

redesigns of NCHS’ long-term care surveys that 

captured the intricacies of each sector while 

producing reliable, accurate, and timely data 

for researchers, policymakers, and providers 

of these services. Lauren’s passion, insight, 

and dedication to survey statistics, aging, and 

long-term services and supports will be greatly 

missed by her colleagues at the National 

Center for Health Statistics.
Series 3, Number 45 1 NATIONAL CENTER FOR HEALTH STATISTICS

Differences in Characteristics of Adult 

Day Services Centers, by Level of Medical 

Service Provision

by Vincent Rome, M.P.H., Jessica Penn Lendon, Ph.D., and Lauren Harris-Kojetin, Ph.D.

Abstract

Objectives

This report provides estimates of the most current 

nationally representative distribution of adult day 

services centers (ADSCs) and participants by level of 

the center’s medical service provision. It also examines 

differences in organizational characteristics, participant 

characteristics, and geographical characteristics of 

ADSCs by medical service provision.

Methods

Data are from the ADSC component of the 2016 National 

Study of Long-Term Care Providers. ADSCs are examined 

by level of medical service provision, defined as ranging 

from nonmedical to low medical to moderate medical to 

high medical based on ADSC directors’ self-identification 

of their centers’ services and participant needs served. 

ADSC organizational characteristics, geographic 

characteristics, and participant characteristics (referred 

to as “case-mix”) were examined according to level of 

medical service provision.

Results

In 2016, 16.1% of ADSCs were nonmedical, 30.6% were 

low medical, 39.7% were moderate medical, and 13.5% 

were high medical. Daily attendance, Medicaid licensure, 

nurse staffing levels, use of electronic health records 

and any health information exchange with physicians, 

pharmacies, and hospitals all increased with increasing 

level of medical service provision. Among participants, 

there was a significant increase by increasing level 

of medical service provision in the percentage of 

participants who were Hispanic and non-Hispanic races 

other than white or black, aged 65 and over, diagnosed 

with selected conditions, needed assistance with any 

activities of daily living, lived in a private residence 

alone, had Medicaid, and had any adverse events.

The percentage of centers located in metropolitan 

statistical areas and those located in the Northeast and 

South census regions increased with increasing level of 

medical service provision.

Conclusion

This report’s findings provide the most up-to-date 

description of the spectrum of ADSC level of medical 

service provision. These results suggest that ADSCs 

are varied in the level of medical services they provide 

and patient characteristics differ according to service 

provision of an ADSC.

Keywords: home- and community-based • Medicaid • 

staffing • models of care • National Post-acute and 

Long-term Care Study • National Study of Long-Term 

Care Providers

Introduction

Adult day services centers (ADSCs) emerged in the United 

States around the 1960s as a novel and cost-effective 

place of care, separate from institutional or home-based 

care for older adults and individuals with disabilities 

(1). Today, ADSCs offer a mix of social and recreational 

activities, assistance with activities of daily living (ADLs), 

and traditional medical care, such as skilled nursing and 

therapeutic services (2). Compared with other home- and 

community-based (HCB) long-term services and supports 

(LTSS) sectors, such as home health agencies and assisted 

living communities, ADSCs serve a more diverse population. 

For example, a higher percentage of ADSC participants are 

racial and ethnic minorities, are under age 65, have a variety 

of health conditions (including intellectual or developmental 

disabilities [IDD]), and use Medicaid (3–6).

Unlike other home- and community-based services (HCBS), 

the federal government does not regulate ADSCs. Instead, 

state agencies may license, certify, or both license and certify 

ADSCs as a social model program that prioritizes the social 

and recreational needs of participants; as a medical model 

program that prioritizes the medical needs of participants; 

or a combination of both the social and medical service 

delivery models (7). As of 2014, 26 states regulated ADSCs 
NATIONAL CENTER FOR HEALTH STATISTICS 2 Series 3, Number 45

through licensure; 10 states through certification; 4 states 

through licensure and certification; 15 states had additional 

certifications, and 11 states did not license or certify ADSCs 

(7). ADSCs that receive public funding, such as from Veterans 

Affairs or Medicaid, are also subject to the certification 

requirements of the respective state agency that administers 

the program. The scope of participants that can be served, the 

level of care provided, and the types of services provided are 

prescribed by state regulations in states that license, certify, 

or do a combination of both. It is through this patchwork of 

state regulations and funding mechanisms that the adult day 

services sector provides community-based medical care.

Previous studies derived a typology of ADSC service delivery 

models by analyzing the organization of resources in 

response to fluctuations in the distribution of participant 

sociodemographic, health, and functional characteristics 

within a center (henceforth referred to as “case-mix”), and 

in the long-term care and post-acute care marketplaces 

in which ADSCs operated (1,8–10). These early studies 

examined various ADSC organizational characteristics, the 

needs of participants, and the types of services ADSCs 

provided. This early work identified three main types of 

ADSC models: (a) centers that provided health, medical, and 

rehabilitation services, along with some social services for 

participants who needed assistance with ADLs; (b) centers 

that provided mostly social services to participants with less 

need for assistance with ADLs; and (c) specialized programs 

that served participants with a particular diagnosis or 

disability, such as visual impairments or mental illness.

The regulatory, political, and operating environments of 

post-acute care and LTSS have transformed over time, and 

the social-medical dichotomy that once characterized the 

ADSC sector is now better characterized as a continuum. The 

two poles of the continuum are the mostly social-oriented 

service delivery model and the mostly medical-oriented 

service delivery model; some combination of the two 

define the middle of the continuum (2). This trend was first 

observed by Conrad, Hughes, Hanrahan, and Wang (11) in a 

1986 national census of 774 ADSCs to determine whether 

ADSCs could be further classified using the provision 

of services, measures related to centers’ organizational 

structures, processes of care, and participant characteristics. 

In addition to identifying two types of specialized centers 

for dementia care and rehabilitation, ADSCs were clustered 

based on the intensity of the clinical and social services 

provided. The results indicated six service delivery model 

types ranging from high intensity of clinical services and 

moderate social services to ADSCs that offered only social 

services (11). In a second national survey of 1,771 ADSCs in 

2001–2002, researchers used a broad measure of services 

delivery model type and found that 37% self-identified as 

a social model program, 21% as a medical model, and 42% 

were some combination of these two model types (12).

More than a decade has passed since the last national study 

examined variation in the characteristics of ADSCs by model 

type. More recent research has focused on identifying 

characteristics and practices of centers among a similar 

subgroup of centers, such as ADSC programs that served 

specific populations, were of a particular model or affiliation 

type, or were from a particular geographic locale or state 

(13–18). In addition, previous nationally representative 

surveys, in addition to the smaller-scale studies, did not 

capture the variation in model type across states or by 

characteristics of ADSCs.

The landscape for institutional and HCB LTSS is changing 

and access to medically oriented HCBS has become an 

increasingly visible issue. There have also been several recent 

policy developments with the specific aim of increasing the 

use of ADSCs among potential LTSS users. Legislation that 

effectively covers medical-model adult day health services 

for veterans using funds from Veterans Affairs (VA) was 

enacted in 2017, and access to these services was broadened 

to all veterans residing in state-sponsored Veterans Homes 

nationally (19). Additionally, ADSCs were added into the 

Medicare Advantage supplemental benefit plan as a healthrelated service (20). ADSCs have also received HCBS waiver 

funding in recent years; about 77% of ADSCs participated in 

Medicaid in 2016 (5).

Based on previous literature, this report includes 

characteristics that describe an ADSC’s organization, 

participant case-mix, and geographic characteristics 

(2,3,15,16,18). This report examines ADSCs by level of medical 

service provision, defined as ranging from nonmedical to 

low medical to moderate medical to high medical based on 

ADSC directors’ self-identification of their centers’ services 

and participant needs served. This report estimates the 

most current nationally representative distribution of ADSC 

characteristics (i.e., organizational, participant case-mix, 

and geographical) by level of medical service provision, 

examines differences in ADSC characteristics between the 

levels of medical service provision and by increasing level 

of medical service provision, and explores the distribution 

of moderately and highly medicalized ADSCs by state. This 

report’s findings provide the most up-to-date description of 

the full spectrum of ADSC levels of medical service provision, 

which provides information on how these providers fit into 

the current LTSS paradigm.

Methods

Data Source

Survey eligibility criteria

This study uses nationally representative data from the 

ADSC survey of the 2016 National Study of Long-Term 

Care Providers (NSLTCP), a biennial study conducted by the 

National Center for Health Statistics (NCHS). To be eligible for 

the study, an ADSC must: (a) be licensed or certified by the 

state specifically to provide adult day services, or accredited 
Series 3, Number 45 3 NATIONAL CENTER FOR HEALTH STATISTICS

by the Commission on Accreditation of Rehabilitation 

Facilities, or authorized or otherwise set up to participate in 

Medicaid (Medicaid state plan, Medicaid waiver, or Medicaid 

managed care), or part of a Program of All-Inclusive Care for 

the Elderly; (b) have an average daily attendance of one or 

more participants based on a typical week; and (c) have one 

or more participants enrolled at the center at the designated 

location at the time of the survey (21). The 2016 survey had a 

response rate of 61.8%. The 2016 NSLTCP data are accessible 

in the form of reports and tables from the National Postacute and Long-term Care Study website (https://www.cdc.

gov/nchs/npals/index.htm). Restricted data files from each 

survey are available to researchers through NCHS’ Research 

Data Center (https://www.cdc.gov/rdc/index.htm).

