Background

As people age, their ability to perform routine daily activities, such as  eating, bathing, dressing, paying bills, and preparing meals declines (see  fig. 1).
About 70 percent of those aged 65 and older are likely to need long-term  services and supports at some point in their lives, for an average of 3   Family or  years. Twenty percent will need that care for at least 5 years.friends often informally assist frail older adults with these daily activities.  However, when they have no one to help them informally, or need  assistance that family and friends cannot provide, older adults rely on  long-term services and supports (LTSS) from paid providers in both  institutional and home and community-based settings.  In either case,  the cost of these services and supports can often be a considerable  financial burden for older adults and families. For eligible low-income  older adults, state Medicaid programs may cover the cost of institutional  long-term services and supports and certain HCBS.
According to the Census Bureau, the proportion of the U.S. population  aged 65 and over is expected to increase from 13 percent in 2010 to  more than 20 percent in 2050 and be more diverse. In 2050, about 22  percent of this group will be 85 and older compared to 14 percent in  2010. As the size of the older population grows, so will the number of older adults needing long-term services and supports, particularly for  those 85 and older.
42 U.S.C. § 3012(b). established grants to states for the provision of services and supports.  The framework of agencies, programs, and activities established by the  act produced what is referred to today as the national aging services  network. With support from AoA, within HHS’ Administration for  Community Living (ACL), the 56 state units on aging, 618 area agencies  on aging (AAA), and 264 Indian tribal and 2 Native Hawaiian  organizations as components of the aging services network, are  responsible for planning, developing, and coordinating home and  community-based services and supports for older adults, nationwide.
Community-based organizations (CBO) are public agencies or private nonprofit  organizations that represent one or more communities or segments of communities and  are engaged in meeting the human services needs of community residents. CBOs can  include local or regional governmental or quasi-governmental organizations, as well as  private nonprofit organizations. the receipt of, need for, and unmet need for services authorized under  Title III of the act. State units on aging are to use their AAAs’ plans as  a basis for an overall state plan that they submit to AoA.

	Several Federal Departments Fund HCBS and Related Supports for Older Adults

Five federal agencies across four departments have one or more  programs that operate within a system of HCBS and related supports that  older adults often require to live as independently as possible in their  homes and communities (see table 1).

		HHS Funds HCBS for Older Adults through the Older Americans Act and Medicaid

			Older Americans Act Programs

The Older Americans Act is the cornerstone for federal leadership in the  development of an HCBS system for older adults. The act authorizes  funding to cover the cost of a range of services for older adults provided  by local HCBS systems—sometimes referred to as core service delivery  activities. HCBS funded under Title III of the act are available to anyone  60 or older, but are to be targeted to those with greatest economic or  social need, particularly low-income and low-income minority older adults,  and older adults living in rural areas, among others.authorizes funding a variety of aging services network support activities or  technical assistance provided to state and local agencies by AoA (see  table 2). Appendix II provides funding information for these programs for  fiscal years 2010 through 2014.

		USDA Has Taken Some Steps to Simplify Receipt of Food Assistance by Older Adults

In addition to Older Americans Act funding for nutrition services, four  programs within the Department of Agriculture target food assistance, at  least in part, to low-income older adults (see table 4). These programs  provide nutrition assistance in a variety of forms, ranging from  commodities, to prepared meals, to vouchers or other targeted benefits  used in commercial food retail locations.
Two of these programs are exclusively for low-income older adults. The  Commodity Supplemental Food Program provides food to participating  states that, in turn, distribute it to older adults. The Senior Farmers’  Market Nutrition Program awards grants to states, territories and Indian  tribes to provide coupons to low-income older adults to purchase fresh  food at authorized farmers’ markets, roadside stands, and community- supported agricultural programs. Appendix II provides funding  information for these two programs for fiscal years 2010 through 2014.
42 U.S.C. § 1766.
Other USDA Programs That Provide  Nutrition Assistance to Older Adults  The Emergency Food Assistance Program (7  U.S.C. §§ 7501-7515) and the Food  Distribution Program on Indian Reservations  (7 U.S.C. § 2013(b)) also benefit older adults.  The Emergency Food Assistance Program  helps supplement the diets of low-income  Americans, including older adults, by  providing them with emergency food and  nutrition assistance at no cost. It provides  food and administrative funds to states to  supplement the diets of these groups. The  Food Distribution Program on Indian  Reservations Program provides USDA foods  to low-income households, including older  adults, living on Indian reservations and to  Native American families residing in  designated areas near reservations and in the  state of Oklahoma.  According to USDA, fiscal  year 2013 obligations for these programs  were approximately $266 million and $100  million, respectively. Assistance provided to  victims of Hurricane Sandy under the  emergency food program in fiscal year 2013 is  not included in this amount. of the Child and Adult Care Food Program offers federal funding,  administered through state health or aging agencies, for meals at adult  day care centers.  These centers help elderly and disabled adults  remain in their homes and communities and avoid premature  institutionalization. According to USDA, this program plays a vital role in  improving the quality of day care and making it more affordable for many  low-income families. In fiscal year 2014, the program served over 71  million meals to older adults who received care in these centers.
SNAP, the largest nationwide nutrition assistance program, enables low- income households to obtain a more nutritious diet by increasing their  purchasing power. SNAP provides an electronic benefit transfer card to  eligible low-income individuals and families, including older adults, that  they can redeem for eligible food items at more than 261,150 stores  across the nation authorized to accept SNAP benefits. USDA, close to nine percent of all SNAP participants in 2013 were age 60  or over.
According to USDA, participation in SNAP does not interfere with older adults receiving  meals free-of-charge at dining facilities that prepare and serve communal meals for older  adults.

