Alabama restarts adult foster care program with help from ARPA

These four women may not have their own sitcom. But they do share a home. And seem thankful for being friends.

Valinda Young cares for three women in Enterprise. Young, 65, is a licensed foster care provider for adults in Alabama. The three women are part of Alabama’s Adult Foster Care program, which provides a home environment for elderly or disabled adults who need extra assistance in their everyday activities.

Young cooks for these women and reminds them to take their medicines. She makes appointments for them when needed or reminds them of their bedtimes. 

They can dress and bathe themselves, Young said, but they do need someone to fix their meals. They wash their own clothes on certain days, and Young said she reminds them to do that.

“And if they don’t know how to do that, I’ve taught them how to do that,” she said.

Adult foster care programs offer 24-hour assistance to older and/or disabled persons who are unable to live alone in their own house or apartment. 

These adults wouldn’t benefit from a nursing home or an assisted living facility because they don’t require the level of care provided by those institutions. The programs place them in settings with a small number of residents.

Margaret Morton, executive director at Sylacauga Alliance for Family Enhancement (SAFE), said those in foster care benefit an environment where they get individual attention and their basic needs met. 

“If they’re in a nursing home, maybe that’s wonderful, but perhaps that individual doesn’t need that level of care,” she said. “So being in a home environment, we’ve seen it with the work that we did, being able to support that individual to stay in their home. They tend to be healthier if they have that support. And their quality of life improves.”

John Matson, vice president of the Alabama Nursing Home Association, said nursing homes provide a medical level of care. Residents at nursing homes are able to get advanced care overseen by medical professionals, where they may need to be connected to oxygen or receive a daily shot.

“Adult foster care requires custodial care, and nursing homes provide medical care,” he said.

The state currently has 18 licensed providers serving 19 adults in foster care. The program is small compared to the approximately 6,000 children in foster care in Alabama, but it shares similar goals.

A safe space for vulnerable adults

There are over 600 vulnerable adults in Alabama who the state deems “out-of-home placements.” The Alabama Department of Human Resources, which oversees the state’s adult foster care program, investigates whether an adult is at high risk of abuse, and whether circumstances would require their removal from a home.

“If we determine that they are in a high risk of abuse and neglect, and circumstances are necessary for them to be removed from their current home, then we would help them find an out-of-home placement, which is an institution or adult foster care,” said Dominic Binkley, a spokesman for DHR. 

It’s unclear how many of these adults would immediately benefit from living in a foster home, as many require different levels of care. Some may benefit more from living in a nursing home or assisted living facility, Binkley said.

The need for these homes continues to grow. The state’s population is aging. The percent of Alabamians aged 65 or older rose from about 14% in 2010 to nearly 18% in 2020. 

With the growth in the elderly population has come growth in reports of elder abuse. In fiscal year 2022, DHR received 12,033 reports of abuse, neglect and exploitation of adults statewide. That is an increase of 115% compared to 2012, when the department had 5,597 reports. Except for one year during the pandemic, the number of reports has increased every year in recent years, Binkley said.

Dr. Cari Levy, the co-director of the Seattle-Denver Center of Innovation (COIN), a part of the U.S. Department of Veterans Affairs, researches long-term delivery care models for frail older adult populations, including veterans. She recently compared rates of COVID cases between VA nursing homes and VA foster care homes and said that veterans in adult foster care fared much better than veterans in nursing homes.

Levy said that reports of social isolation were much lower for those in foster care because they lived together during COVID stay-at-home orders. It was more of a problem for nursing home residents who were isolated to their rooms.

Saving money

Foster care system can also help the state save money by keeping adults out of nursing homes and assisted living communities. 

It costs about half as much to place an adult in foster care than it does in a nursing home, said Kelly Munly, an assistant professor of human development and family studies at Penn State Altoona, a university in Pennsylvania.

“I think most people, if they can’t take care of themselves, would be directed toward a nursing care center, which is twice as expensive,” she said. “So any kind of public funding that would go towards supporting a smaller, home-like setting would save a state half the cost.”

A comprehensive range of residential, community, and in-home services are typically necessary to balance long-term care systems and reduce Medicaid use of nursing home care. While most beneficiaries who receive services outside of a nursing home live in their own home, residential settings provide a supportive, home-like environment for vulnerable adults who lack caregivers, need on-demand support, or require oversight or supervision.

Programs vary by state, said Munly. States like California, in terms of licensing, don’t differentiate between adult foster care and assisted facilities and it’s one license for both. Colorado licenses Alternative Care Facilities, which is similar to assisted living but in smaller homes that are less structured, family environment that cares for three or more adults.

Alabama requires licensed providers to be at least 19 years old, able to read, and have a driver’s license and access to a car. Some providers, like Young, may care for up to three adults if they have the capacity and choose to do so. 

Providers choose how many adults they foster or if they need a break, which is why some providers may not be fostering any adults right now while a provider, like Young, may foster as many as it is allowed.

A new program 

Alabama had an adult foster care program in the late 1970s, but the modern program grew out of a one-time American Rescue Plan Act grant from the Administration for Community Living.

DHR used ARPA funding for the recruitment of adult foster homes starting in April 2021. The department started the project by providing “refresher” training to each county DHR office so that staff were familiar with adult foster home recruitment and licensing. DHR created recruitment materials such as fliers, banners, brochures, and tablecloths, and within a year, each office had these materials in hand.

DHR also bought TV ads to broaden their recruitment efforts, which is how Young learned about the program. These ads have been broadcast on television and radio since last October, as well as in newspapers and online. DHR has also attended sporting events across the state to promote the program.

The state is the only one in the nation that does not offer some sort of waiver to pay for the program. With so few providers in the state currently, it’s unclear how providing a waiver would shape the program.

Binkley said the department has been working hard to “reinvigorate” the program by focusing on recruiting providers.

The 18 licensed providers are spread across 11 counties, but the department’s goal is to have at least one provider in each of the 67 counties.

Since last October, DHR’s state office has received 54 applications from prospective adult foster care providers. According to DHR data, 21 potential providers are awaiting licensure.

‘A blessing’

In Young’s house, all four women go to church together. On holidays, they all spend time with Young’s family. They save money for birthday celebrations, whether a nice dinner or a vacation.

“One lady that had never seen the beach ever,” Young said. “And it was just so amazing. She had never seen the water. She was afraid of the water and so now she’ll lay in it. It’s so awesome to see their faces light up and the smiles and it’s such a blessing and a joy to be able to take them and do things they’ve never done before.”

For Young, being able to provide a home for her “ladies,” as she calls them, has been a “blessing,” especially at her age.

“Their gratitude – their smile on their face. The little things that I do that I think don’t mean anything to them, they’ve never had it before,” she said. “I guess it’s just so heartwarming to know that I’m actually giving them this little thing that I thought didn’t mean nothing, but to them it’s the greatest thing ever.”

She said she doesn’t know what happened to these ladies before they came into foster care, but they all came in with different challenges, including anxiety, depression and PTSD. One of the women had a meltdown when she first arrived in Young’s home, but that has been the only incident to date.

“It was kind of funny because in the beginning all she wanted was to move out into her own place, which was actually the plan, and now she doesn’t want to leave,” Young said. “She doesn’t want to go, doesn’t want to move out, she just wants to stay here.”