The multimode survey was administered to ADSC 

administrators, directors, or otherwise knowledgeable ADSC 

staff by mail or web, or by computer-assisted telephone 

interviewing follow-up for nonrespondents. The ADSC 

survey included two questionnaires (Version A and Version 

B), each containing survey items common to both versions, 

which were used to produce national and state estimates, 

and survey items unique to each questionnaire, which can 

only be used to produce national estimates (21).

Three different weights (adjusting for nonresponse bias and 

unknown survey eligibility) were used, the first for measures 

common to both questionnaire versions, the second for 

measures collected only from questionnaire Version A, and 

the third for measures collected only from questionnaire 

Version B. The majority of the characteristics included in 

this report are common to both questionnaire versions, with 

the exception of participant living arrangements and the 

prevalence of falls (adverse event). As a result, the sample 

size and variance for these characteristics differ.

Measures

Level of medical service provision

The 2016 NSLTCP ADSC survey used a self-reported measure 

of the level of center medical service provision that asked:

“Which one of the following best describes the participant 

needs that the services of this center are designed to meet? 

(1) only social/recreational and no health/medical needs 

of participants; (2) primarily social/recreational and some 

health/medical needs; (3) equally social/recreational and 

health/medical needs; (4) primarily health/medical and 

some social/recreational; (5) only health/medical and no 

social/recreational needs.”

This report classifies ADSC level of medical service provision 

as an ordinal variable with four categories that represent 

increasing levels of medical service provision of ADSCs. 

The 4th and 5th categories of the measure were collapsed 

because there were too few ADSCs that only provided 

services for health or medical needs. Table 1 provides 

the weighted number and percent distribution of ADSCs 

and participants by the following levels of medical service 

provision:

1. Nonmedical centers had services designed to meet 

only social or recreational needs and no health or 

medical needs of participants;

2. Low medical centers had services designed to meet 

primarily social or recreational needs and some health 

or medical needs;

3. Moderate medical centers had services designed to 

meet both social or recreational needs and health or 

medical needs equally;

4. High medical centers had services designed to meet 

primarily health or medical needs and some social 

or recreational needs of participants or had services 

designed to meet only health or medical and no social 

or recreational needs.

To report state variation in the level of medical service 

provision, the four levels of medical service provision 

described above were further collapsed into a dichotomous 

variable that included one category for centers that were 

moderate to high medical centers and a second category for 

centers that were nonmedical to low medical. States were 

categorized by quartiles of the weighted percentages of 

moderate to high medical centers.

Organizational characteristics

Average capacity was defined by averaging the maximum 

number of participants allowed, which may be called the 

allowable daily capacity and is usually determined by law or 

by fire code but may also be a program decision. Average daily 

attendance was defined as the average of the approximate 

daily attendance at each center based on a typical week. 

For-profit ownership status was defined as the percentage 

of ADSCs that were a private for-profit organization, 

publicly traded company, or limited liability company. Chain 

affiliation was defined as the percentage of ADSCs owned 

by a person, group, or organization that owns or manages 

two or more ADSCs, which may include a corporate chain. 

Medicaid licensure was defined as the percentage of ADSCs 

authorized or otherwise set up to participate in Medicaid 

(Medicaid state plan, Medicaid waiver, or Medicaid managed 

care).

Staffing level was measured by using the number of full- and 

part-time employees and contract registered nurses (RNs), 

licensed practical or vocational nurses (LPNs or LVNs), aides, 

social workers, and activities staff. Aides were defined as 

certified nursing assistants, nursing assistants, home health 

aides, home health care aides, personal care aides, personal 

care assistants, and medication technicians or medication 

aides. Both employee and contract staff full-time equivalents 

(FTEs) were combined for each of the staffing measures 

included in this analysis. Center staffing was measured using 

the average number of employee and contract staffing hours 
NATIONAL CENTER FOR HEALTH STATISTICS 4 Series 3, Number 45

per participant per day (HPPD), which is the ratio of the 

average number of hours providing care for a participant per 

day for each of the following staff types: RNs, LPNs or LVNs, 

nurse aides, social workers, and activities staff members. 

The number of FTEs for a given staff type was converted into 

hours by multiplying each FTE (or fraction of an FTE) for the 

staff type at the center by 35 hours, then dividing the total 

number of hours for the staff type by the average daily 

number of participants, and dividing that estimate by 5 days:

If the derived HPPD for any of the staff types was more than 

24 hours, these values were top-coded to 24. If one or more 

of the staff HPPD measures had a response, but others were 

missing, the missing values were recoded to 0. If all staff 

measures were coded as missing, then the case was dropped 

from the analytic sample on staffing. Staff HPPD is referred to 

as “staffing levels” in the Results and Discussion sections and 

is typically presented as a ratio or as hours or minutes. The 

staff HPPD ratio can be converted to minutes by multiplying 

the ratio by 60. Staff HPPD does not necessarily reflect the 

amount of care given to a specific participant.

Sources of revenue was measured by asking what proportion 

of paid participant fees comes from the following sources: 

Medicaid; private insurance; out of pocket; other federal, 

state, or local government sources; other sources; Veterans 

Affairs; Medicare; and Older Americans Act.

This report includes whether an ADSC specialized in providing 

focused care for participants with a particular condition, 

diagnosis, or disability. A center was considered specialized 

if it selected one or more of the following specializations: 

Alzheimer disease or other dementias, IDD, severe mental 

illness, post-stroke disorders, multiple sclerosis, and some 

other condition or disability.

ADSC health information technology use, which facilitates 

delivery of care to participants, was included using 

measurements of the use of electronic health records 

(EHRs) and health information exchange (HIE). EHR use 

was measured as a dichotomous variable by asking 

centers whether or not they used a computerized version 

of participants’ health and personal information for the 

management of participant health care, other than for 

accounting or billing purposes. HIE capability was measured 

as a dichotomous variable by asking whether the center 

exchanged computerized information with physicians, 

pharmacies, or hospitals.

This report includes nine variables used to examine whether 

or not ADSCs provided the following services to participants: 

daily round-trip transportation (to and from the center); 

dietary (dietary and nutritional services); hospice; mental 

health (services targeting a person’s mental or psychiatric 

well-being, and may include diagnosing, describing, 

evaluating, and treating mental conditions); nursing (must 

be performed by an RN or LPN or LVN and are medical in 

FTE • 35 average daily number of participants 5

nature); pharmacy (filling of or delivery of prescriptions); 

social worker (provided by licensed social workers or persons 

with a bachelor’s or master’s degree in social work, and may 

include an array of services such as psychosocial assessment, 

individual or group counseling, and referral services); 

therapy (physical, occupational, or speech or pathology); 

and transportation for medical or dental appointments. 

These services are reported as the percentage of centers 

that provided the services either by center employees or by 

arrangement with an outside vendor.

Distribution of participant characteristics at the 

center level (case-mix)

This report included several types of participant case-mix 

characteristics—sociodemographics (race and ethnicity, age, 

gender, and Medicaid use), living arrangements, selected 

conditions, functional ability, and adverse events. These 

case-mix variables typically measured the percentage of 

participants at a center with a given characteristic (e.g., 

percentage male). Participant race and ethnicity categories 

included non-Hispanic white, Hispanic, non-Hispanic black, 

and non-Hispanic other. Age categories included 18–44, 

45–54, 55–64, 65–74, 75–84, and 85 and over. Sex included 

male and female participants. Medicaid use was measured 

as the percentage of participants who had any services 

paid for by Medicaid in the last 90 days. Living arrangement 

was measured by asking about the number of participants 

who lived in a private residence with a relative, a private 

residence alone, a private residence with a nonrelative, an 

assisted living or residential care facility, a nursing home, or 

some other living arrangement.

Selected conditions of participants were measured in six 

variables as the percentage of participants diagnosed with 

Alzheimer disease or other dementias, depression, diabetes, 

heart disease, IDD, and severe mental illness. Functional 

ability of participants was assessed using six variables asking 

for the percentage of participants at the center who needed 

any assistance with six ADLs: bathing, walking, dressing, 

toileting, transferring in and out of a chair, and eating. 

Adverse events were measured with three variables as the 

percentage of participants at the center who in the previous 

90 days were discharged from an overnight hospital stay, 

used emergency department services, or had a fall.

Geographic characteristics

Three measures of geography were used—U.S. Census 

region, metropolitan statistical area status, and state. 

Census region (Northeast, Midwest, South, and West) was 

defined as groupings of conterminous states, in addition 

to Washington, D.C., Alaska, and Hawaii, into geographic 

areas corresponding to groups used by the U.S. Census 

Bureau. Metropolitan and micropolitan statistical areas are 

geographic entities defined by the Office of Management and 

Budget for use by federal statistical agencies in collecting, 

tabulating, and publishing federal statistics. A metropolitan 
Series 3, Number 45 5 NATIONAL CENTER FOR HEALTH STATISTICS

statistical area contains a core urban area population of 

50,000 or more, and a micropolitan statistical area contains 

an urban core population of at least 10,000 (but fewer than 

50,000). Each metropolitan or micropolitan statistical area 

consists of one or more counties and includes the counties 

containing the core urban area, as well as any adjacent 

counties that have a high degree of social and economic 

integration (as measured by commuting to work) with the 

urban core (22). States included all 50 U.S. states and the 

District of Columbia.

Analysis

The unit of analysis was the ADSC. The survey sample 

included 2,836 ADSCs. Of these, 22 centers did not have 

any information for model type and were excluded from 

the analytic sample. Additional variables with missing data 

were excluded from the analyses on a variable-by-variable 

basis. The percentage of missing data ranged from 0.4% for 

Medicaid licensure to 13.8% for the number of participants 

with a diagnosis of heart disease.