		Federal Housing Program for Older Adults No Longer Funds Construction

Affordable housing is the nucleus of a system of HCBS and supports for  older adults because, without access to affordable housing, care in  nursing homes and similar facilities is the only option for low-income, frail  older adults. The Department of Housing and Urban Development  administers the Supportive Housing for the Elderly (Section 202)  program, which plays a critical role in addressing the demand for  affordable, supportive housing for older adults in this country. Currently,  the program maintains the supply of multi-family housing stock for low- income older adults through renewal of existing rental assistance  contracts that cover the difference between a property owner’s HUD- approved operating costs for a project and the tenants’ payments. In  addition, Section 202 supports independent living by funding the salaries  of nearly 1,300 service coordinators, nationwide, who help residents in  Section 202-funded properties find the HCBS and supports they need to  continue living in their own homes.program totaled $358 million in fiscal year 2014. Appendix II provides  funding information for this program for fiscal years 2010 through 2014.
Other HUD Programs That Serve Older  Adults  In addition to the Section 202 program,  several other HUD programs serve older  adults. For example, local public housing  agencies can apply to HUD for approval to  designate public housing developments or  portions of developments, such as buildings  or floors, for occupancy by only elderly  families, only disabled families, or elderly and  disabled families. HUD refers to this as  “designated public housing”. 42 U.S.C. §  1437e.     According to HUD, older adult tenants  generally are well represented in HUD’s major  rental assistance programs and as of  December 2014, 42.5 percent of project- based Section 8 units and 31 percent of  Public Housing units (42 U.S.C. § 1437b)  were rented by older adult households, while  22 percent of Housing Choice Vouchers  assisted older adult households. Section 8  units refer to low-income housing units under  section 8 of the United States Housing Act of  1937 (Pub. L. No. 75-412, 50 Stat. 888 (as  added by the Housing and Community  Development Act of 1974, Pub. L. 93-383, 88  Stat. 633, 662-66, (codified as amended at 42  U.S.C. § 1437f)). Under the project-based  Section 8 program, HUD contracts with  property owners that receive rental subsidies  for units rented to low-income tenants.  The Federal Housing Administration (FHA), a  component of HUD, also administers the  Home Equity Conversion Mortgage program.  12 U.S.C. § 1715z-20. The program allows  older adult homeowners access to FHA-  insured reverse mortgages to convert the  equity in their homes into monthly streams of  income and/or lines of credit. According to  HUD, in fiscal year 2013, FHA endorsed more  than 60,000 of these loans nationwide.
Up until fiscal year 2012, the Section 202 program also provided capital  advances to private, nonprofit organizations (sponsors) to finance the  construction, rehabilitation, or acquisition of new affordable rental housing  units for very low-income older adults. According to HUD officials,  appropriations for capital advances were discontinued beginning in fiscal  year 2012 as a result of the Consolidated and Further Continuing  Appropriations Act of 2012. They also indicated that, for fiscal year  2015, the department proposed to Congress adding rental assistance  contracts and funding for service coordinators to units set aside for older  adults in developments funded through the Low-Income Housing Tax   However, according to HUD officials, no  Credit and other programs.funds for new Section 202 rental assistance contracts were appropriated  in fiscal year 2015.

		Federal Transportation Program for Older Adults Requires Coordinated Transit Planning

The Department of Transportation’s Enhanced Mobility of Seniors and  Individuals with Disabilities program mainly supports projects that improve  mobility for seniors and people with disabilities in four ways.program funds, public transportation projects planned, designed, and carried out to  meet the special needs of these targeted groups when public  transportation is insufficient, inappropriate, or unavailable; public transportation projects that improve access to fixed-route  service and decreased reliance on complementary paratransit; public transportation projects that exceed the requirements of the  Americans with Disabilities Act (ADA); and alternatives to public transportation, such as volunteer driver  programs, accessible and/or senior friendly taxi services and other  transportation options.
The Federal Transit Administration (FTA) within DOT operates this  program, which provides formula grants to states that typically award this  funding to eligible local human services agencies to, for example,  purchase accessible vehicles (e.g., vehicles with lifts) to provide  transportation to older adults or persons with disabilities for a range of  purposes. At least 55 percent of program funds must be used for public  transportation capital, which includes the purchase or lease of buses,  mobility management, and other expenses. Obligations for this program  totaled $240 million in fiscal year 2014.
To qualify for funding, the Enhanced Mobility program requires recipients  to develop coordinated public transit human services plans with other  organizations that have a stake in their local transit systems. Recipients  also are required to contribute matching funds to their projects. Only  projects that are part of a locally coordinated human services  transportation plan are to be approved for this funding.
In addition to promoting well-coordinated transit systems, the Enhanced  Mobility program’s planning requirement also facilitates coordination of  resources across federal programs. According to AoA officials,  coordination between this program and AoA’s HCBS program under Title  III of the Older Americans Act, for example, has led to an agreement  between FTA and AoA that the funding AAAs receive under Title III can  be used as matching funds for local projects receiving Enhanced Mobility  program funding.

		Federal Funding Is Usually Channeled to Local HCBS Systems through State Agencies

Federal funds for HCBS and other supports for older adults typically are  targeted to local governments, other community-based organizations, and  service providers. Figure 3 illustrates federal funding streams for HCBS  and other supports for older adults.
While HUD provides funding directly to nonprofit sponsors, AoA, CMS,  USDA, and DOT direct their funding to state agencies that, in turn,  allocate them to state or local governments, CBOs, and other service  providers. Formula grants under the Older Americans Act, for example go  to each state unit on aging, which distributes this funding among their  AAAs.  AAAs have key local planning and service delivery  responsibilities and some degree of latitude in determining what HCBS to  provide for older adults in their service areas. CMS pays a share of each  state Medicaid agency’s medical assistance expenditures for HCBS; state  Medicaid agencies pay the service providers that deliver the care.

