Addressing Homelessness Among Older Adults: Final Report

Prepared for

the Office of the Assistant Secretary for Planning and Evaluation (ASPE)

at the U.S. Department of Health & Human Services

Westat

October 2023

OFFICE OF BEHAVIORAL HEALTH,

DISABILITY, AND AGING POLICY

Addressing Homelessness Among

Older Adults: Final Report

Office of the Assistant Secretary for Planning and Evaluation

The Assistant Secretary for Planning and Evaluation (ASPE) advises the Secretary of the U.S. Department

of Health and Human Services (HHS) on policy development in health, disability, human services, data,

and science; and provides advice and analysis on economic policy. ASPE leads special initiatives;

coordinates the Department's evaluation, research, and demonstration activities; and manages cross-

Department planning activities such as strategic planning, legislative planning, and review of regulations.

Integral to this role, ASPE conducts research and evaluation studies; develops policy analyses; and

estimates the cost and benefits of policy alternatives under consideration by the Department or

Congress.

Office of Behavioral Health, Disability, and Aging Policy

The Office of Behavioral Health, Disability, and Aging Policy (BHDAP) focuses on policies and programs

that support the independence, productivity, health and well-being, and long-term care needs of people

with disabilities, older adults, and people with mental and substance use disorders. Visit BHDAP at

https://aspe.hhs.gov/about/offices/bhdap for all their research activity.

NOTE: BHDAP was previously known as the Office of Disability, Aging, and Long-Term Care Policy

(DALTCP). Only our office name has changed, not our mission, portfolio, or policy focus.

This research was funded by the U.S. Department of Health and Human Services Office of the Assistant

Secretary for Planning and Evaluation under contract and carried out by Westat. Please visit

https://aspe.hhs.gov/topics/homelessness-housing for more information about ASPE research on

homelessness and housing.

ADDRESSING HOMELESSNESS AMONG OLDER ADULTS: FINAL REPORT

Authors

Kathryn A. Henderson, Ph.D.

Nanmathi Manian, Ph.D.

Debra J. Rog, Ph.D.

Evan Robison, MPH

Ethan Jorge

Monirah Al-Abdulmunem, MS

Westat

October 26, 2023

Prepared for

Office of Behavioral Health, Disability, and Aging Policy

Office of the Assistant Secretary for Planning and Evaluation

U.S. Department of Health and Human Services

The opinions and views expressed in this report are those of the authors. They do not reflect the views

of the Department of Health and Human Services, the contractor or any other funding organization. This

report was completed and submitted April 2023.

Acknowledgments

The authors would like to acknowledge the contributions of their colleagues, Ilene Rosin, for

assistance with data collection, and Dr. Andreea Balan-Cohen, Dr. Cindy Gruman, and

Dr. Beth Rabinovich for review of this report. We would also like to thank our project officers at

the U.S. Department of Health and Human Services, Office of the Assistant Secretary for

Planning and Evaluation, Lauren Anderson, Emma Nye, and Emily Rosenoff for providing us

guidance and support throughout the project.

We also thank the subject matter experts and service providers we interviewed for this project

for graciously providing us their time and knowledge. Most importantly, we are grateful to the

individuals with lived experience of homelessness in older adulthood who shared with us their

experiences and recommendations.

Table of Contents

EXECUTIVE SUMMARY ................................................................................................................................. 4

SECTION 1. INTRODUCTION ....................................................................................................................... 12

Overview of Report .............................................................................................................................. 13

Methodology ........................................................................................................................................ 13

SECTION 2. SIZE, CHARACTERISTICS, AND NEEDS OF THE POPULATION OF OLDER ADULTS

EXPERIENCING HOMELESSNESS ADULTS EXPERIENCING HOMELESSNESS .............................................. 14

Prevalence of Homelessness Among Older Adults .............................................................................. 14

Pathways into Homelessness for Older Adults .................................................................................... 15

Characteristics of Older Adults Experiencing Homelessness ............................................................... 17

Service Needs of Older Adults Experiencing Homelessness ................................................................ 19

SECTION 3. SYSTEMS AND SERVICES AVAILABLE TO SERVE OLDER ADULTS AT RISK OF OR

EXPERIENCING HOMELESSNESS ................................................................................................................. 27

Homelessness Assistance ..................................................................................................................... 28

Housing Programs and Residential Long-Term Care Options .............................................................. 32

Health Care, Long-Term Care, and Behavioral Health Services ........................................................... 39

Income Supports and Other Needs ...................................................................................................... 45

SECTION 4. GAPS AND POTENTIAL STRATEGIES ........................................................................................ 50

Gaps in Service Delivery and Coordination .......................................................................................... 50

Gaps in Knowledge ............................................................................................................................... 53

Potential Strategies .............................................................................................................................. 54

Conclusion ............................................................................................................................................ 56

APPENDIX: OVERVIEW OF METHODOLOGY .............................................................................................. 58

REFERENCES ................................................................................................................................................ 62

ACRONYMS ................................................................................................................................................. 77

List of Exhibits

Exhibit 1. Sample Racial/Ethnic Composition for Studies of Older Adults Experiencing

Homelessness ....................................................................................................................... 18

Exhibit 2. Comparison of Characteristics and Needs of Older Adults Experiencing

Homelessness ....................................................................................................................... 20

Exhibit 3. Systems Framework for Addressing Homelessness Among Older Adults ........................... 27

Exhibit 4. Types of Housing Assistance Available for Older Adults Experiencing

Homelessness ....................................................................................................................... 32

Exhibit 5. Types of Residential Long-Term Care Available for Older Adults Experiencing

Homelessness ....................................................................................................................... 36

Exhibit A-1. Key Words and Search Terms Used to Identify Relevant Published and

Unpublished Literature ........................................................................................................ 58

Exhibit A-2. Sources Searched to Identify Relevant Published and Unpublished Literature .................. 59

Executive Summary

The number of older adults at risk of and currently experiencing homelessness has increased

rapidly in recent years, a trend that is projected to continue and further accelerate (Culhane et

al., 2013; Culhane et al., 2019). Older adults at risk of or experiencing homelessness have

unique needs compared to other populations experiencing homelessness. As a first step in

understanding how to address the needs of this population, the U.S. Department of Health and

Human Services’ (HHS) Office of the Assistant Secretary for Planning and Evaluation contracted

with Westat to conduct a study of what is known about older adults experiencing

homelessness, including an examination of the size, characteristics, and needs of this

vulnerable population and the services, housing, and supports needed and available to serve

them. The study included an environmental scan of published research, evaluations, and white

papers as well as discussions with subject matter experts, housing and service providers, and

people with lived experience of homelessness as older adults.

This report provides a roadmap for understanding the population of older adults at risk of or

experiencing homelessness and what services and supports are available to serve them. Using

an equity lens, we examine these topics with attention to what is known about racial and ethnic

groups disproportionately impacted by homelessness. We highlight the challenges older adults

face in accessing the assistance available; innovative practices, especially those implemented

during the Novel Coronavirus (COVID-19) pandemic, that could ease these challenges; and

remaining gaps that need to be filled to effectively tackle the problem. We end with

recommendations to better identify and serve older adults at risk of or experiencing

homelessness.

POPULATION OF OLDER ADULTS EXPERIENCING HOMELESSNESS

Older adults are the fastest-growing age group of those experiencing homelessness, composing

nearly half of the homeless population (Kushel, 2022) and their numbers are estimated to triple

by 2030 (Culhane et al., 2019). Older adults are especially vulnerable to homelessness as many

live on fixed incomes insufficient to cover all their expenses, especially housing expenses

(Sermons & Henry, 2010). Half of renters ages 50 and older pay more than 30 percent of their

income on housing (Joint Center for Housing Studies, 2018).

Two trends in the growth of homelessness among older adults are apparent: aging of those

who first experienced homelessness earlier in life and continue to experience homelessness as

older adults and, increasingly, people experiencing homelessness for the first time in older age.

The first group represents a cohort effect: individuals born in the second half of the post-World

War II baby boom (1954-1963) who throughout their lives have had an elevated risk of

homelessness due to limited employment opportunities, coupled with mental health and

substance use disorders. The second group of older adults are experiencing homelessness for

the first time after age 50 after having lived relatively stable lives including long periods of

employment and residential stability. For this group, homelessness is often preceded by

stressful life events, such as the death of a spouse or partner, divorce, loss of work, eviction, or

the onset of health problems, coupled with limited or fixed incomes (Cohen, 2004; Crane et al.,

2005).

CHARACTERISTICS OF OLDER ADULTS EXPERIENCING HOMELESSNESS

Older adults with earlier experiences of homelessness have had increased vulnerabilities

throughout their lives, including more adverse childhood experiences, more mental health

conditions, greater alcohol and drug use, higher rates of incarceration, and more

underemployment than those with later entry into homelessness (Brown et al., 2016). In

addition, this group has spent more time homeless both overall and in their current episodes

than those individuals whose first homelessness occurred in older age (Brown et al., 2016).

The few studies that have examined the racial and ethnic composition of older adults

experiencing homelessness are limited in their generalizability due to having small samples

drawn from limited geographic regions. Despite this limitation, their findings are consistent

with national level data in that the percentage of African Americans who are experiencing

homelessness is disproportionately large compared to the overall percentage of African

American older adults (HUD, 2023; Moses, 2019).

SERVICE NEEDS OF OLDER ADULTS EXPERIENCING HOMELESSNESS

Compared to their housed counterparts, older adults experiencing homelessness have higher

rates of health service utilization and more health and health-related concerns, including:

• Significantly shorter life spans (Metraux et al., 2011; Schinka & Byrne, 2018; Brown et al.,

2016; Kushel 2020).

• Higher prevalence and severity of physical and geriatric conditions including memory loss,

falls, difficulty performing activities of daily living (ADLs), cognitive impairment, and

functional impairments (Brown et al., 2011; Brown et al., 2017; Hahn et al., 2006; Hwang et

al., 1997).

• More complex health needs, comparable to housed individuals who are 10-20 years older

(Cohen, 1999; Gelberg et al., 1990; Homelessness Policy Research Institute [HPRI], 2019;

Brown et al., 2016).

• Higher rates of mental health and substance use disorders (Brown et al., 2011; CDC, 2008;

Spinelli et al., 2017).

“Like my body isn't so resilient. When I was younger,

I, mean, I went everywhere and bounced back. And

now it's harder to get up out of the chair, let alone

get up off the sidewalk if you're sleeping outside.”

– Adult currently experiencing homelessness, 59

As such, this population has greater need for health care supports, such as access to

medications, durable medical equipment, and assistive technology, as well as assistance with

ADLs, compared to their housed counterparts.

Compared to individuals younger than 50 years who are homeless, older adults experiencing

homelessness have higher rates of chronic illnesses, geriatric conditions, and cognitive

impairments as well as high blood pressure, arthritis, and functional disability (Garibaldi et al.,

2005; Gelberg et al., 1990). Among people experiencing homelessness, older adults and

younger adults have comparable rates of mental health and substance use disorders (DeMallie

et al., 1997; Gelberg et al., 1990; Gordon et al., 2012).

Among older adults experiencing homelessness, older adults who first experienced it earlier in

life have more behavioral health needs and service utilization than those who first experienced

homelessness after age 50. Differences are most pronounced in rates of current mental health

issues, including depressive symptoms, post-traumatic stress disorder, and substance use, as

well as hospitalizations for mental health conditions (Brown et al., 2016).

Finally, food insecurity, lack of transportation, and loss of community surface as additional

challenges for older adults experiencing homelessness. Older adults experiencing homelessness

have rates of food insecurity that are nearly two times higher than estimates among all people

living in poverty (Coleman-Jensen et al., 2016; Tong et al., 2018). Lack of transportation poses a

particularly significant barrier for older adults, who are more likely to have mobility limitations

due to health impairments, including poor eyesight and impaired cognition.

SYSTEMS AND SERVICES AVAILABLE TO SERVE OLDER ADULTS AT RISK OF OR EXPERIENCING

HOMELESSNESS

Homelessness Assistance

Older adults may face unique challenges accessing homelessness assistance, including limited

knowledge about the services available for which they are eligible, heightened anxiety about

and lack of trust in working with providers,

limited access to technology to complete online

applications (National Council on Aging [NCOA],

2022), and difficulty attending scheduled

appointments, providing documentation of

eligibility, or completing the necessary

paperwork (Grenier et al., 2013). As noted by experts, many crisis and interim housing facilities

may not be accessible to older adults with mobility challenges and difficulty performing ADLs or

these facilities may be unable to provide the kind of supports that older adults need. Although

some organizations and municipalities offer programs aimed specifically at older adults, most

communities do not provide this type of assistance.

Homelessness assistance includes

prevention services, identification,

engagement, and assessment services,

as well as crisis or interim housing.

Housing Assistance

Access to housing assistance can be difficult

given the current lack of availability and the high

and growing demand among low-income older

adults. Consequently, large numbers of older

adults who are eligible for rental assistance

either have a long wait time for assistance or do

not end up receiving the assistance (Public and

Affordable Housing Research Corporation

[PAHRC], 2020), a finding reflected in our

discussions with people with lived experience.

Experts also noted a lack of residential options

with sufficient support to enable older adults to

age in place.

Health Care, Long-Term Care, and Behavioral

Health Services

Older adults face a number of challenges

receiving the health care they need. Meeting

basic needs such as food and housing often takes

precedence over seeking treatment for physical

and behavioral health needs. Lack of available

providers within communities, limited provider

capacity, a lack of transportation, and mobility

challenges further exacerbate difficulties in

obtaining the health care that older adults experiencing homelessness need (Baggett et al.,

2011; Canham et al., 2020; Kushel et al., 2012; Lee et al., 2020; Ye et al., 2019).

Basic Needs Assistance

Older adults experiencing homelessness often

have difficulty accessing needed assistance.

Individuals without fixed addresses and those

with limited access to technology, as well as

those with health or behavioral health

conditions, may have difficulty establishing

eligibility for assistance or completing their

applications (Tong et al., 2018). Moreover, all of these basic needs programs may be limited in

rural areas.

Housing assistance includes programs

that provide time-limited assistance as

well as a wide range of permanent

subsidized housing options with and

without supportive services. These

include permanent supportive housing,

permanent subsidies, low-income tax

credit housing, and a range of residential

and institutional care settings that may

provide medical management, support

services, and social activities.

Health care, long-term care, and

behavioral health services, including

medications, are available for older

adults through a variety of federal and

state-funded mechanisms including

Medicare, Medicaid, VA benefits (for

eligible veterans), and OAA and SAMHSA

funded programs.

Assistance for basic needs, such as

income, food, transportation, and social

engagement are provided through a

range of federal, state, private, and non-

profit programs.

INNOVATIVE PROGRAMS TO SERVE OLDER ADULTS EXPERIENCING HOMELESSNESS

Numerous agencies and municipalities are implementing innovative programs to address the

specific challenges older adults experiencing homelessness face, including with accessing

needed assistance. A sample of the programs is highlighted throughout this report. For

example:

• The Native American Disability Law Center in New Mexico and Arizona creates accounts

for clients in an online benefits application portal to help individuals apply for energy

assistance and other public benefits.

• The Hearth program in Boston, Massachusetts provides outreach to older adults at risk

of or experiencing homelessness to apply for, locate, and move into subsidized housing.

• Serving Seniors in San Diego, California provides transitional housing with facilities

accessible to people with mobility challenges and supportive services focused on the

unique needs of older adults experiencing homelessness.

• The Southern California Clinical and Translational Science Institute in Los Angeles County

is pilot testing the integration of the Community Aging in Place--Advancing Better Living

for Elders (CAPABLE) program with permanent supportive housing to provide home-

based services, such as occupational therapists, nurses, and handypersons, to formerly

homeless older adults who experience difficulties with ADLs.

• St. Paul’s Programs of All-Inclusive Care for the Elderly (PACE) program in San Diego,

California, provides formerly homeless older adults subsidized housing with wrap-

around supportive services, including primary and specialty health services, medication

assistance, mental health services, occupational therapy, and dentistry, as well as meals

and nutrition counseling, social activities,

social services, and transportation

assistance.

Moreover, during the COVID-19 pandemic,

numerous federal, state, and local agencies

provided additional assistance to older adults

experiencing homelessness to access shelter,

housing, and services through increased funding,

policy changes or waivers, and new service

delivery models. Many of these innovations may

be continued or expanded to better serve

vulnerable older adults, especially those who

experience homelessness.

ADDRESSING GAPS IN SERVICE DELIVERY AND COORDINATION

The environmental scan and discussions identified a number of critical gaps in housing and

service availability, accessibility, delivery, and coordination. The following interventions and

Examples of Programs Implemented

During the Pandemic

• Expanded eviction prevention

resources.

• Placement of people experiencing

homelessness into motel rooms.

• Medicare coverage of telehealth

services.

• USDA’s SNAP Online Purchasing Pilot.

policy changes offer strategies to enable providers and policymakers to better meet the

housing and support needs of older adults experiencing housing instability and homelessness.

• Identification, outreach, and navigation services particularly targeted to older adults

experiencing homelessness who have specific barriers to receiving assistance, such as

fears of losing their independence or difficulty understanding eligibility requirements

Few non-homelessness providers with whom older adults are connected, such as health

clinics and benefits offices (e.g., Supplemental Nutrition Assistance Program [SNAP]

offices), routinely screen for risk of homelessness. Older adults experiencing

homelessness for the first time may not know what types of assistance are available or

where to go to get it. They may also wait too long to request assistance to maintain

their housing. Older adults experiencing homelessness need resources and assistance to

learn about both the available supports for which they are eligible and the processes of

applying for and accessing these supports.

• Increased access to benefits and services to provide a greater number of older adults at

risk of or experiencing homelessness the assistance they need to address housing, health,

and other challenges. Experts noted that restrictive eligibility criteria such as strict income

and/or asset requirements, age or disability requirements, and other restrictions prevent

or complicate access to key services for older adults experiencing homelessness.

• Crisis and interim housing tailored to older adults. There is a need for emergency

shelter accommodations that include beds that are on the first floor or bottom bunk,

24-hour access to bedrooms and bathrooms, and refrigeration or locked storage for

medications and medical supplies, as well as crisis or interim housing accessible to older

adults with limited mobility, difficulties with ADLs, and needing assistance with limited

health care and medication management.

• Permanent supportive housing tailored to older adults with histories of homelessness.

Older adults with histories of homelessness often have greater functional impairments

and behavioral health challenges, as well as limited connection to their communities.

There is a need for permanent supportive housing with physical accommodations (e.g.,

wheelchair accessible buildings, grab bars in units) to address these needs as well as

access to the types of case management and nursing assistance (e.g., medication

management, wound care) that will allow them to age in place.

• Consistent case management assistance to assist older adults with accessing the

housing and other supports they need.

• Increased capacity of affordable housing. More permanent supportive housing is

needed, as well as a continuum of supports to provide tailored assistance to a diverse

population of individuals, ranging from those who may need only shallow rental

subsidies to those who need intensive medical management and support services.

• Coordination across systems to address the variety and unique needs of older adults

experiencing homelessness. Barriers to coordination include siloed funding streams,

varying eligibility criteria, overburdened staff, and data sharing barriers.

GAPS IN KNOWLEDGE

Gaps in knowledge include a lack of:

• Research around equity in services and outcomes.

• Research on the connection between health and homelessness among older adults.

• Documentation of the types of assistance available to older adults and their respective

eligibility criteria and enrollment requirements.

• Additional data on older adults experiencing homelessness.

POTENTIAL STRATEGIES

Through the information identified in this scan, we offer a number of potential strategies for

policymakers and service providers to better identify and serve older adults at risk of or

experiencing homelessness. Strategies for policymakers at federal, state, and local levels to

consider include:

• Additional prevention resources for older adults at risk of homelessness, including

short-term rental assistance, resources to help with property taxes, and assistance with

home maintenance costs.

• Assistance with other costs of living, including food, transportation, and other expenses

that would allow rent-burdened older adults to meet their needs.

• Additional types of affordable housing assistance, such as shallow subsidies and

affordable assisted living.

• Expanded state coverage for home and community-based services (HCBS), such as

assistance with medication management and wound care; assistance with ADLs; and

home management services, to help support individuals as they age.

• Identification of older adults by HUD as a key sub-population in its Annual

Homelessness Assessment Reports to provide more national data on older adults

experiencing homelessness.

• Better cross-system coordination, including through shared goals, flexible or blended

funding streams, better integrated data, and coordination between the No Wrong Door

Initiative with coordinated entry systems.

• Continuation of demonstration projects started during the pandemic, such as the U.S.

Department of Agriculture (USDA)’s SNAP Online Purchasing Pilot, that facilitated

access to services for older adults with limited mobility as well as flexibilities around

Medicaid enrollment and housing vouchers.

Potential strategies for service providers include:

• More proactive identification by service providers, such as health clinics and those

participating in the No Wrong Door Initiative, of older adults who are severely rent-

burdened or otherwise at risk of homelessness.

• Better documentation of services and supports available in local communities to enable

older adults at risk of or experiencing homelessness to know what assistance is

available and how they can access it.

• Additional assistance accessing medical equipment, such as eyeglasses and hearing

aids, that may be damaged or lost while people experience homelessness.

• Training for case management staff on issues specific to older adults.

• Improved access to income assistance for eligible individuals through programs such as

Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI)

Outreach, Access, and Recovery (SOAR) to provide a sustainable source of income for a

larger share of older adults experiencing homelessness.

Section 1. Introduction

The number of older adults living in poverty is

increasing (Li & Dalaker, 2021) due in part to the

aging of the United States population overall,

coupled with the growing affordable housing

crisis (Aurand et al., 2021) and the public health

and economic crises that resulted from the

Coronavirus Disease 19 (COVID-19) pandemic.

Older adults are increasingly likely to be housing

cost-burdened (i.e., housing costs require more

than 30 percent of household income) and

severely housing cost-burdened (i.e., housing

costs require more than 50 percent of household

income). In 2019, around 5 million households headed by someone aged 65 or older paid at

least 30 percent of their income on rent, and another 5 million paid at least 50 percent (Joint

Center for Housing Studies, 2019). Not surprisingly, the population of older adults at risk of or

experiencing homelessness is also growing rapidly and is projected to continue to grow over the

next decade (Culhane et al., 2013; Culhane et al., 2019). Until recently, older adults who

experience homelessness have largely struggled with housing issues throughout much of their

adult lives (Culhane et al., 2013), concomitant with other health and life challenges. Yet, recent

research has identified a growing subgroup of older adults who become homeless for the first

time after the age of 50, due largely to economic factors (Brown et al., 2016; Crane et al., 2005;

Shinn et al., 2007).

