Diabetes and adult day health services.

The increase in diabetes and related comorbid conditions among older adults has generated greater demand for health care services. Approximately 18.3 percent (8.6 million) of the U.S. population age 60 and older has diabetes (American Diabetes Association [ADA], 2005).This population is more likely to experience heart attacks, strokes, hypertension, blindness, end-stage renal disease, and lower-limb amputations than their nondiabetic counterparts (Centers for Disease Control and Prevention, 1998; Clark et al., 2001). Expectedly, older adults with diabetes consume more health care resources. Their frequency of physician visits, acute care hospital stays, and placement in extended care facilities surpasses that of those without this disease (Ahmed, Allman, & DeLong, 2003; Balkrishnan et al., 2003). Annual diabetes health care costs reached $92 billion in 2002 and are expected to increase as the number of older adults and the frequency of diabetes both rise above levels ever experienced in the United States (ADA, 2003). As Gilmer and colleagues (2005) suggested, until diabetes is properly managed, health care systems will not be able to control escalating expenses.

Advances in diabetes education and training are improving diabetes self-management and glycemic control outcomes for older adults. Strategies and programs being developed and tested to help older adults age in place with diabetes include flexibility and resistance training (Herriott, Colberg, Parson, Nonnold, & Vinik, 2004), food label nutrition education (Miller, Edwards, Kissling, & Sanville, 2002), problem-solving skills (Robertson, 2003) to address the burden of medication costs (Piette, Heisler, & Wagner, 2004), empowerment interventions (DeCoster & Dabelko, in press), depression care management (Williams et al., 2004), and community-based methods to improve activity (Kochevar, Smith, & Bernard, 2001). Social workers are well positioned to implement these interventions using strategies that are fundamental to social work practice, such as advocacy, case management, community organizing, education, group facilitation, interdisciplinary team coordination, resource brokering, and therapy (DeCoster & Cummings, 2005). Many older adults suffer from advanced stages of diabetes and severe comorbid conditions and therefore need in-depth assistance and higher levels of care. In the past few years, adult care programs have emerged as one possible solution for improving the health status of this at-risk population and for delaying more expensive levels of care, such as nursing facilities. To date, however, little is known about the role of diabetes among clients in this long-term care option. To maximize the effectiveness and cost-savings of adult day programs, coordinators need to understand the unique qualities of their clients with diabetes.

BACKGROUND

This exploratory examination was part of a larger study on factors that influence the length of stay in adult day programs (see Dabelko, 2004). The purpose of this study is to describe adult day program participants with diabetes to document the prevalence of the disease within this population. An understanding of adult day program participants with diabetes provides foundation knowledge for the development of targeted diabetes interventions within this care setting. Adult day services (ADS) are typically state-licensed, community-based, nonprofit programs affiliated with large organizations such as nursing homes, hospitals, or multipurpose senior organizations. According to the Access to Respite Care and Help National Network (ARCH) (ARCH, 2002), ADS programs are designed for community-dwelling older adults needing supportive services during weekdays. ADS services are diverse, targeting functionally and cognitively impaired adults, but typically do not offer intense client supervision. Some are designed as respite programs for full-time caregivers; others address the needs of caregivers working outside the home. ADS programs assist with nutritional, recreational, social, and activities of daily living (ADL) issues. Adult day health programs often offer higher levels of skilled-nursing and rehabilitative care than social day programs. A third variant offers Alzheimer's-specific care. Older adults in adult day programs may be physically, mentally, or functionally impaired, or they may simply need companionship or supervision during part of the day. The programs are structured, usually through a personal care plan, to cover daily needs of each client.

ADS programs have become viable alternatives to institutionally based residential programs, reducing health care costs and representing a growing and significant component of the health care system. As of 2004 more than 4,000 ADS programs existed in the United States, a dramatic rise, due in part to new funding sources such as Medicaid waiver programs (Robert Wood Johnson Foundation [RWJF], 2005). Daily costs range from $25 to $75, with most programs providing services on a sliding fee scale. The daily cost of ADS is significantly less than nursing home care, which ranges from $110 to $350 per day. In Ohio, older adults living at home and participating in the community-based care Medicaid waiver program, in which ADS plays a significant role, saved the health care system more than $40,000 per person per year by avoiding nursing home placements (Ohio Association of Area Agencies on Aging, 2005). Despite older adults' preferences for ADS and its potential savings, institutional-based care continues to receive two-thirds of public long-term care funds (Borrayo, Salmon, Polivka, & Dunlop, 2002). Although advocates claim these preferences and cost savings exist, little is empirically known about the outcomes experienced by individuals who attend adult day programs.