	In Selected Localities, Area Agencies on Aging and Community-Based Organizations Planned and Delivered Services to Older Adults, Using a Mix of Funding Sources

		Community-Based Organizations Collaborated to Plan and Deliver HCBS Funded Through a Mix of Federal, State, and Local Programs

In San Francisco, California; Montgomery County, Maryland; and the  Atlanta, Georgia region, similar steps were taken to plan HCBS and  related supports for the growing population of older adults in their  communities. To assist in planning, every AAA is required to have an  advisory council. The Montgomery County Commission on Aging serves  as the Montgomery County AAA’s advisory council. Each year the  commission conducts a summer studies program through which its  members engage outside experts and county officials to examine issues  such as care giving, senior transportation, and greater representation of  older adults in county decision making. According to commission  members, the AAA’s new senior transportation mobility manager was  hired in part because of their recommendations. In addition to reporting  on community needs and activities, the Advisory Committee on Aging,  within Atlanta’s AAA, promoted public awareness of resources for older  adults, and assisted municipalities, educational institutions, private  businesses, and nonprofit organizations in developing older adult  programs and services.
The AAA operated by the Atlanta Regional Commission is the largest AAA in Georgia  and serves 10 of the 29 counties in the Atlanta metropolitan region. sources served as the basis for the area plan each AAA submitted to its  state unit on aging.
In the three localities we visited, HCBS and related supports for older  adults were delivered through a broad network of CBOs and programs. In  each locality, these services and supports primarily relied on funding from  federally-supported programs, state and local government programs, and  from private sources such as foundation grants, charitable donations, and  fees for services. The AAA in each locality played a key role in  determining what HCBS programs and related supports would receive  funding from the Older Americans Act as well as other sources. Each  locality’s system of HCBS and related supports for older adults provided  information and referral, nutrition and in-home services, as well as  affordable housing and transportation services. There were some  differences, however, in how these services and supports were funded  and delivered in each locality.

			Information and Referral for HCBS and Related Supports

While a variety of CBOs provided information and referral services to help  older adults find appropriate available HCBS and related supports in each  locality, each AAA’s Aging and Disability Resource Center served as the  primary referral service in each locality. In San Francisco, the AAA  responded to the city’s multi-lingual population by creating 12 ADRC  “outstations” throughout the city. These outstations provide services in  multiple languages, such as English, Spanish, Mandarin, and American  Sign. In Atlanta, the AAA also developed a referral database containing  more than 25,000 registered providers of aging and long-term care  services, covering nutrition services, housing options and services, and  transportation assistance. This database was accessible, through  subscription, to CBOs throughout the region that worked with older adults.  In Montgomery County and San Francisco, “villages” of older adults  served as important sources of information and referral for HCBS and  related supports for their members. In addition to providing information  and referral services, San Francisco Village is trying to diversify its  membership in terms of socio-economic status. While the majority of its  members are considered “middle-income,” the Village has received a  grant from the San Francisco AAA to subsidize membership for low- income older adults. Subsidized memberships fees are $100 per  individual or $150 per household, as compared to regular membership  fees of $600 and $750, respectively. The San Francisco village, one of  two we spoke with, also provided companionship visits and assistance  with errands.
The “Village” Model for Aging in Place  Villages are grassroots, community-based membership organizations that  facilitate access to HCBS and strengthen social supports for older adults as  they age in their homes and communities. They are created and funded  primarily by older adults and rely heavily on members volunteering to help other  members. Usually governed by an advisory council or board, villages are  operated by volunteers or by some mix of paid staff and volunteers.
A recent report, based on a survey of 69 villages in the United States, found  that villages largely consist of older adults of middle to high socio-economic  status, who are most likely between ages 65 and 74. The average annual  membership fee was $431 for an individual and $587 for a household, but  approximately two-thirds of the villages charging fees offered discounted  memberships based on income. Villages focus on providing access for their  members to social and non-medical supports, emphasizing transportation,  technology assistance, and home repair and maintenance. Many also negotiate  with outside service providers for discounted fees for their members. The report  found that approximately half of the villages were receiving at least 45 percent  of their funds from membership fees. And, half of the villages received at least  20 percent of their budgets from fund-raising and charitable donations.  Government funding and contributions from nonprofit organizations each  accounted for 5 percent or less of village budgets. Currently, over 200 villages  belong to the national Village to Village Network, an organization that helps  establish and manage villages.
The five report authors represented four universities: Rutgers, the State University of New Jersey,  New Brunswick; the University of California, Berkeley; the University of Michigan, Ann Arbor; and the  University of Maryland, Baltimore.
Service programs in naturally occurring retirement communities (NORC)  were also important sources of information and referral for older adult  residents of certain communities in the Atlanta region, including the  service programs in the East Point and Toco Hills NORCs.

			In-Home Services

In all three localities, each AAA’s ADRC program was the primary entry  point for older adults into the system of HCBS and related supports. As  such, the ADRC was the first point of contact for older adults seeking  publicly-funded in-home services, such as personal care and homemaker  services. In each locality, ADRC program staff assessed the individual  needs and financial resources of older adults seeking such services,  developed service plans for them, and referred them to providers for in- home services that, in some cases, were funded under the Older  Americans Act. In Montgomery County, for example, the Senior Care  program provided in-home services funded by the state. Older adults who  were determined to be eligible for Medicaid HCBS under the state  Medicaid program were referred to the county Department of Health and  Human Services for care.
In addition to Medicaid and Older Americans Act funding, CBOs relied on  other sources of financial support to cover the cost of in-home services  for older adults. Senior Connections, a CBO in Atlanta, employed certified  home-care aides to assist homebound older adults and those with   It charged for its services, other than meals,  physical limitations.according to a sliding scale, based on an individual’s income. Senior  Connections also relied on financial support from the county, United Way,  private donations, and fundraisers to subsidize the cost of services to its  clients in need.

