Encyclopedia of Gerontology and Population Aging

Living Edition
| Editors: Danan Gu, Matthew E. Dupre

Adult Foster Homes

  • Cari LevyEmail author
  • Paula Carder
  • Leah Haverhals
Living reference work entry
DOI: https://doi.org/10.1007/978-3-319-69892-2_295-1



Adult foster homes (AFH) are a type of residential long-term care available throughout the United States. An AFH is a private residence where the owner or a paid caregiver lives with a small number of residents, usually fewer than six, who receive personal care, social/recreational activities, and health oversight.


Many of these homes serve older adults with physical disabilities, including those with cognitive impairment. Most states (38) license AFHs (Carder et al. 2015), though the definition, capacity, types of services, and staffing requirements vary. AFHs might be purpose-built, but more often are converted single-family residences (Folkemer et al. 1996; Mollica et al. 2008).

Examples of Application

AFH in Oregon

Some states limit AFH services to meals, social activities, and assistance with basic needs like laundry and housekeeping. Others permit or require that AFHs admit residents who meet the state’s nursing home level of care as approved by the Centers for Medicare and Medicaid Services. For example, Oregon adopted AFH rules as a community-based alternative to nursing facilities in 1983 (Kane et al. 1991). In 2017, over 1700 AFHs were licensed in Oregon with a capacity for 6550 residents (Carder et al. 2018). These AFHs are not required to have overnight awake staff, but must be staffed 24-hours a day and have a method for residents to contact staff at night. They are not required to employ licensed nurses, in part because the state’s Nurse Practice Act allows registered nurses to teach AFH staff to perform nursing tasks.

A recent survey of AFHs, assisted living facilities (AL), and memory care communities (MCC) in Oregon found that AFH and MCC residents have similar functional deficits. For example, 39% need assistance with eating in AFHs and MCCs, compared to 7% in ALs. Table 1 provides a comparison of AFH residents to those residing in ALs and MCCs.
Table 1

Characteristics of residents in Oregon residing in adult foster homes, assisted living facilities, and memory care communities, 2018


Number of Facilities

Total capacity

Adult foster homes

N = 1740

N = 6552

Assisted living

N = 225

N >15,000

Memory care communities

N = 179

N = 6268

Over age 85 (%)




Diagnosed with Dementia (%)




Fell prior 90 days (%)




Went to ER prior 90 days (%)




Discharged from hospital prior 90 days (%)




Take antipsychotic medication (%)




Currently need assistance with


 Eating (%)




 Mobility (%)




 Using bathroom (%)




Of those leaving setting in prior 90 days


 Died (%)




 Moved to memory care unit (%)




Current Medicaid clients (%)




Average private pay monthly fee




Medicaid reimbursement per montha




Received hospice care prior 90 days (%)




AFHs and ALs share many of the same challenges, but differ in nuanced and important ways (Carder et al. 2008). AFHs have difficulty competing with ALs because they are relatively “invisible” and have fewer amenities. AFHs might charge less to appeal to consumers and lack the economies of scale of large ALs. Although AFHs might attract staff who value the interpersonal relationships afforded by small homes, limited benefit packages or career development opportunities can impede staff retention. Regulatory challenges can affect AFHs if states require nursing home-level practices and oversight. These and other challenges can result in a “fragile future” for AFHs (Carder et al. 2008). Yet, AFHs continue to provide cost-effective services, often in a personalized, quasi-familial fashion, to large numbers of older adults.

MFH Program

The Veterans Health Administration (VHA) Medical Foster Home program (MFH) is a national, home-based, long-term care program which cares for veterans who meet nursing home eligibility criteria but desire a more familial, personalized long-term care residence (Levy et al. 2014). The program officially expanded to all Veterans Affairs Medical Centers (VAMCs) after a pilot in 2008 (Denham 2018). The MFH program now serves over 1000 veterans in over 700 MFHs, affiliated with 177 VAMCs (U.S. Department of Veterans Affairs 2018).

Each MFH program is run by a MFH coordinator, who plays an important role in program growth and sustainability (Haverhals et al. 2017; Jones et al. 2018). One primary duty of each MFH coordinator is caregiver recruitment. MFH caregivers care for veterans but do not become official VHA employees, rather, the MFH coordinator of each program works to create a match between the veteran, caregiver, and caregiver’s home, which is the caregiver’s private residence and where the veteran will reside if enrolled in the MFH program (Jones et al. 2018). The veteran or veteran’s family negotiate a rate to pay the caregiver directly for the care provided to the veteran, usually based on the coordinator’s guidance. Veterans pay out of pocket for this care, which on average ranges from $1500–$3000 per month. Only three veterans or residents who need long-term care may reside and receive care in each MFH, leading to a model of personalized, focused, around-the-clock care from the MFH caregiver(s).

Veterans enrolled in MFHs are typically provided in-home medical care by VHA’s interdisciplinary home-based primary care (HBPC) teams. VHA HBPC programs are designed to deliver comprehensive primary care to veterans generally within a 30–50-mile radius of a VAMC. The interdisciplinary team may consist of: a physician, registered nurses, social workers, rehabilitation therapists, pharmacists, dieticians, and psychologists. Veterans in the program meet nursing home level of care (Wyte-Lake et al. 2014). According to the VHA MFH directive, such medically complex needs include: “functional, cognitive, or psychosocial impairment resulting from conditions such as complex chronic disease, psychological disorder, spinal cord injury or Polytrauma” (Veterans Health Administration Office of Geriatrics and Extended Care Operations 2017, p. 4).


AFHs serve a subset of individuals, in both state and federal-run healthcare systems, in need of long-term care who seek a personalized and a more home-like setting of care. Lessons learned from the success of these examples can inform other models of AFHs looking to create or expand their long-term care offerings.

To increase access to AFHs as an option for long-term care, local and national policy will need to formally support this model of care through specific directives designed to support caregivers and work with them to meet policy requirements to provide care. Recruitment of AFH caregivers may become increasingly difficult if caregivers do not have access to benefits and other workplace incentives in order to meet state and federal licensure requirements.



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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.VA Eastern Colorado Health Care SystemAuroraUSA
  2. 2.OHSU-PSU School of Public HealthPortlandUSA

Section editors and affiliations

  • Xiaoling Xiang
    • 1
  • Emily Nicklett
    • 2
  1. 1.School of Social WorkUniversity of MichiganAnn ArborUSA
  2. 2.School of Social WorkUniversity of MichiganAnn ArborUSA