Considering the rise in demand, cost-savings motivation, proliferation of programs, and lack of required national accreditation, experts are concerned about the expanding implementation and quality of ADS. This concern is expressed in the literature as the appropriateness of ADS and the goodness-of-fit with client needs, compared with other care options (Evashwick, 2001; Palley, 2003). Researchers have investigated appropriate-ness across factors associated with client enrollment in and disenrollment from ADS programs (Cox, Reifler, &Yates, 1998; Reifler, Henry, & Cox, 1995; RWJE 2003; Weissert et al., 1990). These factors can include attendance, cessation of need, client demographics, death, financial and social resources, institutionalization, and caregiver characteristics. Although severity of illnesses has been considered (Dabelko & Gregoire, 2005; Fisher & Lieberman, 1999), researchers consistently fail to analyze actual medical diagnoses with enrollment and disenrollment. According to Travis and McAuley (1999), "the emphasis on functional status has been accompanied by a gradual decrease in attention to the medical conditions that long-term clients bring to the service arena" (p. M262). They assert that this emphasis on caring for but not treating the disease has "gone too far," minimizing the chronic illness and related needs, implying that ADS programs have become a form of palliative long-term care. Diabetes is one such chronic disease with special needs and issues. Disease-based interventions within congregate settings such as adult day programs have the potential to be financially responsible and result in higher levels of participant compliance. Having an understanding of the profile of adult day participants with diabetes will lead to more effective intervention planning and implementation.

METHOD

Sample

In February, March, and April 2001, Dabelko collected data from client records of a single nonprofit agency operating five older adult day programs in central Ohio. The programs served clients with diverse racial and economic backgrounds and were located in urban and rural settings. All five programs operated as combined medical and social care models. The subjects included all new intakes from January 1, 1999, to December 31, 2000. There were 295 clients admitted to the programs during this time period. Of these 295 clients, 280 attended the programs after the initial intake. This study was based on those 280 clients.

Measures

Demographics. Demographic variables included gender, age, race, education, language, religious affiliation, and marital status. Race/ethnicity was coded as white and nonwhite. Language was defined as the primary language spoken at home as reported by client or caregiver at intake. Religious preference was defined as religious identification reported by client or caregiver at intake. With limited variability, religious preference was coded as preference or no preference for a particular religion. For ease of analysis, marital status was recoded as single or married. The single category included those who were widowed, divorced, or single.

Mental and Physical Health. Mental health variables included psychological diagnosis and cognitive functioning. The psychological diagnosis was defined as a mental health diagnoses by a physician or the licensed social worker at intake. Mental health diagnosis include anxiety, depression, bipolar disorder, schizophrenia, obsessive--compulsive disorder, and unspecified mental health disorders. The overwhelming majority of the diagnoses were anxiety and depression.

Cognitive functioning was measured using diagnosis and behavioral measures such as forgetfulness/confusion and wandering. It has been argued that diagnosis of a dementing illness with a behavioral impairment measure is a more valid indicator of cognitive functioning than diagnosis alone (Schaie & Willis, 1999). However, because no standard assessment tool was used with all clients, cognitive impairment was probably underestimated in this study.

Physical health measures included prior hospitalization, nursing home stay, ADL and instrumental activities of daily living (IADL), nutrition, and incontinence. Prior hospitalization was measured in the number of times the person was hospitalized in the past three years before intake as reported by client or caregiver. Prior nursing home stay was recorded if it ever occurred before intake as reported by client or caregiver. ADL limitations were measured in seven areas: transfer/mobility, bathing, grooming, dressing, toileting, eating/feeding, and taking medications. Points were given for level of assistance needed per activity: 1 = no help needed, 2 = supervision needed, and 3 = hands-on assistance needed. All cases had at least four of the seven indicators present. Means substitution was used for the missing data. IADL limitations were measured in 11 areas: medication administration, shopping, meal preparation, telephone use, transportation arrangements, ability to take short walks, light housework, laundry, heavy housework, home maintenance, legal/financial management. Points were given for level of assistance needed per activity: 1 = no help needed, 2 = supervision needed, and 3 = hands-on assistance needed. All cases had at least seven of the 11 indicators present. Means substitution was used for the missing data. The ADL and IADL scales were part of the standard assessment used by the National Aging Program Information System Resources as required by the Administration on Aging.