			Nutrition Services

As a part of HCBS, meals for older adults can be provided in a  congregate setting away from recipients’ homes or delivered to their  homes. Four of the CBOs we visited across the three localities provided  meals, and we observed some differences in their delivery and funding in  each locality. For example, Senior Connections in Atlanta offered  congregate and home-delivered meals for older adults at a per meal and  package price, with meals available to those who qualified based on  income, age, and county of residence at no-cost or subsidized with Older   Further, Senior Connections delivered meals to  Americans Act funding.senior facilities, opened its congregate meals to residents at area housing  complexes and workers at businesses, at a cost to the latter, and offered  nutrition counseling. There was also a senior multipurpose facility in  Atlanta that offered congregate meals daily, and membership dues for the  facility covered the cost of these meals.
Staff at two CBOs we visited told us that they also referred the low- income older adults they served to SNAP and helped them complete the  required paperwork.  Despite the options USDA has provided states for  making their SNAP application process simpler, according to some CBOs  we contacted in two of the three localities, older adults continue to  consider the annual recertification process in their states burdensome,  especially considering that their anticipated monthly benefit could be as  low as $16.

			Housing and Transportation

We consistently heard in each locality that housing options and  transportation were among the services most in demand by older adults.  Among the five Section 202 properties we visited across our three  localities, services and amenities provided for their older adult residents,  include service coordinators who connected especially frail residents to  the supportive services they needed (see appendix III for a description of  the Section 202 properties we visited). For example, a service coordinator  in a Montgomery County Section 202 property assessed residents’ needs  and referred them to various community resources. This coordinator also  helped establish support networks and volunteer services for residents. At  one Atlanta property, the service coordinator was in charge of organizing  education and wellness programs, such as stroke awareness, healthy  eating on a budget, and music therapy, as well as making referrals and  providing residents with information about outside services. According to  some of the sponsors of Section 202 housing properties we interviewed,  the program’s service coordinators save federal dollars because they  delay older adults’ reliance on federally funded nursing home care.
At one of the Section 202 properties we visited, staff expressed concern  over the suspension of federal funding for construction of housing units  for low-income older adults under the Section 202 program. Further,  some sponsors of existing Section 202 housing told us that using low- income housing tax credits for older adults may not be realistic because  households with extremely low incomes may not be able to afford the  rents that would be charged even under a tax credit program.
Some CBOs and local governments we contacted across our three  localities provided transportation services for older adults that received  funding under the federal Enhanced Mobility program. For example,  Dekalb County, Georgia collaborated with CBOs to operate a senior  shuttle service that provided county residents who were 60 and older with  curb-to-curb rides. Similarly, the Montgomery County transportation  project we contacted coordinated transportation services for older adults  in Montgomery County and was funded with Enhanced Mobility funds.  San Francisco used a DOT, Federal Transportation Administration grant  to provide peer escorts to accompany older adults with dementia.

		The Three Localities Faced Similar Challenges in Meeting the Demand for HCBS and Supports