Weighted estimates and confidence intervals were calculated 

for all ADSCs included in the analytic sample nationally and 

for each of the four levels of medical service provision, 

using Stata SE 14.2 (23). To calculate the average capacity, 

average daily attendance, and sources of revenue from paid 

participant fees, Stata’s survey mean procedure (svy: mean) 

was used. For the participant characteristics, ratios were 

estimated using svy:ratio. The svy: proportion procedure was 

used to produce both univariate and bivariate proportions 

of the characteristics of interest by level of medical service 

provision. For weighted counts of ADSCs and participants, 

svy: tab and svy: total were used, respectively.

Differences in the estimates of the selected characteristics 

between levels of medical service provision were evaluated 

using Stata’s lincom post-estimation command following the 

execution of the survey estimation command. Lincom

calculates contrasts of the weighted estimates and standard 

error of the difference, and estimates the confidence 

intervals, t or z statistics, and p values for the linear 

combinations of the coefficients (23). The formula for 

executing lincom after the proportion is:

Finally, a weighted least-squares regression method was 

used to identify linear trends of increasing or decreasing 

level of medical service provision for each of the 

characteristics included in the report:

All statistical significance tests are two-sided using p less 

than 0.05 as the level of significance. Statistically significant 

increases or decreases by increasing level of medical 

service provision are indicated in the figures and tables. In 

the Results section, statistically significant differences by 

increasing level of medical service provision are described 

as “overall increases” or “overall decreases” by increasing 

level of medical services provided. In the tables, these linear 

differences by increasing level of medical service provision 

are described as “increase,” “decrease,” or “none.” Pair-wise 

differences between each level of medical service provision 

are described in the text as “increased” or “decreased” to 

indicate statistical significance between categories when 

overall increases or decreases by increasing level of medical 

service provision were not observed or when differences 

between the levels of medical service provision warranted 

further discussion. Lack of comment regarding any 

differences does not mean that significance was tested and 

ruled out.

Tables 1 and 2 include all characteristics examined in this 

report. Some percentages are not presented in this report 

based on NSLTCP guidelines to suppress estimates with small 

sample sizes because it may pose a risk to the confidentiality 

of respondents. For example, the percentage of ADSCs that 

specialized in providing services to participants with “other 

conditions or disabilities” or the percentage of ADSCs that 

provided hospice services were not reported due to the 

small number of centers reporting these characteristics, 

which could pose a risk to participant confidentiality when 

examined in relation to geography and other characteristics. 

Results

National Estimates

In 2016, 4,560 adult day services centers served 284,300 

participants in the United States (Table 1). The highest 

percentage of centers were moderate medical (39.7%), 

followed by low medical (30.6%), nonmedical (16.1%), and 

high medical (13.5%). Moderate medical centers served 

the highest percentage of participants (45.6%), followed by 

low medical and high medical centers (21.7% and 21.0%, 

respectively), and lastly nonmedical centers (11.7%).

Organizational Characteristics

Average capacity and average daily attendance

Figure 1 shows the average capacity and average daily 

attendance nationally and by level of medical service 

provision. Across all centers, the average capacity was 65.7 

participants and the average daily attendance was 42.0 

participants. Overall increases were observed for average 

capacity and average daily attendance by increasing level of 

medical service provision. The average capacity increased 

from 51.3 participants among nonmedical centers and 52.7 

participants among low medical centers to 73.0 participants 

among moderate medical centers to 90.5 participants 

among high medical centers. The average daily attendance 

increased from 34.2 participants for nonmedical ADSCs and 

31.0 participants for low medical centers to 46.7 participants 
NATIONAL CENTER FOR HEALTH STATISTICS 6 Series 3, Number 45

Staffing levels

Figure 3 shows the staffing levels (i.e., HPPD) by level of 

medical service provision. Nationally, total staffing (RN, LPN 

or LVN, aide, social worker, and activity staff) levels were 2 

hours and 23 minutes (2.39 HPPD). Staffing levels were 55 

minutes (0.92 HPPD) for aides, 43 minutes (0.72 HPPD) for 

activities staff, 23 minutes (0.38 HPPD) for RNs, 13.2 minutes 

(0.22 HPPD) for LPNs or LVNs, and 8 minutes (0.14 HPPD) for 

social workers.

An overall decrease in total staffing levels was observed by 

increasing level of medical service provision—2 hours and 

10 minutes (2.16 HPPD) among nonmedical centers, 2 hours 

and 50 minutes (2.83 HPPD) among low medical centers, 2 

hours and 22 minutes (2.36 HPPD) among moderate medical 

centers, and 1 hour and 44 minutes (1.73 HPPD) among high 

medical centers. This overall decrease is largely explained by 

less aide time for high medical centers and higher activities 

staffing levels among nonmedical and low medical centers 

compared with moderate and high medical centers.

Compared with nonmedical centers, centers with low, 

moderate, and high medical provision had increased RN and 

LPN or LVN staffing levels. For RNs, staffing levels increased 

from 10 minutes (0.16 HPPD) among nonmedical centers 

to 26 minutes (0.44 HPPD and 0.43 HPPD) among low and 

moderate centers, and 23 minutes (0.38 HPPD) for high 

medical centers. For LPNs or LVNs, staffing levels increased 

for moderate medical to 62.6 participants for high medical 

centers.

Medicaid licensure, for-profit ownership, and 

chain affiliation

Figure 2 shows the percentage of ADSCs that were licensed 

by Medicaid and under for-profit ownership, nationally and 

by level of medical service provision. Among all ADSCs in 

the United States, 77.1% were licensed by Medicaid and 

44.7% were for profit. Overall increases were observed 

in the percentage of Medicaid-certified ADSCs and the 

percentage of for-profit ADSCs by increasing level of medical 

service provision. The percentage of ADSCs with Medicaid 

certification increased from 53.5% among nonmedical to 

69.8% among low medical to 86.9% among moderate medical 

to 92.7% among high medical centers. The percentage of 

for-profit centers decreased from 37.8% to 33.8% among 

nonmedical and low medical centers, respectively, but 

increased to 49.4% among moderate medical centers, and 

to 63.4% among high medical centers.

The percentage of ADSCs owned by a chain was higher 

among high medical centers (47.6%) compared with 41.4% 

among low medical and moderate medical centers (Table 2). 

However, the difference between high medical centers and 

nonmedical centers was not significant (47.6% and 43.8%, 

respectively).

 

Figure 1. Average capacity and average daily attendance of adult day services center participants, overall and 

by level of medical service provision: United States, 2016

NOTES: Average capacity is the maximum number of participants allowed at the center. This may be called the allowable daily capacity and is usually determined by law or by fire 

code, but may also be a program decision. A statistically significant increase by increasing level of medical service provision was found for all characteristics included in this figure. 

Figure excludes cases with missing data. Average daily attendance is the average daily number of participants who attended the center based on a typical week. 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016
 
Series 3, Number 45 7 NATIONAL CENTER FOR HEALTH STATISTICS

 

Figure 2. Percentage of adult day services centers by Medicaid licensure and for-profit ownership, overall and 

by level of medical service provision: United States, 2016

Figure 3. Average staff hours per participant per day, overall and by level of medical service provision: 

United States, 2016

 

 

 

 

 

 

NOTES: Medicaid licensure includes centers that were authorized or set up to participate in Medicaid (Medicaid state plan, waiver, or managed care) or part of a Program of 

All-Inclusive Care for the Elderly. For-profit centers are those that self-identified with "private, for profit" or "publicly traded company or limited liability company (LLC)" ownership. 

A statistically significant increase by increasing level of medical service provision was found for all characteristics included in this figure. Figure excludes cases with missing data. 

Percentages are based on unrounded estimates. 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 

1Statistically significant increase by increasing level of medical service provision.

2Statistically significant decrease by increasing level of medical service provision. 

NOTES: Employee and contract staff are included for all staff types. Aides refer to certified nursing assistants, home health aides, home care aides, personal care aides, personal 

care assistants, and medication technicians or medication aides. Average hours per participant per day were computed by multiplying the number of full-time equivalent employees 

for the staff type by 35 hours, and dividing by average daily attendance of participants and by 5 days. A statistically significant decrease by increasing level of medical service 

provision was found for the total staff level estimates. Figure excludes cases with missing data. Rates are based on unrounded estimates and may not add to totals due to rounding. 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 
NATIONAL CENTER FOR HEALTH STATISTICS 8 Series 3, Number 45

from 4 minutes in nonmedical centers (0.06 HPPD) to 

16 minutes (0.27 HPPD and 0.26 HPPD) among low and 

moderate medical centers to 11 minutes (0.19 HPPD) among 

high medical centers. Aide staffing levels increased from 44 

minutes (0.74 HPPD) among nonmedical centers to 1 hour 

and 5 minutes (1.09 HPPD) among low medical centers and 

58 minutes (0.96 HPPD) among moderate medical centers, 

and then decreased to 41 minutes (0.68 HPPD) among high 

medical centers.

An overall decrease was observed by increasing level of 

medical service provision for activities staff, from 1 hour 

and 3 minutes (1.05 HPPD) among nonmedical centers to 55 

minutes (0.91 HPPD) among low medical centers to 34

 minutes (0.56 HPPD) among moderate medical centers to 

20 minutes (0.34 HPPD) among high medical centers.

