The four variables, in order of importance for tenure security. Lease control is first because it determines whether the adult can be evicted at the provider’s discretion. Staffing stability is second because the home is only as good as the people in it. Cost structure is third because predictable cost is the difference between staying and being displaced when waiver budgets shift. Autonomy is fourth because the right level of autonomy depends on the adult; this is the variable to tune to person, not to default high or low.

Who controls the lease, and why it matters.

In a group home, the provider holds the lease. The adult is a resident under the provider’s roof. Discharge from the home is a clinical or behavioral decision the provider makes, subject to state licensing rules. The procedural protections are weaker than residential tenancy law would provide. If the adult’s behavior changes, if the provider has staffing problems, or if the provider closes the home, the adult moves. The HCBS Settings Rule has tightened the procedural protections, but the underlying arrangement remains: the provider can ask the adult to leave more easily than a landlord can evict.

In supported living, the adult holds the lease. State and federal landlord-tenant law applies. Eviction requires cause, notice, and (in most states) a court process. The adult’s housing stability is not dependent on the provider’s clinical judgment. Services can change without the adult losing their home. This is the model the Olmstead decision and the HCBS Settings Rule both push the system toward, and it is the model with the strongest tenure security available in the adult disability service array.

In shared living, the host family typically owns or rents the home. The adult occupies a room in someone else’s residence. Tenancy is informal in most states; if the match breaks down, the adult moves. Strong matches survive years; weak matches break down quickly. The model rewards careful pairing and active relationship maintenance by the case manager.

Intentional communities vary. Camphill, L’Arche, and similar communities use a range of legal structures. Ask. Read the resident agreement. Understand what the adult signs and what protection the agreement provides.

Staffing: turnover is the operational reality.

Direct Support Professional turnover in the United States routinely runs above 40-50% annually, varying by state and provider. Some providers run at 30%; some at 80%. A home with high turnover is a home where the adult learns a new caregiver every six weeks. A home with stable staffing is a home where the adult is known. Ask every provider, on every tour, what their turnover rate is. Reputable providers will tell you. The number is one of the strongest predictors of residential outcome quality.

Ask, also, about overnight stability. The overnight aide is the person in the building when the adult wakes up at three in the morning. If the overnight position has been vacant or covered by rotating temps for months, the home has a fundamental problem that the daytime tour will not reveal. Ask. The honest answer is informative even when it is not the answer you wanted to hear.

Cost structure: predictability matters more than rate.

Group home costs are generally bundled into a daily rate paid by Medicaid through the HCBS waiver, with the adult’s SSI or SSDI contributing a “room and board” payment. Supported living separates the residential cost (paid by the adult through SSI, SSDI, employment income, or housing voucher) from the support cost (paid by the waiver). Shared living pays the host family a stipend. Intentional communities usually require an entrance fee plus monthly resident contribution; some accept HCBS waiver participation, some do not.

Predictability matters more than the headline rate. Models that absorb shocks (a temporary increase in staffing need, a behavior change, a hospitalization) without renegotiating cost are operationally stable. Models that require the family to fund gaps when waiver budgets shift are not. Ask each provider how the cost responds to changes in support level. The answer reveals the operational sustainability.

Autonomy: tune to person, not to default.

The least useful framing of housing choice is to ask “how much autonomy does the adult need.” Different adults need different amounts of autonomy in different domains, and the same adult needs different amounts at different life stages. A useful framing instead: which combination of supervision and freedom produces the daily life the adult would choose if they could see all the options. Some adults thrive with high supervision and structure. Some adults thrive with minimal staff presence and full lease control. Most adults are somewhere in between, and the right point on the spectrum may shift as the adult grows into their adult life.

The HCBS Settings Rule requires specific autonomy protections in any Medicaid-funded setting: lockable bedroom, control over food access, choice of visitors, freedom to come and go as a typical adult would. These are floors, not ceilings. A good provider exceeds the floor. A struggling provider treats the floor as an aspiration. Ask the question. Read the answer.

Tour-day questions.

The five tour-day questions in the action block above are the minimum. Bring a written list, written by the family in advance. Ask each question of each provider. Note the responses. Note the body language. Note who answers and who looks away. Take photos with permission. Ask to walk through every common space and at least one private bedroom (with the resident’s consent). Ask to see the daily schedule posted on the kitchen wall. Ask to see the menu. Ask to taste a sample. The visit is the data. The brochure is not.

Bring the adult on a separate visit if the first tour is just the family. Bring the adult on a meal visit if the first adult visit went well. Offer to do a trial overnight or trial weekend. Providers that are confident in their operation accept trial stays; providers that are not confident find reasons to decline. Both responses are informative.

What other states make easier.

Several state Medicaid agencies publish provider quality data publicly, including incident rates, complaint histories, and HCBS Settings Rule compliance status (Massachusetts, Ohio, Tennessee). Several states fund Family Resource Centers and parent navigators who tour homes with families and translate brochure language into operational reality (Pennsylvania, Wisconsin). The National Core Indicators state-by-state survey publishes resident outcome data including stability, autonomy, and community participation, which is worth checking when comparing across states or before choosing among state-specific provider options. Michigan publishes some provider information but with less consumer-facing organization than peer states. Other states made different choices about transparency. Michigan didn’t, fully.

Your assignment this week.

Tonight: build the four-by-four scoring grid. This week: identify the providers in your region for each model. Schedule three tours, one for each of the three most-relevant models given your adult’s needs. Write the question list. Take the tour. Take the second tour with the adult. Schedule the trial weekend if a model survives the question list. None of this is exotic. None of it was supposed to be this hard to learn. Other states publish more. Michigan didn’t, fully. Now we know what we are fighting. Together.