According to AAA and CBO officials, the growing population of older  adults, in conjunction with constraints on federal, state, and local  government funding, made it difficult to meet older adults’ needs for  affordable housing, in-home and nutrition services, and transportation. In  addition, the growing diversity of the older adult population—differences  in language, culture, and customs—compounded these challenges. Some  CBOs also indicated that as funding from public programs has remained  flat in recent years, they were finding it difficult to secure funds from other  sources to sustain the HCBS and supports they provide to older adults.
In all three localities that we visited, we were told that there were lengthy  waiting lists—one consequence of funding constraints—for a number of  HCBS and supports. AAA officials in Atlanta and Montgomery County  reported that while Medicaid funding for HCBS has been increasing in  recent years, hundreds of older adults referred to Medicaid for in-home  services under state Medicaid waiver programs were ending up on  waiting lists because their state Medicaid agencies had not met their  funding match. In one locality, there was concern that the state Medicaid  program may have chosen to devote a higher percentage of state  Medicaid resources to nursing home care than to HCBS. In Montgomery  County, an AAA official said that of the 23,000 people, statewide, who  were on Maryland’s waiting list for the state’s Medicaid Community First  Choice option, about 10 to 12 percent were Montgomery County  residents. In Atlanta, the AAA director said that there were 800 people in  the region who were eligible for services under one of the state’s  Medicaid 1915(c) waiver programs and on a waiting list because the  program was closed due to lack of state Medicaid matching funds.  According to the Atlanta AAA director, applicants would be assessed for  eligibility for Medicaid funded in-home services as soon as more state  funds became available. Only older adults who are low-income are  eligible for Medicaid-funded HCBS, and in Atlanta and Montgomery  County, AAA officials described a mix of Older Americans Act, state, and  local funds that they used to serve older adults who were not eligible for  Medicaid. In the Atlanta region and Montgomery County, officials reported  that there were also waiting lists for Older Americans Act-funded HCBS.
CBO officials also reported waiting lists for affordable senior housing.  Among the Section 202 properties that reported information on waiting  lists, waiting periods ranged from 6 months to 10 years, indicating that the  existing supply of affordable units available to older adults under Section  202 and other programs was not meeting the demand. Further, Section  202 is no longer producing new units. Congress did not approve new  rental assistance contracts through the Section 202 demonstration funded  in fiscal year 2014 and there was no funding for new units in fiscal year  2015. Given the increasing size of the older adult population and  projections that many will need assistance with their housing costs, the  demand for affordable housing for older adults will likely continue to  exceed the supply.
The demand for nutrition services has also grown in recent years. Two  CBO officials noted shortfalls in meeting the demand for nutrition services  in their communities. Senior Connections representatives, who provided  meals for older adults in several Georgia counties, told us that one county  had more than 200 individuals on its waiting list, mainly for meals and in- home care. In a previous study, we reported that officials told us that  requests for home-delivered meals were increasing as older adults were  remaining in their homes longer rather than moving into assisted living  facilities or nursing homes. Moreover, complicated application  requirements may be impeding their access to food assistance through  SNAP, which USDA and HHS officials told us may be used by the  participant as a voluntary contribution toward the cost of congregate and  home delivered meals for older adults, if the provider is authorized by  USDA to accept SNAP benefits for this purpose (e.g. is an authorized  SNAP retailer). Three USDA initiatives--the Combined Application  Project, Standard Medical Deduction, and the Elderly Simplified  Application Project--to allow states to simplify the application and  recertification requirements for older adults have been adopted by 17, 16,  and 6 states, respectively. According to a USDA official, all three  initiatives include evaluation and reporting requirements, due to their  status as demonstration projects, that can be viewed as burdensome by  state agencies. According to the official, those evaluation and reporting  requirements may deter states from applying to operate a project.
CBOs in each locality also reported high demand for transportation  services for older adults, but one we visited, which assisted older adults  with different modes of transportation, had temporarily suspended its  transportation voucher program until new funding was made available  through a DOT grant. Further, local officials said that flexibility was critical  in providing older adults with the right type of transportation assistance to  address their needs. For example, a San Francisco mobility program  manager noted that an increasing number of baby boomers living at  home had dementia. She stated that there were day programs for older  adults available at senior centers, but these individuals needed  transportation to the centers. Some older adults who did not meet the  specific requirements for paratransit required assistance that was not  available through the fixed-route bus system even when subsidies made  trips more affordable to them. Further, those with dementia needed more  hands-on assistance in transit than was available through paratransit.  To respond to this need, local officials in San Francisco said that in July  2014 the city launched its peer escort transportation service. According to  the mobility manager, in this instance, the city was able to use FTA grant  funds to acquire vehicles for the peer escort service, but had to find  another grant to fund a small stipend for the escorts. Several  transportation service providers across the localities expressed a need to  reduce restrictions on the use of federal transportation grant funding. For  example, CBO and local government officials told us that they would like  to spend more transportation grant funds to transport older adults to  recreational events. They said that some programs allowed funding for  older adult transportation to hospital and other non-emergency medical  appointments, but not recreational transportation, even though this was  important to older adults’ quality of life. This is consistent with our findings  in a previous report that when flexible transportation services exist and  are accessible, older adults can more comfortably age in place in their  homes and communities.
In the three localities, a diverse older adult population has compounded  the task of meeting increasing demand for HCBS and supports, and  challenged CBOs to find ways to accommodate differences in language,  culture, and customs.  Representatives of a Montgomery County village told us that they served individuals who represented more than 57  countries of origin and shared a common characteristic—many were first  generation Americans. One Section 202 property in the Atlanta region  relied on its collaboration with an Asian community center to meet the  social needs of its Korean residents, who represented 20 percent of all  residents. The property had also hired a part-time language interpreter to  facilitate communications with these residents.
At the same time that Older Americans Act funding has been essentially  flat in recent years, some local CBOs reported finding it difficult to secure  from non-federal sources the funds they need to sustain the services they  provide to older adults. For example, the mobility manager at the CBO  which suspended its transportation voucher program told us that local  fundraising was challenging in the low-income community where the CBO  was located. Moreover, in addition to constraints on Older Americans Act  funding, our 2014 analysis of state and local budgets suggests that states  and local governments will continue to face fiscal challenges in the  coming years absent substantial policy changes. Further, HHS budget  documents note that states, tribes, and localities that depend on federal  funds for these services have limited options to offset losses of federal  funding.
Developing the capacity to compete in new markets for HCBS and  opportunities may be a strategy for AAAs and CBOs to address these  challenges. For example, the San Francisco AAA is taking advantage of  the business acumen learning collaborative formed by ACL’s Center for  Consumer Access and Self-Determination. As one of the sites selected to  participate in the learning collaborative in 2013, San Francisco’s AAA  convened a network of 15 CBOs. The stated outcome for network  members is to build their organizational capacity to contract with  managed health care entities. The goal was that future contracts with  health plans and managed care providers would provide revenue to the  CBOs that were part of the AAA’s network. ACL’s business acumen  learning collaborative is in line with the Older Americans Act, which  requires AoA to provide technical assistance designed to assist state  units on aging (SUA), AAAs, and service providers in serving older  individuals with the greatest economic and social needs. The act also  requires the establishment, directly or through AoA grants or contracts, of  national technical assistance programs to fund technical assistance to  SUAs, AAAs, and CBOs funded under the act in implementing home and  community-based long-term care systems.federal funding is constrained, local entities may be best served by having  greater opportunities for technical assistance that could help them form  strategic networks and identify additional sources of non-federal financial  support. Local partnerships between service providers could in turn  facilitate the type of care coordination that would benefit older adults.

	AOA Has Collaborated with Other Agencies but Has Not Brought Them Together to Develop a Cross- Agency Federal Strategy for HCBS and Supports

AoA, within HHS, is the principal agency designated to carry out the  provisions of the Older Americans Act. As we reported in table1 earlier,  AoA and CMS fund a range of HCBS for older adults while the other  agencies that fund home and community based services—HUD, DOT,  and USDA, do so in their respective areas. AOA funds HCBS and related  supports and has reached out to the other agencies to collaborate on  selected projects. However, AoA has not yet brought all five agencies  together to develop a cross-agency federal strategy for home and  community-based services and related supports.