Sources of revenue

About 59.7% of all revenue from paid participant fees among 

all centers was from Medicaid; followed by 14% of revenue 

from out-of-pocket spending; 12.8% from other federal, 

state, or local sources; 3.9% from “other” sources; 3.8% 

from VA; 2.3% from Medicare; 1.8% from Older Americans 

Act funding; and 1.7% from private insurance (Figure 4).

An overall increase was observed by increasing level of 

medical service provision in the percentage of Medicaid, 

Medicare, and VA revenue. The percentage of Medicaid 

 

 

 

 

 

 

 

Figure 4. Percentage of revenue from paid participant fees, overall and by level of medical service provision: 

United States, 2016

1Statistically significant decrease by decreasing level of medical service provision

2Statistically significant increase by increasing level of medical service provision. 

NOTES: Figure excludes cases with missing data. Percentages are based on unrounded estimates and may not sum to 100 due to rounding. 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 
Series 3, Number 45 9 NATIONAL CENTER FOR HEALTH STATISTICS

revenue increased from 47.2% and 50.2% among nonmedical 

and low medical centers to 65.4% among moderate medical 

centers to 79.5% among high medical centers. Medicare 

revenue increased from 0.5% among nonmedical centers to 

1.5% among low medical centers to 3.6% among moderate 

medical centers, but decreased slightly to 2.3% among high 

medical centers. Similarly, VA revenue increased from 1.4% 

among nonmedical centers to 4.4% among low medical 

centers to 4.7% among moderate medical centers, before 

dipping to 2.6% among high medical centers.

Overall decreases were observed by increasing level of 

medical service provision for out-of-pocket spending; 

other local, state, and federal government sources; “other” 

sources; Older Americans Act funding; and private insurance. 

The percentage of revenue from out-of-pocket spending 

decreased from 16.9% among nonmedical centers and 

18.8% among low medical centers to 11.9% among moderate 

medical centers to 6.4% among high medical centers. 

Revenue from other federal, state, or local government 

sources decreased from 21.6% among nonmedical centers to 

16.6% among low medical centers to 8.7% among moderate 

medical centers to 5.6% among high medical centers.

Electronic health records and health information 

exchange

Of all ADSCs, 23.9% used EHRs and 9.2% used HIE with 

physicians, hospitals, or pharmacies (Figure 5). Overall 

increases were observed by increasing level of medical 

service provision for both the use of EHRs and HIE. About 

9.8% of nonmedical ADSCs used EHRs, which increased 

to 17.9% among low medical centers, to 31.2% among 

moderate and 32.7% among high medical centers. About 

2.8% of nonmedical centers used HIE with physicians, 

pharmacies, or hospitals, which increased to 6.2% among 

low medical centers, to 13.3% and 11.5% among moderate 

and high medical centers, respectively.

Specialization

Centers that specialized in meeting the need of one or 

more diagnoses or disabilities nationally totaled 22.4% 

of all centers (Table 2). An overall decrease was observed 

by increasing level of medical service provision for the 

percentage of ADSCs that were specialized. Almost 40% of 

nonmedical centers were specialized, compared with 28.7% 

among low medical centers and 13.4% and 14.0% among 

moderate medical and high medical centers, respectively.

Of the 22.4% of specialized centers, 70.6% specialized 

in meeting the needs of participants with IDD, 44.8% in 

Alzheimer disease or other dementias, 20.5% in severe 

 

 

Figure 5. Percentage of adult day services centers that used electronic health records and health information 

exchange, overall and by level of medical service provision: United States, 2016

NOTES: A statistically significant increase by increasing level of medical service provision was found for all characteristics included in this figure. Figure excludes cases with missing 

data. Percentages are based on unrounded estimates.
 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 
NATIONAL CENTER FOR HEALTH STATISTICS 10 Series 3, Number 45

mental illness, 20.1% in post-stroke disorders, and 11.5% in 

multiple sclerosis (Figure 6).

Among the centers that specialized, an overall increase was 

observed by increasing level of medical service provision 

for specialization in Alzheimer disease or other dementias, 

post-stroke disorders, severe mental illness, and multiple 

sclerosis. The percentage of ADSCs that specialized in 

Alzheimer disease or other dementias, severe mental illness, 

and multiple sclerosis was lower for nonmedical and low 

medical centers compared with moderate medical and high 

medical centers. About 36.9% and 41.7% of nonmedical and 

low medical centers specialized in Alzheimer disease or other 

dementias compared with 55.1% and 57.3% of moderate 

and high medical centers, respectively. The percentage of 

centers that specialized in post-stroke disorders increased 

from 9.5% among nonmedical centers to 18.0% among low 

medical centers to 28.6% among moderate medical centers 

to 41.7% among high medical centers. The percentage of 

centers that specialized in severe mental illness increased 

from 13.2% among nonmedical centers and 16.0% among 

low medical centers to 34.1% among moderate medical 

centers and 27.0% among high medical centers. Similarly, the 

percentage of centers that specialized in multiple sclerosis 

increased from 5.9% and 8.4% among nonmedical centers 

and low medical centers, respectively, to 18.5% and 24.6% 

among moderate medical centers and high medical centers, 

respectively.

An overall decrease was observed by increasing level of 

medical service provision for ADSCs that specialized in IDD. 

However, the percentage of nonmedical, low medical, and 

high medical centers that specialized in IDD were similar 

(73.1%, 73.7%, and 67.5%, respectively), but slightly higher 

than the percentage of moderate medical centers that 

specialized in IDD (63.6%).

Services provided

More than one-half of all ADSCs nationally provided daily 

roundtrip transportation (80.7%), skilled nursing services 

(64.6%), transportation for medical or dental appointments 

(52.7%), and social work services (52.3%) (Figure 7). Less 

than one-half of all centers provided any therapeutic (46.9%), 

mental health (33.9%), or pharmacy services (30.1%).

An overall increase was observed by increasing level of 

medical service provision for all selected services provided 

either by center employees or arrangement with outside 

vendors. Percentages were different between all levels of 

medical service provision for daily roundtrip transportation, 

transportation to medical appointments, therapeutic, social 

work, skilled nursing, mental health, pharmacy, and dietary 

services. Compared with 14.0% among nonmedical centers, 

the provision of skilled nursing services increased to 50.7% 

among low medical, 86.8% among moderate medical, and 

91.7% among high medical. The provision of any therapeutic 

Figure 6. Percentage of specialized adult day services centers by specialization, overall and by level of medical 

service provision: United States, 2016

 

 

 

1Statistically significant decrease by increasing level of medical service provision.

2Statistically significant increase by increasing level of medical service provision. 

NOTES: Specialized centers are those that serve only participants with a particular diagnosis, condition, or disability. The numerator for this figure is the number of centers that 

specialized in the diagnosis, condition, or disability, and the denominator is the number of centers that indicated they were specialized. Overall, 22.4% of adult day services centers 

provided specialized services in 2016. Figure excludes cases with missing data for each of the specializations listed, as well as any cases with information missing for whether or not 

the center offered any specialized services. Percentages are based on unrounded estimates. 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 
Series 3, Number 45 11 NATIONAL CENTER FOR HEALTH STATISTICS

Figure 7. Percentage of adult day services centers that provided selected services, overall and by level of 

medical service provision: United States, 2016

 

NOTES: For the purposes of this report, provision of services is defined as those provided by center employees or through arrangement with an outside vendor. A statistically 

significant increase by increasing level of medical service provision was found for all services included in this figure. Figure excludes cases with missing data. Percentages are based 

on unrounded estimates.
 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 
NATIONAL CENTER FOR HEALTH STATISTICS 12 Series 3, Number 45

services increased from 14.2% among nonmedical centers to 

35.2% among low medical centers to 59.3% among moderate 

medical centers and to 76.6% among high medical centers.

Distribution of Participant Characteristics 

at the Center Level (Case-Mix)

Sex

Overall, 58.2% of participants were female and 41.8% 

of participants were male in 2016 (Table 2). An overall 

increase was observed by increasing level of medical service 

provision for the percentage of female participants, and a 

corresponding overall decrease by increasing level of medical 

service provision for male participants. The percentage of 

female participants increased from 53.2% among nonmedical 

centers to 55.7% among low medical centers and to 59.8% 

and 60.2% of participants among moderate medical centers 

and high medical centers, respectively.

Participant age

In 2016, the majority of participants were aged 65 or over 

(62.7%). About 20.3% of participants were between the ages 

of 65 and 74, 26.0% of participants were between the ages 

of 75 and 84, and 16.4% of participants were aged 85 or over 

(Figure 8).

Overall decreases were observed for the percentage of 

participants aged 18–44 and 45–54 by increasing level of 

medical service provision. The percentage of participants 

aged 18–44 decreased from 33.4% among nonmedical 

centers to 21.5% among low medical centers to 10.7% 

among moderate medical centers and to 7.8% among 

high medical centers. The percentage of participants aged 

45–54 decreased from 13.2% among nonmedical centers to 

11.2% among low medical centers to 7.6% and 7.5% among 

moderate medical and high medical centers, respectively.

Overall increases were observed by increasing level of 

medical service provision for the percentage of participants 

aged 65–74, 75–84, and 85 and over. The percentage of 

participants aged 65–74 increased from 14.7% among 

nonmedical and 18.5% among low medical centers to 21.8% 

and 22.1% among moderate medical and high medical 

centers, respectively. The percentage of participants aged 

75–84 increased from 16.3% among nonmedical to 20.4% 

among low medical to 28.7% among moderate medical and 

to 31.3% among high medical centers. The percentage of 

participants aged 85 and over increased from 9.8% among 

nonmedical and 14.4% among low medical centers to 18.2% 

among both moderate and high medical centers.

