What is adult foster care?

In the U.S., roughly 11 million older adults require help performing everyday activities. [1] Demand for services to assist older adults with their daily activities will increase precipitously in the coming years, as the number of Americans over the age of 65 is expected to more than double from 40 million to 81 million by 2040. [2]

Recent studies suggest that the vast majority of older adults would choose to age in place if it were a viable option. [3] For those who cannot remain in their own home but would prefer a homelike environment to a nursing facility, adult foster care (AFC) can be an appealing residential alternative.

There is no standard definition for AFC, but generally, an AFC home is one in which several older adults who can no longer live independently reside with a homeowner who provides the services they need. Services commonly include assistance with the activities of daily living (e.g., eating, bathing, and dressing), household chores, and meal preparation. [4] Social or recreational programming and arranging for transportation are among other common services and can be specified in a resident agreement that providers and residents sign. [5] States often limit the number of individuals who can reside in an AFC home, typically ranging from one to six persons. [6] As with the definition, the terminology for small, service-enriched, homelike settings for older adults also varies. AFC homes are also commonly called adult family homes, family care homes, homes plus, and supportive care homes. [7]

AFC homes are typically licensed and regulated by state or county-based agencies, and these smaller operations are sometimes subject to the same regulations that are applied to larger assisted living facilities. However, some states do not license or certify adult foster care homes at all, and others have exemptions for those that serve only one or two persons. [8]

A recent review of state policies and practices related to adult foster care concluded that there are nearly 19,000 licensed and certified AFC homes nationwide with room to accommodate just over 64,000 residents. These figures likely underestimate the actual supply, however, because they do not include homes licensed as assisted living facilities. [9]


What are the advantages of adult foster care?

For older adults who wish to live in a more independent, homelike environment, an adult foster care home can be an attractive setting in which to receive needed services. One study finds that "moving to an adult foster care home - at least in contrast to moving to a nursing home - can be an experience that allows many elderly people to see themselves in control and that such perceived control is associated with higher satisfaction and activity following the transition." [10]

Relative to institutional care, AFC homes are also a cost-effective way to age in the community. Because AFC homes are often housed in existing single-family units, caregivers shoulder most capital costs (e.g., mortgage payments, modifications, and repairs), and public-sector costs are limited to providing financial assistance to those who qualify (see below). AFC caregivers also typically provide lower-level - and thus less expensive - services relative to those available in a nursing facility. [11]

In addition to their cost-effectiveness, foster care homes also have the advantage of being more integrated into their surrounding residential communities than larger institutional facilities. In combination with more formal regulation, the eyes and ears of neighbors can add an informal layer of community oversight that can help ensure the provision of quality care. [12]


How is adult foster care funded?

An older adult with sufficient financial resources typically pays out-of-pocket for AFC services, room, and board. For adults with incomes low enough to qualify for Medicaid, AFC homes are considered a "residential care" living arrangement that can be eligible for funding through Medicaid Home and Community-Based services (HCBS) waivers. Under the HCBS waiver option, states may develop waiver programs that, if approved by the Centers for Medicare and Medicaid Services, use Medicaid funding to provide services for older adults in a variety of settings, including AFC homes. Waiver program costs cannot be higher than the costs that participants would have otherwise incurred in a nursing facility. Not all states offer HCBS waiver programs for residential care, however.

To participate in an approved AFC waiver program, individuals must meet the state's criteria for needing institutional (e.g., nursing home) care. [13] Unlike nursing home services to which qualified Medicaid beneficiaries are entitled, states can restrict the number of eligible participants, cap spending, and create waiting lists for HCBS waiver programs. [14] This feature gives states more control over these programs but may also lead to long waiting lists when supply does not keep pace with demand.

Services provided in AFC homes can be covered by Medicaid for those who qualify, but expenses related to room and board cannot. Low-income older adults who receive Supplemental Security Income (SSI) typically apply these funds to room and board costs. [15] Where costs are higher, states can supplement the federal SSI payment to cover room and board costs in residential care settings like AFC.

Compared to nursing home care, adult foster care can be less costly for states and the federal government alike. Overall costs for nursing home care run significantly higher than costs for AFC, and states are often on the hook for a share of the higher nursing home costs - a share that can greatly exceed the state SSI supplement that they would provide to someone in adult foster care. [16]

Learn more about the challenges of adult foster care and steps that states can take to make it a viable option for more older adults Go back to learn about other housing models geared to older adults

[1] Providing More Long-Term Support and Services at Home: Why It's Critical for Health Reform. 2009. Washington, DC: AARP Public Policy Institute.
[2] Table 2. Projections of the Population by Selected Age Groups and Sex for the United States: 2010-2050. 2008. Washington, DC: Population Division, U.S. Census Bureau.
[3] Lifecycle Housing: The Needs of Older Adults and Livable Communities. 2009. By Rodney Harrell. Washington, DC: AARP Public Policy Institute. Presented at the APA National Planning Conference, April 29, 2009.
[4] Long-Term Care: Federal Oversight of Growing Medicaid Home and Community-Based Waivers Should be Strengthened [PDF] 2003. Washington, DC: U.S. General Accounting Office.
[5] Adult Foster Care: A Resource for Older Adults [PDF] 2008. By R. Mollica, M. Booth, C. Gray, and K. Sims-Kastelein. New Brunswick, NJ: Rutgers Center for State Health Policy.
[6] "Choosing an Adult Foster Home or Nursing Home: Residents' Perceptions about Decision Making and Control." 1999. By James Reinardy and Rosalie A. Kane. Social Work 44(6), pp. 571-585.
[7] Ibid.
[8] Residential Care and Assisted Living Compendium: 2007. By Robert Mollica, Kristin Sims-Kastelein, and Janet O'Keeffe. Washington, DC: Office of Disability, Aging and Long-Term Care Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services; Adult Foster Care: A Resource for Older Adults [PDF] 2008.
[9] Building Adult Foster Care: What States Can Do. 2009. Washington, DC: AARP Public Policy Institute.
[10] "Choosing an Adult Foster Home or Nursing Home: Residents' Perceptions about Decision Making and Control." 1999. By James Reinardy and Rosalie A. Kane. Social Work 44(6), pp. 571-585.
[11] "Cheaper for Whom? Costs Experienced by Formal Caregivers in Adult Family Living Programs." 2005. By Donna Dosman and Norah Keating. Journal of Aging and Social Policy 17(2), pp. 67-83.
[12] Adult Foster Care: A Resource for Older Adults [PDF] 2008.
[13] Long-Term Care: Federal Oversight of Growing Medicaid Home and Community-Based Waivers Should be Strengthened [PDF] 2003.
[14] Ibid.
[15] "Residential Care Provision in Medicaid Home- and Community-Based Waivers: A National Study of Program Trends." 2006. By Martin Kitchener, Mauro Hernandez, Terence Ng, and Charlene Harrington. The Gerontologist 46(2), p. 165-172.
[16] See: Community Partnerships for Older Adults


The views expressed herein are for information, debate and discussion, and do not necessarily represent official policies of AARP.