		AoA Has Reported Collaboration on Certain Projects

The Older Americans Act directs AoA to facilitate, in coordination with  CMS and other federal agencies as appropriate, the provision of services  and supports in the home and community. However, AoA, CMS, HUD,  DOT, and USDA fund programs that deliver HCBS and supports to older  adults through individual agency efforts, for the most part. While AoA has  formed collaborative projects with each of the five agencies that fund  HCBS for older adults, most of the collaborative arrangements reported  are between AoA and one or two other federal agencies. Table 5 below  lists the HCBS and support programs for older adults covered in this  report.
ADRCs are located in  communities. The  ADRC program seeks  to improve older  adults’ access to  HCBS.
Three of the programs include projects that one of the participants has  identified as an interagency collaboration,
AoA has worked with USDA to allow state distribution of USDA foods  in lieu of all or part of their cash allotments under the Nutrition  Services Incentive Program to supplement the home-delivered and  congregate meal programs funded by the Older Americans Act.
AoA collaborates with CMS in implementing the ADRC program,  previously discussed. The AoA officials we interviewed identified the  ADRC program as the focus of the agency’s effort to improve older  adults’ access to HCBS at the local level. AoA is currently working to  implement the no wrong door system—the updated model of the  ADRC program—throughout the aging services network.officials also reported that they collaborate with AoA in the ADRC  program.
DOT
According to DOT officials, DOT changed its requirements to allow other federal funds to be used as the local match for DOT funds.Under the revised requirement, local agency recipients of Section  5310 grant funds could use grant funds from AoA as a match for FTA  Section 5310 funds.
However, as table 5 shows, the five agencies administer most of the  programs independently, without involvement by other agencies at the  federal level.
In addition to these programs that fund HBCS for older adults, agency  officials reported collaboration on projects in which AoA and one or more  other agencies participate. These projects, including a housing  demonstration project, development of a data base, and specification of  standards for an electronic HCBS record, focus mainly on federal  program development tasks, rather than front line service delivery,
AoA participates in DOT’s Coordinating Council on Access and  Mobility, which is a federal interagency council for transportation  services, established by Executive Order. The Council oversees  activities and makes recommendations intended to simplify customer  access to transportation and improve the efficiency of services using  existing resources. While the five agencies that fund HCBS are  represented on this council, their discussions focus on better  coordinating transportation funding streams, programs, and  transportation services.
AoA also collaborated with HUD and HHS’ Office of the Assistant  Secretary for Planning and Evaluation to develop design options for a  demonstration of publicly assisted rental housing coordinated with  health and long-term care services and support for low-income older  adults. The goal is a sustainable, collaborative system between  housing and human services agencies.
HUD officials also told us that AoA and HUD support contractors who  are developing a database that links demographic health status and  health service utilization data for older adult residents of public  housing.
AoA, HUD, and CMS collaborate on a housing and supportive  services project known as the Housing Capacity Building Initiative for  Community Living. This initiative is a series of projects that focus on  strategies for providing supportive services to older adults and  individuals with disabilities who live in the community. Thus far, most  of the projects focus on individuals with disabilities.
CMS has an agreement with the HHS Assistant Secretary for  Planning and Evaluation to develop standards for an electronic record  for HCBS, according to CMS officials.
CMS also is working with HUD’s 10 regional offices to examine what  is required to integrate Section 202 developments into the larger  community. In the past year, conversations have centered on HUD’s  challenge with Section 202 developments that are more isolated from  other community elements.
Of the three collaborations identified in table 5 earlier, plus the six  described above, three involve three or more of the agencies that fund  HCBS for older adults. However, only DOT’s Coordinating Council on  Access and Mobility included all five agencies.
While these projects represent steps toward interagency collaboration,  they do not allow all five agencies to consider jointly the broad  implications of their independent initiatives for older adults, their common  target population. For example, three CMS programs provide incentives  for state Medicaid Programs to reduce the use of institutionally-based  long-term services and supports in the community. At the same time,  Congress eliminated funding for capital advances under the Section 202  program. According to HUD officials, HUD is encouraging localities to  look to existing affordable housing resources in the community in the  absence of funding for housing construction under the Section 202  program. AoA is collaborating with HUD and CMS by helping to  determine how best to provide services to older adults in multifamily  housing in the community. However, as we previously discussed, while  attributable not only to changes in the Section 202 program, the demand  for older adult affordable housing will likely continue to exceed the supply.  One implication of these simultaneous developments is that, if there is no  housing available, older adults may be unable to receive services unless  they reside in an institutional setting. Collaboration to develop mutually  reinforcing or joint strategies could help ensure that federal resources for  HCBS and supports are used efficiently and effectively.
Others also have pointed out the potential consequences of the lack of  collaboration among the agencies that administer programs for older  adults. For example, a 2014 report prepared for the Department of Health  and Human Services noted that the disconnects among Medicare,  Medicaid, acute and chronic health care providers, affordable housing  programs, aging programs, and home and community based services  may lead to lower-quality care, premature institutionalization, and higher  costs for public and private health and long term care. This study reported  that the factors contributing to higher costs were premature transfers to  nursing homes and residential care facilities, repeated trips by emergency  medical technicians to an individual’s home, repeated trips to hospital  emergency rooms, and frequent hospitalizations.

		Federal Agencies Support Interagency Collaboration

Officials we interviewed at AoA, DOT, HUD, and CMS all voiced support  for interagency collaboration. The AoA officials we interviewed stated that  the agency believes that collaboration with other federal agencies is  necessary to build a comprehensive system of home and community-  based services and has taken steps to formalize some of the agency’s  collaborative relationships.
HUD officials also thought that all of the HHS, HUD, DOT, and USDA  programs and resources directed to older adults should be aligned to  better serve them, especially because of the changing demographics of  the older adult population.
DOT officials emphasized that all federal agencies that fund HCBS for  older adults should reach beyond barriers to coordination at the federal  level. They suggested that the transportation services that community  based organizations operate should be connected to locally coordinated  planning organizations, such as a metropolitan council of governments.
They said that they hope AoA will promote the message that joint  planning is needed.
CMS officials reported a positive experience collaborating with ACL and  HUD. They said that they were unaware of any challenges to  collaboration and found that any differences in the participating agencies’  organizational cultures that exist often enhance collaboration.
When asked at what point AoA plans to coordinate a more  comprehensive, cross-agency approach to administering the federal  programs that fund HCBS, an AoA representative said that the agency  does not have adequate resources to cover the cost of such a  collaborative process. While we recognize that AoA is a small agency and  faces many competing priorities for its resources, our recent work on  interagency collaboration found that most collaborative groups in  government are not directly funded, but leverage the existing resources of  the participating agencies in order to operate.

