Most people want to age at home. But that is not always possible, physically or financially.
Rather than move to a large assisted living community or a skilled nursing facility, another alternative exists, perhaps in an area near home. Depending on where you live, the concept may be called adult family homes, board and care homes, residential assisted living or residential care homes.
States, which license the homes, have more than 30 terms to refer to these types of living arrangements. Think of it as assisted living but in a house.
In Wisconsin, about half of the assisted living providers are adult family homes, but they offer only about 1 in 7 of all assisted living beds. In many states, these small homes are an option that often slips under the radar.
Residential care homes can provide the same basic services as large assisted living centers. Staffers help with personal needs, including bathing, dressing, eating, medication management, toileting — and emergencies. Some states allow for various levels of care in the homes, from independent living to high levels of assisted living, so make sure you know what's included.
Most offer transportation to medical appointments or will contract with a third party. What you won't find is the same level of care as in a nursing home.
Typically, there are five to 10 people (but maybe as many as 20, depending on state regulations), who live in a home, which is licensed in every state using the same requirements as any other assisted living community. Staff who directly care for residents must have mandated annual training.
Residents must have care plans. Employees are required to keep records on them, too.
Each state has its own standards. Some homes allow pets or have staff that can speak multiple languages. Some focus on memory care, specific disease management or general care. Someone is on site 24/7.
Private individuals usually own group homes. Staff may live in the house, and so may their families. That said, a company also may own several houses.
Residential care homes often cheaper
The cost for services at board and care homes across the country hasn't been precisely calculated. A 2019 cost-of-care survey from Genworth, a Richmond, Virginia-based company that sells long-term care insurance, puts the national median charge for assisted living at nearly $50,000 a year and the national median charge for skilled nursing at $90,000 to more than $100,000 annually, depending on whether a resident is living in a double or single room.
The report does not include the costs at group homes, but the fees are less than traditional assisted living or skilled nursing. In California, where the high cost of living was exceeded only in Hawaii and the District of Columbia, the average yearly costs in a six-bed home is $36,000 for a shared bedroom and $48,000 to $84,000 for a private room. Genworth estimates the California care costs at $54,000 for an assisted living facility and $105,000 to almost $128,000 for a nursing home.
The local market determines prices, but expect to pay less than a larger assisted living community, in part because of fewer amenities such as on-site beauty salons or art classes. Expect homes that specialize in dementia care to be on the higher side because of additional safeguards to keep residents from wandering or engaging in other behavior that could put them in danger.
Monthly charges are either paid out of your own pocket, through long-term care insurance, or if the home has a Medicaid contract, via government financing. Veterans and their surviving spouses may qualify for a benefit called Aid and Attendance.
Advantages of group home living
The lower price, higher staff-to-client ratio — for example, Florida limits its adult family care homes to five residents at most — and family-oriented setting distinguish this option. Other pluses:
• More personalized care and continuity of care is possible, unlike in larger assisted living communities. With fewer older adults, staff can more easily detect physical and emotional changes in residents.
• The staff-to-client ratio is often higher than in large assisted living complexes or skilled nursing.
• Meals are home cooked and can be customized.
• The homelike, smaller environment may be a better fit for those with dementia and could help any resident form friendships with fellow residents and staff more easily.
• The presence of other residents encourages socialization, and can lessen loneliness and enhance well-being.
• A smaller monthly fee generally is the result of fewer amenities.
The disadvantages of small scale
Living in a small house with just a few people can feel homey — or not serve a resident's needs. The downside to this arrangement:
• Fewer opportunities to discover compatible friends, participate in activities or use amenities (than can be found in a larger assisted living community) can make for less stimulation.
• Potentially less privacy. Residents have a room and shared spaces rather than their own apartments.
• No physician and rarely an on-site nurse. However, a home sometimes contracts with a medical professional or practice to make house visits. If complex medical tasks are necessary, the resident must bring in help or move to a nursing home.
What to ask when visiting
To explore residential care homes for your loved one or yourself, you need to visit and ask a lot of questions. This is a major move, so you'll want to look at places more than once and at different times of the day.