 

 

 

 

 

Figure 8. Percentage of participants in adult day services centers by age, overall and by level of medical 

service provision: United States, 2016

1Statistically significant decrease by increasing level of medical service provision.

2Statistically significant increase by increasing level of medical service provision. 

NOTES: Denominator used to calculate percentages of participants was the number of participants enrolled on a given day in 2016. Age category "17 and under" is not shown 

above and represents 0.1% of the population of participants nationally. Percentages are based on unrounded estimates and may not sum to 100 due to rounding. Figure excludes 

cases with missing data. 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 
Series 3, Number 45 13 NATIONAL CENTER FOR HEALTH STATISTICS

Participant race and ethnicity

Overall, 42.1% of participants were non-Hispanic white 

and the majority (57.9%) of participants were of a race 

and ethnicity other than non-Hispanic white; 22.6% were 

Hispanic, 19.9% were non-Hispanic other, and 15.3% were 

non-Hispanic black (Figure 9).

An overall increase was observed by increasing level of 

medical service provision for the percentage of participants 

that were Hispanic and non-Hispanic other. The percentage 

of Hispanic participants increased from 19.6% among 

nonmedical centers and 20.0% among low medical centers to 

23.1% among moderate medical centers and 25.8% among 

high medical centers. The percentage of non-Hispanic other 

participants was 17.5% among nonmedical centers, 13.8% 

among low medical centers, and 19.9% among moderate 

medical centers, which increased to 27.7% among high 

medical centers.

However, an overall decrease was observed by increasing 

level of medical service provision for the percentage of nonHispanic white and non-Hispanic black participants. The 

percentage of non-Hispanic white participants was higher 

for nonmedical and low medical centers (48.5% and 50.5%, 

respectively) compared with 40.4% among moderate medical 

and 33.6% among high medical centers. The percentage 

of non-Hispanic black participants was higher for low 

medical and moderate medical centers (15.5% and 16.6%, 

respectively) compared with 14.3% among nonmedical and 

12.9% among high medical centers.

Participant diagnoses

About 31.4% and 30.9% of participants were diagnosed with 

diabetes and Alzheimer disease or other dementias, 28.2% 

of participants were diagnosed with IDD or depression, 

27.1% of participants were diagnosed with heart disease, 

and 9.3% of participants were diagnosed with severe mental 

illness in 2016 (Figure 10).

An overall increase was observed by increasing level of 

medical service provision for the percentage of participants 

with a diagnosis of diabetes, Alzheimer disease or other 

dementias, depression, heart disease, and severe mental 

illness, but an overall decrease by increasing level of medical 

service provision for participants diagnosed with IDD. The 

percentage of participants with diabetes increased from 

15.9% among nonmedical centers to 22.0% among low 

medical centers to 35.4% among moderate medical centers 

to 40.6% among high medical centers. The percentage of 

participants with a diagnosis of Alzheimer disease or other 

dementias increased from 21.2% among nonmedical centers 

to 33.4% of participants among low medical centers and 

33.5% of participants among moderate medical centers, and 

decreased slightly to 28.2% among high medical centers. 

The percentage of participants with depression increased 

from 19.2% among nonmedical centers to 23.1% among low 

Figure 9. Percentage of participants in adult day services centers by race and Hispanic origin, overall and by 

level of medical service provision: United States, 2016

 

 

 

 

Statistically significant decrease by increasing level of medical service provision.

2Statistically significant increase by increasing level of medical service provision. 

NOTES: Denominator used to calculate percentages of participants was the number of participants enrolled on a given day in 2016. Percentages are based on unrounded estimates 

and may not sum to 100 due to rounding. Figure excludes cases with missing data. Non-Hispanic other includes non-Hispanic American Indian or Alaska Native, non-Hispanic 

Asian, non-Hispanic Native Hawaiian or Other Pacific Islander, non-Hispanic of two or more races, and unknown race and ethnicity. 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 

1
NATIONAL CENTER FOR HEALTH STATISTICS 14 Series 3, Number 45

medical centers to 29.7% among moderate medical centers 

to 34.6% among high medical centers. The percentage 

of participants with heart disease increased from 9.2% 

among nonmedical centers to 19.2% among low medical 

centers to 31.1% among moderate medical centers to 36.2% 

among high medical centers. The percentage of participants 

with severe mental illness increased from 6.6% among 

nonmedical centers and 6.8% among low medical centers to 

10.2% among moderate medical centers and 11.2% among 

high medical centers. The percentage of participants with 

IDD decreased from 60.0% among nonmedical centers to 

42.2% among low medical centers to 19.1% among moderate 

medical centers to 15.5% among high medical centers.

Participants with Medicaid as payer source

Among all participants, 65.8% used Medicaid to pay for 

any services (Table 2). An overall increase was observed 

by increasing level of medical service provision for the 

percentage of participants who had any services paid for 

by Medicaid. The percentage of participants using Medicaid 

increased from 50.6% among nonmedical centers to 56.8% 

among low medical centers to 68.4% among moderate 

medical centers to 78.5% among high medical centers.

Figure 10. Percentage of participants in adult day services centers diagnosed with selected conditions, overall 

and by level of medical service provision: United States, 2016

Statistically significant increase by increasing level of medical service provision.

2Statistically significant decrease by increasing level of medical service provision.
 

NOTES: Denominator used to calculate percentages of participants was the number of participants enrolled on a given day in 2016. Figure excludes cases with missing data. 

Percentages are based on unrounded estimates. 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 

1
Series 3, Number 45 15 NATIONAL CENTER FOR HEALTH STATISTICS

Figure 11. Percentage of participants in adult day services centers needing any assistance with activities of 

daily living, overall and by level of medical service provision: United States, 2016

Participant activities of daily living

Among all participants nationally, 45.9% of participants 

needed assistance with walking, 38.8% with bathing, 36.2% 

with dressing, 33.5% with toileting, 28.5% with transferring 

in and out of a chair, and 23.2% with eating (Figure 11).

An overall increase was observed in the percentage of 

participants needing assistance by increasing level of medical 

service provision for all ADLs. Percentages were different 

between all levels of medical service provision for walking, 

bathing, dressing, and transferring. For toileting and eating, 

though differences were observed between some levels of 

medical service provision, no increase was observed in the 

percentage of participants needing assistance by increasing 

level of medical service provision.

Participant living arrangements

Overall, 51.7% of participants lived in a private residence 

with relatives, 20.0% lived in a private residence alone, 

16.2% in assisted living or residential care, and 11.2% lived 

in a private residence with nonrelative(s), had other living 

arrangements, or lived in a nursing home (Figure 12).

An overall increase was observed by increasing level of 

medical service provision for the percentage of participants 

who lived in a private residence alone, from 10.5% and 12.9% 

NOTES: Denominator used to calculate percentages of participants was the number of participants enrolled on a given day in 2016. A statistically significant increase by increasing 

level of medical service provision was found for all characteristics included in this figure. Figure excludes cases with missing data. Percentages are based on unrounded estimates. 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 
NATIONAL CENTER FOR HEALTH STATISTICS 16 Series 3, Number 45

among nonmedical and low medical centers to 22.7% and 

26.6% among moderate and high medical centers. An overall 

decrease was observed by increasing level of medical service 

provision for the percentage of participants in assisted living 

or residential care, from 25.5% among nonmedical centers 

to 19.2% among low medical centers to 14.2% among 

moderate medical centers and 12.4% among high medical 

centers.

The percentage of participants who lived in a private 

residence with nonrelative(s) was similar between 

nonmedical, low medical, and high medical centers (5.8%, 

6.3%, and 4.9%, respectively).

Participant adverse events

Among all participants, 7.8% had a fall, 7.2% had an 

emergency department visit in the last 90 days, and 4.5% had 

an overnight hospitalization in the last 90 days (Figure 13). 

An overall increase was observed by increasing level of 

medical service provision for the percentage of participants 

that had a fall, emergency department visit, and overnight 

hospitalization.

The percentage of participants with a fall increased from 

4.2% among nonmedical centers to 6.6% among low medical 

centers to 9.1% among moderate medical and 8.1% among 

high medical centers. The percentage of participants with an 

emergency department visit increased from 4.0% and 5.9% 

among nonmedical and low medical centers, respectively, 

to 8.2% among moderate medical and high medical centers. 

The percentage of participants with a hospitalization 

increased from 2.2% among nonmedical centers to 3.5% in 

low medical centers to 5.3% among moderate medical and 

4.9% in high medical centers.

Geographic Characteristics

U.S. Census region

About 32.3% of ADSCs were located in the South, 30.7% were 

located in the West, 20.2% were located in the Northeast, 

and 16.8% were located in the Midwest (Figure 14). An 

overall increase was observed by increasing level of medical 

service provision for the percentage of centers located in 

the South and Northeast. The percentage of centers in the 

South increased from 22.2% and 26.7% among nonmedical 

and low medical centers to 40.4% among moderate medical 

and 32.7% among high medical centers. The percentage 

of centers in the Northeast increased from 12.3% among 

nonmedical centers and 14.2% among low medical centers 

to 21.8% among moderate medical centers to 38.7% among 

high medical centers.

An overall decrease was observed by increasing level of 

medical service provision for the percentage of centers 

located in the West and Midwest. The percentage of centers 

 

 

 

 

 

 

Figure 12. Percentage of participants in adult day services centers among selected living arrangements, overall 

and by level of medical service provision: United States, 2016

1Statistically significant decrease by increasing level of medical service provision.