Nutritional risk was measured as a score on the nutrition risk assessment scale, ranging from 0 to 21 as reported by client or caregiver. Scores from 0 to 2 indicated low risk, 3 to 5 indicated moderate risk, and 6 or more, high risk. The 11 items included questions about ability to eat with regard to medical, physical, social, or financial limitations. This checklist was developed as part of the Nutrition Screening Initiative, a collaborative effort by the American Academy of Family Physicians, the American Dietetic Association, and the National Council on Aging. Finally, incontinence included urinary and bowel incontinence. Self-reporting of incontinence may have limited validity. Fultz and Herzog (1993) pointed out the difficulty in gaining accurate reports of incontinence from older adults because of its often gradual onset and embarrassing nature.

Financial and Social Resources. Financial indicators examined included primary funding source of care, income, and out-of-pocket costs. Because of the distribution of the data, funding was coded as public or private. Out-of-pocket costs were measured in total dollars clients agreed to pay for care and transportation per day at intake.

Social resources examined included number of individuals living in the household, relationship of the primary caregiver, service intensity, and primary transportation provider. Relationship of primary caregiver included categories of immediate family, extended family, and nonfamily. Immediate family was defined as a child or spouse. Extended family was defined as other family, such as a grandchild or daughter-in-law. Nonfamily was defined as a friend or paid professional. Service intensity was defined as the number of days scheduled to attend the center per week. Transportation provider was defined as the primary provider of transportation to and from the center. Transportation provider was either the center (formal support) or the family (informal support) as decided at intake.

Disenrollment Status. Three categories were defined as reasons for disenrollment: (1) institutionalization, (2) no longer wanting or needing services (opting out of services), and (3) death. For ease of data analysis, these three categories were created from eight different reasons identified by the client, the caregiver, or a licensed social worker at discharge. Institutionalization includes permanent placement in a long-term care facility or an assisted-living facility. No longer wanting or needing services includes no longer wanting or needing services, services not matching needs (according to the client or the caregiver), too ill to attend, cost, and dissatisfied with services. Length of stay was defined in weeks.

Analysis

Bivariate descriptive statistics were used to profile the differences between participants with a diabetes diagnosis and those without a diabetes diagnosis. To determine the significant differences between the two groups, we performed a series of t tests and chi-square tests. Associations between variables using Pearson r and lambda were also examined. The frequencies reported in the tables may not equal the total sample size because of missing values.

RESULTS

Approximately 30 percent of the adult day program participants in this study have diabetes. There was a significant difference in race and age between the participants with a diabetes diagnosis and those without (Table 1). Of the participants with diabetes, 61 percent were African American, compared with only 42 percent in the group of participants without a diabetes diagnosis ([chi square] = 7.350, p [less than or equal to] .01). The average age of participants with diabetes was 75 years, three years younger than the participants without diabetes (t = 2.92, p [less than or equal to] .01).

There was a significant difference between the two groups in cognitive functioning as measured by behavioral limitations ([chi square] = 6.286, p [less than or equal to] .01). Fewer participants in the diabetes group (58 percent) had cognitive behavioral limitations, such as wondering and forgetfulness, compared with the other group (73 percent) (Table 2).

Participants with diabetes had lower physical functioning, had a higher number of diagnoses, had a higher number of hospital stays in the past three years, and were at higher nutritional risk. The average score on the ADL index for participants with diabetes was 12.8, compared with 11.9 for those without diabetes (t = -1.638, p [less than or equal to] .10). A higher score suggests a need for more hands-on help with daily living activities such as bathing, dressing, and toileting. On average, participants with diabetes had more diagnoses (mean = 2.67), compared with the other group (mean = 1.58, t = -8.915, p [less than or equal to] .01). Participants with diabetes were slightly more likely to have had a previous hospital stay, compared with the participants without diabetes (t = -2.1450, p [less than or equal to] .05). Finally, on average, those with diabetes were at moderate to high nutritional risk (mean = 4.94), compared with those without diabetes who were at low to moderate risk (mean = 3.98) (Table 2). Individuals with diabetes had more medical, physical, social, and financial limitations to healthy eating than those without diabetes.

A higher percentage of adult day program participants with diabetes relied on public funding to cover the cost of care (87 percent, compared with 73 percent, [chi square] = 6.806, p [less than or equal to] .01) (Table 3). A higher percentage of immediate family members were primary caregivers for those with diabetes, and a higher percentage of participants with diabetes relied on the center for transportation to and from the program.