The growth in this population and the different pathways they follow into homelessness

underscore the critical importance of understanding the needs of this vulnerable population

and what services and housing can best address them. Drawing on published literature and

interviews with researchers, providers, and people experiencing homelessness, this report

provides an overview of the characteristics and needs of older adults at risk of or experiencing

homelessness, differences between individuals who are newly experiencing homelessness in

older age and those who first experienced homelessness earlier in life, and the types of

services, housing, and supports needed to serve them. Using an equity lens, we examine these

topics with attention to what is known about racial and ethnic groups disproportionately

impacted by homelessness. Finally, we add to this summary an exploration of the programs,

policies, services, and supports that exist to prevent and address homelessness across the

systems that serve older adults. Brought together, the research and systems’ offerings provide

a roadmap for determining what is available now to both prevent homelessness among those

at risk as well as what is available to serve those who are experiencing homelessness. We

highlight the challenges older adults face in accessing the assistance they need, innovative

practices, especially those implemented during the COVID-19 pandemic that could ease these

challenges, and remaining gaps that exist that need to be filled to effectively tackle the

problem.

Terminology

Throughout the report, we use the term

“older” adults to refer to people 50

years of age and older, and the term

“senior” to refer to people 62 years of

age and older. We use the term

“elderly” only when referring to specific

eligibility criteria for the various

programs and services discussed.

OVERVIEW OF REPORT

Section 2 provides a discussion of the population of older adults experiencing homelessness,

including the prevalence of and pathways into homelessness. We examine the characteristics

and needs of older adults experiencing homelessness, including sociodemographic

characteristics, health and behavioral health conditions, and basic needs. Where possible, we

compare these characteristics and needs to those of housed older adults as well as to younger

adults who are homeless to understand how the characteristics and needs of older adults

experiencing homelessness may be unique. Section 3 addresses the systems and services

available to serve older adults at risk of or experiencing homelessness, including homelessness

and housing supports, health and behavioral health services, income supports, and other basic

needs assistance programs. For each of these service areas, we describe the assistance

available to low-income older adults generally and to older adults experiencing homelessness

specifically. We highlight challenges older adults face in accessing assistance and innovative

programs or strategies available to serve them. We also address changes in policies or practices

during the COVID-19 pandemic to facilitate access to needed services for older adults

experiencing homelessness may be beneficial to continue post-pandemic. In Section 4, we

identify critical gaps in the housing and services available to meet the needs of older adults at

risk of or experiencing homelessness and in existing research. We end with potential strategies

to better identify and serve older adults at risk of or experiencing homelessness.

METHODOLOGY

This report incorporates findings from an environmental scan, including a review and synthesis

of published research, evaluations, and white papers, discussions with subject matter experts

and housing and service providers, and interviews with people with lived experience of

homelessness in older adulthood. Each of these methods is described in further detail in the

Appendix. For the environmental scan, we used a systems approach for identifying key

resources, including focused searches on literature and other resources within the fields of

homelessness and housing, health and behavioral health, and aging. We also conducted

discussions with a diverse set of subject matter experts and housing and service providers.

Throughout the report, these individuals are referred to as experts and providers. We also

collected data through tailored conversations from individuals between the ages of 56 and 74

who were experiencing or had experienced homelessness as older adults. Six people were

currently experiencing homelessness at the time of the discussion and were staying in shelters,

in tents, or on the sidewalk. Eight people were housed, with seven in permanent supportive

housing and one in low-income housing. The goals of these conversations were to learn more

about their experiences accessing the housing, supports they needed, and challenges they

faced.

Section 2. Size, Characteristics, and Needs of the Population of Older

Adults Experiencing Homelessness

PREVALENCE OF HOMELESSNESS AMONG OLDER ADULTS

Homelessness among older adults is increasing, with a growing proportion of the population

experiencing homelessness aged 50 and older.

People aged 50 and older are the fastest-growing age group of those experiencing

homelessness, and their numbers are estimated to triple by 2030 (Culhane et al., 2019).

According to the U.S. Department of Housing and Urban Development (HUD), in 2021, people

aged 55 and older composed 19.8 percent of the sheltered homeless population (HUD, 2023),

an increase from 17.9 percent in 2020. This rate is even higher when we focus on adult-only

households experiencing homelessness: 28.7 percent in 2021 (HUD, 2023). Among sheltered

homeless adults with chronic patterns of homeless, those aged 55-64 made up the largest share

of people experiencing chronic homelessness (27.0 percent), and a total of 35.7 percent were

aged 55 and older in 2021 (HUD, 2023). The percentage of individuals aged 51 and older in

emergency shelters, transitional housing, and safe havens increased more than 10 percent in a

decade, from 23.0 percent in 2007 to 33.8 percent in 2017

(HUD, 2018). Among people

experiencing sheltered homelessness, people ages 55-64 compose a larger proportion (14.7

percent in 2021) than those ages 65 and older (5.1 percent in 2021) (HUD, 2023). In addition,

the percentage of older adults in permanent supportive housing grew during this time from

23.9 percent in 2007 to 38.7 percent in 2017 (HUD, 2018).

Age is the predominant way to define older adults experiencing homelessness, though the

specific age is not universally agreed upon in the literature or in practice.

Most current research on older adults at risk of or experiencing homelessness focuses on those

who are 50 and older. The experts with whom we spoke agreed that defining older adults in

this way makes sense for both research and practical purposes, because the health and mobility

of adults experiencing homelessness at age 50 is similar to that of housed adults who are 15-20

years older. Housing and service providers, on the other hand, noted that they are often

required to define older adults as age 55 and older or 62 and older because of eligibility

restrictions imposed by their programmatic funding sources. For example, Supportive Housing

for the Elderly vouchers provide rental assistance and supportive services to low-income

households that include at least one member who is 62 years or older. Individuals 55 and over

are eligible for other HUD-funded assistance for elderly and disabled households such as

In its Annual Homelessness Assessment Reports to Congress, HUD publishes the percentage of people

experiencing unsheltered homelessness only for three age groups: under 18, 18-24, and over 24. Data for older

adults (55-64 and 65 and older) are only available for sheltered populations.

In HUD’s Annual Homelessness Assessment Reports to Congress, the age categories for older adults changed in

2017 from 51-62 and 62 and older to 55-64 and 65 and older in 2018. Thus, we cannot measure changes over

time in the size of the population of older adults experiencing sheltered homelessness from before 2017 to

present.

Housing Choice Vouchers and public housing. Nutrition assistance, such as Meals on Wheels, is

provided by State Units on Aging and Area Agencies on Aging to adults aged 60 and older. To

provide services to individuals under 55, service providers often must use private funding

sources.

A couple of experts suggested, however, that defining “older adults” among those experiencing

homelessness, especially in relation to determining eligibility for assistance, should be based on

individuals’ health needs or functional limitations rather than age-based criteria alone. They

noted that many adults experiencing homelessness in their 40s and 50s have disabilities

requiring the same level of services and supports typically provided to older adults. Moreover,

due to increased mortality rates among people experiencing homelessness, many of these

individuals never reach “older adult” ages. One provider indicated, however, that there was

insufficient age granularity in data collected on adults experiencing homelessness to best

determine at which ages physical and mental health vulnerabilities are heightened, knowledge

that could help guide the categorization of older adults among those experiencing

homelessness.

PATHWAYS INTO HOMELESSNESS FOR OLDER ADULTS

Income supports for older adults at risk of homelessness are often insufficient to cover their

expenses.

SSI and SSDI are often the primary sources of income for older adults at risk of or experiencing

homelessness, with earned income, panhandling, and monetary assistance from relatives as

supplementary sources (Cohen et al., 1999; Garibaldi et al., 2005; Gonyea et al., 2010). These

income supports are often insufficient to cover the cost of housing and other expenses

(Airgood-Obrycki, 2019). Living on limited, fixed incomes, older adults experience housing cost

burden more frequently than the general population, potentially resulting in housing loss

(Sermons & Henry, 2010). According to the Joint Center on Housing Studies of Harvard

University, people older than age 50 have the highest risk of paying more than 30 percent of

their income on rent or mortgage, with as many as one half of renters ages 50 and older doing

so in 2018 (Joint Center for Housing Studies, 2018). Approximately 10 million households

headed by someone over age 65 pay at least 30 percent of their income on housing, and half of

those pay over 50 percent (Joint Center for Housing Studies, 2019). Nationally, more than 1.7

million extremely low-income renter households with an older adult are severely cost-

burdened, spending more than half their income on rent (Prunhuber & Kwok, 2021). Being cost-

burdened by housing limits resources available for other expenses, including health care,

transportation, and healthy food. With an overwhelming portion of their incomes dedicated to

rent, many severely rent-burdened older adults go without heat, food, or medication to pay

their rent (Prunhuber & Kwok, 2021). Cost-burdened older adults are more likely to report an

inability to fill a prescription or adhere to health care treatments due to cost (Center for

Housing Policy, 2015). Moreover, the challenge of affording housing on limited incomes is

exacerbated for Black and Latinx older renters, who are more likely than White older renters to

have insufficient income and few assets as they enter retirement years (Prunhuber & Kwok,

2021).

The population of older homeless adults is comprised of two subgroups with different

trajectories into homelessness.

The growth of homelessness among older adults can be attributed to two trends: aging of those

who first experienced homelessness earlier in life and continue to experience homelessness as

older adults, and those experiencing homelessness for the first time in older age.

Older adults who first experienced homelessness earlier in their lives represent a cohort effect:

individuals born in the second half of the post-World War II baby boom (1954-1963) who have

had an elevated risk of homelessness throughout their lives and have reached aged 50 and

older in the last decade (Culhane et al., 2013). This group of individuals became adults in a time

when there was an oversupply of workers and undersupply of housing, resulting in depressed

wages, high unemployment, and increased rents. These inauspicious circumstances combined

with back-to-back recessions in the late 1970s and early 1980s contributed to intermittent

employment in low-wage jobs and frequent periods of unemployment (Culhane et al., 2013),

and subsequently, increased vulnerability to housing instability and homelessness throughout

their lives. Moreover, this group of older adults experiencing homelessness typically have had

more risk factors (e.g., mental health and substance use disorders) for homelessness

throughout their lives than older adults who first experience homelessness after age 50, thus

increasing their vulnerability to homelessness throughout their lives (Culhane et al., 2013;

Brown et al., 2016). In discussions, experts and providers noted that whereas these individuals

may have initially entered homelessness as younger adults due to economic factors, they often

are unable to regain long-term stability due to physical or behavioral health challenges.

The second group of older adults are people who experience homelessness for the first time

after age 50, largely due to economic instability in their later years. In the Health Outcomes in

People Experiencing Homelessness in Older Middle Age (HOPE HOME) study, almost one-half of

the 350 older adults included in the sample (43 percent) had not experienced homelessness

before age 50 (Brown et al., 2016). In a qualitative study including 79 older adults experiencing

homelessness, Shinn and colleagues (2007) similarly found that over half of the respondents

lived relatively stable lives, typically involving long periods of employment and residential

stability, before becoming homeless at an average age of 59. In an international study of adults

aged 50 and older newly experiencing homelessness in Boston, England, and Melbourne, Crane

and colleagues found that only about one-third of the sample had experienced homelessness

prior to the current episode (Crane et al., 2005). For older adults experiencing homelessness for

the first time, homelessness is often caused by stressful life events, such as the death of a

spouse, divorce, loss of work, eviction, or the onset of health problems, coupled with limited or

fixed incomes (Cohen, 2004; Crane et al., 2005). Seniors and people with disabilities compose

nearly half of renters with extremely low incomes (i.e., at or below the poverty guideline or 30

percent of the area median income) (Aurand et al., 2021), making them vulnerable to

homelessness when stressful events occur (Brown et al., 2016; Kushel, 2020).

Experts and providers reinforced these findings: older adults relying on decreased or fixed

incomes often cannot withstand rising housing costs, including increasing rents, increasing

property taxes, and ongoing home maintenance costs. One expert noted that most states do

not have rent control or eviction protection. Another noted that few, if any, tax relief programs

are available nationally for older adults who cannot afford their property taxes, so increasing

house values can lead to financial strain even for those who own their own homes. Additional

factors experts and providers noted that can exacerbate older adults’ risk of homelessness

include financial exploitation, decreased perception of risk that can accompany cognitive aging,

and loss of social supports as family and friends move or pass away. Multiple interviewees

reported that individuals who have been self-reliant for many years often do not reach out for

assistance until their situation is dire due to shame or lack of knowledge about the supports

available offered and how to navigate the system.

These findings also were reflected in the

experiences of the people with lived experience

with whom we spoke. Among the 14 older adults

we engaged in conversation, the majority

indicated they had multiple experiences with

homelessness throughout their lifetimes; two

people experienced homelessness for the first

time as older adults. Both of the newly homeless

individuals reported their homelessness was

caused by changes in their incomes. One individual lost her housing when her rent increased

and her husband’s income declined. Another lost his housing when health problems prevented

him from doing his job. Among those who had previous experiences with homelessness, four

people attributed their recent experiences to mental health issues and substance use disorder,

and two people reported physical injuries led them to lose their jobs and subsequently their

housing. Two people reported having lost their most recent housing when a loved one passed

away and one person reported his house burned down and they had no other place to go. The

remaining three individuals did not cite a cause for their recent homelessness.

CHARACTERISTICS OF OLDER ADULTS EXPERIENCING HOMELESSNESS

Older adults who experienced homelessness earlier in life differ significantly on a range of

characteristics and needs from older adults who first experience homelessness after the age

of 50.

Early evidence suggests that older adults who experienced homelessness earlier in life have had

more vulnerabilities throughout their lives than older adults with later entry into homelessness.

Older adults with earlier experiences of homelessness have more adverse childhood

experiences, chronic medical conditions, drug use, and out-of-home placement during

childhood; more mental health, alcohol and drug use, and incarceration during young

adulthood; and more underemployment, drug use, and traumatic brain injury during middle

adulthood (Brown et al., 2016). In contrast, individuals with later onset homelessness have

“I got peripheral neuropathy in my

hands. My occupation was a ballet

accompanist. When my hands started

getting numb from the peripheral

neuropathy, I could not do that, the line

of work, anymore… That was the first

time that I was not working.” – Male, 65

typically been married, held jobs, and maintained housing in the past but experience

homelessness for the first time after age 50 (Brown et al., 2016; Shinn et al., 2007). Although

often living in poverty throughout their adult lives, these individuals have long work histories,

usually in low-paying, physically demanding work.

Exhibit 1. Sample Racial/Ethnic Composition for Studies of Older Adults Experiencing Homelessness

Category

Studies of Older Adults Experiencing Homelessness

Study

Brown et al.,

2010

Brown et al.,

2015

Garibaldi et al., 2005

Gordon et al.,

2012

Location

Oakland

Boston

Pittsburgh and Philadelphia

Multi-site

Sample

776 older

adult

attendees (50

and older) at

an outreach

event

204 older

adults (50 and

older)

recruited from

emergency

shelters

74 older adults (50 and older)

recruited from unsheltered

enclaves, shelters, and

transitional housing or single-

room occupancy dwellings

408 older

adults (55 and

older)

experiencing

homelessness

with mental

illness

Racial/Ethnic Composition of Sample

Black/African

American

54%

40%

81%

28%

White/Caucasian

29%

40%

19%

60%

Latino

10%

Multiracial/Other

races

13%

Racial/Ethnic

Composition of Overall

Population

Oakland

Boston

Pittsburgh

Philadelphia

N/A

Black/African

American

22%

24%

23%

41%

White/Caucasian

29%

44%

64%

35%

Latino

27%

20%

15%

Multiracial/Other

races

10%

These samples of older adults are often sub-sets of larger samples included in the studies.

Terminology reflects that used in the included studies.

U.S. Census, 2021.

Those who first experienced homelessness prior to age 50 typically have experienced

homelessness for longer periods of time overall and in their current or recent episodes.

Not surprisingly, older adults who first experienced homelessness prior to age 50 have spent

more time homeless (4.2 years) than those individuals whose first homelessness occurred at

age 50 or older (2.0 years) (Brown et al., 2016). In the HOPE HOME study, the two groups also

differed in the length of their current episode of homelessness. Nearly three-fourths (73

percent) of those with first homelessness before age 50 were continuously homeless for one

year or longer in their current episode, compared to 60 percent of those who first experienced

homelessness after the age of 50 (Brown et al., 2016). Those with earlier experiences of

homelessness also spent a greater period of time during the three-year follow-up period living

in unsheltered and institutional settings (shelters, jails, transitional housing), whereas

individuals newly experiencing homelessness as older adults spent greater periods of time

cohabiting or living in rental housing during the follow-up period (Lee et al., 2016).

The limited data available on the racial/ethnic composition of the population of older adults

experiencing homelessness suggests an overrepresentation of people of color.

Data on racial/ethnic composition for this population are available only from a handful of

regional studies. Exhibit 1 provides the racial/ethnic background of each of the study

populations. These studies vary considerably in the geographic area in which they are set and in

the sampling strategies used to identify the population. Despite the differences in how they

were conducted and in their specific findings, each study found a larger percentage of African

Americans experiencing homelessness than the broader population, a finding that is similar to

national data on the overall population of people experiencing homelessness (HUD, 2020;

Moses, 2019).

SERVICE NEEDS OF OLDER ADULTS EXPERIENCING HOMELESSNESS

In this section, we review the service needs of older adults experiencing homelessness and how

they compare to the needs of older housed adults and younger adults experiencing

homelessness. Where available, we include evidence on the differences between the subgroups

of older adults experiencing homelessness for the first time compared to those who have

previously experienced homelessness and between racial/ethnic groups that are

disproportionately likely to experience homelessness.

Exhibit 2 provides a summary of the characteristics and service needs of older adults

experiencing homelessness presented here in comparison to older housed adults and younger

homeless adults.

Exhibit 2. Comparison of Characteristics and Needs of Older Adults Experiencing Homelessness

Older Adults Experiencing

Homelessness

Finding

Compared to:

Older Housed Adults

Younger Adults

Experiencing

Homelessness

Physical Health Needs

Average life expectancy

64-69 years

Shorter life expectancy

---

Rates of health and

geriatric conditions

30-39% ADL impairment;

21-59% experience

hypertension

Higher rates

Utilization of acute

health care services

43-70% have emergency

department visits;

10-43% have hospitalizations

Higher utilization

Comparable rates

Behavioral Health Needs

Rates of mental health

conditions

~40%

Higher rates

No clear patterns

Rates of substance use

disorder

26-63%

Higher rates

No clear patterns

Basic Needs

Rates of food insecurity

~55%

Higher rates

Lack of transportation

---

As compared to 3 nationally representative samples of older adults.

Indicates studies show inconsistent findings on the differences between older and younger adults

experiencing homelessness.

As compared to national estimates of population living in poverty.

Physical Health Needs

Older adults experiencing homelessness have significantly shorter life spans than housed

older adults, though they die from similar chronic conditions.

Studies consistently document a shorter life span of older adults experiencing homelessness

despite the range of sub-populations studied, including individuals staying in shelters in New

York City (Metraux et al., 2011); veterans in transitional homeless programs (Schinka et al.,

2017; Schinka & Byrne, 2018); and individuals experiencing homelessness in Oakland, California

(Brown et al., 2016; Kushel, 2020). For example, Metraux and colleagues (2011) matched

administrative records for adults staying in the New York City shelter system with death records

from the Social Security Administration. They found that older adults experiencing

homelessness have a life expectancy of approximately 64 years for men and 69 years for

women (Metraux et al., 2011), compared to national life expectancies of 76 years for men and

81 years for women (Xu et al., 2020). Further, Hwang and colleagues (1997; 2008) found that

both older adults experiencing chronic homelessness and those who first became homeless

later in life had elevated mortality rates. Finally, although the most common causes of death

among older homeless adults are similar to housed older adults, for example, cancer and

cardiovascular disease, these illnesses occur approximately 20 years earlier (Kushel, 2020).

Older adults experiencing homelessness have health challenges similar to older adults who

are housed but who are of more advanced ages.

Adults experiencing homelessness between ages 50 and 62 often have health conditions that

are more severe than housed individuals their own age, but similar to those of housed people

who are 10-20 years older (Cohen, 1999; Gelberg et al., 1990; HPRI, 2019; Brown et al., 2016).

Compared to their housed counterparts, older adults experiencing homelessness have a higher

prevalence and severity of physical and geriatric conditions including memory loss, falls,

difficulty performing ADLs, and cognitive impairment (Brown et al., 2011; Brown et al., 2017;

Hahn et al., 2006; Hwang et al., 1997). Moreover, comorbid conditions among older adults

experiencing homelessness are common, including hypertension, arthritis, cognitive

impairment, frailty, hearing difficulty, and urinary incontinence (Kushel, 2020; Brown et al.,

2011, Brown et al., 2016; Brown, 2017; Gelberg et al., 1990). Additionally, in discussions,

experts and providers noted that sleep deprivation resulting from sleeping in unsheltered

locations such as tents or cars or in shelters that were crowded or offered limited hours of

access exacerbated older adults’ physical and mental health challenges and accelerated

cognitive decline.

Older adults have different health conditions than younger adults who are homeless, though

adults of all ages experiencing homelessness have poorer health status than those who are

housed.

Among those experiencing homelessness, older adults compared to younger adults have higher

rates of chronic illnesses such as high blood pressure; geriatric conditions, including arthritis,

and functional disability; and cognitive impairments (Garibaldi et al., 2005; Gelberg et al., 1990).

To illustrate, in a cross-sectional, community-based survey of homeless adults in two United

States cities, older adults were 3.6 times as likely to have a chronic medical condition as those

under age 50 (Garibaldi et al., 2005). Older adults also were more likely to report two or more

medical conditions (59 percent vs 28 percent) compared to the younger adults experiencing

homelessness (Garibaldi et al., 2005). A five-year study of 28,000 adults who received care at

the Boston Health Care for the Homeless Program reported death rates of almost 2.5 times

higher for those ages 45-64 compared to those ages 25-44 (Baggett et al., 2013). When

compared to the general housed population of the same ages, people 25-44 years old

experiencing homelessness had mortality rates 9 times higher, while people 45-64 years old

experiencing homelessness had mortality rates 4.5 times higher (Baggett et al., 2013).

Older adults experiencing homelessness utilize acute health care services at high rates and

significantly more than the general population of older adults.

Older adults experiencing homelessness use acute health care services at high rates, with rates

across studies ranging from 43 percent to 70 percent for emergency department visits and 10-

43 percent for inpatient hospitalizations (Brown et al., 2010; Brown et al., 2011; Raven et al.,

2017). Very few studies have compared national rates of acute health care services utilization

between older adults experiencing homelessness to those of their housed counterparts. In a

study comparing older adults experiencing homelessness in Boston to three nationally

representative samples of older adults, 43 percent of the older homeless adults had been

admitted to the hospital more than once in the prior year compared to 11 percent of the

nationally representative sample. Moreover, whereas 70 percent of the older adults

experiencing homelessness had more than one emergency department visit in the prior year,

only 19 percent of the nationally representative sample of older adults did (Brown et al., 2011).

Further, most older adults experiencing homelessness in the sample had received ambulatory

care (87 percent) within the previous 12 months (Brown et al., 2011). A study using a similar

sample of older adults experiencing homelessness found a small proportion of the sample

accounted for half of all emergency departments and inpatient visits; those who spent the

majority of the past six months homeless, either unsheltered or staying in shelters, had

significantly higher rates of emergency department visits than those who had spent most of

their time housed (Brown et al., 2010).