Before you go further, though, make sure state officials have licensed the home. Depending on where you live, that might be a department of elder services, health or social services. While you're at it, see if the department's website has any formal complaints against the group home.
Taking the pulse of the home is a must. Does it seem relaxed? Are residents up and about? Are staff warm, welcoming and receptive, or do they seem rushed and indifferent? See how they interact with residents.
If you can, ask residents about their experiences and definitely talk to their families. Find out what they like or don't not like about the place. Are their needs being met? Is the staff responsive?
Many of the questions you'll want answered are the same ones that should be on your checklist for larger assisted living facilities. This is also what you need to know:
1. Ownership. Who are the owners? What is their background, and how long have they been in business? Do they live on-site, and how involved are they?
2. Staffing. Is a staff member on duty all the time? What is the staff-to-resident ratio? What are the qualifications of the staff?
3. Cleanliness and safety. How clean are the residents’ rooms and the common spaces? Are private and shared rooms available? Where are the bathrooms? Do you see handrails and call buttons? If not, how do residents reach staff? Ask to see an inspection report and complaints against the home; officials are required to show you.
4. Costs. What does the monthly fee include? Three meals a day, snacks, housekeeping, laundry, cable TV and internet access? Does the home have more than one pricing model?
5. Health care. How do residents access medical services? Is transportation available to a doctor or other health care providers and is that included in the monthly fee? What happens when a resident is hospitalized? Does the home have a group of doctors or nurses who make house calls? If your loved one needs more assistance (perhaps for incontinence) than is offered, what is the next step? Can you bring help in?
6. Other residents. How many others live in the home, and what are their needs? How independent or impaired are they? If someone has dementia, what safety measures are in place, and how does staff care for the resident?
7. Social interaction. What happens on a typical day? Does staff have any organized activities? What are the rules?
Most important: Can your loved ones see themselves living there? Does this place feel like the right fit?
If you're not sure, take a look at other group homes. One of them is likely to feel the most like home.
Sally Abrahms, a longtime AARP contributor, cared for both her parents and in-laws. She writes on aging and boomers for national publications.
House hunting for group homes
Here are the 10 states with the highest number of residents 65 and older as of 2018, as well as ways to find state-licensed senior-care group homes in each state:
• California: 5.7 million residents age 65-plus. Department of Social Services; choose elderly assisted living, and group homes are listed among all elderly assisted living choices.
• Florida: 4.4 million. Department of Elder Affairs and Agency for Health Care Administration; choose adult family care home as facility/provider type.
• Texas: 3.6 million. Health and Human Services; personal care homes are listed among all Type A assisted living facilities.
• New York: 3.2 million. Office of Children and Family Services.
• Pennsylvania: 2.3 million. Department of Aging and Department of Human Services; choose personal care homes as the service code.
• Ohio: 2 million. Department of Aging; choose assisted living (RCF) as the type of facility, but be aware that the results will show large and small facilities in one list.
• Illinois: 2 million. Department of Public Health; download a spreadsheet that includes large assisted living and smaller shared housing licensed establishments.
• Michigan: 1.7 million. Department of Licensing and Regulatory Affairs; choose adult family home as facility type, but be aware that results will include some places for developmentally disabled adults; homes for the aged include smaller homes as well as centers with larger capacity.
• North Carolina: 1.7 million. Department of Health and Human Services; download a PDF of adult care homes; the maximum number of residents for which a home is licensed is in parentheses.
• Georgia: 1.5 million. Department of Community Health, choose personal care home as facility type, but be aware that results will show large and small facilities in one list.
Because most group homes are a fraction of the size of assisted living communities, you won't see advertisements as you often do for the larger entities. But you can get personalized help:
• The federal Administration for Community Living's Eldercare Locator can steer you to local resources online, or call 800-677-1116, 9 a.m. to 8 p.m. ET weekdays, to speak to a specialist.
• Your local senior center or county senior services department also can offer referrals.
• A geriatric care manager can act as a private advocate for you or your loved one and can help you find a group home. After an initial assessment of several hundred dollars, hourly rates for these aging specialists can range from $100 to $200. Most insurance plans, including traditional Medicare, do not cover this service.