No differences were found between the two groups by reasons for disenrollment or by length of stay (Table 4). Additional multivariate analysis was conducted to determine whether demographic, health, financial, and social variables that were significant in the univariate analysis could be placed in a multivariate model. Logistic regression was used to examine disenrollment status, and Cox regression was used to examine length of stay. Both techniques did not yield a model in which diabetes was a significant factor in determining disenrollment or length of stay.

DISCUSSION

The number of individuals with diabetes who attend adult day programs in this study is approximately 12 percent higher than in the general population, suggesting that diabetes interventions in adult day programs may be an effective way to reach individuals with the disease. Unfortunately, national data on the number of ADS participants with diabetes diagnoses has not been collected. Emphasis on cognitive and functional status among the adult day program participant population has resulted in a significant lack of national information on health conditions of individuals in adult day programs. The 2001-2002 national census of adult day centers describes the health status of participants through "conditional" classes, including dementia, frail (in need of supervision, but not cognitively impaired), mentally retarded or developmentally disabled, physically disabled, chronic mental illness, HIV/AIDS, and brain injury (Partners in Caregiving, 2002). The lack of emphasis on health conditions limits program and policy development that is responsive to the unique needs of individuals with diabetes or other health conditions associated with high rates of acute and long-term care health services use.

Individuals with diabetes consume more health care resources than those without the disease (Ahmed et al., 2003; Balkrishnan et al., 2003).With annual diabetes health care costs reaching $92 billion (ADA, 2003), new innovative approaches to disease management are needed. Adult day centers provide access to many individuals with diabetes in one location, making targeted interventions more logistically possible and financially responsible. With almost 90 percent of the older adults with diabetes in this study dependent on public dollars to pay for their care, a publicly funded intervention program based within adult day centers targeting individuals with diabetes to support self-management and glycemic control for individuals with diabetes appears fiscally responsible. Similar to the individuals who receive Medicare support for end-stage renal disease, older adults with diabetes could receive special status within the Medicare system by receiving targeted coverage in adult day programs. Nationally, more than 80 percent of adult day centers provide medication administration, weight monitoring, and injections. Approximately 65 percent provide blood sugar testing (Partners in Caregiving, 2002). Nutritional services, a key component of diabetes management, are also provided by most programs. With fewer than 40 percent of all adults and even fewer elderly people participating in diabetes education programs (U.S. Department of Health and Human Services, 2000; Lawton, 1994), new ways to engage large numbers of older adults with diabetes in intervention programs is needed to improve the health of more than 16 million individuals and to help control rapidly rising health care costs.

The outcomes of the services provided to individuals with diabetes in adult day centers are unclear. In the present study, the length of stay and disenrollment rates of those with diabetes and those without diabetes were not statistically different. Knowing that older adults with diabetes are at higher risk of health conditions that result in institutionalization or death suggests that this finding is surprising. However, without diabetes-specific outcome measures, like glycosolated hemoglobin (A1C), use of other health services such as the emergency room and so forth, this study cannot precisely determine program effectiveness as it relates to diabetes management. More research should be conducted to examine the differential experiences and outcomes of individuals with diabetes who attend adult day centers and those who do not attend adult day centers. Interventions that have been shown to be effective should be tested within adult day programs. Social workers and nursing staff should be trained on effective diabetes interventions. Future research should focus on diabetes-specific outcomes such as hemoglobin A1C, amputations, and blindness. These outcomes are indicators of overall physical and mental well-being, issues critical to social work practice.

Coverage for ADS under Medicare has been explored. A number of bills supporting Medicare reimbursement for ADS were introduced in the last Congressional session, with limited success. The one exception is the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173), which includes a demonstration project for medical adult day care services. However, the direct benefit to ADS participants and programs is limited. The Centers for Medicare and Medicaid Services demonstration project is in the early stages of development and only provides reimbursement to home health care agencies who provide ADS as a substitute to in-home services. It does not allow for adult day programs to become Medicare-certified or reimbursed directly. New legislation recently introduced, the Medicare Substitute Adult Day-care Services Act of 2005 (H.R. 1981), allows adult day programs to be certified and reimbursed directly for services. In addition, this legislation allows for the cancellation of the controversial demonstration project. Diabetes provisions in the 1997 Balanced Budget Act (P.L. 105-33) allow health care agencies to receive reimbursement from Medicare for diabetes education, a possible new source of financial support for adult day programs (Leichter, 1999).