Older adults experiencing homelessness use the emergency department most frequently for

injuries and exposure to violence; complications resulting from substance use, including alcohol

and tobacco; and treatment of mental health disorders (Raven et al., 2017). Among people

experiencing homelessness, emergency departments remain a low-barrier access point to seek

pain management and medical treatment for chronic medical conditions and pain that could be

managed in outpatient settings. Although over two-thirds of the sample of adults 50 and older

experiencing homelessness in the study reported having a regular non-emergency place for

routine care, it was not associated with reduced use of the emergency department (Raven et

al., 2017).

Older adults and younger adults experiencing homelessness use acute health care services at

similar rates, despite differences in having health insurance and a regular health care place or

provider.

In Brown’s 2010 study of health care utilization by people experiencing homelessness, adults

aged 50 and older were more likely to have health insurance, a regular place for health care,

and a regular health care provider (e.g., medical doctor, nurse practitioner, or registered nurse)

than those under 50. However, both groups had similar rates of acute health care utilization in

the prior year, including emergency department visits (43 percent of older adults vs. 49 percent

of younger adults) and inpatient hospitalizations (32 percent of older adults vs. 40 percent of

younger adults) (Brown et al., 2010). This study showed no significant differences between age

groups in the type of visit; most visits were for physical ailments (85 percent for older adults vs.

88 percent for younger adults) as opposed to emotional problems (19.5 percent for both age

groups) (Brown et al., 2010).

Behavioral Health Needs

Older adults experiencing homelessness, especially women, are more likely to have mental

health conditions than older housed adults.

In studies with samples of older adults experiencing homelessness (Brown et al., 2011; Kaplan

et al., 2019), older adults in permanent supportive housing (Henwood et al., 2018), and

veterans (Schinka et al., 2012), between 40 percent and 58 percent either screened for or

reported mental health conditions. For example, 56 percent of older adults in permanent

supportive housing reported at least two chronic mental health conditions (Henwood et al.,

2018). Depression was the most common condition identified; other conditions include

schizophrenia and post-traumatic stress disorder. These rates of mental health conditions are

higher among older adults experiencing homelessness than older housed adults (which range

from 18 percent to 34 percent), measured both by diagnoses and symptomology (Brown et al.,

2011; U.S. CDC, 2008).

Some studies find evidence of gender differences in rates of mental health conditions among

older adults experiencing homelessness. Compared to older homeless men, older homeless

women were two and one-half times more likely to have any chronic mental health condition

and more likely to be diagnosed with more mental health conditions (Winetrobe et al., 2017;

Dickins et al., 2021).

Findings from the Health and Retirement Study indicate race and ethnic differences in the

behavioral health conditions of older adults experiencing homelessness. Compared to their

White counterparts, Black and African American older adults experiencing homelessness are

significantly more likely to report a history of illicit drug use and less likely to report a history of

mental illness or domestic violence than White older adults experiencing homelessness

(Chekuri et al., 2016).

Older adults experiencing homelessness also have more substance use disorders than the

general population.

Although there are no studies that directly compare older homeless adults to their housed

counterparts on substance use, a few studies have compared older homeless adults to

population-based samples and to other samples. Studies generally find that a higher percentage

of older adults experiencing homelessness

report alcohol and/or drug use than population-

based samples (e.g., CDC, 2008). In the HOPE

HOME cohort of older adults experiencing

homelessness, for example, rates of binge

drinking were significantly higher in older

homeless adults than in three large-scale studies

of older adults using population-based samples

(30 percent vs. 1 percent, 7 percent, and 3 percent) and a greater percentage of the older

adults experiencing homelessness reported moderate or greater severity of alcohol use (26

percent) than housed adults of all ages (5 percent) served in a U.S. Department of Veterans

Affairs (VA) primary care clinic (Brown et al., 2019). This sample also had a higher rate of

current illicit substance use (63 percent) than a national community-based sample of adults of

all ages experiencing homelessness (23 percent) (Spinelli et al., 2017).

“I've dealt with a lot of trauma as well. I lost

my best friend that I've known since I was

17 years old due to COVID, so there you go

again now. Setback is you start using again,

just to numb the pain, you know what I

mean?” – Male, 59

Studies to date yield inconsistent findings on the differences in mental health conditions and

substance use between older and younger adults experiencing homelessness.

It is unclear whether there are age differences in the prevalence of behavioral health conditions

among individuals experiencing homelessness. Whereas some studies have found a higher

prevalence of mental health conditions such as anxiety, depression, and post-traumatic stress

disorder (Garibaldi et al., 2005; Tompsett et al., 2009) among older adults experiencing

homelessness than among their younger counterparts, other studies have found either no

significant differences in the rates of these conditions (DeMallie et al.,1997; Gelberg et al.,

1990) or the opposite finding (Gordon et al., 2012).

Similarly, the limited studies that contrast rates of substance use between older and younger

adults experiencing homelessness yield mixed findings. Some studies suggest that, among

people experiencing homelessness, younger adults are more likely to use drugs than older

adults while older adults may be more likely to use alcohol (DeMallie et al., 1997; Gordon et al.,

2012). Yet other studies fail to find such differences (Hecht & Coyle, 2001; Gelberg et al., 1990)

or find that there is a lower prevalence of substance use disorders for older versus younger

adults experiencing homelessness (Burt et al., 1999; Dietz et al., 2009).

Preliminary evidence suggests older adults who first experienced homelessness earlier in life

are more likely to have behavioral health conditions than those who first experienced

homelessness after age 50.

In the only study to compare differences between newly and chronically homeless older adults,

Brown and colleagues (2016) found that participant characteristics and life course experiences

differed by age at first homelessness. Compared to

individuals whose first homelessness occurred at

age 50 or older, individuals with first homelessness

before age 50 showed a greater prevalence of

behavioral health disorders at different stages in

life. For example, this group had higher rates of

drug use in childhood and mental health problems

in young and middle adulthood, as well as a higher

prevalence of current mental health issues,

including depressive symptoms and post-traumatic

stress disorder, and drug use, and higher rates of

hospitalizations for mental health problems in

adulthood (Brown et al., 2016).

Individuals who had experienced homelessness as older adults reported high rates of physical

and behavioral health problems, echoing findings from the literature.

All of the older individuals with lived experience of homelessness with whom we spoke

discussed suffering from physical and behavioral health problems, including diabetes, HIV,

traumatic brain injury, glaucoma, arthritis, bipolar disorder, post-traumatic stress disorder, and

substance use disorder. A few people also reported having experienced strokes or cancer in the

past. Many of the interviewees, including all of those who were homeless at the time of our

“I mean, I'm going to be 60 years old. It's

getting cold out and… I'm not settled

carrying a backpack around every

freaking day. It's like my back is starting

to bother me. I got health issues. I only

got one kidney that's functioning 40%

because I had cancer a little over a year

ago. That's the second time I had cancer

in 6 years. So, it's like, you know what? I

need to be settled down in a place.” –

Male, 59

interview, reported physical pain and mobility issues, often attributed to being unsheltered. For

example, one individual reported they had lost several toes due to frostbite contracted while

being outside in bad weather.

Basic Needs

Older adults experiencing homelessness have high rates of food insecurity.

Food insecurity coupled with insufficient nourishment complicates chronic disease

management and presents a major challenge for older homeless adults who have a high

prevalence of chronic disease and limited mobility (Brown et al., 2011; Patanwala et al., 2018).

Food insufficiency among older adults is associated with significantly greater odds of

hospitalization for any reason, psychiatric hospitalization, and high emergency department

utilization (Baggett et al., 2011). Individuals who are food insecure -- having limited access to

adequate food due to lack of resources -- have poorer health and are more likely to consume

foods deficient in nutrients (Robaina & Martin, 2013). Also, severely cost-burdened older adults

who are in the bottom income quartile reduce their spending on food by 30 percent more than

those who are not cost-burdened (National Association of Area Agencies on Aging [n4a], n.d. b).

Among participants in the HOPE HOME study, over half reported food insecurity, with one-third

reporting low food security and one-quarter reporting very low food security (Tong et al.,

2018), consistent with food insecurity estimates among other homeless populations (e.g.,

Parpouchi et al., 2016) and nearly two times higher than national estimates among the United

States population living in poverty (Coleman-Jensen et al., 2016).

Lack of transportation poses a significant barrier for older adults experiencing homelessness.

Adults experiencing homelessness commonly indicate their most used modes of transportation

include public transit and walking (Chan et al., 2014; North et al., 2017; Murphy, 2019), which

are more difficult for older individuals with mobility challenges. Lack of transportation has been

cited as a barrier for adults experiencing homelessness, as it reduces access to shelter and

housing, medical and behavioral health care, social engagement, food, and other supportive

services (Greysen et al., 2012; Hui & Habib, 2014, 2017; Niño, Loya, & Cuevas, 2009; Murphy,

2019; Turnbull, Muckle, & Masters, 2007). Among studies of older adults experiencing

homelessness, mobility challenges (i.e., difficulty walking without help) and challenges with

instrumental ADLs such as using public transportation are common (Henwood et al., 2018).

Thus, it is reasonable to conclude that older adults experiencing homelessness face

transportation barriers even beyond those of younger adults experiencing homelessness.

However, there is little available research focused on transportation issues specifically among

older adults experiencing homelessness.

Older adults experiencing homelessness, including those who are newly placed into housing,

experience loss of community.

Many of the experts and providers with whom we spoke noted that mobility limitations,

frequent address changes, receipt of housing assistance in a new neighborhood, and the death

of family and friends contribute to formerly homeless older adults having limited social

networks. Multiple interviewees noted that social and physical isolation among this population

can contribute to further cognitive and physical declines. One housing provider noted that

formerly homeless older residents in her organization’s properties often struggle to identify

someone who can serve as their medical power of attorney following years of social isolation.

Section 3. Systems and Services Available to Serve Older Adults at Risk

of or Experiencing Homelessness

Exhibit 3 presents a conceptual systems framework for understanding the different services

needed by older adults experiencing homelessness and the service delivery systems that may

offer these services. The framework highlights the two subgroups of older adults experiencing

homelessness identified through recent studies and the pathways of services, housing, and

support likely needed to become stably housed. These two subgroups provide a rubric for

understanding the types of assistance older adults experiencing homelessness need, but within

the broader acknowledgement that each person has their own unique history and needs.

Exhibit 3. Systems Framework for Addressing Homelessness Among Older Adults

Older individuals who repeatedly experience homelessness often require extensive outreach

and emergency shelter before obtaining housing and supports. To achieve long-term stability,

many require ongoing case management to help link them to needed health and behavioral

health care, income supports, and other services. In contrast, older adults who have not

previously experienced homelessness, but have experienced adverse events that threaten their

housing stability, tend to need lighter touch or prevention-focused services to regain housing

stability. Critical services for this population are those that help identify them before they

become homeless so that they may be prevented or diverted from homelessness through

various systems’ efforts to connect them to income supports, medical insurance, rental and

utility assistance, nutrition assistance, and transportation assistance. For those who need

Provide crisis

supports

Connect to

housing

Provide

supportive

services

Maintain

supports for

long-term

stability

Prevent/divert

homelessness

Provide housing

assistance, as needed

Connect to needed

long-term supports

First

Homelessness

Earlier in Life

First

Homelessness in

Older Adulthood

Care

coordination

Housing

Behavioral

health

Basic

needs

Income and

Benefits

Systems involved:

- Homeless

- Housing

- Aging

- Veterans

- Health Care & LTC

- Behavioral Health

- Social Services

Health and

Long-Term

Care

additional housing assistance, shallow subsidies (limited rental assistance for a longer period of

time) or temporary subsidies and connections to needed supports may be sufficient to help

them get back on their feet (Goldberg et al., 2016; Sermons & Henry, 2010).

We reviewed available information across the systems and sectors shown above for each of the

areas of needs older adults at risk of or experiencing homelessness have (e.g., housing, health

and long-term care, behavioral health, income and benefits, basic needs). We identified the

services, housing, and supports available to low-income older adults and those experiencing

homelessness specifically. We paid particular attention to innovations implemented during the

COVID-19 pandemic that might be continued or expanded to better serve vulnerable older

adults, especially those who experience homelessness. Where documented in the literature, we

discuss the challenges service providers and recipients encounter in providing or receiving

assistance. Finally, we identify the gaps in services and supports in serving older adults

experiencing homelessness.

In this section, we describe the full range of services, housing, and supports available for adults

at risk of or experiencing homelessness available across communities. Not all communities have

all these types of assistance and those that do may have insufficient capacity to meet the need.

In addition, not all are tailored to older adults. We indicate those services that are specifically

targeted to older adults or other activities in place to help older adults access or use the

service.

HOMELESSNESS ASSISTANCE

Homelessness assistance programs are available for older adults who are at risk of or

experiencing homelessness in communities across the country. HUD is the primary funder of

homelessness assistance, which is administered locally through Continuums of Care (CoCs).

Many communities also receive state, local, and private funding for homelessness programs.

This assistance includes:

• Homelessness prevention.

• Identification, engagement, and assessment of people experiencing homelessness such

as outreach programs, drop-in centers, and coordinated entry systems.

• Crisis or interim housing assistance.

Homelessness Prevention

Services available for older adults at risk of becoming homeless that stabilize their housing

situation include energy assistance, home repair programs, and eviction prevention resources.

Local government agencies or non-profit organizations typically administer these programs and

make them available to all low-income households, not specifically elderly households.

Energy assistance programs help with home energy bills, energy crises, weatherization, and

energy-related minor home repairs. These assistance programs are provided through a range of

federal, state, and local funding sources including the U.S. Department of Health and Human

Services (HHS) Low-Income Home Energy Assistance Program (LIHEAP) and the Low Income

Household Water Assistance Program, and the U.S. Department of Energy’s Weatherization

Assistance Program.

Home modification and repair assistance programs help older adults address health and safety

hazards in and improve accessibility of their homes to reduce the risk of falls and accidents. The

USDA’s Section 504 Home Repair program and local Area Agencies on Aging offer such

programs. Each program has its own eligibility criteria and application process.

Eviction prevention resources are available for older adults at risk of homelessness. Prior to the

COVID-19 pandemic, this assistance typically included financial assistance for 1-2 months’ rent

and was available through a range of federal, state, and local public and private sources,

including faith-based and non-profit organizations. In response to the financial crisis caused by

the COVID-19 pandemic, the U.S. Department of the Treasury’s (USDT’s) Emergency Rental

Assistance (ERA) Program provided up to 18 months of rental and utility assistance both for

arrears and prospective payments (USDT, n.d.).

Eligibility for eviction prevention through this

program was limited to renters with household incomes below 80 percent of the area median

income who experienced COVID-related financial hardship and could demonstrate a risk of

homelessness or housing instability.

Profile of Prevention Services for Older Adults

In New Mexico and Arizona, the Native American Disability Law Center, a non-

profit organization that advocates for the legal rights of Native Americans with

disabilities, creates accounts for their clients in an online benefits application

portal, including setting up email addresses for those who do not have them. This

process helps individuals apply for and track LIHEAP funds, as well as other public

benefits.

The Home Safe Program in California was established in 2018 to support the

safety and housing stability of individuals involved with Adult Protective Services

by providing housing-related assistance using evidence-based practices for

homeless assistance and prevention. Home Safe offers a range of strategies to

prevent homelessness, including housing-related intensive case management,

short-term housing-related financial assistance, deep cleaning to maintain safe

housing, eviction prevention, and landlord mediation (Benioff Homelessness &

Housing Initiative, 2021).

Two separate ERA programs were established: ERA1 provides up to $25 billion under the Consolidated

Appropriations Act, 2021, which was enacted on December 27, 2020, and ERA2 provides up to $21.55 billion

under the American Rescue Plan Act of 2021, which was enacted on March 11, 2021. ERA1 ended in September

2022. ERA2 is set to expire in September 2025.

Identification, Engagement, and Assessment Programs

Homelessness assistance programs focused on identifying people experiencing homelessness

and engaging them in services include street outreach teams, mobile vans, and drop-in centers,

among others. Most outreach and engagement programs are not limited to older adults;

however, some programs across the country specifically target older adults.

Profile of Outreach Services for Older Adults

Hearth, Inc. in Boston, Massachusetts, funded through both public and private

sources, provides outreach to individuals aged 50 years and older who are at risk

of or experiencing homelessness. A team of six case managers, supervised by a

licensed social worker, visits homeless shelters weekly to identify older adults

needing permanent housing. Outreach workers help these older adults apply for,

locate, and move into subsidized housing and connect to other necessary

services and assistance. The program also employs an “at risk” case manager who

works with older adults who are at risk of homelessness, referred through day

shelters, medical providers, elder services, and visiting nurse association

agencies, among other sources. When at risk elders are identified and enrolled in

the program, the case manager helps to stabilize housing by accessing services

including tenant counseling, landlord mediation, money management, and

eviction prevention (Brown et al., 2013).

Crisis/Interim Housing Programs

Crisis or interim housing

is short-term assistance designed to address an immediate housing

crisis. Assistance includes emergency shelter, motel vouchers, and transitional housing.

According to the 2018 Annual Report to the Annual Homeless Assessment Report,

approximately, more than 16 percent of people living in sheltered homeless situations were

over the age of 55 (HUD, 2020), and the rate is increasing. Limited crisis or interim housing

programs are in place specifically for older adults experiencing homelessness.

Profile of Crisis or Interim Housing for Older Adults

One noteworthy program is the Serving Seniors’ Transitional Housing Program in

San Diego, California, which provides transitional housing and supportive services

for 90-120 days to adults aged 62 and older experiencing homelessness. The

program tailors its shelter facilities and services to the specific needs of older

adults, including having facilities accessible to people with mobility challenges

and case management focused on the unique needs of older adults.

The terms crisis and interim housing are typically used interchangeably to denote temporary housing situations

people experiencing homelessness may live while looking for permanent housing. In contrast to emergency shelter

and motel vouchers, transitional housing often includes more supportive services and allows longer stays, often up

to 24 months.

Challenges with Homelessness Assistance for Older Adults Experiencing Homelessness

Older adults experiencing homelessness may face unique challenges in accessing available

homelessness assistance. In discussions, both experts and providers noted that many older

adults at risk of homelessness do not reach out for assistance until it is too late because they do

not know where to go for help or they are too proud to ask for it. This is particularly true for

those experiencing homelessness for the first time who may lack knowledge about the services

available in their communities or about their eligibility for assistance. For example, many older

renters, particularly those not working prior to the pandemic, may not know they are eligible

for eviction prevention through the ERA Program (Prunhuber, 2021). Providers also report that

older adults who experience homelessness are sometimes difficult to engage in services due to

their belief that participation might result in being “put in a home,” losing their independence

or having their money taken from them (Corporation for Supportive Housing [CSH], 2011).

Finally, age-related hearing and vision loss may contribute to heightened anxiety and lack of

trust.

Those who do know about homelessness assistance may have a hard time accessing it because

of poor health or limited mobility (CSH, 2011; SeniorNavigator, n.d.), or they may lack access to

technology to complete online applications (NCOA, 2022). Accessibility challenges and difficulty

performing ADLs also may make using some assistance, such as emergency shelters, more

difficult (Goldberg et al., 2016).

Equipment such as hearing aids and glasses are

at risk of being broken or lost in both

unsheltered environments and shelters (Kushel,

2012). Shelters closed during the day pose

challenges for older adults who need a safe

location to rest (SeniorNavigator, n.d.). Features

of some shelter environments, such as bunk

beds and shared bathing facilities, may be

difficult for older adults who have medical

conditions and may increase their risk of falls

and injury (Goldberg et al., 2016). Walking long distances or waiting in long lines for food and

other services can limit access for people with mobility issues (National Coalition for the

Homeless, 2009). Finally, limited assistance, such as one-time prevention resources or time-

limited rental assistance, may be insufficient to meet the needs of older adults on limited, fixed

incomes who also have declining health.

Expanded Services During the COVID-19 Pandemic

During the COVID-19 pandemic, numerous federal, state, and local agencies provided additional

assistance to people experiencing homelessness to access shelter, housing, and needed

services. The Coronavirus Aid, Relief, and Economic Security (CARES) Act provided additional

funding for states through existing federal programs, including $45 billion for the Federal

Emergency Management Agency Disaster Relief Fund, $4 billion for Emergency Solutions

“I broke my glasses, because I kept

taking them off and sleeping with them

on the street. I had them cobbled

together with tape, which never quite

fixed them. Eventually, I was given a pair

of hand-me-down glasses [by a case

manager] that were not my prescription,

but it was better than nothing.” –

Female, 51

Grants, and $5 billion for 11 Community Development Block Grants. Communities could use

these funds to secure, rehabilitate, and maintain sites for non-congregate shelters such as

dorms, motels, and hotels. In discussions, experts and providers noted that efforts such as

California’s Project Roomkey to move older adults experiencing homelessness out of

congregate shelters and off of the streets into motel rooms were practical and compassionate

approaches. These approaches not only provided people with a safe, stable place to stay but

also made it easier for case managers to locate and regularly connect with them.

HOUSING PROGRAMS AND RESIDENTIAL LONG-TERM CARE OPTIONS

Housing assistance programs range from those that provide time-limited assistance to

permanent subsidized options with and without supportive services. Exhibit 4 outlines the

types of housing options available. As noted, however, not all options are available in all

communities or in the quantity needed. Each housing option is described in more detail below.

Based on their examination of the shelter, hospital, and nursing home use by older adults

experiencing homelessness, Culhane and colleagues (2019) argue that the majority of older

adults experiencing homelessness have moderate needs that could be met by rapid re-housing,

shallow rental subsidies, and rental vouchers with light case management. Older adults who

enter homelessness at a later age and have fewer service needs may require more of a “light

touch” approach. Service-intensive assistance, such as permanent supportive housing and

additional supports like palliative care and long-term care (such as personal care to assist with

ADLs), should be reserved for those homeless older adults with the greatest needs (Culhane et

al., 2019). Older adults who have experienced chronic or repeated homelessness are more

likely to fit within this category of higher need.

Exhibit 4. Types of Housing Assistance Available for Older Adults Experiencing Homelessness

Type of Assistance

Description

Rapid re-housing

Time-limited rental assistance, coupled with housing navigation and case

management

Permanent supportive housing

Non-time-limited rental assistance with voluntary supportive services

Subsidized permanent housing

Non-time-limited rental assistance for use in a range of settings, from

scattered single-family houses and apartments to high-rise apartments for

elderly households

Low-income tax credit properties

Properties with certain percentages of units set aside for low-income

households at reduced rents

Rapid Re-housing Programs

Rapid re-housing, a Housing First

approach, provides access to permanent housing through

time-limited rental assistance along with housing navigation to locate and secure an available

unit, relocation services, and case management (HUD Exchange, n.d.). First developed on a

federal level in 2009 through HUD’s Homelessness Prevention and Rapid Re-housing Program

funded under the American Recovery and Revitalization Act, rapid re-housing has continued to

expand through federal investments, including investments from HUD, VA, HHS, and the U.S.

Department of Labor (DoL). A variety of non-federal investments, including general revenue

funds, and state funding (e.g., federal block grant funds, state housing trust funds) have

increasingly been provided for rapid re-housing programs (Dunton & Brown, 2019).

