July 26, 2022 – Susan Snead used to live in an apartment complex for older adults. The complex had a nice dayroom, and neighbors would knock on her door every now and then to check in.
But despite not being lonely, Snead, 89, did live alone in downtown Charleston, SC. Eventually, that became dangerous.
“I fell a few times,” she says. “I had to call somebody to come and get me up.”
Sometimes help would come from the apartment complex’s office. Sometimes it came with a police escort.
Over time, needing to make those calls became a burden. Making and keeping appointments with her doctor, something she had to do regularly, as she has diabetes, got harder, too.
“It kind of wore me out,” she says. “Like you’re going up a hill.”
As she was beginning to accept she could no longer live alone, Snead, an Air Force veteran, learned about a program run by the Department of Veterans Affairs called Medical Foster Home.
Medical foster homes are privately owned homes in which a licensed caregiver lives with and supervises residents around the clock. Caregivers help aging veterans with activities of daily living like bathing, cooking, making and getting to appointments, getting dressed, and taking daily medication.
Caregivers can take care of up to three residents in their home at a time. While most residents are veterans, caregivers sometimes care for non-veteran residents, such as a veteran’s spouse or a caregiver’s family member.
Veterans typically pay about $1,500 to $3,000 out-of-pocket per month for the service, depending on location.
According to the VA, the concept of medical foster homes has been around since 1999, when VA hospitals across the country began reaching out to people willing to provide live-in care for veterans. The option is led by local VA hospitals, which approve caregivers and provide administrative services. There are now 517 medical foster homes, the VA says.
Much like other residential care facilities, medical foster homes get regular inspections for safety, nutrition, and more.
In 2019, Snead signed up for the program. She expected to be cared for, but she found a sense of family with her caregiver, Wilhelmina Brown, and another veteran in the home.
Brown started taking care of people – but not necessarily veterans – in 1997 when her grandmother was unable to care for herself, she says.
“My grandmama carried me to church every Sunday, she carried me to the beach – everywhere she went, she took me with her,” Brown says. As her grandmother got older, “I said, ‘I’m going to take care of her in my home.’”
Caring for others must come from the heart, Brown says.
She cooks her residents’ meals three times a day with dietary restrictions in mind, washes their dishes, does their laundry, remembers birthdays, and plans little parties.
“That’s my family,” Brown says.
In 2020, the COVID-19 pandemic upended the world – but at the same time, it highlighted the advantages of the medical foster home model.
Home-based primary care keeps veterans out of nursing homes – something that became particularly important as COVID-19 hit nursing homes and long-term care facilities.
Caregivers in the system were also able to help veterans, often living in rural areas, pivot and adapt to telehealth during a time of crisis.
One study, published in the journal Geriatrics in June 2022, set out to identify how medical foster homes were able to deliver safe, effective health care during the early stages of the pandemic.
Researchers interviewed 37 VA care providers at 16 rural medical foster home programs across the country. The interviews took place between December 2020 and February 2021. They found medical foster home caregivers, coordinators, and health care providers communicated to move office visits to the home, helped veterans navigate telehealth, advocated to get veterans vaccinated in-home, and relied on each other to fight social isolation.
Caregivers also adapted quickly to telehealth, according to Leah Haverhals, PhD, a health research scientist and communications director for the Seattle-Denver Center of Innovation for Veteran Centered and Value Driven Care, who led the study.
Most veterans in the foster home program are older and find new technology difficult to use.
Caregivers, coordinators, and health care providers were largely new to the technology, too.
While the study found that most veterans and caregivers preferred in-person care, they were able to work together to make the best of telehealth.
“That speaks to the nature of the care being given, being able to pivot in a crisis like that,” Haverhals says.
If caregivers didn’t already have computers or telehealth-compatible devices, the VA provided iPads that would connect to the internet using cellular signals. According to the study, this helped to overcome connectivity issues that may have caused problems in rural areas.
Snead says Brown helped a lot with her telehealth calls.
“If we had to do things over the phone or with video, she was able to set that up to work with the person on the other end. She knows a lot about that stuff – about computers and things like that,” Snead says, adding that she hadn’t worked with computers since retirement in 1998.
Telehealth helped health care providers identify infections and quickly prescribe antibiotics to veterans in rural areas and provide other care that was more safely delivered in private homes.
“The findings from our study highlighted that when working together for the common goal of keeping vulnerable populations like veterans in MFHs [medical foster homes] safe during times of crisis, adaptation and collaboration facilitated the ongoing provision of high-quality care,” Haverhals’s group wrote. “Such collaboration has been shown to be critical in recent research in the U.S. on supporting older adults during the pandemic.”
Cari Levy, MD, PhD, a professor at the University of Colorado School of Medicine, and a co-author of the study, specializes in palliative and tele-nursing home care for the VA.
Levy, who has worked for the VA for about 20 years, says how medical foster homes provided care during the pandemic carries lessons for civilian clinics. One of the most important lessons, she says, is that medical professionals will need to provide more care where people are, especially in populations that are too sick to get to the clinic.
“For years, there was all this hope that telehealth would expand,” but it took a pandemic to authorize approval from federal agencies to explode, she says. “I shudder to think what would have happened if we didn’t have telehealth. Fortunately, it was the right time to be able to flip a switch.”
Crisis aside, Levy says her dream would be for health care providers to do more home-based care. The model allows people to preserve the relational aspects of medicine, which can counteract a lot of the moral injury and burnout in the field, she says, adding:
“I see this as the kind of medicine many people intended to do when they got into medicine.”