Adult Foster Homes
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.
Characteristics of residents in Oregon residing in adult foster homes, assisted living facilities, and memory care communities, 2018
Number of Facilities
Adult foster homes
N = 1740
N = 6552
N = 225
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
Using bathroom (%)
Of those leaving setting in prior 90 days
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.
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.
- Carder PC, Morgan LM, Eckert JK (2008) The fragile future of small board-and-care homes. In: Golant S, Hyde J (eds) The assisted living residence: a vision for the future. Johns Hopkins University Press, Baltimore, pp 143–166Google Scholar
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- Carder PC, Tunalilar O, Elliott S et al (2018) Oregon resident and community characteristics report – assisted living, residential care, memory care, 2017. Report submitted to Oregon Department of Human Services. https://www.pdx.edu/ioa/sites/www.pdx.edu.ioa/files/Media%20Root/2018_CBC_AL.RC_.MC_REPORT.pdf. Accessed 1 Oct 2018
- Folkemer D, Jensen L, Lipson L et al (1996) Adult foster care for the elderly: a review of state regulatory and funding strategies. AARP Public Policy Institute, Washington, DCGoogle Scholar
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- Mollica R, Booth M, Gray C et al (2008) Adult foster care: a resource for older adults. Rutgers Center for State Health Policy. http://www.nasuad.org/sites/nasuad/files/hcbs/files/139/6942/AFC_report_for_submission_to_website_6-9-08.doc. Accessed 1 Oct 2018
- Oregon Department of Human Services (2018) Rate schedule. https://www.oregon.gov/DHS/PROVIDERS-PARTNERS/LICENSING/AdminAlerts/Medicaid%20Rate%20Changes%20Effective%20July%201%202018%20SUPPLEMENTAL.pdf. Accessed 1 Oct 2018
- U.S. Department of Veterans Affairs (2018) National Medical Foster Home dashboard data. Unpublished internal documentGoogle Scholar
- Veterans Health Administration Office of Geriatrics and Extended Care Operations (2017) VHA Directive 1141.02 Medical Foster home program proceduresGoogle Scholar