Most rapid re-housing programs target families or individuals meeting specific eligibility criteria,

such as the Veterans Affairs Supportive Housing program that serves veterans. Although

households served through these programs may include older adults, none are specifically

targeted to older adults (Gubits et al., 2018). According to HUD guidelines, rapid re-housing is

an effective intervention for different types of households experiencing homelessness,

including those with no income, those with disabilities, and those with poor rental history (HUD

Exchange, n.d.). Poor candidates for the intervention, per HUD guidelines, include those

experiencing chronic homelessness and in need of permanent supportive housing, and those

who are seeking a therapeutic residential environment, including those recovering from

substance use disorders (HUD Exchange, n.d.). Additionally, individuals who are on fixed

incomes and unlikely to increase their income over time (including older adults) may be poor

candidates for the intervention as the housing assistance is time-limited.

Permanent Supportive Housing

Permanent supportive housing is a non-time-limited intervention that combines rental

assistance with voluntary supportive services for people experiencing chronic homelessness

(National Alliance to End Homelessness [NAEH], 2021). Eligibility requirements for HUD-funded

permanent supportive housing include one year or more of documented chronic

homelessness,

a documented disabling condition (e.g., chronic mental health conditions,

chronic health conditions, and substance use disorders), limited income earning potential, and

a need for intensive case management. Permanent supportive housing programs can be “site-

based” (in an apartment building with multiple units) or “scattered-site” (with units spread

throughout a community).

Permanent supportive housing is an effective solution to homelessness for older adults (Chung

et al., 2018; Henwood et al., 2014; Lipton et al., 2000; Tsemberis et al., 2004), including those

with mental health and substance use disorders (Kushel, 2020; Perl & Bagalman, 2015).

Housing First indicates individuals move into permanent housing directly from homelessness rather than

spending a period of time in temporary, service-rich interventions, such as transitional housing, before entering

housing.

Chronic homelessness includes one year of consecutive homelessness or four or more episodes of homelessness

within the last three years that accumulate to at least one year.

Investments in permanent supportive housing have helped decrease the number of chronically

homeless individuals of all ages by 8 percent since 2007 (NAEH, 2021). In addition, through the

use of permanent supportive housing the VA has seen reductions in chronically homeless

veterans, the majority of whom are over the age of 51 (U.S. Interagency Council on

Homelessness, 2018).

Permanent supportive housing is also cost-effective for people with complex health and social

needs (Culhane et al., 2002; Metraux et al., 2003). For example, a study by Bamberger and

Dobbins (2015) found that many formerly homeless older adults who were placed in nursing

homes could be housed successfully in permanent supportive housing at lower cost and with

more independence. Studies of permanent supportive housing serving all populations of adults

document decreases in emergency room visits (Martinez & Burt, 2006), use of emergency

detoxification services (Larimer et al., 2009), and incarcerations (Larimer et al., 2009), as well as

increases in housing stability (Barrow et al., 2004).

Few studies examine outcomes of permanent

supportive housing specifically for older adults.

The few that are available compare older and

younger adults experiencing homelessness. One

study found that older adults in permanent

supportive housing spent fewer days homeless,

had less involvement with the justice system,

and spent more time in independent/single-

room occupancy and congregate/residential settings compared to younger adults in permanent

supportive housing (Henwood et al., 2014). Evidence on other outcomes of permanent

supportive housing for people experiencing homelessness, including severity of mental health

conditions, quality-of-life, substance use, and hospital admissions, is mixed (Aubry et al., 2020).

A number of permanent supportive housing programs across the country are tailored for older

adults who have experienced homelessness.

Profile of Permanent Supportive Housing for Older Adults

In Los Angeles, the Southern California Clinical and Translational Science Institute

is pilot testing the integration of the Community Aging in Place--Advancing Better

Living for Elders (CAPABLE) program with permanent supportive housing for older

adults who have experienced homelessness. CAPABLE is a short-term program

that provides home-based services, such as visiting occupational therapists,

nurses, and handypersons to older adults so that they can age in place. The Los

Angeles pilot program provides CAPABLE services to formerly homeless older

adults who are 50 years or older, live in permanent supportive housing, and

experience difficulties with ADLs.

“I think now the best thing that ever

happened to me, for me to have my own

house, to have a key. I can lay my head

down and I don't have to fear no one

coming in, or being hurt, or anything like

that.” – Male, 59

Other Community-Based Housing Options for Older Adults

Housing for older adults is available through local housing providers and public housing

agencies in the form of permanent subsidies (e.g., Section 8 Housing Choice Vouchers and

Section 202 Supportive Housing for the Elderly vouchers), and low-income tax credit properties.

Although these housing options are available to individuals who are at risk of or experiencing

homelessness, eligibility for these options is open to a broader population of low-income older

adults.

Subsidized Permanent Housing involves rental assistance programs that help low-income

individuals afford housing in the private market. Low-income older adults may qualify for long-

term housing assistance through public housing agencies that administer housing assistance

programs and often develop and maintain affordable housing properties. The Housing Act of

1937 first established publicly supported housing to provide decent and safe rental housing for

eligible low-income families, elderly persons, and persons with disabilities (HUD, n.d. a).

Publicly supported housing includes a range of types, from scattered single-family houses and

apartments to high-rise apartments for elderly households.

Two of the largest subsidized housing programs for older adults are the Supportive Housing for

the Elderly (Section 202) and the Housing Choice Voucher (Section 8) programs. Section 202

provides rental assistance and supportive services to low-income households with net incomes

of less than 50 percent of the area median income (or less than 30 percent in some properties)

that include at least one member who is 62 years or older (HUD, n.d. b). Section 202 properties,

operated by private and non-profit housing providers, are designed to accommodate

individuals who need some assistance with ADLs by including grab bars and ramps in the

apartments. Care and supportive services, such as meals, housecleaning, and transportation,

are also typically available at these residences (HUD, n.d. b). The Section 202 program serves

approximately 400,000 households annually (Couch, 2021); residents are, on average, 79 years

old with an average income of less than $10,000. Ninety percent of residents are single women

(Novak, 2018).

Housing Choice Vouchers, formerly referred to as Section 8, can be used in privately owned and

managed properties (i.e., project-based vouchers) or in private units that residents select

themselves (HUD, n.d.). These vouchers are available to households whose total annual income

does not exceed 50 percent of the area median income.

Eligibility for Housing Choice

Vouchers is limited to U.S. citizens and non-citizens with eligible immigration status. Housing

Choice Vouchers are not limited to seniors; however, as of 2016, half (51 percent) were elderly

or disabled (Sard, 2018).

Low Income Tax Credit Properties provide another opportunity for affordable housing for older

adults. The Low-Income Housing Tax Credit (LIHTC) program, created by the Tax Reform Act of

1986, provides tax credits for the acquisition, rehabilitation, or new construction of rental

A public housing agency is required to provide 75 percent of its vouchers to applicants whose incomes do not

exceed 30 percent of the area median income.

housing. LIHTC units are not limited to low-income households; however, 20 percent of units in

LIHTC properties must be rented to households with incomes less than 50 percent of the area

median income or 40 percent of units must be rented to households with incomes less than 60

percent of the area median income. According to HUD data on LIHTC tenant data, more than a

third of households (33.8 percent) in LIHTC properties include at least one resident aged 62 or

older (HUD User, 2019).

Long-Term Care Options for Individuals with High Needs

Exhibit 5 outlines the types of residential long-term care available for individuals needing a high

level of care. These options are primarily for individuals with debilitating health issues or

serious conditions that require frequent medical supervision and round-the-clock care.

Exhibit 5. Types of Residential Long-Term Care Available

for Older Adults Experiencing Homelessness

Type of Assistance

Description

Residential care

A range of congregate care settings that typically include housing,

medical management, supportive services, and social activities

Institutional long-term care

Institutions such as nursing homes for individuals who can no longer live

independently and need a significant amount of supervised care with

meals, assistance with ADLs, and health management

Residential Care settings provide both housing and on-site supportive services for individuals

who need some assistance with ADLs or some amount of supervision because of cognitive

impairments. These residential care settings may provide housing, medical management,

support services, social activities, and, in some cases, assistance with ADLs. Residential care

settings are licensed at the state level. States and localities use over 30 terms to refer to group

housing for older adults, and licensure requirements vary. Depending on the state terminology,

size, and services offered these residential care settings can go by a number of names including

Board and Care Homes, Adult Care Facilities, Residential Care Facilities, and Assisted Living

Facilities (Lewin Group, 2011; n4a, n.d. a).

In some places, residential care homes provide room, board, and services but are not licensed

by the state. Some operate legally, whereas others are operating illegally, raising concerns

about the quality of such places. These homes often serve vulnerable individuals with limited

financial resources.

In addition to residential care facilities, Adult Foster Care Homes provide room, board, and in-

home supports offered in a home-like environment with shared living and dining areas. Most

states limit the size of adult foster care homes to no more than five residents. The majority of

costs associated with adult foster care are private pay, though some states offer limited

support through their Medicaid State Plans.

The monthly costs of these residential care settings are far lower than nursing homes, but most

of these residential care facilities are private pay. Financial assistance from Medicaid for

supportive services within residential care settings can be covered through several different

Medicaid authorities. The most common services are Medicaid Home and Community-Based

Services (HCBS) 1915(c) Waivers and through the Medicaid State Plan Personal Care or Personal

Assistance Services. In recent years, states have also started using Medicaid managed care to

provide long-term services and supports.

However, Medicaid does not cover the housing portion of the cost of such residential care, and

therefore cannot cover “room and board”. Some states have enacted policies to make such

settings more available to lower-income residents. For example, some states limit the

maximum amount that can be charged for housing or provide non-Medicaid assistance to

Medicaid-eligible persons (e.g., a resident may spend their SSI income on the room and board

and Medicaid covers the services or the state may provide a state-funded housing supplement).

Finally, many states provide non-Medicaid state assistance to help older adults with low

incomes afford assisted living. Veterans may qualify for assistance paying for congregate living

through the VA’s Aid and Attendance or Housebound programs. In addition, Section 202

subsidies and other funding for housing can cover some of the housing costs for residents in

certain facilities.

Institutional Long-Term Care is available for individuals who can no longer live independently

and need a significant amount of assistance with ADLs. Nursing homes provide the most

comprehensive package of services and are available to individuals who need 24-hour

supervised care with meals, activities, and health management. A physician supervises each

resident’s care, and a medical professional is almost always present. Like assisted living, costs

vary depending on the level of care provided. Costs are extremely high, reaching an average of

$8,000 per month. Medicaid will pay 100 percent of the cost of nursing home care for

beneficiaries.

Challenges with Housing Assistance for Older Adults Experiencing Homelessness

Perhaps the most significant challenge with housing assistance for older adults experiencing

homelessness is that there is not enough housing available to meet the growing need among

low-income older adults. The lack of affordable housing coupled with increases in the numbers

of older adults eligible for housing assistance creates challenges in finding and maintaining

housing for those experiencing homelessness. Only 37 affordable and available homes exist for

every 100 extremely low-income renters in the United States (those with incomes less than 30

percent of the area median income), nearly a third of whom (30 percent) are seniors (Aurand et

al., 2021). The number of low-income older adults who are eligible for rental assistance but do

not receive it also has increased more than 5 percent between 2017 and 2018 (PAHRC, 2020).

Although over time more older adults are living in publicly supported housing (increasing 2.9

percent between 2018 and 2019), the amount of affordable housing available is not keeping

pace with demand. Adults living in the housing are aging, more older adults are entering public

housing for the first time, and seniors living in publicly supported housing are staying longer,

averaging 12.3 years in 2017, an increase of 5 percent since 2013. Yet the share of eligible

seniors who receive housing assistance declined from 41 percent to 40 percent from 2017 to

2018 (PAHRC, 2020).

New funding for the Housing Choice Voucher

program has been largely unchanged since 1983,

and most appropriations maintain existing

operations (Couch, 2020). With respect to

Section 202 units, the supply is not sufficient to

meet the growing number of adults who qualify,

a challenge further exacerbated by low vacancy

rates (Kochera, 2006) and having many facilities in need of repair (Libson, 2005). Long wait

times for eligible older adults often result from these challenges. As an example, the length of

time senior households spent on waitlist for public housing and Housing Choice Voucher

increased by 18 percent between 2016 and 2017, from 22.9 months to 27 months (PAHRC,

2020).

As housing providers noted, lacking necessary

vital documents such as a birth certificate or

Social Security card, which can be lost through

encampment sweeps or while staying on the

street, can be a common barrier for older adults

to receiving housing assistance. In addition,

people experiencing homelessness are often unaware of their eligibility for housing assistance.

The people with lived experience with whom we spoke were unaware of whether they qualified

for housing assistance or reported long waitlists to get it. Others mentioned discrimination by

landlords who did not want to rent to them because they experienced homelessness.

Expanded Services During the COVID-19 Pandemic

The CARES Act included a moratorium on tenant evictions from rental properties that receive

federal funding or have Federal Government-backed mortgages from March 2020 until July

2020. The Centers for Disease Control and Prevention (CDC) announced an additional eviction

moratorium on September 1, 2020, that was extended multiple times and ended in August

2021. In addition, some states, localities, territories, and Tribal areas, continue to implement

statewide and/or local and county eviction moratoriums.

CARES Act funding also allowed communities to provide supportive housing services and more

medium and long-term housing assistance, such as rental assistance and housing navigation

services. Moreover, HUD granted waivers to all communities to help prevent the spread of

COVID-19 and mitigate the pandemic’s economic impacts; these waivers included a suspension

of time limits on temporary assistance programs, such as rapid re-housing, and a series that

facilitate access to public housing. Waivers pertained to income verifications, review of

citizenship and Social Security numbers, and proof of family composition for public

housing tenants and inspections that were not possible or, in some instances, safe during the

pandemic.

“A lot of [landlords] don't want to house

homeless people because of the

baggage that comes with homeless

people.” – Male, 62

“As far as getting housing and stuff, I

really don't have communication with

the housing people. They just tell me I'm

still pending or waiting for a place.” –

Female, 60

HEALTH CARE, LONG-TERM CARE, AND BEHAVIORAL HEALTH SERVICES

Physical and behavioral health services play a critical role in the lives of many older adults

experiencing homelessness due to the elevated incidence of health problems they experience

relative to their housed counterparts (Cohen, 1999; Gelberg et al., 1990; HPRI, 2019; Brown et

al., 2016). For many older adults at risk of homelessness, health expenses contribute to their

becoming homeless (Bielenberg et al., 2020; Center for Housing Policy, 2015). The high cost of

health care and long-term services and supports lead to extended periods of poverty for more

than two-thirds of older adults aged 65 and older (Johnson & Favreault, 2021).

Medicare and Medicaid

Health care, long-term care, and behavioral health services, including prescription medications,

are available for older adults at risk of or experiencing homelessness through a variety of

federal and state-funded mechanisms including Medicare, Medicaid, and VA benefits (for

eligible veterans) among others. Benefits provided by each of these programs as well as the

eligibility requirements vary within programs and across states. Medicare and Medicaid serve

as the primary source of health insurance for older adults experiencing homelessness.

Medicare is a federally-funded health insurance program that helps with the cost of health

care, but it does not cover all medical expenses or the cost of most long-term care.

Beneficiaries can receive Medicare benefits through Medicare fee-for-service (FFS)

(“traditional” Medicare) or Medicare Advantage plans. Medicare Advantage Plans are offered

by private companies approved by Medicare. A key limitation of Medicare for older adults

experiencing homelessness is its eligibility criteria. Medicare is limited to individuals aged 65

and older who have a work history or as an entitlement benefit to younger people receiving

Social Security disability benefits for at least two years or with end stage renal disease.

Medicare-eligible individuals with low-incomes (i.e., in 2022, less than $1,153 per month for an

individual and resources limited to $8,400, which would likely apply to a large majority of older

adults experiencing homelessness) can receive additional coverage through the Qualified

Medicare Beneficiary program (i.e., Medicare Savings Programs) (Medicare.gov, n.d.). The

program provides financial assistance with part A premiums (hospital insurance), Part B

(medical insurance) premiums, as well as with deductibles, coinsurance, and copayments for all

individuals who meet the eligibility criteria.

Medicare typically provides full or partial coverage for services from doctors and other health

care providers; outpatient care; preventive services such as screenings, vaccinations, and

wellness visits; inpatient care in hospitals, skilled nursing facilities, and hospice care; and home

health care, as well as for prescription drugs and some medical equipment such as wheelchairs

and walkers. Medicare provides limited vision, hearing, and dental coverage for older adults.

In addition to physical health services, Medicare provides coverage for behavioral health

services including depression screenings, diagnostic tests, individual and group psychotherapy,

psychiatric evaluation, medication management, hospitalizations, and treatment of substance

use disorders in both inpatient and outpatient settings.

Medicare is available to a wide range of older adults, but some Medicare Advantage special

needs plans (SNPs), which are designed to provide targeted care and limit enrollment to

defined groups of Medicare beneficiaries, are beginning to focus specifically on people

experiencing homelessness. For instance, LA Care, a health plan based in Los Angeles, has

partnered with SNP Alliance, Massachusetts General Hospital, and other academic,

professional, and non-profit health care organizations to come up with a homelessness-focused

Medicare Advantage SNP (Jain et al., 2020).

Medicaid provides health insurance for low-income Americans, including families with children,

elderly people, and people with medically certified disabilities. Older adults ages 50-64 who are

not yet eligible for Medicare but do meet income eligibility (133 percent of the federal poverty

line) are also eligible for Medicaid in the 38 states and the District of Columbia that broadened

their eligibility under the Affordable Care Act. However, in the 12 states that as of January 2021

have not expanded coverage under the Affordable Care Act, receipt of Medicaid by adults

without children is rare (Garfield & Orgera, 2021). As of 2019, 10.5 percent of all adults ages 50-

64 nationally were uninsured, for which the primary reason reported was that insurance was

not affordable (Cha & Cohen, 2020).

Like Medicare, Medicaid typically provides full or partial coverage for a wide range of health

services, including medical appointments, hospitalizations, preventive services, outpatient care,

medications, and medical equipment as well as limited vision, hearing, and dental coverage.

Medicaid coverage of behavioral health services, in contrast to Medicare coverage, varies

greatly across states. All states provide some mandatory services for all Medicaid clients such as

medically necessary inpatient hospital services, outpatient services, and institutional long-term

care; however, Medicaid coverage for adults 65 and older varies by state for services such as

detoxification, prescribed medications, targeted case management, rehabilitation services,

therapies, medication management, clinic services, licensed clinical social work services, peer

supports, and hospital stays.

State Medicaid programs can cover HCBS for individuals with disabilities and older adults with

functional impairments (Costello, 2021) These services can include assistance with personal

care, care coordination, and non-medical transportation. In addition, states can elect to cover

housing-related services and supports, such as pre-tenancy services, home accessibility

modifications, and transition services (Costello, 2021).

For individuals who are eligible for both programs, referred to as “duals”, Medicaid provides

assistance for Medicare premiums as well as other services not typically covered by Medicare.

As duals are a diverse population with extensive and complex needs, the Centers for Medicare

& Medicaid Services (CMS) has developed the Financial Alignment Initiative in an effort to work

with states to improve the coordination of all Medicare and Medicaid covered benefits and

enhance the care provided to dually eligible beneficiaries. As of January 2020, 11 states are

participating in this initiative (CMS, 2022).

Increasingly, to meet the needs of individuals with complex medical needs such as older adults

experiencing homelessness, providers and funders are offering coordinated care models that

integrate primary care, behavioral health services, and social services through a single program.

For example, PACE is a Medicare program, available as a state Medicaid option, that provides

comprehensive medical and social services to certain frail, community-dwelling elderly

individuals, most of whom are dually eligible for Medicare and Medicaid (Medicaid.gov, n.d.). In

several communities, this model is being implemented in partnership with housing providers

and targeted specifically to older adults experiencing homelessness.

Profile of Coordinated Care Models for Older Adults

St. Paul’s PACE program in San Diego, California, provides a coordinated model of

care to formerly homeless older adults aged 55 years or older who are dually

eligible for Medicare and Medicaid. In partnership with local housing developers,

older adults are provided subsidized housing with wrap-around supportive services,

including primary and specialty health services, medication assistance, mental

health services, occupational therapy, dentistry, as well as meals and nutrition

counseling, social activities, social services, and transportation assistance. This

program reports reduced hospital use among older adults and lower rates of

hospital readmissions and potentially avoidable hospitalizations, such as for

congestive heart failure and asthma (Meret-Hanke, 2011; Segelman et al., 2014).

Veterans Affairs Health Care

Some older adults at risk of or experiencing homelessness may also be eligible for health care

through the Veterans Health Administration (VHA). Eligibility includes having served prior to

September 7, 1980; having served after September 7, 1980, and served for 24 months or the

full period of active duty; having been discharged for a disability that was caused or made

worse by active-duty service; and having been discharged for a hardship.

Of the 8.7 million

veterans enrolled in health care through the VHA in 2021, 30 percent (2.6 million) were

between ages 45 and 64, and 49 percent (4.2 million) were over age 65 (Wang et al., 2021;

Vespa, 2020). According to HUD, 55 percent of the veterans experiencing sheltered

homelessness in 2021 were aged 55 or older (HUD, 2023).

VHA benefits typically offer coverage for services and medications comparable to Medicare and

Medicaid; however, VHA health care benefits are not the same for all participants and are

subject to change based on funding availability. Participants are assigned to different priority

levels according to various factors, such as income and whether they have any medical

condition that derives from their military service. If federal funding for VHA health care drops or

does not keep pace with costs, individuals in the lower priority groups may lose VHA coverage.

A hardship discharge is a mechanism through which activity members of the military can be released from duty

due to hardship such as the death or permanent disability to the member's immediate family, such as the spouse

who is the primary guardian to the children of the family when the military personnel would be deployed.

VHA benefits also provide coverage for behavioral health treatment, including a broad range of

mental health conditions, substance use disorders, post-traumatic stress disorder, and serious

mental illness through both inpatient and outpatient settings. Moreover, general and

psychogeriatric mental health services are provided as an integral part of primary care within

the Patient Aligned Care Teams as well as VHA nursing homes and residential care facilities

where many veterans receive care. The VHA also has a set of programs that fall under the

heading Geriatrics and Extended Care, which are designed to help veterans diagnosed with

chronic health issues or life-limiting illnesses. Among other things, these programs can provide

respite care, adult day care, outpatient and inpatient hospital services, nursing homes,

palliative care, and hospice.

Older Americans Act Funded Programs

Older adults experiencing homelessness may also benefit from health and support programs

available through Older Americans Act (OAA) funded programs. The OAA coordinates the

distribution of funds for many programs for older adults, both health-related and otherwise

(ACL, 2022). These funds originate with the federal Administration of Aging, which oversees 56

State Units on Aging, which in turn oversee over 600 Area Agencies on Aging and almost 300

Tribal organizations, totaling around 20,000 service providers (ACL, n.d.; Siegler et al., 2015).

