Part of the Transforming Life as We Age Special Report
Call them adult foster homes, board and care homes, residential homes, group or adult care homes. Regardless of the moniker, these small-setting, family-like environments blend neatly into local communities, and are a viable housing option for older adults who may need help with daily living basics, but not the clinical care or amenities of traditional assisted living facilities and nursing homes.
It’s a choice that may not be on a family’s radar until a health crisis leads to the realization that their loved one can no longer live alone. Families then often face a sudden dilemma: they cannot move the person in with them, but institutional care is not necessary. Traditional, multi-unit assisted living can be too impersonal and prohibitively expensive. But there’s another, less well-known option. Adult foster homes can be an ideal alternative for some.
“We know that housing is a primary social determinant of health, and knowing where and what a person is going home to after [hospital] discharge is critical, especially for older adults,” said Janet Hunko, director, Housing Bureau for Seniors at Michigan Medicine, the academic medical center of the University of Michigan. The bureau works with the University of Michigan Health System to help older adults find appropriate housing for their needs.
Adult Foster Homes: A Home-Like Setting
While licensing and other requirements vary by state, adult foster homes share a common philosophy of providing a home-like setting for a small number of clients (usually one to six adults). They provide residents with 24/7 supervision (usually owner-occupied), meals, personalized supportive assistance, maximum autonomy and social interaction while helping with tasks like bathing and dressing, medication management and transportation to medical appointments.
The goal is to allow residents to age in the community for as long as possible and avoid more costly institutional care. Residents maintain independence, often attending activities outside the home, such as workshops or senior center programs.
“They can be one of the best options for some people because it’s a home-like setting. It’s like a family, there’s much more one-on-one,” said Amy Goyer, AARP family and caregiving expert and author of Juggling Work, Life, and Caregiving. “But you do have to keep in mind there are going to be some bad ones, and you have to still be on top of it to make sure your loved one is getting the care you expect them to get.”
Some homes will provide additional services as residents’ health needs change, such as hiring nurses or home health aides. Others prefer that residents function mostly independently and will suggest alternative placement should cognitive or physical health decline past a certain point.
There were some 30,000 licensed adult foster homes in the United States, serving 168,000 individuals in 2014, according to market research firm Open Minds. Data from the National Center for Health Statistics show those living in four- to 25-bed residential care settings (which also include smaller, traditional assisted living facilities) are predominately female, white and under age 75, compared with larger facilities. This data does not take into account one- to three-bed care homes, which may not have to report such information to their state.
Many Suited to Rural Areas
Adult homes are an especially welcome option in rural areas, where limited populations can’t support larger multi-unit housing. They also work well in suburban and urban areas, thanks to their smaller, less overwhelming, footprint, which fits into a neighborhood.
In the right environment, an older adult can really thrive. So why don’t more people know about these intimate, community-based options?
“The whole point of these homes is that they’re naturally integrated into the community,” said Goyer. “So you wouldn’t necessarily know about them unless you’ve done your homework or someone has referred you.” It’s often a hospital social worker or discharge planner who may first suggest this alternative for an older adult who struggles to live independently.
There’s still a lot of old thinking about what aging people want and need, Keren Brown Wilson told Joanne Elgart Jennings, producer of PBS NewsHour Weekend, which ran a segment about adult foster care homes on its broadcast Sunday, July 15. Wilson is president of the Jessie F Richardson Foundation, a nonprofit focusing on housing and community supports for underserved older adults. She said much of elder care is constrained by medical thinking, including how the government pays for long-term services.
“Older people are not as sick as they are frail,” Wilson said. “And what they really need for long-term care is not medical care, so much as personal care. And they [the government] don’t want to pay for personal care. They don’t want to pay for the kinds of things that help people stay independent longer.”
A mix of private pay and Medicaid — under what’s known as a home and community care waiver — pays for care in these homes. While fees vary depending on location, size and amenities, adult foster homes can be a cost-effective alternative compared with other elder housing options.
In Massachusetts, for example, daily cost in an adult foster home ranges from $50 to $85, about half that of a nursing home, according to Open Minds. Foster homes are also less expensive than traditional assisted living, which has a national median cost of $125 daily, or $3,750 per month, reports Genworth Financial.
Quality and Standards Vary
There are no national guidelines for this type of adult residential housing, though. Certification and licensing vary by state, as do training, services and oversight.
In New York, a “family type home” serves one to four residents and is certified by the Office of Children and Family Services. However, operators caring for five or more residents must be licensed as an adult home. In California, the Department of Social Services licenses adult family homes for up to six residents. In Michigan, it’s the Department of Health and Human Services that licenses and regulates adult family homes, which are inspected every two years to ensure they meet basic care standards.
Some foster homes may not be as well monitored by state agencies as larger facilities, according to Hunko. Professionalism can be inconsistent from home to home, and staffing is sometimes a problem, especially when residents require nursing care or other assistance beyond what an owner/operator provides.
Additionally, abuse or neglect may be more difficult to pinpoint, so it’s important to speak with other residents and to check with the state ombudsman to see whether a specific home has any complaints or violations. Goyer encourages family members or friends to drop by unannounced from time to time, to ensure that their loved one’s needs and expectations are being met.
A good way to find out more is by contacting the local Area Agency on Aging, Goyer said. Its staffers can tell you whether there’s a group home nearby and help guide you to other community services.
As the population of older adults continues to increase, so will the need for supportive, affordable, community-based housing. “They’re going to be sicker, they’re going to be a less financially stable, have less assets, have fewer children, have more divorces, have more debt. So it’s not a very rosy picture in terms of trying to figure out how to support these people,” said Wilson, an adjunct professor at Portland State’s Institute on Aging.
That’s why finding the appropriate environment for each individual is so critical to successful aging. “If a person doesn’t have appropriate housing, everything else is that much harder,” said Hunko. However, with the right supports in place, we can lessen our reliance on institutional care.
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