Adult Family Homes Versus Nursing Homes

Since you’re here, you’ve probably started to think about what to do if someone you care about is in need of a place to stay that’s going to take care of their health and medical needs. The best advice for families looking for senior care is to learn about the choices and costs, know the realistic options for their situation, and have a plan—which requires making decisions before the crisis. Too many families let this situation creep up on them and face serious decision-making while dealing with mom or dad’s crisis. 

If that’s you, that’s OK! We’re here to support you no matter how dire or urgent your situation, and to tell you: you have options and there is hope. There are options for long-term senior care that include comfortable, home-style living and are not financially impossible. 

There are three basic options for senior care: Adult Family Homes, in-home care, and assisted living facilities.

Adult Family Homes: A safe place for senior care

Adult Family Homes (AFH’s) are a relatively new and rapidly growing option in senior care. These are private homes that have been converted to meet requirements for senior care of up to six residents. Each resident has a room and receives help with activities of daily living by at least one trained caregiver. 

This high level of care is due to the favorable caregiver-to-resident ratio in Adult Family Homes, which is typically one or two staff providing 24/7 care for no more than 6 residents. In Assisted Living Facilities, this ratio is often one staff to 12 residents or greater. 

In-home care: A good option for low needs

In-home care remains the most frequent approach to managing elderly parents who are unable to live alone. U.S. Census Bureau statistics report that only around 5% of elders age 65+ live in some form of assisted living, including those called nursing homes, congregate care, assisted living, and board and care homes. But as seniors get older, the percent in such facilities increases. Around 25% of seniors 85+ and 50% of seniors 95+ live in some type of care facility. For many families, In-Home care is a good option, at least while care needs remain low and manageable for those without medical training.

As the need for higher and higher levels of care develops, it means the elder will need to have caregivers in the home for increasing hours to provide more help with daily living activities. It’s not uncommon for the hours caregivers need to be present in the home to increase from 4 to 8 hours, then to 12 or more hours per day. 

Assisted living facilities: Big-business senior care

Assisted living facilities (ALFs) makes up the most common institutional option when an elder cannot remain at home, and family members are unable to take them into their houses for continuing care. There is a wide range of services and quality of care within this vast industry. At one end of the spectrum is the small neighborhood facility with 8-15 rooms for residents, who are provided around-the-clock support for activities of daily living. Medical and memory care typically are not included. Usually these facilities cost $6,000 – $8,000 per month. At the other end is an option called Continuing Care Retirement Communities (CCRC), also known as “life plan communities” that incorporate the entire continuum of aging care from independent living to medical, memory, and skilled nursing care. These are expensive, several-tiered large organizations that typically have a substantial entry fee, ranging from the low-to mid six figures. Additionally there are hefty monthly charges that can be well above $5,000 depending on the plan chosen. Only about 15% of the U.S. population has the financial resources to take advantage of these “age in place” organizations.

The Adult Family Home difference

Adult Family Homes constitute a growing segment of the senior care industry.  In Washington State, there are about 3,200 AFHs with over 19,000 beds. Many families are discovering the advantages of placing their mom or dad in an AFH. These small senior residences keep seniors in a familiar community, offer a home-style atmosphere, low staff-to-resident ratios, personalized care, and flexibility as the elder’s care needs increase. AFHs are regulated differently than Assisted Living Facilities and tend to have residents who have higher care needs. 

Because of the flexibility of AFHs, different homes are able to have different specializations. While some may be homes that focus on providing their signature home-style environment to seniors who only need their meals cooked for them and reminders to take their medication, for example, others may specialize in caring for seniors deemed “too difficult” for other facilities, such as those with advanced dementia or other challenging behaviors. No matter what your loved one’s situation, there’s an Adult Family Home that is customized to meet their needs.

What’s wrong with large assisted living facilities?

When most people think of assisted living facilities or nursing homes, they have in mind large institutions that resemble apartment complexes housing up to 100 or more seniors. Although many facilities provide care that is acceptable if not good, institutions that are larger give less personalized care. There is more staff turnover and less loyalty to employers and residents in these large institutions. Most institutions of this type in the industry are motivated by profit and not by relationships. 

Moving from the family home, or from living in children’s homes, is inevitably traumatic for elder people. When this move is into a large, impersonal assisted living facility, the trauma is multiplied. The resident is placed in a small, unfamiliar room with only a few personal possessions. Now they must rely on a revolving door of strangers to provide for their needs. Unless their room has a tiny kitchenette, the senior cannot even get a cup of tea without depending on a staff member.

The number and training of staff also is a key measure of the quality of the living situation. With high staff-to-resident ratios, the large corporate ALFs do not have enough caregivers to respond quickly to elders’ needs, sometimes leaving them neglected when they’re in need. 

Unfortunately, some seniors never fully bounce back from the disruption of leaving their familiar home and moving into a vastly different environment. Some slip into a downward spiral that leaves them worse off, slowly deteriorating mentally and physically. 

ALFs vary in the extent of services each provides, and one all-too-common scenario is the resident whose care needs have outstripped what the facility can manage. This situation of being “evicted” from the ALF places additional financial and emotional stresses on the elder and family.

Here is a recurring scenario for elders placed in large assisted living facilities. The mom or dad who could no longer live by themselves, or required more care than family members could manage, has been placed in an ALF that seems the perfect place. The transition went smoothly and the elder is getting all needs met, giving the family peace of mind that they are safe and well cared for. For some time things go well and the elder enjoys the amenities and friendship in the facility. As aging progresses and the elder needs more physical care, the family knows they must move up from the basic care package, but had planned in advance and could afford increased fees. But, if the elder develops dementia, another entire level of care is needed. About five to eight percent of people over age 65 have some form of dementia, most frequently Alzheimer’s disease. This number doubles every five years after that. Memory issues affect 50% of seniors over 85 years old.(8) In this example scenario, at first the dementia is mild and the facility continues to manage things, but as the disease progresses the elder becomes increasingly difficult to contain, is prone to wandering, and gets combative toward staff. At this point, the facility decides it can no longer manage the necessary care and gives the family an “eviction” notice that they must move their elder within a week or two. 

Families with enough money and resources can handle this by finding a memory care facility, but for many it’s an overwhelming challenge. If they face the problem of having used up their available resources, they are at the mercy of available government-supported care. In many situations, a social worker or discharge nurse is assigned to help the family figure out a plan. This usually involves discussion and provision of material describing facilities based on what the limited funds will allow. The family is responsible for researching and performing the vetting process. In many situations the optimum facilities are full and given the importance of timing, the family’s hand is forced and they struggle to make the best decision, too often with insufficient and or difficult to interpret information and inadequate guidance. If they must get mom or dad qualified for Medicaid (federal and/or state public assistance for health care), their options shrink even more. There are limited numbers of Medicaid beds in any given facility, and the nicer elder care facilities do not have any beds at all, as they only work with private pay residents. In some instances when there is a loyal, established relationship, a facility may have a policy allowing a resident to stay on after a predetermined amount of time, and be converted into a Medicaid resident. There are requirements to qualify for Medicaid including spending down assets to certain levels, and properly filling out a new Medicaid application every year to stay in the program. Navigating through this complex, bureaucratic government system takes persistence and time.  

Repeated moves for elderly people, particularly those with memory issues, is a traumatic and confusing experience. Those who experience serious illnesses, such as strokes or heart attacks, will be shifted from ALF into a skilled nursing facility after acute hospitalization. They spend weeks or months in rehabilitation, only to return to the same or a different ALF. Each change means relating to new caregivers and contending with a new environment. It can be too much for many elders, who decline quickly and have their lives shortened. 

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