The OAA funds a number of programs and services directly, such as Aging and Disability

Resource Centers, Elder Rights Support programs, and the Alzheimer’s Disease Initiative

(Congressional Research Service, 2022). However, the majority of OAA funds (72.8 percent in

FY2022) go directly to State Units on Aging and Area Agencies on Aging, which allocate funds

locally to address the health and social needs of their constituents (Congressional Research

Service, 2022). One such source is the Title III-D Disease Prevention and Health Promotion

grant, which Area Agencies on Aging use to fund evidence-based disease prevention and health

promotion services in settings such as senior centers, community centers, and various

congregate settings (California Department of Aging, n.d.).

One important development in recent years is the No Wrong Door System initiative, a

collaborative effort by the Administration for Community Living (ACL), CMS, and VHA. The

initiative strives to create a more consumer-driven, efficient system for accessing long-term

services and supports for older adults and individuals with disabilities services. Since 2003, the

No Wrong Door initiative has supported 33 states with funding to help transform their systems

to make it easier for consumers and their families to learn about the services available and how

to access them (ACL, 2022).

Substance Abuse and Mental Health Service Administration Funded Programs

Older adults experiencing homelessness with mental health and/or substance use disorders can

access services through programs of the Substance Abuse and Mental Health Services

Administration (SAMHSA), a federal agency within HHS (SAMHSA, n.d.). Individuals can receive

comprehensive care, including 24/7 crisis services, referrals to clinics and services, and care

coordination, through Certified Community Behavioral Health Clinics (CCBHCs), or through

SAMHSA’s National Helpline (SAMHSA, n.d.). CCBHC services are available to individuals of all

ages and are free for those unable to pay (SAMHSA, n.d.). SAMHSA also provides a variety of

grants to states and local organizations specifically assisting those experiencing co-occurring

homelessness and behavioral health disorders with a variety of services, including case

management, peer support, and treatment for mental health and substance use disorders

(SAMHSA, n.d.).

Other Sources of Health Care

Older adults, including those who may be uninsured, can also access health care through

community-based outpatient clinics including Federally Qualified Health Centers (FQHCs),

Health Care for the Homeless clinics, Community Health Centers, Migrant Health Centers, and

Primary Care in Public Housing (Health Resources and Services Administration [HRSA], 2018).

Each of these organizations is grant-funded to provide specific services to underserved

populations.

In particular, the Health Care for the Homeless Program supports FQHCs that provide health

care to people experiencing homelessness. Anyone experiencing homelessness is eligible to

receive assistance from a Health Care for the Homeless clinic, though clinics are primarily

located in urban locations. Eligibility includes people living in unsheltered locations, shelters or

transitional housing, “doubled-up” situations with family or friends, people exiting institutions

without a stable housing situation, and people in any other unstable or non-permanent living

situation. Nearly 300 Health Care for the Homeless clinics across the country provide primary

health, mental health, substance use disorders, and social services with intensive outreach and

case management to link clients with additional services. In 2020, Health Care for the Homeless

clinics served nearly 1 million patients, with 7.43 percent over the age of 65, a proportion that

has been steadily increasing in recent years (HRSA, 2020).

Challenges with Health Services for Older Adults Experiencing Homelessness

Older adults experiencing homelessness face a number of challenges accessing the health care

they need, including lack of health insurance; a need for immediate focus on basic needs, such

as food and housing, instead of health needs; limited appointments and providers; a lack of

transportation to access assistance (Canham et al., 2020; Kushel et al., 2012; Watson et al.,

2008) among others.

Lack of insurance: There are no nationally representative data on rates of health insurance

coverage for older adults experiencing homelessness; however, two studies have been

conducted in single cities. These studies found that the majority of older adults experiencing

homelessness have some type of health insurance, with Medicare and Medicaid being the

primary sources (Lee et al., 2020; Ye et al., 2019). Using Homeless Management Information

Systems data on 1,204 older adults aged 55-90 living in Tampa, Florida who received

homelessness assistance in the last year, Lee and colleagues (2020) found that 88 percent had

insurance. Similarly, in a study of 17 older adults experiencing homelessness in Wilmington,

Delaware, Ye and colleagues (2019) found that all but two participants reported having health

insurance.

Older homeless adults who lack health coverage tend to be aged 50-65 and fall between the

cracks of governmental safety nets -- not old enough to qualify for Medicare and ineligible for

Medicaid assistance in many states (Dipietro et al., 2014). In an examination of the Health Care

for the Homeless User Survey, Baggett and colleagues (2011) found that, among people

experiencing homelessness, those aged 45 and older were more likely than younger adults to

have an unmet need for prescription medications (2010).

Primary focus on basic needs: Many older adults experiencing homelessness, including those

with health insurance, do not receive the health care they need because they first focus on

addressing their basic and immediate needs, such as securing shelter and food (Baggett et al.,

2011; Van Dongen et al., 2019). This delay of attention to medical needs often results in older

adults experiencing homelessness relying on emergency departments and street outreach

programs for health care (Chung et al., 2018; McDonald et al., 2006).

Limited appointments or providers: Some research has found that over half of adults aged 50

and older who are experiencing homelessness report having access to a regular place of care

(Chung et al., 2018; Kaplan et al., 2019). Access to health care, including routine exams or

wellness checks, for older adults who are experiencing homelessness is still lower than their

housed counterparts, due in part to individuals not knowing where to go or inability to get and

keep appointments (McDonald et al., 2006; Ye, 2019). Moreover, older adults with memory

problems may struggle to attend scheduled appointments (Grenier et al., 2013).

Lack of transportation: In the limited research available documenting older homeless adults’

barriers to receiving needed health care, research found that a lack of transportation to

appointments or difficulty navigating public transportation was cited as among the most

common reasons for lack of health care receipt among older adults experiencing homelessness

(Canham et al., 2020; Ye et al., 2019).

In discussions, people with lived experience

noted barriers to service receipt including

unreliable telephones, inability to get walk-in

appointments, appointments that were too far

out to remember, and, for two individuals, lost Medicaid cards which prevented them from

getting the health services that they needed.

Additionally, in discussions, experts and housing providers noted that behavioral health care

services are rarely tailored to geriatric populations. Conditions related to aging, such as

memory problems, may be interpreted as behavioral health problems. Moreover, if behavioral

health providers are not attentive to feelings common to older adults, such as shame and

distrust of assistance, they will be less effective in providing them the assistance they need.

Expanded Services During the COVID-19 Pandemic

Various new policies and practices were put into place to facilitate access to health care during

the COVID-19 pandemic. HRSA’s COVID-19 Coverage Assistance Fund and COVID-19 Uninsured

“I have trouble keeping [appointments]

because I forget a lot.” – Female, 60

Program covered the costs of administering COVID-19 vaccines to uninsured and underinsured

patients. CMS expanded Medicare coverage of telehealth and provided payment policy and

regulatory flexibility for Medicare-covered services. In addition, the Families First Coronavirus

Response Act required that Medicaid programs keep people continuously enrolled through the

end of the month in which the COVID-19 public health emergency ends.

INCOME SUPPORTS AND OTHER NEEDS

Income Supports

SSI, SSDI, and state-funded general assistance programs provide income supplements to aged,

blind, and disabled people (and some family members) to help meet basic needs such as food,

clothing, and housing. As of 2022, an eligible individual’s monthly maximum federal SSI

payment was $841. All but four states supplement this amount with additional assistance

ranging from $10 to $400 a month. SSDI payment amounts are based on an individual’s lifetime

average earnings before becoming disabled, with average monthly amounts ranging from $800

and $1,800. Because many older adults live on fixed incomes, another strategy some

communities are exploring to assist older adults is to provide shallow rental subsidies (typically

several hundred dollars a month of limited, needs-based payments), such as Santa Monica’s

Preserving Our Diversity program, which provides rental assistance to low-income seniors to

maintain their housing (Sharma, 2019).

For people who were employed and lost their jobs, unemployment insurance benefits can

provide some temporary income supports. The basic unemployment insurance program is

operated by individual states and overseen by the DoL. Most states provide up to 26 weeks of

benefits, replacing about half of a recipient’s wages, on average (Stone & Chen, 2014). Eligibility

and benefit levels differ by state. Some recipients may also be eligible for the Extended Benefit

program, which provides an additional 13-20 weeks of compensation to workers if the state’s

unemployment situation has worsened. Studies estimate unemployment rates among people

experiencing homelessness range from 57 percent to over 90 percent compared to less than 5

percent for the general population (HPRI, 2020); however, it is not clear how many older adults

experiencing homelessness are eligible for or receive unemployment insurance benefits.

Providers and organizations can assist older adults experiencing homelessness with the

application process to apply for these benefits (Perret, 2021; Brown et al., 2013). The SOAR

program, an evidence-based model, also helps older adults with mental illnesses, co-occurring

substance use disorders, or other impairments to apply for SSI and SSDI (Kushel, 2020). One

study found that SOAR applicants were twice as likely to have their initial application approved

than all other homeless applicants (Kauff et al., 2016). On a national level, SOAR applicants who

were of older age and living in an institutional setting, such as a hospital or a residential

treatment center, were associated with a higher rate of application approval among homeless

adults at risk of or experiencing homelessness (Lowder et al., 2017).

Food and Nutrition Assistance

Administered by the USDA, SNAP provides monthly benefits to low-income households to

purchase food. It is the largest USDA food assistance program, serving more than 5 million older

adults annually (U.S. Government Accountability Office, 2019). SNAP is funded through

“mandatory” federal funding, meaning that funding for the program is automatically expanded

or contracted to meet demand (Blancato & Whitmere, 2021). State Units on Aging and Area

Agencies on Aging also provide nutrition services to adults aged 60 and older. For example,

Meals on Wheels is a program that delivers meals to home-bound individuals who are unable to

purchase or prepare their own meals.

Transportation Assistance

Transportation assistance for older adults experiencing homelessness is available through a

range of services. At the state level, the Aging Services Division provides a range of services to

eligible older adults, including transportation to shopping and medical appointments (Eldercare

Directory, n.d.). Eligible older adults may contact their local offices to arrange for transportation

to medical appointments and shopping centers, among other locations. Older adults who need

special accommodations, such as those who use a wheelchair or have other mobility

impairments, can use the accessible transportation.

Although service availability and eligibility differ from state to state, older adults receiving

Medicaid coverage may use travel services to reach medical facilities. The transportation

voucher program involves assistance with fares or rides without charge to eligible low-income

older adults and people with disabilities (Haarstad, 2008). In addition, Medicaid Advantage

plans have flexibility to offer expanded benefits that go beyond Medicare FFS and can address

barriers to health, including non-emergency transportation to and from doctor’s appointments,

lab tests, pharmacies, massage therapy, fitness centers, and other health care-related

destinations.

Social Engagement Services

Many communities offer services to combat social isolation that many older adults experience,

including senior centers, adult day centers, and in-home social engagement programs, though

few of these programs are specifically for older adults experiencing homelessness. These

programs are often funded through Area Agencies on Aging but can be supported through

other federal, state, and municipal sources as well as through faith-based and private sources.

Such services typically provide wellness and exercise classes, arts programs, and community

building opportunities (ACL, n.d.; Berg-Weger et al., 2020; Siegler et al., 2015). The availability

of such programs, the services they provide, and eligibility for participation vary nationally.

Adult Protective Services

Adult protective services (APS) programs respond to allegations of abuse, neglect, or

exploitation of vulnerable adults, such as older adults and those with disabilities (National Adult

Protective Services Resource Center [NAPSRC], n.d.). They investigate allegations and, as

needed, address the health and safety needs of the victims through providing a range of

services and case management (NAPSRC, n.d.). APS programs collaborate with a number of

professionals in the health, safety, and social services fields to address allegations as well as

other needs victims may require (National Adult Protective Services Association, n.d.). States

receive the majority of their funding for APS programs from the Federal Government through

the Social Services Block Grant, which they can supplement through general revenue funds or

other funding intended for older adults, such as funding through the OAA (Ramsey-Klawsnik,

2018). Program administration varies by state and can occur at the state level, the county level,

through local agencies such as Area Agencies on Aging, or some combination of all three

(Ramsey-Klawsnik, 2018). Each APS program can determine its own eligibility and reporting

requirements in addition to definitions of abuse, neglect, and exploitation; some programs

offer services only to adults over age 60, while others use varying combinations of age and

disability to determine eligibility (Ramsey-Klawsnik, 2018).

Challenges with Income Supports and Other Needs

Older adults experiencing homelessness face a range of challenges in accessing assistance and

services for meeting basic needs, such as income, food, and transportation. People

experiencing homelessness may have difficulty accessing financial benefits for which they are

eligible. Individuals with serious mental illnesses, medical impairments, or substance use

disorders and who are at risk of or experiencing homelessness face challenges when applying

for SSDI benefits (Donaldson et al., 2020). Some applicants find it difficult to produce the

documents needed to establish or maintain their eligibility.

Studies have also identified several barriers in accessing food assistance programs among older

adults experiencing homelessness, such as difficulty applying for or renewing their benefits due

to limited access to technology and no fixed addresses, low health literacy, and cognitive

impairment, that may complicate the ability to understand eligibility criteria and complete

necessary documentation (Tong et al., 2018). USDA researchers suggest that older adults,

especially those who have been self-sufficient for the majority of their life, may feel stigma

around receiving welfare, especially in a public setting such as a grocery store (SNAP, n.d.). Data

on the rate of SNAP participation for older adults experiencing homelessness are not available,

yet data for all eligible elderly households indicate that only about a third participates in SNAP

(e.g., Ziliak & Gundersen, 2020). In response to the low participation levels and unique

economic circumstances of elderly households, the USDA Food and Nutrition Service has

implemented waivers and demonstration projects that aim to reduce barriers to participation,

reduce administrative burden, and improve access to SNAP for elderly people (Levin et al.,

2020).

In discussions, experts and providers echoed this

sentiment, noting that many older adults

experiencing homelessness or recently placed in

housing need assistance applying for and

maintaining benefits, including SSDI, SNAP, and

others, especially those older adults who are not internet savvy, do not have access to the

necessary technology, or struggle to understand the steps required to apply for and maintain

“For me, I don't know how the computer

works… Everything now you have to do it

on the computer.” – Male, 66

their benefits. Among people with lived experience of homelessness, two reported needing

help navigating the recertifications for their benefits and, in particular, being confused by all of

the mail they received from different agencies. Others reported not knowing how computers

worked and feeling frustrated that they needed to use computers to apply for benefits and

other assistance.

Yet an additional challenge for older adults experiencing homelessness is that SNAP does not

allow recipients to purchase prepared food, thus requiring access to cooking facilities and an

ability to safely store uncooked food (Tong et al., 2018). However, several states (five as of April

2022) have implemented a SNAP Restaurant Meals Program that allows select SNAP recipients

to use their SNAP benefits to pay for restaurant meals. Eligibility differs across states but is

typically limited to SNAP recipients who are 60 years or older, are experiencing homelessness,

or have a disability (USDA, 2021).

Transportation assistance is available for many

older adults experiencing homelessness;

however, barriers can limit access to some

services, particularly for those in rural areas and

with mobility limitations (Ravensbergen et al.,

2022). Limited research is available on the

accessibility of public transportation for older

adults, though the literature suggests significant variation by city (Ravensbergen et al., 2022).

Individuals with lived experience with homelessness reported transportation difficulties,

including not knowing how to navigate bus systems and feeling vulnerable with using public

transportation due to poor eyesight and the lack of proper eyewear, physical limitations, or

memory problems.

Expanded Services During the COVID-19 Pandemic

Assistance to meet a range of older adults’ basic needs were expanded during the COVID-19

pandemic. The pandemic exacerbated food insecurity for older adults at risk of or experiencing

homelessness due to a loss of, or disruption in, food from nutrition programs (Goger, 2020). To

address this challenge, numerous providers implemented innovative strategies, such as

converting in-person nutrition programs for older adults into “grab and go” programs or home-

delivered meals. Additionally, when some traditional senior nutrition food distribution channels

were overwhelmed, providers found new local and corporate partners. For example, members

of National Association of Nutrition and Aging Services Programs (NANASP) and n4a partnered

with Tivity Health to provide Nutrisystem and South Beach Diet frozen home-delivered meals to

older adults in areas with food shortages. A January 2021 survey of the NANASP members

found that around 90 percent of respondents reported that they were still serving more meals

now than prior to the pandemic, with many providers stating that their demand had doubled or

more (NANASP, 2021).

During the pandemic, states began more widespread adoption of the USDA’s SNAP Online

Purchasing Pilot to allow SNAP participants the option of grocery shopping online, which prior

“[My case manager is] going to give me

bus passes, but the problem is that my

eyesight and it's just not good and I just

don't feel, I feel vulnerable out there.” –

Female, 59

to March 2020 was in place in only New York and Washington State. The program has

continued to expand following the pandemic. As of April 2023, the District of Columbia and

every state except Alaska were participating in the program (USDA, 2021).

In addition, during the pandemic, federally-funded unemployment insurance was expanded to

include workers not traditionally covered by unemployment insurance benefits, provide a flat

benefit level to all recipients (at a higher rate than was typically provided by states), and extend

the period of time for which recipients could receive benefits.

In 2021, the Federal Government drastically increased its direct contribution to APS programs

through the CARES ACT and the American Rescue Plan Act (ACL, 2021). No formal APS

administration changes happened at the federal level in response to the pandemic, though

some APS programs took on larger roles in service referrals and direct provision as community-

based organizations and nursing homes struggled to stay open and provide care for older adults

(Liu & Delagrammatikas, 2021).

Providers with whom we spoke noted that several changes implemented during the pandemic

had both positive and negative impacts for the older adults they served. For example, multiple

housing providers were able to provide iPads or other devices to their residents, expanding the

ways to connect with family and friends; however, older adults with limited technological

proficiency were less able to use these new methods of connection. For these older adults, the

pandemic was thought to accelerate physical and cognitive decline. Similarly, many meal

services such as soup kitchens transitioned to meal delivery assistance. This shift was an

advantage for those who struggled to access services, yet also removed an opportunity for

socialization for many older adults.

Section 4. Gaps and Potential Strategies

ADDRESSING GAPS IN SERVICE DELIVERY AND COORDINATION

The environmental scan and discussions identified a number of critical gaps in housing and

service availability, accessibility, delivery, and coordination. The following interventions and

policy considerations may help providers and policymakers better meet the housing and

support needs of older adults experiencing housing instability and homelessness.

Identification, Outreach, and Navigation Services

Various interviewees recommended better screening and identification of housing instability

among non-homelessness providers with whom older adults are connected, such as health

clinics and benefits offices, would help prevent many at risk older adults from becoming

homeless. Older adults experiencing homelessness need outreach and navigation that is

targeted sensitive to their specific barriers to receiving assistance. Experts and providers noted,

in particular, that services are needed to help older adults learn about the available supports

that match their eligibility and to navigate the process of applying for and accessing that

assistance.

Individuals with lived experience of

homelessness echoed this sentiment. Two

people who experienced homelessness for the

first time as older adults reported that they did

not know who to turn to for assistance or what

assistance was available. Although most

individuals reported being connected to a case

manager who helped them figure out where to

go, they reported primarily learning about the assistance available through other people on the

street.

Increased Access to Benefits and Services

Experts and providers noted that restrictive eligibility criteria also prevent or complicate access

to key services for this population. Some criteria, such as for Medicaid long-term care (including

HCBS), have strict income and/or asset requirements that require recipients to exhaust nearly

all savings before receiving coverage. The asset limits for Medicaid eligibility for these services

are typically no more than $2,000 for an individual or $3,000 for couple.

Other programs, such

as SSI, have strict age and/or disability criteria, limiting services to people over age 60 or 62.

Veterans who have been dishonorably discharged are ineligible for VA assistance. Permanent

supportive housing programs are often limited to those who have experienced chronic

homelessness and are thus unavailable to older adults who are at risk but do not have histories

of homelessness. Undocumented individuals are ineligible for most types of federally-funded

California is implementing a new policy that is phasing out this asset limit beginning in July 2022 (Justice in Aging,

2022).

“They should have more people that will

go down there to try to help them to get

off the damn street because once you're

on the street, it is so hard to keep it

together and get off the street.” –

Male, 57

assistance.

Experts noted that overall, older adults experiencing homelessness are at

increased risk of morbidity and mortality compared to the housed population and need access

to these benefits and services.

Crisis and Interim Housing Tailored for Older Adults

Experts and providers reported a need for homelessness assistance that was tailored to older

adults’ unique challenges. For example, emergency shelter accommodations should include

beds that are on the first floor or bottom bunk, 24-hour access to bedrooms and bathrooms,

and refrigeration or locked storage for medications and medical supplies. Additionally, they

noted, providers who serve older adults at risk of or experiencing homelessness must be

sensitive to the emotional needs of older adults, who may be struggling with shame and

sadness due to needing assistance or being disconnected from their families.

Permanent Supportive Housing Tailored to Older Adults with Histories of Homelessness

Older adults with histories of homelessness often have additional challenges moving into

permanent supportive housing than older adults without such histories. These include greater

functional impairments and behavioral health challenges, as well as limited connection to their

communities. There is a need for additional permanent supportive housing specifically tailored

to these older adults with physical accommodations (e.g., wheelchair accessible buildings, grab

bars in units) to address these needs as well as access to the types of case management and

nursing assistance (e.g., medication management, wound care) that will allow them to age in

place.

Consistent Case Management Assistance

The majority of older adults with lived

experience with whom we spoke indicated that

case management help was critical to getting

the assistance they needed. When asked how

they knew where to go for assistance, ten of the

14 individuals said they learned about help

through their case managers. For those in permanent supportive housing, this case

management was, most often, associated with the housing program. People not in housing

mentioned that case managers at emergency shelters were also helpful in providing guidance

about where to go for help. Four individuals spoke of the difficulties navigating the system

when they did not have case managers or when there was case manager turnover, which

prevented them from getting the help they needed. Research shows that low wages and a

demanding work environment are associated with high rates of case manager and supervisor

turnover in many organizations, both of which can disrupt clients’ access to appropriate and

Beginning in May 2022, California expanded Medi-CAL access to all individuals who are 50 years or older

regardless of immigration status. Under this expansion, all individuals who meet Medi-CAL full-scope eligibility

are eligible for primary, specialty, behavioral health, and long-term care as well as in-home supportive services,

HCBS, transportation, vision, and hearing aid coverage (Office of Governor Gavin Newsom, 2022).

“I talked with [my case manager] 1 time

and now he's gone for 2 or 3 weeks

doing something, I don't know what, and

won't be back.” – Female, 59

timely services (Gabrielian et al., 2022). A current shortage of direct care workers and case

managers exacerbates the challenges of system navigation for many older adults.

Inadequate Capacity of Affordable Housing

Echoing findings from the research, experts and providers spoke of the need for more

affordable housing for older adults at risk or experiencing homelessness. In particular, they

identified a need for more permanent supportive housing as well as other subsidized housing

for older adults, including Supportive Housing for the Elderly (Section 202) and Housing Choice

Voucher (Section 8) units. For most housing assistance programs, such as Section 8 vouchers,

waitlists can be years long, and once an individual receives a voucher, low housing vacancy

rates and landlord bias can effectively prevent people from securing affordable housing.

