LTSS Choices

Adult Family Care - A Viable Alternative to Nursing Homes

Published March 15, 2021

People who need long-term services and supports want alternatives to nursing homes as living options.  Adult Family Care (AFC), which is not as well known among consumers as home care and assisted living, gives older adults and people with disabilities a viable alternative. In AFC, sometimes called adult foster care or adult family homes, residents live full-time in a house or other small residential setting where they receive assistance with activities of daily living, personal care, and help with medications and other health care tasks, in collaboration with health care professionals. 

LTSS Nursing Home

More than 40 years ago, Oregon and Washington were the first states to establish AFCs as an option for both private pay residents and those receiving public funds. And while most states have subsequently added AFC to their array of long-term residential care options, many have had difficulty recruiting providers and consumers. This report, written for consumers, advocates, and state policy staff, summarizes some of the key features of AFC as well as ideas for expanding its availability.  

Adult Family Care is regulated by states using one of three different approaches or vehicles: 1) staff and operator licensing/certification requirements, 2) state Medicaid standards, and 3) assisted living regulations. (See Appendix 1 in the PDF report, State Approaches to AFC Regulation.)

Key Components

The report highlights key components found in state regulations on AFC and examples from selected states of features and ideas for further advocacy to expand awareness and availability of AFC.

  • Admission/retention and acuity – Each state sets its own criteria for admission, and the minimum requirements vary, from needing assistance with activities of daily life to requiring treatment for a health condition. Admissions criteria range from general to highly specific, depending on the state. The majority pay out of pocket
  • Resident agreements – Roughly three quarters of states require resident agreements that describe the arrangement between the AFC provider and the resident. Agreements vary by state but generally cover admission policies, services that AFC operators will provide to the resident, charges, resident rights, and other expectations and obligations of the resident and the provider. (See Appendix 2 for state-by-state detail on agreements.)
  • Staffing and training standards – Staffing is a critical element in AFC and state regulations usually require that providers have sufficient staff available to provide 24-hour supervision and to meet the needs of residents. States use an array of AFC staff training approaches, ranging from simple overviews of licensure to providing operational and business training for providers. 
  • Medication administration – State Nurse Practice Act regulations restrict unlicensed assistive persons from providing nursing care, but can sometimes allow unlicensed persons to assist with medications and other frequent health maintenance tasks. The ability to administer medications may determine whether an AFC provider can serve residents with higher care needs. 

Expanding Access

The report concludes with case studies from states that have succeeded in making AFC more widely available as a service delivery model, and outlines four detailed recommendations based on those successes: 1) prioritize recruitment, screening, and licensing of providers; 2) develop consumer awareness and resources they can use; 3) develop resources for case managers and providers; 4) consider financial assistance and reimbursement for providers.


Adult Family Care - A Viable Alternative to Nursing Homes

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Suggested Citation

Mollica, Robert and Kathleen Ujvari. Adult Family Care: A Viable Alternative to Nursing Homes. Washington, DC: AARP Public Policy Institute, March 15, 2021.


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