2Statistically significant increase by increasing level of medical service provision. 

NOTES: Denominator used to calculate percentages of participants was the number of participants enrolled on a given day in 2016. Percentages are based on unrounded estimates 

and may not sum to 100 due to rounding. Figure excludes cases with missing data. 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 
Series 3, Number 45 17 NATIONAL CENTER FOR HEALTH STATISTICS

in the West was higher among nonmedical centers (54.3%), 

which decreased to 33.6% among low medical centers and 

to 21.5% and 23.1% among moderate medical and high 

medical centers. About 11.2% of centers in the Midwest 

were nonmedical, which increased to 25.5% for low medical 

centers, and decreased to 16.3% among moderate medical 

centers and to 5.4% among high medical centers.

Metropolitan statistical area

An overall increase was observed by increasing level of 

medical service provision in the percentage of ADSCs in 

metropolitan statistical areas (Figure 15), which ranged 

from 85.3% among nonmedical centers to 81.6% among low 

medical centers to 85.2% among moderate medical centers 

to 89.9% among high medical centers. However, an overall 

decrease was observed by increasing level of medical service 

provision in centers located in micropolitan statistical areas: 

11.2% among nonmedical and 11.7% among low medical 

centers compared with 9.9% among moderate medical and 

6.4% among high medical centers.

State variation

Figure 16 shows a U.S. map of the quartile distribution 

of moderate and high medical ADSCs for the states that 

reported this information. Eight states were in the highest 

quartile, where greater than 68.2% to 100% of ADSCs were 

moderate or high medical centers, including Kentucky, 

Louisiana, Maryland, New Hampshire, New Jersey, North 

Carolina, Texas, and Virginia. Eight states were in the next 

highest quartile, where greater than 50.6% to 68.2% of 

centers were moderate medical or high medical, including 

Connecticut, Georgia, Missouri, Nebraska, Nevada, New 

York, Oklahoma, and South Carolina. Eight states were in 

the next quartile, where greater than 33.5% to 50.6% of 

centers were moderate medical or high medical, including 

California, Illinois, Indiana, Minnesota, North Dakota, Ohio, 

Pennsylvania, and Tennessee. Nine states were in the 

lowest quartile (18.2%–33.5%) of the percent distribution 

of moderate medical or high medical centers, including 

Arizona, Arkansas, Colorado, Florida, Hawaii, Idaho, Iowa, 

Michigan, and Wisconsin.

Figure 13. Percentage of participants in adult day services centers with falls, emergency department visits, and 

overnight hospitalizations in the last 90 days, overall and by level of medical service provision: 

United States, 2016

 

 

 

NOTES: Denominator used to calculate percentages of participants was the number of participants enrolled on a given day in 2016. A statistically significant increase by increasing 

level of medical service provision was found for all characteristics included in this figure. Figure excludes cases with missing data. Percentages are based on unrounded estimates. 

All characteristics included in this figure were measured using a scale of 90 days before the survey. For example, respondents were asked, "As best you know, about how many of 

your current participants had a fall in the last 90 days?" 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 
NATIONAL CENTER FOR HEALTH STATISTICS 18 Series 3, Number 45

 

 

 

Figure 15. Percentage of adult day services centers according to metropolitan statistical area status, overall 

and by level of medical service provision: United States, 2016

Figure 14. Percentage of adult day services centers among U.S. Census regions, overall and by level of medical 

service provision: United States, 2016

 

 

1

1Statistically significant decrease by increasing level of medical service provision.

2Statistically significant increase by increasing level of medical service provision.
 

NOTES: Percentages are based on unrounded numbers and may not sum to 100 due to rounding. Figure excludes cases with missing data. 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 

Statistically significant decrease by increasing level of center medicalization.

2Statistically significant increase by increasing level of center medicalization. 

NOTES: Metropolitan statistical areas and micropolitan statistical areas are geographic entities delineated by the Office of Management and Budget for use by federal statistical 

agencies in collecting, tabulating, and publishing federal statistics. A metropolitan statistical area contains a core urban area of 50,000 or more population, and a micropolitan 

statistical area contains an urban core of at least 10,000 (but less than 50,000) population. Each metropolitan or micropolitan statistical area consists of one or more counties and 

includes the counties containing the core urban area, as well as any adjacent counties that have a high degree of social and economic integration (as measured by commuting to 

work) with the urban core (see reference 23 in this report). Percentages are based on unrounded estimates. Percent distributions may not add to 100 because of rounding. 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 
Series 3, Number 45 19 NATIONAL CENTER FOR HEALTH STATISTICS

Discussion

Organizational Characteristics

ADSCs with higher levels of medical service provision had 

higher average capacity and average daily attendance 

than those that were less medically oriented. Compared 

with nonmedical centers, more medically oriented ADSCs 

had higher licensed nurse staffing (RNs and LPNs or LVNs) 

levels, reflecting the fact that a more highly skilled nursing 

workforce is needed to address medical needs. Activity 

staffing decreased as the level of medical service provision 

increased, likely due to their focus on social and recreational 

activities rather than medical care. Total staffing HPPD fell 

by more than one-half from low medical to high medical 

centers. This is largely reflective of the 74% decrease in 

activities staff HPPD from low to high medical centers. States 

tend to regulate components of medical-based providers at a 

more stringent level than nonmedical providers, particularly 

when it comes to licensed nurse staffing requirements (7). 

One study of nursing home staffing levels and state staffing 

requirements found that increases in state licensed nurse 

staffing requirements led to decreases in other support 

staffing levels (24).

A higher percentage of moderate and high medical ADSCs 

were licensed by Medicaid, had a greater share of revenue 

from Medicaid, and a greater percentage of participants using 

Medicaid, compared with the less medically oriented ADSCs. 

This finding is reflective of Medicaid’s emphasis on medical 

needs rather than social or recreational needs. Medicaid 

participants have complex health needs with poorer health 

outcomes, are more racially and ethnically diverse, and are 

often more economically disadvantaged than other users of 

long-term care (25). Additionally, many participants aged 65 

and over may be Medicaid and Medicare eligible (i.e., dual 

eligible)—a well-researched segment of the institutional 

and community-based LTSS population. They are a group 

of interest because, while they are a small fraction of 

the total users of Medicaid, they represent a majority of 

Medicaid dollars (26). The percentage of ADSCs that were 

for profit, used EHRs, and exchanged health information 

with physicians, pharmacies, or hospitals also increased by 

increasing level of medical service provision.

Figure 16. Percentage of moderate and high medical adult day services centers, by state: 

United States, 2016

 

 

 

 

 

 

NOTES: Percentages are based on unrounded estimates and were estimated by summing the number of moderate medical and high medical centers in each state and calculating 

a percentage based on the total number of centers in each state. "Not reported" indicates that the state estimate could not be reported because it does not meet confidentiality 

standards.
 

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016. 
NATIONAL CENTER FOR HEALTH STATISTICS 20 Series 3, Number 45

The percentage of centers that specialized in meeting the 

needs of participants with a particular diagnosis or disability 

decreased by more than one-half from nonmedical to high 

medical. However, among the ADSCs that indicated they 

were specialized, the percentage of centers that specialized 

in a particular diagnosis or disability increased by level of 

medical service provision for each of the specializations, 

with the exception of IDD and Alzheimer disease or other 

dementias. Evidence suggests that ADSCs that specialize in 

participants with a diagnosis of IDD typically serve a less 

functionally impaired and younger population compared 

with non-IDD centers (16). In many states, such as California, 

centers that serve the IDD population are generally focused 

on socialization or recreational services rather than medical 

services (7).

Increases were observed by level of medical service provision 

in the percentage of ADSCs that provided the selected 

services, in particular skilled nursing, any therapeutic 

services, and transportation for medical or dental 

appointments. This finding reflects that, compared with 

other centers, ADSCs that self-identify as being designed to 

meet the medical needs of participants are more likely to 

provide these medically oriented services.

Distribution of Participant Characteristics 

at the Center Level (Case-Mix)

High medical ADSCs had a higher percentage of racial 

and ethnic minorities and participants aged 65 and over. 

Compared with other LTSS providers, ADSCs consistently 

serve a higher percentage of minorities (4,27). Higher 

percentages of participants with diagnoses needing more 

medical care, such as diabetes, depression, heart disease, 

and severe mental illness, were found in moderate and high 

medical centers. However, the percentage of participants 

diagnosed with IDD in high medical centers was lower, 

consistent with the finding that a lower percentage of 

centers that specialized in IDD were high medical centers.

A higher percentage of participants that needed assistance 

with each of the ADLs were in moderate and high medical 

centers. The percentage of participants that lived alone in 

a private residence increased as the level of medical service 

provision increased; this may indicate that this population 

may be more likely to rely on ADSCs to meet their needs 

in the absence of support at home. The percentage of 

participants living in an assisted living or similar residential 

care community decreased by increasing level of medical 

service provision, potentially indicating that ADSCs may 

be used more for social and recreational services rather 

than medical. The percentage of participants with any 

services paid for by Medicaid was higher in high medical 

centers, which parallels the findings of a higher percentage 

of Medicaid licensure and Medicaid revenue. Increases 

in the percentage of participants with an adverse event, 

such as falls, emergency department visits, and overnight 

hospitalizations increased with increasing level of medical 

service provision.