Lack of Coordination Across Systems

Across discussions, the most-widely identified issue with serving older adults experiencing

homelessness was a lack of coordination across the various systems that serve older adults at

risk of or experiencing homelessness. This lack of

coordination happens on multiple levels. At a

systems level, cross-systems coordination has

not been a federal priority, funding streams are

often siloed, and eligibility criteria vary. Multiple

experts indicated that many programs, for

example, may make sense fiscally but run into

barriers due to the “wrong pocket problem”

such that the money that needs to be spent

comes from a different coffer than money that

will be saved. For example, greater investments

in prevention services or housing stabilization services will likely result in improved health

outcomes. Yet, the savings that result from those improvements are unlikely to benefit

agencies that provide prevention or housing assistance.

Experts and providers noted that it is no one person’s or agency’s job to coordinate across

systems and social service agencies are often too understaffed to take this on. Others indicated

that most systems are quite complex and use different language and data systems, making it

difficult to communicate. Coordination may be further challenged by program requirements

that are hard for people experiencing homelessness to meet. For example, some PACE

programs serve older adults living in subsidized housing with wrap-around supportive services,

including primary and specialty health services, medication assistance, mental health services,

occupational therapy, dentistry, as well as meals and nutrition counseling, social activities,

social services, and transportation assistance. Although this model has successfully coordinated

care for homeless people in a few select locations, such as San Diego, as a Medicare benefit

option, it was not originally designed to serve this high-need population. Individuals with long

histories of homelessness may have more functional impairments and behavioral health needs

than is covered by PACE payment rates.

“All the different agencies, they don't

communicate with each other like they

should. And, well, a couple of times I've

got responses from the agencies that I

need to recertify and I have sat down

and went through all that paperwork

and sent it off and I still get the

threatening letters.” – Male, 74

Finally, many aging, health, and long-term care service systems do not routinely screen for

housing instability among their clients and thus service providers are unaware that they need to

coordinate with housing and homelessness providers. When they are aware of the coordination

that is needed, HIPAA regulations can make it difficult for care providers to communicate about

their shared clients. Moreover, distinct data systems across systems make it difficult for

providers to track individuals’ service receipt to ensure they are getting the assistance they

need.

GAPS IN KNOWLEDGE

The experts and providers interviewed largely concurred that insufficient research has focused

specifically on older adults experiencing homelessness, a small but growing population of

people. Those interviewed provided insight into areas they would like to see additional

research to inform policy and services moving forward.

Research on Equity in Services and Outcomes

One key area raised by many individuals with whom we spoke was the need for more research

focused on equity in services and outcomes for older adults experiencing homelessness. Racism

and language barriers can prevent individuals from accessing the assistance they need, though

providers may not understand the extent to which this occurs. Experts pushed for additional

research unpacking whether there are differences by race and ethnicity in the types and

amount of assistance received by people experiencing homelessness as well as the causes of

those differences. One expert also called for research exploring the extent to which older adults

who are LGBTQ+ receive the assistance they need.

Research on the Connection between Health and Homelessness among Older Adults

Another area in which older adults are understudied is the intersection of health and

homelessness. Experts noted cognitive impairment in older age may contribute to individuals’

risk of homelessness as they struggle to manage their finances. Yet, interviewees called for

more research exploring cognitive decline once individuals become homeless. One expert

noted that individuals experiencing sleep deprivation or severe depression, common conditions

among those who are homeless, may be misdiagnosed with dementia on health assessments.

Another cited preliminary research indicating that cognitive tests for people experiencing

homelessness are far more unstable over time than among their housed counterparts and that

moving into housing results in improved cognition. Yet more research is needed in this field,

including to understand racial-ethnic differences in cognitive decline for people experiencing

homelessness (Nye et al., 2022).

Documentation of Available Assistance

Experts also cited a need for additional documentation of the types of assistance available to

older adults at risk of or experiencing homelessness as well as the eligibility criteria and

enrollment requirements across systems. This work can guide federal and state policymakers

about what help is available, where gaps in assistance exist, and when individuals are most

likely to need interventions to help them access and maintain the services they need. This

report serves as a starting point to meet this need, yet additional work is needed to document

the complex eligibility and enrollment requirements for programs, particularly those that vary

by state or municipality. One expert suggested they would like to see a map of all of the

moments that a Medicaid-eligible individual could lose or be denied coverage for failing to

provide necessary documentation. This exercise, they argued, could inform policy

recommendations to simplify the process as well as provide case managers with guidance

about the types of assistance needed.

Additional Data on Older Adults Experiencing Homelessness

Finally, interviewees identified a need for additional data focused on older adults experiencing

homelessness. Some experts pointed to state and local municipalities, such as Washington

State, Rhode Island, Allegheny County, and Los Angeles County, that have integrated databases

that could provide insight into the service needs and experiences of older adults experiencing

homelessness across multiple systems. However, federal homelessness data include limited

information about older adults, making it hard to identify the size and composition of the

population or their service needs.

POTENTIAL STRATEGIES

Through the information identified in this study, we offer a number of potential strategies for

policymakers and service providers to better identify and serve older adults at risk of or

experiencing homelessness. Strategies for policymakers to consider include:

• Additional prevention resources. Experts and providers with whom we spoke identified

prevention services as both cost-effective and compassionate approaches to serving

older adults at risk of homelessness. These services include short-term rental assistance

until affordable housing can be located, permanent shallow rental subsidies, resources

to help with property taxes, and assistance with home maintenance costs.

• Assistance with other costs of living. With increasing costs of food, transportation, and

other expenses, rent-burdened older adults will increasingly struggle to pay for housing.

Providing assistance with these other expenses, through established programs such as

Meals on Wheels and new programs developed during the pandemic, will allow for

additional resources to be allocated towards housing without sacrificing other needs.

• Additional types of affordable housing assistance. Shallow subsidies that provide a

small, ongoing amount of rental assistance to older adults on fixed incomes could

prevent or end their homelessness. In discussions, many experts and providers spoke of

the need for a broader range of affordable housing situations, such as affordable

assisted living for older adults who need limited assistance but do not require nursing

home-level care.

• Expanded state coverage for HCBS for at risk individuals. HCBS can help support older

adults and individuals with disabilities live in the community. Such services include

assistance with medication management and wound care; assistance with ADLs; home

management services, such as housekeeping and home repairs; transportation to

medical appointments as well as other locations such as grocery and clothing stores;

opportunities for social engagement; and case management assistance. Strategies might

include ensuring that eligible individuals in transitional housing and permanent

supportive housing have access to needed personal care to help with ADLs. States can

also consider covering housing-related services and supports under their HCBS systems,

such as pre-tenancy services for individuals transitioning from homelessness or

institutions or assistance with home modifications (Costello, 2021).

• Identification of older adults by HUD as a key population. One limitation to

understanding the size and characteristics of the population of older adults experiencing

homelessness is the limited data available. Despite older adults comprising a growing

share of the population of adults experiencing homelessness, HUD does not designate

older adults as a population of focus in its Annual Homelessness Assessment Reports.

Thus, no national data are available on the characteristics (e.g., gender, race, ethnicity)

or geographic distribution of older adults experiencing homelessness and no data exist

on the number of older adults experiencing unsheltered homelessness.

• Better cross-systems coordination. Many interviewees noted that most systems that

serve older adults experiencing homelessness do not coordinate with one other. They

suggested addressing homelessness among this population through cross-systems

coordination needs to be a federal priority and can be fostered through shared goals,

flexible or blended funding streams, and better integrated data systems. On a local

level, CoCs could work with ACL to ensure that No Wrong Door providers and providers

of coordinated entry are well-connected and can easily make referrals between their

programs to best meet the needs of older adults experiencing homelessness.

• Continuation of programs started during the pandemic. A number of programs

adopted or expanded during the pandemic, such as telemedicine and the USDA’s SNAP

Online Purchasing Pilot, provided older adults access to the assistance they needed

when they could not leave their homes. A continuation of these programs would

increase access to assistance for older adults with mobility limitations due to health

impairments, including poor eyesight and poor memory.

Potential strategies for service providers include:

• More proactive identification of older adults at risk of homelessness. Experts and

providers both noted that many older adults at risk of homelessness do not reach out

for assistance until it is too late to maintain their housing because they do not know

where to go for help or they are unwilling to ask for it. While Area Agencies on Aging are

increasingly fielding calls on assistance to address housing instability and homelessness,

there could be more proactive identification of older adults at risk of losing their

housing. Service providers, such as health clinics and those participating in the No

Wrong Door Initiative, may be in a good position to implement strategies (such as

routine screenings) to identify older adults who are severely rent-burdened or

otherwise at risk of homelessness and then work to connect those adults to available

services.

• Better documentation of services and supports available in local communities. This

documentation of assistance, as well as the eligibility criteria for receipt of assistance,

will enable more older adults at risk of or experiencing homelessness to know what

assistance is available and how they can access it. This resource must be regularly

maintained and easy for people to access, such as through city or county websites, local

service providers, and locations older adults frequently visit (e.g., public libraries).

• Additional assistance accessing medical equipment for people experiencing

homelessness. Older adults experiencing homelessness face challenges accessing

assistive technology, such as eyeglasses and hearing aids, that may be lost or damaged

while they are living in places not suitable for human habitation or are moving

frequently from shelter to shelter. Homelessness providers could connect with services

in their communities to assist older adults with providing or replacing this equipment. In

addition, shelter and transitional housing providers should provide accommodations for

people with limited mobility such as grab bars and shower safety seats.

• Training for case management staff on issues specific to older adults. With the rate of

older adults experiencing homelessness increasing, CoCs should provide training for

front-line staff on issues specific to older adults experiencing homelessness. Such

training could provide staff with sensitivity to and strategies for addressing feelings of

distrust of assistance, concerns about losing their independence, and difficulty using

public transportation and remembering scheduled appointments. Training could also

address the range of service needs that are more common among older adults

experiencing homelessness and list the providers in the community that can help

address such needs.

• Improved access to sufficient income assistance for eligible individuals. Programs such as

SSI are designed to prevent destitution, premature illness, and death among people who

are 65 and older, blind, or disabled. Yet few older adults experiencing homelessness under

age 65 receive the benefit, despite having significant health and mental health challenges.

More aggressive outreach and enrollment through programs such as SOAR would provide

a sustainable source of income for a significant share of older adults experiencing

homelessness. In addition, SSI payments are insufficient to support individuals with their

living expenses. In 19 states and the District of Columbia, statewide average one-bedroom

rents are higher than monthly SSI payments and in the remaining states, monthly rents are

equal to 75 percent or more of monthly SSI payments (Schaak et al., 2017).

CONCLUSION

Older adults at risk of and experiencing homelessness are an especially vulnerable population

with a higher prevalence and severity of a number of health and behavioral health challenges

than both their housed counterparts and younger adults experiencing homelessness. As the

number of older adults experiencing homelessness continues to grow, it is critical to

understand their unique set of needs as well as the services and supports that are available and

accessible to address them. This environmental scan provides a roadmap for better

understanding this population, including older adults’ pathways into homelessness, their

characteristics, and service needs. It outlines the range of services and supports available to

address those needs across service delivery systems. Finally, it documents the unique

challenges older adults experiencing homelessness face in accessing the assistance available

and offers a number of potential strategies for better serving this population.

Appendix: Overview of Methodology

This report incorporates findings from an environmental scan, including a review and synthesis

of published research, evaluations, and white papers; discussions with subject matter experts

and housing and service providers; and conversations with people with lived experience of

homelessness in older adulthood. Each of these methods is described in further detail below.

ENVIRONMENTAL SCAN

We used a systems approach for identifying key resources, including focused searches on

literature and other resources within the fields of homelessness and housing, health and

behavioral health, and aging. We began the literature review with identification and review of

the seminal articles on older adult homelessness (e.g., Brown et al., 2011, 2016; Brown et al.,

2016; Culhane et al., 2013; Culhane et al., 2019; Kushel, 2020; Shinn et al., 2007) and the

bibliographies of the leading scholars in the field to identify both published and unpublished

relevant resources, including reports, evaluations, and datasets along with research articles.

From this initial review, we developed a list of key words to use in a broader search, augmented

with terms based on our knowledge of services and supports available across systems to serve

older adults at risk of or experiencing homelessness.

Exhibit A-1 outlines the key words and search terms used.

Exhibit A-1. Key Words and Search Terms Used to Identify Relevant

Published and Unpublished Literature

Population:

• Older adults

• Aging adults

• Seniors

• Elderly people

• Veterans

Conditions:

• Low-income

• Equity/

discrimination

• Rent-burdened

• Unsheltered

• Food insecurity

• Uninsured/

underinsured

Services:

• Homelessness prevention

• Outreach/engagement

• Crisis/interim housing

• Rapid re-housing

• Permanent supportive

housing

• Affordable housing/low-

income housing

• Medicare/Medicaid

• Medical respite care

• Income supports (SSI/SSDI)

• Food and nutrition

assistance

• Transportation assistance

Systems:

• Homelessness

• Housing

• Health care

• Behavioral health

• Social services

• Aging services

• VA

The sources searched for relevant literature are detailed in Exhibit A-2.

We conducted a series of systematic searches using the key words to identify the population of

interest in combination with conditions, services, and systems. For example, searches included

“older adults” combined with “low-income”, “homelessness prevention”, “homelessness

services”, and so on. Using these combinations of terms, we searched a variety of databases of

published literature to identify research on characteristics, service needs, and interventions for

older adults experiencing homelessness. We also searched government agency websites for

information about eligibility and coverage of services and supports across a range of systems.

Next, we searched the websites of research organizations, service providers, and advocacy

organizations for additional information about the needs of older adults at risk of or

experiencing homelessness, the challenges they face in accessing assistance, and specific

programs that are working to address these challenges. Finally, we identified additional studies

and reports recommended by experts and providers during the interview phase of the project.

This process identified 364 potential sources.

Exhibit A-2. Sources Searched to Identify Relevant Published and Unpublished Literature

• Seminal articles in field

• Bibliographies of leading scholars

• Databases of published literature (PsycINFO, ProQuest, SAGE Research Methods, FirstSearch, PubMed,

LitCovid)

• Government agencies

– Administration for Community Living/Administration on Aging

– Centers for Disease Control and Prevention

– Centers for Medicare & Medicaid Services

– Substance Abuse and Mental Health Services Administration

– U.S. Department of Health and Human Services

– U.S. Department of Housing and Urban Development

– U.S. Department of Veterans Affairs

– U.S. Interagency Council on Homelessness

– U.S. Social Security Administration

• Research, service, and advocacy organizations

– AmeriCorps

– Assisted Living Org

– Association of Mature American Citizens Foundation

– Benioff Homelessness and Housing Initiative

– Center for Housing Policy

– Center on Budget and Policy Priorities

– Corporation for Supportive Housing

– Council of Large Public Housing Authorities

– Homelessness Policy Research Institute

– Joint Center for Housing Studies, Harvard University

– Abdul Latif Jameel Poverty Action Lab Justice in Aging

– LeadingAge

– National Adult Protective Services Association

– National Adult Protective Services Resource Center

– National Alliance to End Homelessness

– National Association of Area Agencies on Aging

– National Coalition for the Homeless

– National Council on Aging

– National Health Care for the Homeless Council

– National Low Income Housing Coalition

– USAging

Once materials were collected, we applied a protocol to appraise the resources for factors that

may influence their interpretation and prioritization. For example, for studies on the

characteristics of the population, we considered the study location, the population included,

and the year of completion. Studies that occurred fully outside of the United States or Canada

were excluded from consideration. For studies on samples that were small or not

representative of all older adults experiencing homelessness (e.g., individuals living in a

particular city or individuals recruited from drop-in centers), we integrated details of the

studies that may influence their generalizability (such as sampling strategy or geographic

location) into the summary of findings to provide appropriate context for the reader. For

literature on program resources and interventions, we prioritized the most current information

available. In the final scan, we incorporated 164 of the materials identified.

Compared to the larger literature on homelessness among all populations, only a few studies

have focused specifically on older homeless adults, and most of these studies have been

conducted within the last decade. Several of the studies reviewed in this report are based on

small samples concentrated in urban areas. These limited samples pose challenges in drawing

generalizations about older adults’ experiences with homelessness and the supports available

for them. Thus, the picture presented here, though illustrative, may not include the experiences

of all older adults, such as those from rural areas. The examination of demographic composition

of the population of older adults experiencing homelessness is especially new; only a few

studies exist examining differences in the needs and trajectories between subgroups of older

adults or the influence of characteristics such as race and ethnicity and immigration status.

Several articles reviewed in this report originate from a single cohort of older adults who

participated in the landmark HOPE HOME study (Brown et al., 2011, 2016; Hurstak et al., 2017;

Kaplan et al., 2019; Kushel, 2020; Lee et al., 2016; Raven et al., 2017). This study followed a

cohort of 350 older adults experiencing homelessness in Oakland, California over three years.

The study used clinical assessments and structured interviews to assess geriatric conditions

(functional, cognitive, and sensory impairment), housing history, behavioral health (mental

health and alcohol and substance use disorders), physical health (chronic diseases), and acute

health care utilization (emergency department visits, inpatient hospitalizations, and skilled

nursing facility placement). As the first study of its kind to focus on this population, it provides

much-needed data on the experiences, trajectories, and consequences of geriatric conditions in

homeless adults aged 50 and older, providing important insights into the type of housing and

services that may be effective for serving this population. Yet there remains a need for

additional research to replicate this study to build on these learnings and assess the

generalizability of the findings for all older adults experiencing homelessness.

DISCUSSIONS

Discussions with Subject Matter Experts and Providers

Between June and October 2022, we conducted a series of discussions with a diverse set of

subject matter experts and housing and service providers on homelessness among older adults.

Nine subject matter experts representing different disciplines of research, policy, practice, and

systems with expertise in aging and homelessness were selected, including those with expertise

in population changes, behavioral health, housing, prevention, health care/long-term care,

veteran populations, aging services, and racial equity. We also selected representatives from

eight housing and service provider agencies located throughout the country, including

providers of homelessness prevention, outreach, and drop-in assistance; health care and

respite care; permanent supportive housing, and aging support services. Throughout the

report, we refer to these individuals as experts and providers, respectively.

These expert and provider discussions supplemented information learned through the

literature review. The discussions followed a semi-structured format and focused on providing a

deeper understanding of:

• The characteristics and needs of older adults at risk of or experiencing homelessness.

• Challenges to and potential strategies for identifying older adults in need and engaging

them in assistance.

• The range of services and supports across service sectors that are available to meet their

needs, including innovative interventions to explore.

• Gaps in services and supports that remain.

• Barriers and facilitators of cross-system coordination.

• Areas for which additional research is needed.

Discussions with People Experiencing Homelessness

We collected data through tailored conversations from individuals between the ages of 56 and

74 who were experiencing or had experienced homelessness as older adults. All but one of the

individuals were recruited for participation through three provider agencies -- two permanent

supportive housing programs for older adults located in the northeast and one drop-in center

for older adults located in the southwest. The final individual was identified through her work

as a national mental health consumer advocate and policy consultant who has written a

personal account of the challenges of experiencing homelessness as an older adult. Six people

were currently experiencing homelessness at the time of the discussion, staying in shelter, in

tents, or on the street. Eight people were housed, with seven in permanent supportive housing

and one in low-income housing. The goals of these conversations were to learn more about

their experiences accessing the housing and supports they needed and the challenges they

faced Westat staff conducted six of these conversations, while the remaining eight

conversations were led by case managers from the participating agencies using protocols

developed by Westat.

 
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REFERENCES 
Administration for Community Living (ACL). (2021) ACL Awards Over $85 Million to Support Adult 
Protective Services Programs. https://acl.gov/news-and-events/announcements/acl-awards-over-
85-million-support-adult-protective-services-programs. 
Administration for Community Living (ACL). (n.d.). Adult Day Care. Eldercare Locator. Retrieved April 4, 
2023, from https://eldercare.acl.gov/public/resources/factsheets/adult_day_care.aspx. 
Administration for Community Living (ACL). (2022). Older Americans Act. Retrieved April 4, 2023, from 
https://acl.gov/about-acl/authorizing-statutes/older-americans-act. 
Airgood-Obrycki, W. (2019). The Growing Problem of Older Adult Homelessness. Joint Center for Housing 
Studies of Harvard University. Retrieved March 10, 2022, from 
https://www.jchs.harvard.edu/blog/the-growing-problem-of-older-adult-
homelessness#:~:text=While%20the%20number%20of%20people,Housing%20America's%20Older
%20Adults%202019. 
Aubry, T., Bloch, G., Brcic, V., Saad, A., Magwood, O., Abdalla, T., Alkhateeb, Q., Xie, E., Mathew, C., 
Hannigan, T., Costello, C., Thavorn, K., Stergiopoulos, V., Tugwell, P., & Pottie, K. (2020). 
Effectiveness of permanent supportive housing and income assistance interventions for homeless 
individuals in high-income countries: A systematic review. Lancet Public Health, 5(6), e342-e360. 
https://doi.org/10.1016/S2468-2667(20)30055-4. 
Aurand, A., Emmanuel, D., Threet, D., Rafi, I., & Yentel, D. (2021). The gap: A shortage of affordable 
homes. National Low Income Housing Coalition. Retrieved January 31, 2022, from 
https://reports.nlihc.org/sites/default/files/gap/Gap-Report_2021.pdf. 
Baggett, T.P., Hwang, S.W., O’Connell, J.J., Porneala, B.C., Stringfellow, E.J., Orav, E.J., Singer, D.E., & 
Rigotti, N.A. (2013). Mortality among homeless adults in Boston: Shifts in causes of death over a 
15-year period. JAMA Internal Medicine, 173(3), 189-195. 
https://doi.org/10.1001/jamainternmed.2013.1604. 
Baggett, T.P., Singer, D.E., Rao, S.R., O’Connell, J.J., Bharel, M., & Rigotti, N.A. (2011). Food insufficiency 
and health services utilization in a national sample of homeless adults. Journal of General Internal 
Medicine, 26(6), 627-634. https://doi.org/10.1007/s11606-011-1638-4. 
Bamberger, J.D., & Dobbins, S.K. (2015). A research note: Long-term cost effectiveness of placing 
homeless seniors in permanent supportive housing. Cityscape, 17(2), 269-278. 
http://www.jstor.org/stable/26326949. 
Barrow, S., Rodríguez, G.S., & Córdova, P. (2004). Final Report on the Evaluation of the Closer to Home 
Initiative. Corporation for Supportive Housing. Retrieved January 31, 2022, from 
https://www.hudexchange.info/resource/891/closer-to-home-evaluation-of-the-closer-to-home-
initiative/. 