Finally, more emphasis on disease-specific care within Programs of All-Inclusive Care for the Elderly (PACE) is another viable route for targeted diabetes interventions. PACE integrates acute and long-term care services for people 55 years or older in a multipurpose adult day health center, supported by Medicare and Medicaid funding streams (Rudolph & Lubitz, 1999). Earlier studies suggested PACE programs reduce nursing home and hospital use and are associated with improved health, quality of life, and overall life satisfaction for both participants and caregivers. The program has also been successful in controlling expenditures (Wieland et al., 2000) and increased life expectancy (Chatterji, Burstein, Kidder, & White, 1998). Diabetes-specific interventions could enhance the outcomes of this service delivery model. The integration of acute and long-term care services provides opportunities for social workers to play a pivotal role in supporting management of chronic diseases like diabetes.

African Americans in this study and nationwide experience a higher rate of diabetes than white Americans. In addition, Wallace and colleagues (1992) found that older African Americans use ADS at twice the rate of older white Americans, and white caregivers tend to have a greater desire to institutionalize a dependent loved one than African American caregivers (Connell & Gibson, 1997). Culturally competent intervention programs for older adults with diabetes are lacking (DeCoster & Cummings, 2005). Adult day centers are well positioned to be laboratories for the development and testing of culturally responsive diabetes interventions. Intervention research in this area is urgently needed.

In the present study, those with diabetes were more likely to depend on an immediate family member as the primary caregiver than those without diabetes. ADS users in general rely more on informal support structures to maintain community-based living than do individuals who receive in-home services (Dabelko & Balaswamy, 2000). Caregivers of individuals with diabetes who attend adult day centers can be important partners in diabetes care and treatment. Opportunities to educate caregivers through caregiver support groups, educational presentations, and written materials are available at most adult day programs. Nationally, more than half of all adult day programs have caregiver support groups (Partners in Caregiving, 2002).

The recent growth in the number of adult day programs specializing in dementia-only care suggests there is interest and potential benefit to separating individuals in adult day programs by level of cognitive functioning. Differences in program models and outcomes between programs targeting individuals with cognitive impairment and those targeting individuals with physical impairment-only needs more study. Likewise, efforts in adult day program to address the needs of older adults with Alzheimer's and diabetes, recently found to be correlated (National Institute of Diabetes and Digestive and Kidney Diseases, 2004), could also benefit from evidence-based clinical trials.

In conclusion, older adults with diabetes who used ADS in central Ohio were significantly different in several ways from those without this disease. Demographically, participants with diabetes were younger, more likely African American, reliant on public funding, and dependent on agency transportation to attend programs. Medically, participants with diabetes had fewer cognitive impairments, yet were in poorer physical health (lower physical functioning, more diagnoses, more hospitalizations, and at greater nutritional risk).This descriptive profile provides a helpful foundation for the development and implementation of diabetes interventions within adult day program settings. Because of the different biopsychosocial factors that influence chronic health care conditions, such as diabetes, social workers are important players in community-oriented interventions (Berkman, 1996).

The present study has some limitations. First, the data were collected from only five programs in one area of central Ohio. Therefore, generalizability to other areas and states is limited. Second, the analysis is based on a relatively small number of people during a single point in time. Last, diabetes-specific measures were not collected. Future research would do well to address the deficit of basic knowledge and program development targeting older adults with diabetes in adult day programs. Practitioners and policymakers need to understand the effects of ADS on diabetes-related short- and long-term outcomes, such as glycemic control, amputations, blindness, premature death, and institutional placement. Likewise, experts need to develop and test age- and culturally appropriate diabetes interventions and protocols for adult day programs. These efforts need to be standardized, to follow recognized ADA treatment and education guidelines, and to provide precise methods to allow for replication.

Original manuscript received January 3, 2006

Final revision received June 16, 2006

Accepted October 13, 2006

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Holly I. Dabelko, MSW, PhD, is assistant professor and Hartford Geriatric Social Work Scholar, College of Social Work, Ohio State University, 325-U Stillman Hall, 1947 College Road, Columbus, OH 43210; e-mail: [e-mail]. Vaughn A. DeCoster, PhD, is associate professor, School of Social Work, University of Arkansas, Fayetteville. An earlier version of this article was presented at the 58th Annual Scientific Meeting of the Gerontological Society of America, November 2005, New Orleans.