Geographic Characteristics

The percentage of centers located in the South and Northeast 

census regions increased by increasing level of medical 

service provision and decreased in the West and Midwestern 

regions. These differences by region are likely driven by 

differences in funding and regulations by state. Additionally, 

there are differences in sources of public funding by state, 

particularly for public sources of funding such as Medicaid, 

to meet the needs of individuals with less medically focused 

diagnoses, such as IDD. Also, the percentage of centers located 

in micropolitan statistical areas decreased by increasing 

level of medical service provision, while the percentage of 

centers located in metropolitan statistical areas increased by 

increasing level of medical service provision.

The percentage of moderate to high medical ADSCs varied 

considerably among the states that reported information on 

ADSCs, ranging from a low of 18.2% in Idaho to a high of 100% 

in New Hampshire. As further evidence of the variability 

across states, a higher percentage of moderate and high 

medical centers were located in the Northeast and South 

census regions compared with nonmedical and low medical 

centers. These state estimates reflect the great variability in 

levels of care within the adult day services sector, which is 

governed by a patchwork of unique, state-based approaches 

to meet the needs of their respective populations.

Conclusion

This report provides the most current national and state-level 

estimates of the level of medical service provision among 

ADSCs in the United States as of 2016, describing differences 

in ADSC organizational, participant case-mix, and geographic 

characteristics, between levels of medical service provision 

and by increasing level of medical service provision. The shift 

of LTSS from institutional to HCBS over recent decades has 

unfolded within an intricate and multifaceted health care 

delivery system. This report indicates that adult day providers 

have the capacity to support the social and medical needs of 

participants.

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Series 3, Number 45 23 NATIONAL CENTER FOR HEALTH STATISTICS

Table 1. Weighted number and percentage of adult day services centers and participants, by level of medical 

service provision: United States, 2016

Characteristic Number1 95% CI Percent2 95% CI

All centers 4,560 4,550 4,570 ... ... ...

Nonmedical centers 740 700 780 16.1 14.8 17.5

Low medical centers 1,400 1,350 1,440 30.6 28.9 32.4

Moderate medical centers 1,800 1,760 1,860 39.7 37.9 41.5

High medical centers 620 580 650 13.5 12.3 14.9

All participants3 284,300 278,030 290,570 ... ... ...

Participants in nonmedical centers 33,280 30,360 36,000 11.7 10.9 12.5

Participants in low medical centers 61,590 58,410 64,760 21.7 21.0 22.3

Participants in moderate medical centers 129,760 124,050 135,460 45.6 44.6 46.6

Participants in high medical centers 59,680 54,900 64,470 21.0 19.7 22.2

... Category not applicable. 1Estimates are rounded as whole numbers to the nearest 10.

2Percentages are based on unrounded estimates.

3The weighted number of adult day services center participants represents current participants in 2016.

NOTES: CI is confidence interval. Percent distributions may not add to 100 because of rounding.

SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016.
NATIONAL CENTER FOR HEALTH STATISTICS 24 Series 3, Number 45 Characteristic All centers Nonmedical Low medical Moderate medical High 

Center capacity Mean (number) 95% CI Mean (number) 95% CI Mean (number) 95% CI Mean (number) 95% CI Mean (number) 

Average capacity1,2 65.7 64.5 66.9 51.3 48.2 54.5 52.7 50.6 54.8 73.0 71.1 74.9 90.5 

Average daily attendance2 42.0 41.1 42.9 34.2 31.6 36.7 31.0 29.7 32.3 46.7 45.2 48.1 62.6 

Center ownership and licensure Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

Medicaid licensure 77.1 76.2 77.9 53.5 50.5 56.4 69.8 67.9 71.7 86.9 85.6 88.1 92.7 For-profit ownership 44.7 43.6 45.8 37.8 34.8 40.8 33.8 31.9 35.8 49.4 47.7 51.2 63.4 Chain 42.6 41.5 43.8 43.8 40.8 46.9 41.4 39.4 43.4 41.4 39.7 43.2 47.6 

Center staffing levels (hours per participant per day) Mean (number) 95% CI Mean (number) 95% CI Mean (number) 95% CI Mean (number) 95% CI Mean (number) 

Registered nurse 0.38 0.36 0.40 0.16 0.11 0.20 0.44 0.38 0.49 0.43 0.39 0.47 0.38 

Licensed practical or vocational nurse 0.22 0.20 0.24 0.06 0.03 0.09 0.27 0.22 0.31 0.26 0.24 0.29 0.19 Aide 0.92 0.89 0.96 0.74 0.62 0.85 1.09 1.02 1.16 0.96 0.90 1.01 0.68 Social worker 0.14 0.13 0.15 0.15 0.11 0.19 0.13 0.11 0.14 0.15 0.14 0.17 0.15 Activities staff 0.72 0.69 0.75 1.05 0.95 1.16 0.91 0.85 0.97 0.56 0.51 0.60 0.34 All staff 2.39 2.30 2.47 2.16 1.90 2.42 2.83 2.65 3.01 2.36 2.21 2.50 1.73 

Center sources of revenue from paid participant fees2 Mean (percent) 95% CI Mean (percent) 95% CI Mean (percent) 95% CI Mean (percent) 95% CI Mean (percent) 

Medicaid 59.7 58.8 60.6 47.2 44.4 49.9 50.2 48.5 51.9 65.4 64.1 66.6 79.5 

Out-of-pocket payment by the participant or family 14.0 13.5 14.6 16.9 15.2 18.6 18.8 17.7 19.9 11.9 11.2 12.5 6.4 

Other federal, state, or local government 12.8 12.2 13.5 21.6 19.4 23.9 16.6 15.3 18.0 8.7 8.0 9.5 5.6 Other sources 3.9 3.5 4.2 7.9 6.5 9.3 4.4 3.7 5.1 2.5 2.1 2.9 1.7 Veterans Affairs 3.8 3.6 4.0 1.4 1.0 1.7 4.4 4.0 4.9 4.7 4.3 5.0 2.6 Medicare 2.3 2.1 2.6 0.5 0.2 0.8 1.5 1.2 1.8 3.6 3.2 4.1 2.3 Older Americans Act 1.8 1.6 2.0 2.9 2.3 3.5 2.2 1.8 2.6 1.4 1.2 1.6 0.7 Private insurance 1.7 1.5 1.9 1.6 1.1 2.2 1.8 1.5 2.2 1.9 1.5 2.2 1.1 

Center technology use Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

Electronic health record use 23.9 22.9 24.9 9.8 8.2 11.8 17.9 16.4 19.6 31.2 29.5 32.9 32.7 

Any health information exchange with physicians, hospitals, or pharmacies 9.2 8.5 9.9 2.8 1.9 4.0 6.2 5.3 7.4 13.3 12.1 14.6 11.5 

See footnotes at end of table. Table 2. Organizational, participant case-mix, and geographic characteristics of adult day services centers, overall and by le

provision: United States, 2016
Series 3, Number 45 25 NATIONAL CENTER FOR HEALTH STATISTICS Table 2. Organizational, participant case-mix, and geographic characteristics of adult day services centers, overall and by le

provision: United States, 2016—Con. Characteristic All centers Nonmedical Low medical Moderate medical High 

Center specialization in particular diagnoses or disabilities Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

Any specialization 22.4 21.5 23.4 39.5 35.7 43.3 28.7 26.3 31.1 13.4 11.8 15.0 14.0 Intellectual or developmental disability3 70.6 68.3 72.7 73.1 68.7 77.1 73.7 70.1 77.0 63.6 58.7 68.2 67.5 

Alzheimer disease or other dementias3 44.8 42.4 47.3 36.9 32.3 41.8 41.7 37.8 45.6 55.1 50.0 60.1 57.3 Parkinson disease3 21.3 19.3 23.4 12.6 9.6 16.2 17.5 14.6 20.7 33.8 29.3 38.7 33.3 Traumatic brain injury3 20.6 18.6 22.7 15.4 12.0 19.4 20.4 17.3 23.8 26.4 22.2 31.1 22.5 Severe mental illness3 20.5 18.5 22.6 13.2 10.0 17.2 16.0 13.2 19.2 34.1 29.5 39.1 27.0 Post-stroke3 20.1 18.2 22.2 9.5 7.0 12.9 18.0 15.2 21.2 28.6 24.3 33.3 41.7 

Multiple sclerosis3 11.5 9.9 13.2 5.9 4.0 8.6 8.4 6.4 11.0 18.5 15.0 22.6 24.6 

Some other condition3 7.8 6.6 9.3 4.9 3.1 7.7 5.7 4.1 7.8 7.4 5.1 10.5 29.0 

Center services provided by employees or through arrangement Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

Transportation (daily roundtrip) 80.7 79.8 81.6 64.2 61.0 67.3 73.5 71.5 75.4 88.8 87.6 90.0 93.3 Dietary and nutritional 68.0 66.9 69.1 35.1 32.0 38.4 59.4 57.2 61.6 80.8 79.2 82.4 89.4 Skilled nursing 64.6 63.5 65.7 14.0 11.9 16.4 50.7 48.4 52.9 86.8 85.3 88.1 91.7 Transportation (medical) 52.7 51.6 53.8 23.6 20.9 26.5 39.5 37.4 41.8 66.2 64.3 68.0 78.5 

