PHILADELPHIA – Tanya Cook climbs into the gray van and starts her day as she always does: picking up the elderly to bring them to daycare. 

Cook, the transportation manager at New Beginnings Adult Day Care in Philadelphia, has a list that’s shorter today than she planned. Two participants canceled at the last minute, but they’ll have over 50 seniors at the center that day. 

Many adult daycare service providers in Mississippi are struggling or have closed in recent years due to low reimbursement rates from Medicaid and years of legislative gridlock. The centers provide crucial services to elderly and disabled people and allow their caregivers to work and have lives outside of caretaking.

Before COVID-19, New Beginnings averaged around 70 participants per day but now only sees 45 to 60 – still a marked improvement from the 30 or so they saw each day after a multi-month shutdown in 2020.

“They keep saying they’re going to wait until this is over,” Cook said. “I don’t know if this will ever be over. But some of them are slowly coming back.”

Adult daycare is a nearly invisible facet of the care system for elderly and disabled people. The centers provide transportation and meals, in addition to administering medication. Attendees participate in exercise and socialization activities. Often, they serve as participants’ only opportunity for social interaction outside of the home. 

Cook had never heard of adult daycare until she started working in one in Oct. 2017. In that time, she’s driven every route in the center’s service area. It covers eight counties total, stretching as far as Morton, more than an hour’s drive away. 

Cook remembers getting calls from participants one month into the COVID-19 shutdown where they asked: ‘Are you going to come get us?’

 “They’re stuck at home all day, so this is their way out of the house,” Cook said. 

That was the case for Jean Anderson, an 85-year-old Philadelphia native who has been coming to New Beginnings for over four years. After her husband passed away, her case worker asked if she’d like to start attending an adult daycare, and she agreed to try it out. 

“I was getting lonely at the house by myself,” Anderson said. “This keeps you from sitting there and doing nothing all day.” 

There were at least 126 adult daycare service providers across Mississippi pre-pandemic, but around 30% of them have closed permanently over the last few years, according to Benton Thompson, president of the Mississippi Association of Adult Day Services.

 “Their volume dropped due to COVID, and they couldn’t continue operations with the same overhead costs and limited revenue,” Thompson said. 

The bulk of those overhead costs come from staffing, which includes a family nurse practitioner and social worker, along with seven other required positions. Under quality assurance standards set by the Mississippi Division of Medicaid, each facility must maintain a minimum staff-to-participant ratio of one to six, or one to four in a facility that serves a high percentage of people who are severely impaired. 

The vast majority of those who use adult daycare services are enrolled in Medicaid’s Elderly & Disabled Waiver program. The waiver provides home and community-based services for Mississippians who would require nursing home level care if not for the alternative forms of care the waiver provides, like adult day care. At New Beginnings, 98% of its clients are on the waiver. As of June 2022, there were 17,022 waiver recipients across the state, according to the Mississippi Division of Medicaid.

The problem with this system, workers and advocates say, is that reimbursement rates have stagnated while costs have continued to rise, meaning only those who bring in a high number of participants can break even.

Currently, adult daycares receive a maximum reimbursement of $60 per person each day from Medicaid. They can only bill for up to four hours of care, though they’re required to be open for eight.

“We’re at the mercy of (Medicaid) case workers,” said Michelle McCool, administrator at New Beginnings. “It’s all based on numbers, and if they don’t refer clients to us, or if there’s a backlog of people waiting to get into the waiver program, we can’t survive.”

Some legislators have attempted to increase the reimbursement rate for adult daycare services every year since 2015. Each time, it has either died in committee or passed in both chambers, with each side unable to agree on a final version. 

If passed, the bills would have more than doubled the level of reimbursement that adult daycares like New Beginnings currently receive. Their per-person reimbursement would increase to $125 and the centers could also be reimbursed for transportation costs separately. Thompson believes the lack of awareness about adult day services is what has caused this repeated failure to act from lawmakers.

“I think it’s due to a lack of knowledge,” Thompson said. “I think most of them sitting up there in Jackson voting on these bills have never been to an adult day service and don’t understand the benefits.”

Thompson believes that expanded utilization of adult daycares would save the government money in the long run by preventing costly hospital stays and delaying costlier institutionalized care in a nursing home setting. He also pointed to the benefits for the primary caregivers of participants who have them, which sometimes provide the only way for them to run errands, work or just simply have a break.

“If you don’t give that caregiver a break, then they’re going to become a participant (person who needs adult daycare),” Thompson said. 

On Friday, Jeanette Carter is one of the few participants at New Beginnings dressed up for that day’s theme: Remembering 9/11. The 68-year-old is wearing a red, starry tank top and American flag baseball cap. She walks around the room, talking to her friends and looking for places to help out before the scavenger hunt.

Carter has been coming to New Beginnings nearly five days a week for over a year and a half. The only days she’s missed were due to catching COVID-19 in Oct. of last year. 

“If this place was open seven days a week, believe me, Jeanette would be here,” Carter said.

She only started coming to New Beginnings after the previous center she went to closed during the pandemic. In that brief period, she was scared of being stuck at home. 

“I get out of hand at times,” Carter said. “I can’t be nobody else but me and they understand me. I don’t know what I’d do without this place.”

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