		Federal Collaboration Could Help Address Local Challenges

As part of our work on collaboration, we previously reported on key  practices to enhance and sustain interagency collaboration. In that  work, we broadly defined collaboration as any joint activity that is  intended to produce more public value than could be produced when the   We also described how agencies can enhance and  agencies act alone.sustain their collaborative efforts by engaging in eight practices, including, define and articulate a common outcome; establish mutually reinforcing or joint strategies; identify and address needs by leveraging resources; agree on roles and responsibilities; establish compatible policies, procedures, and other means to operate develop mechanisms to monitor, evaluate, and report on results;  reinforce agency accountability for collaborative efforts through  agency plans and reports; and   reinforce individual accountability for collaborative efforts through  performance management systems.
These practices can serve as a framework for collaboration among the  five agencies that administer HCBS that would allow them to consider  and establish a cross-agency federal strategy for administering HCBS.  For example, as the five agencies collaborate, CMS officials might  contribute lessons learned by state Medicaid agencies that would help  develop joint strategies for using HCBS to prevent frequent use of  emergency medical services by older adults.
More specifically, using the eight practices for collaborative efforts, a  cross agency federal strategy could help the federal agencies address  some of the challenges associated with funding and delivery of HCBS in  the localities we visited. For example,
Officials at AoA and local officials said that federal rules governing the  use of funds for transportation for older adults could be more flexible  or subsidize transportation for older adults for different purposes,  including health care and recreation. AoA, DOT, HUD, CMS, and  USDA might define common outcomes for local transportation for  older adults that took into account different transportation modes and  the range of transportation purposes, and incorporate these objectives  into their grant awards.
AoA and the Center for Consumer Access and Self-Determination,  also within ACL, have taken the initiative to help develop AAAs’ and  other community-based organizations’ capacity to contract with  healthcare entities to provide HCBS. AoA, HUD, DOT, and USDA,  could help ensure that HCBS such as affordable housing, non- medical transportation, and additional nutrition assistance are  provided at the community level by first defining common outcomes  for these services. AoA, HUD, DOT, and CMS also could develop  lessons learned for the local networks that AAAs and CBOs form to  provide these services that could contribute to efficient and effective  use of federal resources.
As previously discussed, although HUD provides older adults with  project rental assistance for units in existing multifamily housing  developments, HUD did not anticipate any new funding for Section  202 capital advances to construct new housing after 2012. On the  other hand, in each locality we visited, we were told that there were  lengthy waiting lists for affordable housing for older adults. Defining  common outcomes for affordable housing construction and rental  assistance with supportive social services, including transportation  and nutrition services, by HUD, CMS, AoA, DOT, and FNS could help  develop strategies for leveraging limited resources for housing  construction.
The diversity of the older adult population presents challenges to  meeting the needs of all older adults. Cross-agency goal setting by  the five federal agencies with a focus on meeting the needs of diverse  populations could help AAAs and community based organizations  serve their clientele more effectively.
In our work on interagency collaboration, we have found that when  federal support in a particular area cuts across federal agencies, as it  does with regard to HCBS and supports for older adults, agency  collaboration is important to ensuring that federal efforts, overall, achieve  meaningful results. Each of the five agencies that fund home and  community-based services and supports for older adults, however, for the  most part does so independently. While AoA is well-positioned to lead  federal agencies in planning a cross-agency federal strategy for the  provision of home and community-based services and supports for older  adults, an AoA representative indicated that the many competing priorities  it has for its limited resources prevent it from doing so. Development of a  cross-agency federal strategy could help provide assurance that federal  resources are used efficiently and effectively to help communities meet  the demand for HCBS and supports for older adults.

	Conclusions

As the older population continues to grow, communities will find it  increasingly difficult to meet the demand for the HCBS and supports  many older adults will need to age in their own homes and communities.  Based on recent trends, federal funding at AoA, HUD, and DOT for HCBS  and supports is not likely to keep pace with demand for these services  and supports, making it important to ensure that the federal resources  available for this purpose are used effectively and efficiently.  Development of a cross-agency federal strategy could better position the  federal agencies to assist area agencies on aging and community-based  organizations with providing HCBS and supports in the most efficient and  effective manner. Under the Older Americans Act, AoA is responsible for  facilitating the provision of home and community-based services and  supports for older adults in this country, in coordination with CMS and  other federal agencies. As a result, AoA is well-positioned to lead  collaboration among the five federal agencies covered in our review.  However, because of increases in Medicaid spending and emphasis on  the role of HCBS in supporting health care patients, CMS has become an  even more important partner to AoA in meeting older adults’ expected  demand for HCBS. Thus, it may be most appropriate for the HHS  Secretary to take the initiative in developing such a cross-agency federal  strategy.

	Recommendation for Executive Action

The Secretary of the Department of Health and Human Services should  facilitate development of a cross-agency federal strategy to help ensure  that federal resources from ACL, CMS, USDA, HUD, and DOT are  effectively and efficiently used to support a comprehensive system of  HCBS and related supports for older adults. Through such a strategy the  agencies could, for example, define common outcomes for affordable  housing with supportive services, non-medical transportation, and  nutrition assistance at the federal level; develop lessons learned for the  local networks that area agencies on aging and community-based  organizations are forming; and develop strategies for leveraging limited  resources.