Social work 52.3 51.2 53.4 31.1 28.1 34.3 39.8 37.6 42.0 61.7 59.9 63.5 78.8 

Therapy 46.9 45.7 48.0 14.2 12.0 16.8 35.2 33.0 37.4 59.3 57.4 61.2 76.6 

Mental health 33.9 32.8 35.1 12.9 10.8 15.4 20.6 18.8 22.6 43.2 41.3 45.2 62.5 

Pharmacy 30.1 29.1 31.2 6.5 5.1 8.4 16.7 15.0 18.5 40.8 38.8 42.8 58.3 

Hospice 20.8 19.9 21.8 9.6 7.8 11.8 18.8 17.0 20.7 25.1 23.4 26.9 26.5 

Participant sex Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

Female4 58.2 57.8 58.6 53.2 52.0 54.3 55.7 54.9 56.4 59.8 59.2 60.4 60.2 

Male4 41.8 41.4 42.2 46.8 45.7 48.0 44.3 43.6 45.1 40.2 39.6 40.8 39.8 

Participant age5 Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

18–44 15.1 14.4 15.8 33.4 30.7 36.0 21.5 19.9 23.0 10.7 9.9 11.5 7.8 45–54 9.0 8.6 9.3 13.2 12.0 14.4 11.2 10.4 11.9 7.6 7.1 8.0 7.5 

55–64 13.2 12.8 13.6 12.6 11.6 13.7 14.0 13.0 14.9 13.1 12.6 13.6 12.8 65–74 20.3 19.9 20.8 14.7 13.1 16.3 18.5 17.5 19.5 21.8 21.1 22.4 22.1 75–84 26.0 25.3 26.7 16.3 14.6 18.1 20.4 19.3 21.5 28.7 27.7 29.6 31.3 85 or over 16.4 15.9 16.9 9.8 8.5 11.0 14.4 13.4 15.3 18.2 17.4 18.9 18.2 

Participant race and ethnicity Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

Non-Hispanic white 42.1 41.0 43.2 48.5 45.8 51.3 50.5 48.6 52.4 40.4 38.6 42.2 33.6 

Hispanic 22.6 21.6 23.6 19.6 17.8 21.4 20.0 18.2 21.8 23.1 21.6 24.7 25.8 

Non-Hispanic other6 19.9 18.7 21.2 17.5 14.9 20.0 13.8 12.0 15.5 19.9 18.0 21.9 27.7 

Non-Hispanic black 15.3 14.7 15.9 14.3 12.7 15.9 15.5 14.4 16.5 16.6 15.5 17.6 12.9 

See footnotes at end of table.
NATIONAL CENTER FOR HEALTH STATISTICS 26 Series 3, Number 45 Table 2. Organizational, participant case-mix, and geographic characteristics of adult day services centers, overall and by le

provision: United States, 2016—Con. Characteristic All centers Nonmedical Low medical Moderate medical High 

Participant diagnoses7 Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

Diabetes 31.4 30.6 32.2 15.9 14.2 17.7 22.0 20.7 23.2 35.4 34.4 36.4 40.6 

Alzheimer disease or other dementias 30.9 30.0 31.8 21.2 18.4 23.9 33.4 31.4 35.5 33.5 32.2 34.7 28.2 

Depression 28.2 27.3 29.0 19.2 16.6 21.8 23.1 21.5 24.8 29.7 28.5 30.9 34.6 

Intellectual or developmental disability 28.2 27.0 29.5 60.0 55.6 64.4 42.2 39.7 44.8 19.1 17.7 20.5 15.5 

Heart disease8 27.1 26.2 28.1 9.2 8.0 10.3 19.2 17.8 20.6 31.1 29.8 32.4 36.2 

Severe mental illness 9.3 8.7 9.8 6.6 5.4 7.7 6.8 6.0 7.5 10.2 9.4 11.0 11.2 

Participant activities of daily living Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

Walking 45.9 44.8 47.0 27.1 24.3 30.0 38.7 37.1 40.4 50.0 48.4 51.6 55.3 Bathing 38.8 37.5 40.0 24.5 21.4 27.6 34.3 32.3 36.4 41.2 39.4 42.9 46.3 Dressing 36.2 35.1 37.3 21.0 18.5 23.5 33.8 31.9 35.6 39.2 37.7 40.8 40.8 Toileting 33.5 32.5 34.5 24.4 21.8 27.0 36.2 34.5 38.0 35.5 34.0 36.9 31.7 Transferring in or out of a chair 28.5 27.5 29.6 13.8 12.0 15.7 24.4 23.0 25.7 31.7 30.1 33.2 34.5 Eating 23.2 22.4 24.1 17.7 15.2 20.2 25.5 24.0 27.0 24.8 23.5 26.2 20.7 

Participant living arrangements Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

Live with a relative 51.7 50.4 53.0 53.4 50.0 56.8 54.3 51.8 56.9 52.2 50.3 54.2 46.9 

Private residence alone 20.0 18.7 21.3 10.5 7.8 13.3 12.9 10.7 15.1 22.7 21.0 24.3 26.6 

Assisted living or residential care 16.2 15.1 17.3 25.5 22.0 28.9 19.2 17.0 21.4 14.2 12.5 15.9 12.4 Private residence with nonrelative 5.2 4.8 5.7 5.8 4.6 6.9 6.3 5.1 7.4 4.7 4.1 5.3 4.9 Other living arrangement 4.5 3.7 5.2 4.1 2.3 5.9 4.0 3.0 4.9 3.3 2.3 4.2 7.8 Nursing home 1.5 1.2 1.8 0.3 0.2 0.5 1.9 1.3 2.6 1.9 1.3 2.4 0.9 

Participant Medicaid payment9 Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

Participants with any Medicaid payment 65.8 64.5 67.2 50.6 45.9 55.2 56.8 54.3 59.2 68.4 66.5 70.3 78.5 

Participant use of care and outcomes9 Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

Falls 7.8 7.3 8.3 4.2 3.6 4.8 6.6 6.0 7.1 9.1 8.4 9.9 8.1 Emergency department visits 7.2 6.9 7.4 4.0 3.5 4.4 5.9 5.6 6.2 8.2 7.7 8.6 8.2 Overnight hospitalization 4.5 4.3 4.6 2.2 1.9 2.5 3.5 3.3 3.7 5.3 4.9 5.6 4.9 

Center U.S. Census region Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

South 32.3 32.1 32.4 22.2 20.2 24.3 26.7 25.3 28.3 40.4 39.1 41.7 32.7 West 30.7 30.6 30.8 54.3 51.7 57.0 33.6 31.9 35.3 21.5 20.1 22.9 23.1 Northeast 20.2 20.2 20.3 12.3 10.6 14.1 14.2 13.1 15.4 21.8 20.7 23.0 38.7 Midwest 16.8 16.7 16.9 11.2 9.7 12.8 25.5 24.2 26.8 16.3 15.4 17.3 5.4 

See footnotes at end of table.
Series 3, Number 45 27 NATIONAL CENTER FOR HEALTH STATISTICS Table 2. Organizational, participant case-mix, and geographic characteristics of adult day services centers, overall and by le

provision: United States, 2016—Con. Characteristic All centers Nonmedical Low medical Moderate medical High 

Center metropolitan statistical area status Percent 95% CI Percent 95% CI Percent 95% CI Percent 95% CI Percent 

Metropolitan 84.8 84.0 85.4 85.3 83.2 87.2 81.6 80.1 83.0 85.2 84.0 86.3 89.9 8

Micropolitan 10.2 9.6 10.9 11.2 9.6 13.2 11.7 10.6 13.0 9.9 9.0 11.0 6.4 

Neither 5.0 4.6 5.5 3.5 2.6 4.6 6.7 5.8 7.7 4.9 4.2 5.6 3.6 

1“Average Capacity” is the maximum number of participants allowed at the center. 2Averages are based on unrounded numbers. 3The denominator used for this calculation includes adult day services centers that indicated they provided specialized services; about 22.5% of all centers indicated they were s4Cases with missing data were imputed. 5“17 and under” is not shown and represents 0.1% of the population of participants nationally. 6Includes non-Hispanic American Indian or Alaska Native, non-Hispanic Asian, non-Hispanic Native Hawaiian or Other Pacific Islander, non-Hispanic of two or more races, and 7The percentage of missing data was 11.2% for Alzheimer disease, 14.3% for arthritis, 14.8% for asthma, 15.0% for chronic kidney disease, 15.3% for chronic obstructive pulmon

11.8% for diabetes, 14.1% for heart disease, 13.1% for hypertension, and 15.8% for osteoporosis. 8Heart disease includes congestive heart failure, coronary or ischemic heart disease, heart attack, and stroke. 9Measured using a scale of 90 days before the survey. For example, respondents were asked “As best you know, about how many of your current participants had a fall in the las

NOTES: CI is confidence interval. Percent distributions may not add to 100 because of rounding. Percentages are based on unrounded estimates. SOURCE: National Center for Health Statistics, National Study of Long-Term Care Providers, Adult Day Services Center Survey, 2016.
NATIONAL CENTER FOR HEALTH STATISTICS 28 Series 3, Number 45

Appendix. Technical Notes

To calculate the appropriate design-based variance, 

subpopulation parameters were applied that specified 

the subpopulation variable of interest (y) and any missing 

observations of the selected characteristics of ADSCs and 

participants examined (x). Subpopulation parameters 

were calculated using Stata's subpop( ), or a combination 

of subpop( ) and over( ), in conjunction with the following 

estimation procedures:

svy subpop if y , ( ! =.& x! =. :) mean x, over y ( )

svy subpop if y , ( ! =.& x 1 ! =. : ) ratio x 1 / x2, over y( )

svy subpop if y , ( ! =.& x! =. :) proportion x, over (y )

svy subpop if y , ( ! =. : ) tab y, count ci se

svy subpop if y , ( ) ! =. : total x 
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