How and why adult day programs influence admissions to long-term care homes for persons living with dementia: A program theory based on a realist review

Technical Summary: How and Why Adult Day Programs Influence Admissions to Long-Term Care Homes for Persons Living with Dementia

Problem Statement
Health systems in Western societies have increasingly adopted "aging in place" (AIP) policies aimed at delaying or preventing the admission of older adults, particularly those living with dementia, to long-term care (LTC) homes. While community-based services like Adult Day Programs (ADPs) are intended to support this goal, the evidence regarding their effectiveness in reducing LTC admissions is inconsistent. Some studies suggest ADPs delay admission, others find no effect, and some indicate they may even accelerate transitions. Existing research often focuses narrowly on whether ADPs "work" as uniform interventions, failing to unpack the "black box" of how, why, for whom, and under what circumstances these programs influence admission outcomes. Furthermore, the literature often overlooks the critical role of unpaid caregivers and the complex relational dynamics between attendees, caregivers, and program staff.

Methodology
This study employed a realist review methodology, designed to develop a program theory that explains the underlying mechanisms and contexts of an intervention's success or failure. The review followed a six-step iterative process:

1. Search Strategy: A comprehensive search was conducted across seven databases (CINAHL, EBM Reviews, JBI EBP Database, Embase, Medline, APA PsycInfo, Social Work Abstracts) from inception to January 6, 2026, alongside reference list screening.
2. Inclusion Criteria: The review included original studies (quantitative, qualitative, or mixed methods) published in English that reported contexts and mechanisms explaining how ADPs influence LTC home admissions for persons with dementia. Studies focusing solely on non-dementia populations or other respite services (e.g., in-home respite) were excluded.
3. Data Extraction and Analysis: Two researchers independently screened studies and extracted Context-Mechanism-Outcome (CMO) statements. Discrepancies were resolved by consensus.
4. Synthesis: CMO statements were synthesized into a program theory. The review utilized various quality assessment tools (QATQS, NOS, AXIS, CASP, MMAT) to rate study quality but did not exclude studies based on quality ratings, instead using quality ratings to inform the strength of evidence for each CMO statement.

Key Results
From an initial pool of 4,748 references, 17 studies met the inclusion criteria. These studies, published between 1991 and 2025, originated from the USA, Canada, the Netherlands, Iceland, Japan, Norway, South Korea, and the UK. The review extracted eight CMO statements, six of which were synthesized into a cohesive program theory.

The resulting program theory posits that ADPs delay LTC home admissions primarily through relational processes involving attendees, caregivers, and staff. The key mechanisms identified are:

• Staff Observation and Early Identification: ADP staff who carefully observe attendees and are well-informed about their health needs can quickly identify changes in condition. This allows for early intervention, preventing crises that might otherwise necessitate institutional care.
• Effective Communication: When staff effectively communicate observed changes and care needs to caregivers, it empowers caregivers to address issues proactively.
• Caregiver Respite and Support: High-quality care that reassures caregivers provides them with "peace of mind" and necessary respite. This sustains their capacity to provide care at home. Crucially, the theory emphasizes that ADPs must offer integrated family support (active guidance and coping strategies) rather than just passive respite.
• Person-Centered Care and Integration: Programs that integrate caregivers into decision-making and provide person-centered care foster higher attendance.
• Sufficient Exposure and Timing: The theory highlights that early access to ADPs is critical. Accessing services early in the caregiving trajectory helps caregivers manage the transition into the caregiving role and slows the deterioration of the attendee. Furthermore, sufficient exposure (frequency and duration of attendance) is required to realize the benefits of monitoring and support.

The review also noted specific nuances, such as the finding that daughters/daughters-in-law may seek ADP support earlier than wives, potentially leading to longer exposure and delayed admission. Conversely, the review identified gaps where ADPs lacking individualized cognitive stimulation or where system-level constraints (like limited bed supply) exist, the effects on admission timing may differ.

Significance and Claims
The paper claims to be the first realist synthesis specifically assessing ADP effects on LTC home admissions. Its primary contribution is the development of a program theory that moves beyond simple efficacy questions to explain the causal pathways of ADP effectiveness.

The authors assert that:

1. Relationality is Key: The delay in LTC admission is not merely a function of the program's activities but is mediated by the relationships between staff, attendees, and caregivers.
2. Context Matters: The effectiveness of ADPs is contingent on specific contexts, including the timing of access (early vs. late), the sufficiency of attendance, and the integration of caregiver support.
3. Policy Implications: To reduce LTC admission risks, policies must ensure structures that facilitate early, continued, and sufficient access to high-quality ADPs. This includes funding for adequate staffing, training staff in observation and communication, and actively supporting caregivers.
4. Reframing the Goal: The authors modestly challenge the assumption that delaying LTC admission is the sole or primary responsibility of ADPs. They suggest that the primary value of ADPs lies in improving the quality of life for attendees and caregivers. If ADPs successfully support these individuals, the reduction in LTC admissions may be a "welcome bonus" rather than the sole metric of success.

Limitations and Future Directions
The authors acknowledge that their program theory cannot prescribe exact organizational measures for every specific context. They identify significant knowledge gaps, particularly regarding:

• Social Determinants of Health: The lack of research on how race, culture, and socioeconomic status influence ADP experiences and outcomes.
• System-Level Contexts: The influence of broader health system factors (e.g., LTC bed supply, funding models) on ADP effectiveness remains under-studied.
• Cultural Safety: The literature lacks a "culturally safe care" lens, which is critical for diverse populations.

The authors conclude that future research must address these gaps and that their program theory should be refined through further engagement with stakeholders (caregivers, attendees, staff) and empirical data analysis.