 
63 
 
Benioff Homelessness and Housing Initiative. (2021). Home Safe Interim Evaluation: Key Findings. 
Retrieved March 31, 2022, from 
https://homelessness.ucsf.edu/sites/g/files/tkssra5216/f/resources/home_safe_memo.pdf. 
Berg-Weger, M., & Morley, J.E. (2020). Loneliness in old age: An unaddressed health problem. Journal of 
Nutrition, Health & Aging, 24(3), 243-245. https://doi.org/10.1007/s12603-020-1323-6. 
Bielenberg, J.E., Futrell, M., Stover, B., & Hagopian, A. (2020). Presence of any medical debt associated 
with two additional years of homelessness in a Seattle sample. INQUIRY: Journal of Health Care 
Organization, Provision, & Financing, 57. https://doi.org/10.1177/0046958020923535. 
Blancato, R., & Whitmire, M. (2021). The Crucial Role of Federal Nutrition Programs in Promoting Health 
among Low-Income Older Adults. American Society on Aging. Retrieved January 31, 2022, from 
https://generations.asaging.org/federal-nutrition-programs-key-older-adults. 
Brown, R.T., Kimes, R.V., Guzman, D., & Kushel, M. (2010). Health care access and utilization in older 
versus younger homeless adults. Journal of Health Care for the Poor and Underserved, 21(3), 1060-
1070. https://doi.org/10.1353/hpu.0.0344. 
Brown, R.T., Kiely, D.K., Bharel, M., & Mitchell, S.L. (2011). Geriatric syndromes in older homeless adults. 
Journal of General Internal Medicine, 27(1), 16-22. https://doi.org/10.1007/s11606-011-1848-9. 
Brown, R.T., Thomas, M.L., Cutler, D.F., & Hinderlie, M. (2013). Meeting the housing and care needs of 
older homeless adults: A permanent supportive housing program targeting homeless elders. 
Seniors Housing & Care Journal, 21(1), 126-135. Retrieved January 31, 2022, from 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3980491/. 
Brown, R.T., Miao, Y., Mitchell, S.L., Bharel, M., Patel, M., Ard, K.L., Grande, L.J., Blazey-Martin, D., Floru, 
D., & Steinman, M.A. (2015). Health outcomes of obtaining housing among older homeless adults. 
American Journal of Public Health, 105(7), 1482-1488. https://doi.org/10.2105/AJPH.2014.302539. 
Brown, R.T., Goodman, L., Guzman, D., Tieu, L., Ponath, C., & Kushel, M.B. (2016). Pathways to 
homelessness among older homeless adults: Results from the HOPE HOME study. PLOS ONE, 
11(5), e0155065. https://doi.org/10.1371/journal.pone.0155065. 
Brown, R.T., Hemati, K., Riley, E.D., Lee, C.T., Ponath, C., Tieu, L., Guzman, D., & Kushel, M.B. (2017). 
Geriatric conditions in a population-based sample of older homeless adults. Gerontologist, 
gnw011. https://doi.org/10.1093/geront/gnw011. 
Burt, M., Aran, L., Douglas, T., Valente, J., Lee, E., & Iwen, B. (1999). Homelessness: Programs and the 
People They Serve: Findings from the National Survey of Homeless Assistance Providers and Clients. 
Technical Report. Washington, DC: Urban Institute. 
California Department of Aging. (n.d.). Program Narrative & Fact Sheets--Disease Prevention and Health 
Promotion. California Department of Aging. Retrieved April 4, 2023, from 
https://www.aging.ca.gov/Providers_and_Partners/Area_Agencies_on_Aging/Disease_Prevention
_and_Health_Promotion/Program_Narrative_and_Fact_Sheets/. 

 
64 
 
Canham, S.L., Custodio, K., Mauboules, C., Good, C., & Bosma, H. (2020). Health and psychosocial needs 
of older adults who are experiencing homelessness following hospital discharge. Gerontologist, 
60(4), 715–724. https://doi.org/10.1093/geront/gnz078. 
Center for Housing Policy. (2015). The Impacts of Affordable Housing on Health: A Research Summary. 
Center for Housing Policy. Retrieved March 10, 2022, from https://nhc.org/wp-
content/uploads/2017/03/The-Impacts-of-Affordable-Housing-on-Health-A-Research-
Summary.pdf. 
Centers for Disease Control and Prevention (CDC), & National Association of Chronic Disease Directors. 
(2008). The State of Mental Health and Aging in America Issue Brief 1: What Do the Data Tell Us? 
Atlanta, GA: National Association of Chronic Disease Directors. Retrieved March 10, 2022, from 
https://www.cdc.gov/aging/pdf/mental_health.pdf. 
Centers for Medicare & Medicaid Services (CMS). (2022). Financial Alignment Initiative (FAI). Retrieved 
March 31, 2022, from https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-
Medicaid-Coordination/Medicare-Medicaid-Coordination-
Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordination. 
Cha, A.E., & Cohen, R.A. (2020). Reasons for Being Uninsured among Adults Aged 18-64 in the United 
States, 2019. NCHS Data Brief, No. 382. Hyattsville, MD: National Center for Health Statistics. 
Retrieved March 31, 2022, from https://www.cdc.gov/nchs/products/databriefs/db382.htm. 
Chan, D.V., Gopal, S., & Helfrich, C.A. (2014). Accessibility patterns and community integration among 
previously homeless adults: A geographic information systems (GIS) approach. Social Science & 
Medicine, 120, 142-152. https://doi.org/10.1016/j.socscimed.2014.09.005. 
Chekuri, L., Turturro, C.L., Nekkalapudi, M., & Mittal, D. (2016). Racial differences in older homeless 
adults: Findings in a homeless sample from Little Rock. American Journal of Geriatric Psychiatry, 
24(3), S67-S68. https://doi.org/10.1016/j.jagp.2016.01.066. 
Chung, T.E., Gozdzik, A., Palma Lazgare, L.I., To, M.J., Aubry, T., Frankish, J., Hwang, S.W., & 
Stergiopoulos, V. (2018). Housing First for older homeless adults with mental illness: A subgroup 
analysis of the At Home. International Journal of Geriatric Psychiatry, 33(1), 85-95. 
https://doi.org/10.1002/gps.4682. 
Cohen C.I. (1999). Aging and homelessness. Gerontologist, 39(1), 5-14. 
https://doi.org/10.1093/geront/39.1.5. 
Cohen S. (2004). Social relationships and health. American Psychologist, 59(8), 676-684. 
https://doi.org/10.1037/0003-066X.59.8.676. 
Coleman-Jensen, A., Rabbitt, M.P., Gregory, C.A., & Singh, A. (2016). Household Food Security in the 
United States in 2016. U.S. Department of Agriculture. Retrieved January 31, 2022, from 
https://www.ers.usda.gov/webdocs/publications/84973/err-237.pdf. 
Congressional Research Service. (2022). Older Americans Act: Overview and Funding. Retrieved from 
https://sgp.fas.org/crs/misc/R43414.pdf. 

 
65 
 
Corporation for Supportive Housing (CSH). (2011). Ending Homelessness among Older Adults through 
Supportive Housing. Retrieved January 31, 2022, from https://www.csh.org/wp-
content/uploads/2012/01/Report_EndingHomelessnessAmongOlderAdultsandSeniorsThroughSup
portiveHousing_112.pdf. 
Costello, A.M. (2021). RE: Opportunities in Medicaid and CHIP to Address Social Determinants of Health 
(SDOH). Baltimore, MD. 
Couch, L.M. (2020). Falling short: Federal housing assistance is failing older adults. Generations Journal, 
44(2), 1-8. Retrieved January 31, 2022, from https://generations.asaging.org/federal-housing-
assistance-older-adults-failing. 
Couch, L.M. (2021). Section 202: Supportive Housing for the Elderly. National Low Income Housing 
Coalition. Retrieved March 31, 2022, from https://nlihc.org/sites/default/files/AG-2021/04-
13_Section-202.pdf. 
Crane, M., Byrne, K., Fu, R., Lipmann, B., Mirabelli, F., Rota-Bartelink, A., Ryan, M., Shea, R., Watt, H., 
Warnes, A.M. (2005). The causes of homelessness in later life: Findings from a 3-nation study. 
Journals of Gerontology Series B: Psychological Sciences & Social Sciences, 60(3), S152-S159. 
https://doi.org/10.1093/geronb/60.3.S152. 
Culhane, D.P., Metraux, S., & Hadley, T. (2002). Public service reductions associated with placement of 
homeless persons with severe mental illness in supportive housing. Housing Policy Debate, 13(1), 
107-163. https://doi.org/10.1080/10511482.2002.9521437. 
Culhane, D.P., Metraux, S., Byrne, T., Stino, M., & Bainbridge, J. (2013). The age structure of 
contemporary homelessness: Evidence and implications for public policy. Analyses of Social Issues 
& Public Policy, 13, 1-17. https://doi.org/10.1111/asap.12004. 
Culhane, D.P., Byrne, T., Metraux, S., Kuhn, R., Doran, K., Johns, E., & Schretzman, M. (2019). Emerging 
Crisis of Aged Homelessness. Retrieved January 31, 2022, from https://aisp.upenn.edu/wp-
content/uploads/2019/01/Emerging-Crisis-of-Aged-Homelessness-1.pdf. 
DeMallie, D.A., North, C.S., & Smith, E.M. (1997). Psychiatric disorders among the homeless: A 
comparison of older and younger groups. Gerontologist, 37(1), 61-66. 
https://doi.org/10.1093/geront/37.1.61. 
Dickins, K.A., Philpotts, L.L., Flanagan, J., Bartels, S.J., Baggett, T.P., & Looby, S.E. (2021). Physical and 
behavioral health characteristics of aging homeless women in the United States: An integrative 
review. Journal of Women’s Health, 30(10), 1493-1507. https://doi.org/10.1089/jwh.2020.8557. 
Dietz, T.L. (2009). Drug and alcohol use among homeless older adults: Predictors of reported current and 
lifetime substance misuse problems in a national sample. Journal of Applied Gerontology, 28(2), 
235-255. 
DiPietro, B., Artiga, S., & Gates, A. (2014). Early Impacts of the Medicaid Expansion for the Homeless 
Population. Kaiser Family Foundation. Retrieved May 1, 2023, from 
https://www.kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-
homeless-population/. 

 
66 
 
Donaldson, L.P., Streeter, C.L., Larkin, H., Briar-Lawson, K., Meyer-Adams, N., Lupfer, K., Elder, J., & 
Grimshaw, A. (2020). The SOAR Model as an effective mechanism for university--Community 
partnerships to end homelessness. Journal of Social Work Education, 56(sup1), S99-S110. 
https://doi.org/10.1080/10437797.2020.1741481. 
Dunton, L., & Brown, S. (2019). Rapid Re-housing in 2018: Program Features and Assistance Models. U.S. 
Department of Housing and Urban Development. Retrieved March 31, 2022, from 
https://www.huduser.gov/portal/sites/default/files/pdf/RRH-CommunityScanReport.pdf. 
Eldercare Directory. (n.d.). Essential Resources for Senior Citizens and Their Caregivers. Retrieved 
January 31, 2022, from https://www.eldercaredirectory.org/state-resources.htm. 
Gabrielian, S., Cordasco, K.M., Finley, E.P., Hoffmann, L.C., Harris, T., Calderon, R.A., Barnard, J.M., Ganz, 
D.A., & Olmos-Ochoa, T.T. (2022). Engaging stakeholders to inform national implementation of 
critical time intervention in a program serving homeless-experienced veterans. Frontiers in 
Psychology, 13, 1009467. https://doi.org/10.3389/fpsyg.2022.1009467. 
Garfield, R., & Orgera, K. (2021). The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand 
Medicaid. Kaiser Family Foundation. Retrieved March 31, 2022, from 
https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-
do-not-expand-medicaid/. 
Garibaldi, B., Conde-Martel, A., & O’Toole, T.P. (2005). Self-reported comorbidities, perceived needs, 
and sources for usual care for older and younger homeless adults. Journal of General Internal 
Medicine, 20(8), 726-730. https://doi.org/10.1111/j.1525-1497.2005.0142.x. 
Gelberg, L., Linn, L.S., & Mayer-Oakes, S.A. (1990). Differences in health status between older and 
younger homeless adults. Journal of the American Geriatrics Society, 38(11), 1220-1229. 
https://doi.org/10.1111/j.1532-5415.1990.tb01503.x. 
Goger, A. (2020). For Millions of Low-Income Seniors, Coronavirus is a Food-Security Issue. Brookings. 
Retrieved March 31, 2022 from https://www.brookings.edu/blog/the-avenue/2020/03/16/for-
millions-of-low-income-seniors-coronavirus-is-a-food-security-issue/. 
Goldberg, J., Lang, K., & Barrington, V. (2016). How to Prevent and End Homelessness among Older 
Adults. Justice in Aging. Retrieved January 31, 2022, from https://www.justiceinaging.org/wp-
content/uploads/2016/04/Homelessness-Older-Adults.pdf. 
Gonyea, J.G., Mills-Dick, K., & Bachman, S.S. (2010). The complexities of elder homelessness, a shifting 
political landscape and emerging community responses. Journal of Gerontological Social Work, 
53(7), 575-590. https://doi.org/10.1080/01634372.2010.510169. 
Gordon, R.J., Rosenheck, R.A., Zweig, R.A., & Harpaz-Rotem, I. (2012). Health and social adjustment of 
homeless older adults with a mental illness. Psychiatric Services, 63(6), 561-568. 
https://doi.org/10.1176/appi.ps.201100175. 
Grenier, A., Barken, R., Sussman, T., Rothwell, D., & Lavoie, J. (2013). Literature Review: Aging and 
Homelessness. Retrieved March 31, 2022, from https://aginghomelessness.com/wp-
content/uploads/2012/10/Literature-Review-Aging-and-Homelessness.pdf. 

 
67 
 
Greysen, S.R., Allen, R., Lucas, G.I., Wang, E.A., & Rosenthal, M.S. (2012). Understanding transitions in 
care from hospital to homeless shelter: A mixed-methods, community-based participatory 
approach. Journal of General Internal Medicine, 27(11), 1484-1491. 
https://doi.org/10.1007/s11606-012-2117-2. 
Gubits, D., Bishop, K., Dunton, L., Wood, M., Albanese, T., Spellman, B., & Khadduri, J. (2018). 
Understanding Rapid Re-housing: Systematic Review of Rapid Re-housing Outcomes Literature. 
U.S. Department of Housing and Urban Development. Retrieved March 31, 2022, from 
https://www.huduser.gov/portal/sites/default/files/pdf/Systematic-Review-of-Rapid-Re-
housing.pdf. 
Haarstad, C. (2008). Transportation Voucher Programs: Facilitating Mobility in Rural Areas. Employment 
Transportation Resources. Retrieved January 31, 2022, from 
http://www.worksupport.com/documents/transportvouchprogmobilrural.pdf. 
Hahn, J.A., Kushel, M.B., Bangsberg, D.R., Riley, E., & Moss, A.R. (2006). Brief report: The aging of the 
homeless population: Fourteen-year trends in San Francisco. Journal of General Internal Medicine, 
21(7), 775-778. https://doi.org/10.1111/j.1525-1497.2006.00493.x. 
Health Resources and Services Administration (HRSA). (2018). Federally Qualified Health Centers. 
Retrieved January 31, 2022, from https://www.hrsa.gov/opa/eligibility-and-registration/health-
centers/fqhc/index.html. 
Health Resources and Services Administration (HRSA). (2020). 2020 Special Populations Funded 
Programs. Retrieved March 31, 2022, from https://data.hrsa.gov/tools/data-reporting/special-
populations. 
Hecht, L., & Coyle, B. (2001). Elderly homeless: A comparison of older and younger adult emergency 
shelter seekers in Bakersfield, California. American Behavioral Scientist, 45(1), 66-79. 
https://doi.org/10.1177/00027640121957024. 
Henwood, B.F., Katz, M.L., & Gilmer, T.P. (2014). Aging in place within permanent supportive housing. 
International Journal of Geriatric Psychiatry, 30(1), 80-87. https://doi.org/10.1002/gps.4120. 
Henwood, B.F., Lahey, J., Rhoades, H., Winetrobe, H., & Wenzel, S.L. (2018). Examining the health status 
of homeless adults entering permanent supportive housing. Journal of Public Health, 40(2), 415-
418. https://doi.org/10.1093/pubmed/fdx069. 
Homelessness Policy Research Institute (HPRI). (2019). Older Adults Experiencing Homelessness. 
Retrieved January 31, 2022, from https://socialinnovation.usc.edu/wp-
content/uploads/2019/08/Older-Adults-Literature-Review-Final.pdf. 
Homelessness Policy Research Institute (HPRI). (2020). Homelessness and Employment. Retrieved May 1, 
2023, from https://socialinnovation.usc.edu/wp-content/uploads/2020/08/Homelessness-and-
Employment.pdf. 
HUD Exchange. (n.d.). Rapid Re-housing. Retrieved March 31, 2022, from 
https://files.hudexchange.info/resources/documents/Rapid-Re-Housing-Brief.pdf. 

 
68 
 
HUD User. (2019). Tenants in LIHTC Units as of December 31, 2019. Retrieved March 31, 2022, from 
https://www.huduser.gov/portal/Datasets/lihtc/2019-LIHTC-Tenant-Tables.pdf. 
Hui, V., & Habib, K.M. (2014). An Investigation of Transport-Related Social Exclusion of the At-Risk 
Community (Homeless People) in Toronto, Canada. Retrieved March 31, 2022, from 
https://trid.trb.org/view/1287880. 
Hui, V., & Habib, K.N. (2017). Homelessness vis-à-vis Transportation-Induced Social Exclusion: An 
Econometric Investigation of Travel Behavior of Homeless Individuals in Toronto, Canada. 
Transportation Research Record, 2665(1), 60-68. https://doi.org/10.3141/2665-07. 
Hurstak, E., Johnson, J.K., Tieu, L., Guzman, D., Ponath, C., Lee, C.T., Jamora, C.W., & Kushel, M. (2017). 
Factors associated with cognitive impairment in a cohort of older homeless adults: Results from 
the HOPE HOME study. Drug and Alcohol Dependence, 178, 562-570. 
https://doi.org/10.1016/j.drugalcdep.2017.06.002. 
Hwang, S.W., Orav, E.J., O'Connell, J.J., Lebow, J.M., & Brennan, T.A. (1997). Causes of death in homeless 
adults in Boston. Annals of Internal Medicine, 126(8), 625-628. https://doi.org/10.7326/0003-
4819-126-8-199704150-00007. 
Hwang, S.W., Colantonio, A., Chiu, S., Tolomiczenko, G., Kiss, A., Cowan, L., Redelmeier, D.A., & Levinson, 
W. (2008). The effect of traumatic brain injury on the health of homeless people. Canadian 
Medical Association Journal, 179(8), 779-784. https://doi.org/10.1503/cmaj.080341. 
Jain, S.H., Baackes, J., & O’Connell, J.J. (2020). Homeless special needs plans for people experiencing 
homelessness. JAMA, 323(10), 927. https://doi.org/10.1001/jama.2019.22376. 
Joint Center for Housing Studies of Harvard University. (2018). Housing America’s Older Adults. 
Retrieved January 31, 2022, from https://www.jchs.harvard.edu/housing-americas-older-adults-
2018. 
Joint Center for Housing Studies of Harvard University. (2019). Housing America’s Older Adults. 
Retrieved January 4, 2023, from https://www.jchs.harvard.edu/housing-americas-older-adults-
2019. 
Johnson, R.W., & Favreault, M.M. (2021). Risk of Economic Hardship Among Older Adults. Washington, 
DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and 
Human Services. Retrieved January 13, 2023, from https://aspe.hhs.gov/reports/risk-economic-
hardship-among-older-adults-issue-brief. 
Kaplan, L.M., Vella, L., Cabral, E., Tieu, L., Ponath, C., Guzman, D., & Kushel, M.B. (2019). Unmet mental 
health and substance use treatment needs among older homeless adults: Results from the HOPE 
HOME Study. Journal of Community Psychology, 47(8), 1893-1908. 
https://doi.org/10.1002/jcop.22233. 
Kauff, J.F., Clary, E., Lupfer, K.S., & Fischer, P.J. (2016). An evaluation of SOAR: Implementation and 
outcomes of an effort to improve access to SSI and SSDI. Psychiatric Services, 67(10), 1098-1102. 
https://doi.org/10.1176/appi.ps.201500247. 

 
69 
 
Kochera, A. (2006). Developing Appropriate Rental Housing for Low-Income Older Persons: A Survey of 
Section 202 and LIHTC Property Managers. AARP Public Policy Institute. Retrieved January 31, 
2022, from https://assets.aarp.org/rgcenter/consume/dd149_lihtc.pdf. 
Kushel, M. (2012). Older homeless adults: Can we do more? Journal of General Internal Medicine, 27(1), 
5-6. https://doi.org/10.1007/s11606-011-1925-0. 
Kushel, M. (2020). Homelessness among older adults: An emerging crisis. Generations, 44(2). Retrieved 
January 31, 2022, from https://stg-generations.asaging.org/homelessness-older-adults-poverty-
health. 
Larimer, M.E., Malone, D.K., Garner, M.D., Atkins, D.C., Burlingham, B., Lonczak, H.S., Tanzer, K., Ginzler, 
J., Clifasefi, S.L., Hobson, W.G., & Marlatt, G.A. (2009). Health care and public service use and costs 
before and after provision of housing for chronically homeless persons with severe alcohol 
problems. JAMA, 301(13), 1349-1357. https://doi.org/10.1001/jama.2009.414. 
Lee, C.T., Guzman, D., Ponath, C., Tieu, L., Riley, E., & Kushel, M. (2016). Residential patterns in older 
homeless adults: Results of a cluster analysis. Social Science & Medicine, 153, 131-140. 
https://doi.org/10.1016/j.socscimed.2016.02.004. 
Lee, K., Murphy, E.R., Cassidy, J., Chen, Z., and Rhee, T.G. (2020). Impacts of health insurance on older 
adults with histories of homelessness. Journal of Social Distress & Homelessness. 
https://doi.org/10.1080/10530789.2020.1819051. 
Levin, M., Kauff, J., Negoita, M., Dragoset, L., Goger, A., Baxter, C., Paprocki, A., Makowsky, L., Gutierrez, 
I., Brown, E., & Sarver, M. (2020). Evaluation of Alternatives to Improve Elderly Access to SNAP. 
USDA Food and Nutrition Service. Retrieved January 31, 2022, from 
https://www.fns.usda.gov/snap/evaluation-alternatives-improve-elderly-access-supplemental-
nutrition-assistance-program. 
Lewin Group. (2011). Design of a Demonstration of Coordinated Housing, Health and Long-Term Care 
Services and Supports for Low-Income Older Adults. Washington, DC: Office of the Assistant 
Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Retrieved 
April 1, 2022, from https://aspe.hhs.gov/reports/design-demonstration-coordinated-housing-
health-long-term-care-services-supports-low-income-older-0. 
Li, Z., & Dalaker, J. (2021). Poverty Among the Population Aged 65 and Older. Congressional Research 
Service. Retrieved March 31, 2022, from https://sgp.fas.org/crs/misc/R45791.pdf. 
Libson, N. (2005). The sad state of affordable housing for older people. Generations: Journal of the 
American Society on Aging, 29(4), 9-15. https://www.jstor.org/stable/26555401. 
Lipton, F.R., Siegel, C., Hannigan, A., Samuels, J., & Baker, S. (2000). Tenure in supportive housing for 
homeless persons with severe mental illness. Psychiatric Services, 51(4), 479-486. 
https://doi.org/10.1176/appi.ps.51.4.479. 
Lowder, E.M., Desmarais, S.L., Neupert, S.D., & Truelove, M.A. (2017). SSI/SSDI Outreach, Access, and 
Recovery (SOAR): Disability application outcomes among homeless adults. Psychiatric Services, 
68(11), 1189-1192. https://doi.org/10.1176/appi.ps.201600568. 