Table 1: Demographics of Older Adults Using Adult Day Services

                              Diabetes       No Diabetes
                              (N = 85)        (N = 195)

Variable                       %    N    %    N     [chi
                                                    square]
Gender
  Female                       71   60   72   140
  Male                         29   25   28    55     0.042
Race
  White                        39   33   57   110
  African American and other   61   51   42    83   7.350 *
Primary language
  English                      97   82   96   187
  Non-English                   4    3    4     3     .052
Religious affiliation
  Yes                          92   77   90   147
  None                          8    7   10    19     .157
Marital status
  Married                      24   20   28    53
  Widowed, divorced, single    76   62   73   140     .278

              M    SD     SE     Range       N     M

Age           75   7.8    .85     56-8       85   78
Education     10   3.1    .35     0-20       79   11

             SD    SE    Range     N       t

Age          9.4   .66   50-90     195   2.92 *
Education    3.7   .29   0-18      167    .635

Note: Column percentages may not equal to 100% due to rounding error.

* p [less than or equal to] .01.

Table 2: Mental and Physical Health of Older Adults Using
Adult Day Services

                                Diabetes  No Diabetes
                                (N = 85)  (N = 195)

Variable                        %     N     %     N    [chi
                                                       square]
Affective state
  Psychological diagnosis      17     14   22     42
  No psychological diagnosis   84     71   79    153     .950
Cognitive functioning
  Dementia diagnosis           11      9   11     22
  No dementia diagnosis        89     76   89    173     .029
  Behavioral limitation        58     49   73    142
  No behavioral limitation     43     36   27     53    6.286 *
Past nursing home stay
  Yes                          30     25   26     51
  No                           70     59   74    143     .356
Incontinent
  Yes                          50     38   45     79
  No                           50     38   55     97     .558

                             M      SD     SE      RANGE    N      M

ADL index (7 items)         12.8   4.05    .46      7-21    79    11.9
IADL index (11 items)       28.7   3.88    .46     19-33    71    28.4
Number of diagnoses         2.67   0.85    .09      1-4     85     1.58
Hospital stays in 3 years   0.98   0.85    .09      0-5     85      .78
Nutritional risk            4.94   2.53    .27      0-12    85     3.98

                             SD        SE    Range    N        t

ADL index (7 items)         4.08      .30    7-21    185   -1.638 ***
IADL index (11 items)       4.60      .35   11-33    177     .535
Number of diagnoses         1.11      .08    1-4     195   -8.915 *
Hospital stays in 3 years    .64      .05    0-5     195   -2.140 **
Nutritional risk            2.56      .18    0-12    195   -2.901 *

Notes: Column percentages may not equal to 100% due to rounding
error. ADL = activities of daily living. IADL = instrumental of
daily living.

* p [less than or equal to]. ** p [less than or equal to] .05.
*** p [less than or equal to] .10.

Table 3: Financial and Social Resources of Older Adult Using Adult Day
Services Diabetes

                                     Diabetes    No Diabetes
                                     (N = 85)     (N = 195)
                                                                [chi
Resource                            %       N      %      N    square]

Primary funding source
  Private                           13      11     27     53
  Public                            87      74     73    142   6.806 *
Relationship of primary caregiver
  Immediate                         86      73     75    147   3.875 **
  Extended                           8       7     17     34   4.009 **
  Nonfamily                          4       3      4      8   0.052
Primary transportation provider
  Caregiver                         12      10     27     50
  Center                            88      75     73    138   7.508 *

                       M      SD     SE      Range        N

Annual income        11,366  8,903   966  5,340-57,000   85
Client daily cost      2.70  10.56  1.24    0-57.50      73
Number in house        2.82   1.36  .149      1-7        84
Days per week          3.07   1.31  .142      1-6        85

                       M      SD     SE      Range        N       t

Annual income        13,137  8,602   631  1,366-60,001   186   .841
Client daily cost      7.00  15.83  1.33    0-57.50      142  2.321 **
Number in house        2.66   1.32  .095      1-10       194   .370
Days per week          2.93   1.29  .093      1-6        194  -.816

Note: Column percentages may not equal to 100% due to rounding error.

* p [less than or equal to] .01. ** p [less than or equal to] .05.

Table 4: Disenrolled Length of Stay and Reasons for Disenrollment
among Older Adults Using Adult Day Services

                               Diabetes     No Diabetes
                               (N = 43)      (N = 100)
                                                            [chi
                               %      N      %      N      square]

Reasons for disenrollment
  Institutionalized            37     16    36      36      .559
  Died                         19     8     13      13      .754
  Opted out of services        44     19    51      51      .559

                               M      SD    SE    Range     N

Length of stay (weeks)        5.72   3.80   .41   1-15.5   85

                               M      SD    SE    Range     N      t

Length of stay (weeks)        5.36   4.0    .28   1-15.5   195   -.710