 
70 
 
Liu, P.-J., & Delagrammatikas, L. (2021). Adult protective service’s role in addressing older and 
dependent adult abuse in the age of COVID. Frontiers in Public Health, 9. 
https://doi.org/10.3389/fpubh.2021.659640. 
Martinez, T.E., & Burt, M.R. (2006). Impact of permanent supportive housing on the use of acute care 
health services by homeless adults. Psychiatric Services, 57(7), 992-999. 
https://doi.org/10.1176/ps.2006.57.7.992. 
McDonald, L., Donahue, P., Janes, J., & Cleghorn, L. (2006). In from the Streets: The Health and Well-
being of Formerly Homeless Older Adults. National Research Program of the National 
Homelessness Initiative. https://doi.org/10.13140/RG.2.1.4680.2647. 
Medicaid.gov. (n.d.). Program of All-Inclusive Care for the Elderly. Retrieved March 31, 2022, from 
https://www.medicaid.gov/medicaid/long-term-services-supports/program-all-inclusive-care-
elderly/index.html. 
Medicare.gov. (n.d.). Medicare Savings Programs. Retrieved August 29, 2022, from 
https://www.medicare.gov/basics/costs/help/medicare-savings-programs#collapse-2624. 
Meret-Hanke, L.A. (2011). Effects of the program of all-inclusive care for the elderly on hospital use. 
Gerontologist, 51(6), 774-785. https://doi.org/10.1093/geront/gnr040. 
Metraux, S., Marcus, S.C., & Culhane, D.P. (2003). The New York-New York Housing Initiative and use of 
public shelters by persons with severe mental illness. Psychiatric Services, 54(1), 67-71. 
https://doi.org/10.1176/appi.ps.54.1.67. 
Metraux, S., Eng, N., Bainbridge, J., & Culhane, D.P. (2011). The impact of shelter use and housing 
placement on mortality hazard for unaccompanied adults and adults in family households entering 
New York City Shelters: 1990-2002. Journal of Urban Health, 88(6), 1091-1104. 
https://doi.org/10.1007/s11524-011-9602-5. 
Moses, J. (2019). Building a Conversation: Aged Homelessness on the Rise. National Alliance to End 
Homelessness. Retrieved January 31, 2022, from https://endhomelessness.org/blog/building-a-
conversation-aged-homelessness-on-the-rise/. 
Murphy, E.R. (2019). Transportation and homelessness: A systematic review. Journal of Social Distress & 
the Homeless, 28(2), 96-105. https://doi.org/10.1080/10530789.2019.1582202. 
National Adult Protective Services Association. (n.d.). Getting to Know Adult Protective Services. 
Retrieved March 6, 2023, from https://www.napsa-now.org/. 
National Adult Protective Services Resource Center (NAPSRC). (n.d.). Adult Protective Services, What You 
Must Know. National Center on Elder Abuse. Retrieved March 6, 2023, from 
https://ncea.acl.gov/NCEA/media/publications/APS-Fact-Sheet.pdf. 
National Alliance to End Homelessness (NAEH). (2021). Permanent Supportive Housing. Retrieved 
January 31, 2022, from https://endhomelessness.org/ending-homelessness/solutions/permanent-
supportive-housing/. 

 
71 
 
National Association of Area Agencies on Aging (n4a). (n.d. a). Housing Options for Older Adults: A Guide 
for Making Housing Decisions. Retrieved January 31, 2022, from 
https://www.usaging.org/files/HousingOptions.pdf. 
National Association of Area Agencies on Aging (n4a). (n.d. b). Housing and Homelessness: Services and 
Partnerships to Address a Growing Issue. Retrieved December 22, 2022, from 
https://www.usaging.org/Files/Housing%20and%20Homelessness%20-
%20Services%20and%20Partnerships%20to%20Address%20a%20Growing%20Issue.pdf. 
National Association of Nutrition and Aging Services Programs (NANASP). (2021). NANASP COVID-19 
Relief and Vaccine Survey--January 2021. Retrieved January 31, 2022, from 
https://www.nanasp.org/sites/default/files/documents/Data_Q3_210222.pdf. 
National Coalition for the Homeless. (2009). Homelessness among Elderly Persons. Retrieved March 10, 
2022, from  
 https://www.nationalhomeless.org/factsheets/Elderly.pdf. 
National Council on Aging (NCOA). (2022). How to Make It Easier for Older Adults to Get Energy and 
Utility Assistance. Retrieved March 31, 2022, from https://www.ncoa.org/article/how-to-make-it-
easier-for-older-adults-to-get-energy-and-utility-assistance. 
Niño, M.D., Loya, M.A., & Cuevas, M. (2009). Who are the chronically homeless? Social characteristics 
and risk factors associated with chronic homelessness. Journal of Social Distress & the Homeless, 
19, 41-65. Retrieved March 31, 2022, from https://www.semanticscholar.org/paper/Who-are-the-
Chronically-Homeless-Social-and-Risk-Ni%C3%B1o-
Loya/9be479666f4e9c87cd1ea6609fca01a8aca81984. 
North, C.S., Wohlford, S.E., Dean, D.J., Black, M., Balfour, M.E., Petrovich, J.C., Downs, D.L., & Pollio, D.E. 
(2017). A pilot study using mixed GPS/narrative interview methods to understand geospatial 
behavior in homeless populations. Community Mental Health Journal, 53(6), 661-671. 
https://doi.org/10.1007/s10597-016-0057-8. 
Novak, M. (2018). Issues on Aging. New York, NY: Taylor & Francis Group. 
https://doi.org/10.4324/9781315445366.  
Nye, E., Lamont, H., & Anderson, L. (2022) Federal Efforts to Address Racial and Ethnic Disparities in 
Alzheimer’s Disease and Related Dementias (Issue Brief). Washington, DC: Office of the Assistant 
Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. 
https://aspe.hhs.gov/reports/federal-efforts-address-adrd-disparities.  
Office of Governor Gavin Newsom. (2022). California Expands Medi-Cal to All Eligible Adults 50 Years of 
Age and Older. CA.gov. Retrieved March 21, 2023, from 
https://www.gov.ca.gov/2022/04/29/california-expands-medi-cal-to-all-eligible-adults-50-years-
of-age-and-older/. 
Parpouchi, M., Moniruzzaman, A., Russolillo, A., & Somers, J.M. (2016). Food insecurity among homeless 
adults with mental illness. PLOS ONE, 11(7), e0159334. 
https://doi.org/10.1371/journal.pone.0159334. 

 
72 
 
Patanwala, M., Tieu, L., Ponath, C., Guzman, D., Ritchie, C.S., & Kushel, M. (2018). Physical, 
psychological, social, and existential symptoms in older homeless-experienced adults: An 
observational study of the HOPE HOME cohort. Journal of General Internal Medicine, 33(5), 635-
643. https://doi.org/10.1007/s11606-017-4229-1. 
Perl, L., & Bagalman, E. (2015). Chronic Homelessness: Background, Research, and Outcomes. 
Congressional Research Service. Retrieved January 31, 2022, from 
https://sgp.fas.org/crs/misc/R44302.pdf. 
Perret, Y.M. (2021). Homelessness and Social Security. Social Security Matters. Retrieved March 31, 
2022, from https://blog.ssa.gov/homelessness-and-social-security/. 
Prunhuber, P. (2021). Do You Think Older Renters on a Fixed Income Can’t Get Help with Back Rent? 
Think Again! Justice in Aging. Retrieved March 31, 2022, from https://justiceinaging.org/wp-
content/uploads/2021/09/Older-Renters-Can-Get-Help-with-Back-Rent-Utilities.pdf. 
Prunhuber, P. & Kwok, V., (2021). Low-Income Older Adults Face Unaffordable Rents, Driving Housing 
Instability and Homelessness. Justice in Aging. Retrieved March 10, 2022, from 
https://justiceinaging.org/wp-content/uploads/2021/02/Older-Adults-Rental-Housing-
Burdens.pdf. 
Public and Affordable Housing Research Corporation (PAHRC). (2020). 2020 Housing Impact Report: 
Seniors. Retrieved March 31, 2022, from http://www.pahrc.org/wp-
content/uploads/2020/04/Spring2020HIR_Seniors-1.pdf. 
Ramsey-Klawsnik, H. (2018). Understanding and Working with Adult Protective Services (APS). National 
Adult Protective Services Association & National Center on Elder Abuse. 
http://eldermistreatment.usc.edu/wp-content/uploads/2018/05/Understanding-and-Working-
with-APS_May2018.pdf. 
Raven, M.C., Tieu, L., Lee, C.T., Ponath, C., Guzman, D., & Kushel, M. (2017). Emergency department use 
in a cohort of older homeless adults: Results from the HOPE HOME Study. Academic Emergency 
Medicine, 24(1), 63-74. https://doi.org/10.1111/acem.13070. 
Ravensbergen, L., Van Liefferinge, M., Isabella, J., Merrina, Z., & El-Geneidy, A. (2022). Accessibility by 
public transport for older adults: A systematic review. Journal of Transport Geography, 103, 
103408. https://doi.org/10.1016/j.jtrangeo.2022.103408. 
Robaina, K.A., & Martin, K.S. (2013). Food insecurity, poor diet quality, and obesity among food pantry 
participants in Hartford, CT. Journal of Nutrition Education & Behavior, 45(2), 159-164. 
https://doi.org/10.1016/j.jneb.2012.07.001. 
Sard, B. (2018). Housing Choice Voucher Program: Oversight and Review of Legislative Proposals. Center 
on Budget and Policy Priorities. Retrieved January 31, 2022, from 
https://www.cbpp.org/research/housing/housing-choice-voucher-program-oversight-and-review-
of-legislative-proposals. 

 
73 
 
Schaak, G., Sloane, L., Arienti, F., & Zovistoski, A. (2017). Priced Out: The Housing Crisis for People with 
Disabilities. Technical Assistance Collaborative, Inc., Consortium for Citizens with Disabilities 
Housing Task Force. Retrieved from https://www.tacinc.org/wp-content/uploads/2020/04/priced-
out-in-2016.pdf. 
Schinka, J.A., Schinka, K.C., Casey, R.J., Kasprow, W., & Bossarte, R.M. (2012). Suicidal behavior in a 
national sample of older homeless veterans. American Journal of Public Health, 102(S1), S147-
S153. https://doi.org/10.2105/AJPH.2011.300436. 
Schinka, J.A., Curtiss, G., Leventhal, K., Bossarte, R.M., Lapcevic, W., & Casey, R. (2017). Predictors of 
mortality in older homeless veterans. Journals of Gerontology: Series B, 72(6), 1103-1109. 
https://doi.org/10.1093/geronb/gbw042. 
Schinka, J.A., & Byrne, T. (2018). Aging and Mortality in Homeless Veterans: Nine Questions.  Retrieved 
from 
https://www.va.gov/HOMELESS/nchav/docs/Schinka_Byrne_AgingLifeExpectancyHomelessVetera
ns_Sept2018_508.pdf. 
Segelman, M., Szydlowski, J., Kinosian, B., McNabney, M., Raziano, D.B., Eng, C., van Reenen, C., & 
Temkin-Greener, H. (2014). Hospitalizations in the Program of All-Inclusive Care for the Elderly. 
Journal of the American Geriatrics Society, 62(2), 320-324. https://doi.org/10.1111/jgs.12637. 
SeniorNavigator. (n.d.). Special Concerns for the Elderly Who are Homeless. Retrieved March 31, 2022, 
from https://seniornavigator.org/article/12426/special-concerns-elderly-who-are-homeless. 
Sermons, M.W., & Henry, M. (2010). Demographics of homelessness series: The rising elderly 
population. Homelessness Research Institute. Retrieved January 31, 2022, from 
https://endhomelessness.org/resource/the-rising-elderly-population/. 
Sharma, A. (2019). Santa Monica to subsidize rent for hundreds of seniors. LAist. 
https://laist.com/news/santa-monica-senior-rental-housing-subsidies. 
Shinn, M., Gottlieb, J., Wett, J.L., Bahl, A., Cohen, A., & Baron Ellis, D. (2007). Predictors of homelessness 
among older adults in New York City: Disability, economic, human and social capital and stressful 
events. Journal of Health Psychology, 12(5), 696-708. 
https://doi.org/10.1177/1359105307080581. 
Siegler, E.L., Lama, S.D., Knight, M.G., Laureano, E., & Reid, M.C. (2015). Community-based supports and 
services for older adults: A primer for clinicians. Journal of Geriatrics, 2015(678625). 
https://doi.org/10.1155/2015/678625. 
Spinelli, M.A., Ponath, C., Tieu, L., Hurstak, E.E., Guzman, D., & Kushel, M. (2017). Factors associated 
with substance use in older homeless adults: Results from the HOPE HOME study. Substance 
Abuse, 38(1), 88-94. https://doi.org/10.1080/08897077.2016.1264534. 
Stone, C., & Chen, W. (2014). Introduction to Unemployment Insurance. Center on Budget and Policy 
Priorities. Retrieved May 1, 2023, from https://www.cbpp.org/research/introduction-to-
unemployment-insurance. 

 
74 
 
Substance Abuse and Mental Health Services Administration (SAMHSA). (n.d.). Programs. Retrieved April 
4, 2023, from https://www.samhsa.gov/programs. 
Supplemental Nutrition Assistance Program (SNAP). (n.d.). Addressing Barriers & Challenges--Seniors. 
Retrieved from 
https://www.budget.senate.gov/imo/media/doc/Addressing%20Barriers%20and%20Challenges%
20-%20Seniors.pdf. 
Tolbert, J., & Ammula, M. (2022). 10 Things to Know About the Unwinding of the Medicaid Continuous 
Enrollment Requirement. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/10-
things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-requirement/. 
Tompsett, C.J., Fowler, P.J., & Toro, P.A. (2009). Age differences among homeless individuals: 
Adolescence through adulthood. Journal of Prevention & Intervention in the Community, 37(2), 86-
99. https://doi.org/10.1080/10852350902735551. 
Tong, M., Tieu, L., Lee, C.T., Ponath, C., Guzman, D., & Kushel, M. (2018). Factors associated with food 
insecurity among older homeless adults: Results from the HOPE HOME study. Journal of Public 
Health, 41(2), 240-249. https://doi.org/10.1093/pubmed/fdy063. 
Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing First, consumer choice, and harm reduction for 
homeless individuals with a dual diagnosis. American Journal of Public Health, 94(4), 651-656. 
https://doi.org/10.2105/AJPH.94.4.651. 
Turnbull, J., Muckle, W., & Masters, C. (2007). Homelessness and health. Canadian Medical Association 
Journal, 177(9), 1065-1066. https://doi.org/10.1503/cmaj.071294. 
U.S. Census Bureau. (2021). U.S. Census Bureau QuickFacts: United States. U.S. Census Bureau. Retrieved 
March 3, 2023, from https://www.census.gov/quickfacts/US. 
U.S. Department of Agriculture (USDA). (2021). FNS Launches the Online Purchasing Pilot. Retrieved 
January 31, 2022, from https://www.fns.usda.gov/snap/online-purchasing-pilot. 
U.S. Department of Housing and Urban Development (HUD). (2018). The 2017 Annual Homeless 
Assessment Report (AHAR) to Congress: PART 2: Estimates of Homelessness in the United States. 
Retrieved March 31, 2022, from https://www.huduser.gov/portal/sites/default/files/pdf/2017-
AHAR-Part-2.pdf. 
U.S. Department of Housing and Urban Development (HUD). (2023). 2021 Annual Homeless Assessment 
Report (AHAR) to Congress, Part 2: Estimates of Homelessness in the United States. Retrieved 
August 21, 2023, from https://www.huduser.gov/portal/sites/default/files/pdf/2021-AHAR-Part-
2.pdf.  
U.S. Department of Housing and Urban Development (HUD) (n.d. a). Housing Choice Vouchers Fact 
Sheet. Retrieved March 31, 2022, from 
https://www.hud.gov/topics/housing_choice_voucher_program_section_8#hcv01. 

 
75 
 
U.S. Department of Housing and Urban Development (HUD) (n.d. b). Section 202 Supportive Housing for 
the Elderly Program. Retrieved March 31, 2022, from 
https://www.hud.gov/program_offices/housing/mfh/progdesc/eld202. 
U.S. Department of the Treasury (USDT). (n.d.). Emergency Rental Assistance Program. Retrieved March 
31, 2022, from https://home.treasury.gov/policy-issues/coronavirus/assistance-for-state-local-
and-tribal-governments/emergency-rental-assistance-program. 
U.S. Interagency Council on Homelessness. (2018). Homelessness in America: Focus on Veterans. 
Retrieved January 31, 2022, from 
https://www.usich.gov/resources/uploads/asset_library/Homelessness_in_America._Focus_on_V
eterans.pdf. 
U.S. Government Accountability Office. (2019). Food Insecurity: Better Information could help Eligible 
College Students Access Federal Food Assistance Benefits. Retrieved January 31, 2022, from 
https://www.gao.gov/products/gao-19-95. 
Van Dongen, S., Klop, J., Onwuteaka-Philipsen, B., De Veer, A., Francke, A., Slockers, M., Van Laere, I., 
van der Heide, A., & Rietjens, J. (2019). Advance care planning and palliative care for homeless 
people in medical respite shelters: A retrospective record review. BMJ Supportive and Palliative 
Care, 9(Suppl 2). https://doi.org/10.1136/spcare-2019-acpicongressabs.41. 
Vespa, J. (2020). Those Who Served: America’s Veterans from World War II to the War on Terror. 
American Community Survey Report. U.S. Census Bureau. 
https://www.census.gov/content/dam/Census/library/publications/2020/demo/acs-43.pdf. 
Wang, Z.J., Dhanireddy, P., Prince, C., Larsen, M., Schimpf, M., & Pearman, G. (2021). 2021 Survey of 
Veteran Enrollees’ Health and Use of Health Care: Data Findings Report. Advanced Survey Design, 
LLC. https://www.va.gov/VHASTRATEGY/SOE2021/2021_Enrollee_Data_Findings_Report-
508_Compliant.pdf. 
Watson, D.P., George, C., & Walker, C. (2008). “Falling through the cracks”: Health care needs of the 
older homeless population and their implications. Jacobs Kronenfeld, J. (Ed.) In Care for Major 
Health Problems and Population Health Concerns: Impacts on Patients, Providers and Policy 
(Research in the Sociology of Health Care, 26), Emerald Group Publishing Limited, Bingley, pp. 187-
204. https://doi.org/10.1016/S0275-4959(08)26009-6. 
Winetrobe, H., Wenzel, S., Rhoades, H., Henwood, B., Rice, E., & Harris, T. (2017). Differences in health 
and social support between homeless men and women entering permanent supportive housing. 
Women's Health Issues: Official Publication of the Jacobs Institute of Women's Health, 27(3), 286-
293. https://doi.org/10.1016/j.whi.2016.12.011. 
Xu, J., Murphy, S.L., Kochanek, K.D., & Arias, E. (2020). Mortality in the United States, 2018. National 
Center for Health Statistics. Retrieved January 31, 2022, from 
https://www.cdc.gov/nchs/data/databriefs/db355-h.pdf. 
Ye, V.M., Caplan, R.J., Consiglio-Ward, L., & Ellison, J.M. (2019). Health care needs of homeless older 
adults: Examining the needs of a senior center cohort. Delaware Journal of Public Health, 5(5), 74-
80. https://pubmed.ncbi.nlm.nih.gov/34467082/. 

Ziliak, J.P., & Gunderson, C. (2020). The State of Senior Hunger in America in 2018. Feeding America.

Retrieved January 31, 2022, from https://hungerandhealth.feedingamerica.org/wp-

content/uploads/2020/05/2020-The-State-of-Senior-Hunger-in-2018.pdf.

ACRONYMS

The following acronyms are mentioned in this report.

ACL

HHS Administration for Community Living

ADL

Activity of Daily Living

APS

Adult Protective Services

CAPABLE

Community Aging in Place--Advancing Better Living for Elders

CARES Act

Coronavirus Aid, Relief, and Economic Security Act

CCBHC

Certified Community Behavioral Health Clinic

CDC

HHS Centers for Disease Control and Prevention

CMS

HHS Centers for Medicare & Medicaid Services

CoC

Continuum of Care

COVID-19

Novel Coronavirus

CSH

Corporation for Supportive Housing

DoL

U.S. Department of Labor

ERA

USDT Emergency Rental Assistance

FFS

Fee-For-Service

FQHC

Federally Qualified Health Center

HCBS

Home and Community-Based Services

HHS

U.S. Department of Health and Human Services

HIPAA

Health Insurance Portability and Accountability Act

HOPE HOME

Health Outcomes in People Experiencing Homelessness in Older

Middle Age

HPRI

Homelessness Policy Research Institute

HRSA

HHS Health Resources and Services Administration

HUD

U.S. Department of Housing and Urban Development

LGBTQ+

Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, Intersex,

Asexual, and More

LIHEAP

HHS Low-Income Home Energy Assistance Program

LIHTC

Low-Income Housing Tax Credit

n.d.

not dated

n4a

National Association of Area Agencies on Aging

NAEH

National Alliance to End Homelessness

NANASP

National Association of Nutrition and Aging Services Programs

NAPSRC

National Adult Protective Services Resource Center

NCOA

National Council on Aging

OAA

Older Americans Act

PACE

Program of All-inclusive Care for the Elderly

PAHRC

Public and Affordable Housing Research Corporation

SAMHSA

HHS Substance Abuse and Mental Health Services Administration

SNAP

Supplemental Nutrition Assistance Program

SNP

Special Needs Plan

SOAR

SSI/SSDI Outreach, Access, and Recovery

SSDI

Social Security Disability Insurance

SSI

Supplemental Security Income

USDA

U.S. Department of Agriculture

USDT

U.S. Department of the Treasury

U.S Department of Veterans Affairs

VHA

Veterans Health Administration

October 2023

FINAL REPORT

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of the Assistant Secretary for Planning and Evaluation

200 Independence Avenue SW, Mailstop 447D

Washington, D.C. 20201

For more ASPE briefs and other publications, visit:

aspe.hhs.gov/reports

ABOUT THE AUTHORS

Kathryn A. Henderson, Ph.D., Nanmathi Manian, Ph.D., Debra J.

Rog, Ph.D., Evan Robison, M.P.H., Ethan Jorge, Monirah Al-

Abdulmunem, M.S., work in Westat.

SUGGESTED CITATION

Henderson, K.A., Manian, N., Rog, D.J., Robison, E., Jorge, E., Al-

Abdulmunem, M. Addressing Homelessness Among Older Adults

(Final Report). Washington, DC: Office of the Assistant Secretary

for Planning and Evaluation, U.S. Department of Health and

Human Services. October 26, 2023.

All material appearing in this report is in the public domain and

may be reproduced or copied without permission; citation as to

source, however, is appreciated.

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