	Agency Comments and Our Evaluation

We provided a draft of this report to HHS, DOT, HUD, and USDA.  HHS  provided general comments that are reproduced in appendix IV.  All four  departments provided technical comments which we incorporated as  appropriate.
HHS concurred with our recommendation and stated that HHS leadership  agrees with the need to continue to coordinate services to address the  often complex conditions of older adults with long term services and  support needs.  HHS also stated that the department continually strives to  improve its strategic coordination and described ways that it facilitates  cross agency strategic efforts, including a community-living initiative with  HUD and an interagency workgroup on Olmstead requirements.also described collaboration by HHS and HUD on policy research projects  concerning housing and supportive services for older adults, including a  comparison of health service utilization by older adults who live in  assisted housing with those who do not and an evaluation of a  demonstration in Vermont that provides services and supports to  residents of HUD-assisted housing.  We continue to encourage HHS to  engage all five agencies—the Administration on Aging and Centers for  Medicare and Medicaid Services in HHS, HUD, DOT and USDA--in  development of a cross agency federal strategy for administering home  and community-based services for older adults. Using the eight practices  to enhance and sustain interagency collaboration that we have identified  in prior work could help the five agencies address some of the challenges  associated with funding and delivery of home and community-based  services to older adults in the communities where they live.
We are sending copies of this report to the appropriate congressional  committees, the Secretaries of the Departments of Health and Human  Services, Housing and Urban Development, Transportation, Agriculture,  and other interested parties. We will also make copies available to others  on request. In addition, the report will be available at no charge on GAO’s  website at http://www.gao.gov. If you or your staff have any questions  about this report, please contact me at (202) 512-7215 or  brownke@gao.gov. Contact points for our Offices of Congressional   Relations and Public Affairs can be found on the last page of this report.  GAO staff who made major contributions to this report are listed in  appendix V.

Appendix I: Community Based Organizations Contacted, by Locality and Type

Appendix I: Community Based Organizations  Contacted, by Locality and Type Benson Manor (Department of Housing and Urban Development (HUD) Section 202)
Dekalb County Senior Transportation Services (Department of Transportation Enhanced  Mobility)
East Point Naturally Occurring Retirement Community (NORC)
Gwinnett Christian Terrace (HUD Section 202)
Chevy Chase at Home Village   Homecrest House (HUD Section 202)
Muslim Community Center Senior Program   Victory Oaks (HUD Section 202)
Village Rides (Department of Transportation Enhanced Mobility)
Armstrong Place (HUD Section 202)
Bayview Hunters Point Multipurpose Senior Services Inc.

Appendix II: Federal FundingTrends for Programs Serving Older Adults

Home & Community-Based  Supportive Services   Aging and Disability Resource  Centers (ADRC)
Aging and Disability Resource  Center (Mandatory)
Aging and Disability Resource  Center (MIPPA) 1915(c) HCBS Waivers  1915(i) HCBS: State Plan Options  Balancing Incentive Program  (BIP)
Money Follows the Person  Demonstration (MFP)
Community First Choice (CFC)
Senior Farmers’ Market Nutrition  Program  Supportive Housing for the  Elderly (Section 202)-Capital  Advance and New Project Rental  Assistance Contracts (PRAC)
Supportive Housing for the  Elderly (Section 202)-Renewals  and Amendments PRACs  Supportive Housing for the  Elderly (Section 202) -Service  Coordinators  Enhanced Mobility of Seniors and  Individuals with Disabilities  (Sections 5310)
An obligation is a legally binding agreement that results in outlays, immediately or in the future.
According to Congressional Research Service, the Aging Network Services Activities program funds  declined starting in fiscal year 2012 because some activities supporting older adults that were  previously included under the Aging Network Support Activities program were moved to separate line  items in fiscal year 2011. These included the Senior Medicare Patrol Program, ADRCs, the National  Center on Elder Abuse, and the National Long-Term Care Ombudsman Resource Center.  Expenditures for Medicaid programs for fiscal years 2007 – 2014 were provided by CMS from the  Medicaid Financial Management Reports.  Appropriations of $10 million for FY 2010 through FY 2014 for ADRCs were made under the Patient  Protection and Affordable Care Act, Pub. L. No. 111-148, §2405 124 Stat. 119, 305.  Area Agencies on Aging, ADRCs and State Health Insurance programs receive funding through  MIPPA to help Medicare beneficiaries apply for the Medicare Part D Extra Help/Low-income Subsidy  and the Medicare Savings Program.  According to USDA, obligations for the Commodity Supplemental Food Program in fiscal year 2010  were $182 million and for fiscal year 2013, $186 million.  Appropriations for capital advances for fiscal years 2012-2014 were for administrative expenses  related to the Capital Advance Program. No appropriations for new capital advances were made that  year.  Amount is significantly higher in fiscal year 2013 and beyond due to the incorporation of the former  New Freedom program into the Enhanced Mobility of Seniors and Individuals with Disabilities  program.

Appendix III: Selected Properties Funded by The Department of Housing and Urban Development’s (HUD) Section 202 Program

Amenities and activities: HUD-funded  service coordinator (and activities director),  part-time language interpreter, laundry  facility, 24-hour surveillance and overnight  security, twice weekly shopping trips, bus  excursions, terrace room (for movies,  gaming, and special events), book club,  free weekly swap meet, sewing and craft  clubs, bingo, wellness and exercise room,  fitness classes, worship services and Bible  study, resident gardens, combined library  and computer room.
Homecrest House is a nonprofit,  nondenominational community formed when  HUD awarded the first Section 202 grant in  1976. This sponsor operates two Section 202  properties in Maryland.  Two adjoining properties by the same  sponsor opened for occupancy in 1979 and  1985, respectively. There are 235 total units.
Amenities and activities: Kitchen, outdoor  patio, laundry facility, community room,  vending machines, wellness room, fitness  center, computer room, library, sunroom,  24-hour security, and health education  meetings.
Bridge Housing Corp. is a San Francisco- based nonprofit housing developer formed in  1983. This sponsor operates five Section 202  properties in California.  Property opened for occupancy in 2011 and  has116 units  (23 designated for homeless older adults)
Amenities and activities: Community room  with kitchen, laundry facility, assigned  covered parking, courtesy patrol,  landscaped courtyard and picnic area.
HUD refers to community-based organizations that receive Section 202 funding to provide affordable  housing to older adults as sponsors.
Project H.A.N.D.S. is a Canada-based international nonprofit organization that helps needy  communities through projects such as outreach clinics and education funding.

Appendix IV: Comments from the Department of Health and Human Services

Appendix V: GAO Contact and Staff Acknowledgements

	GAO Contact

	Staff Acknowledgements

In addition to the contact named above, Clarita Mrena (Assistant  Director), Sara Edmondson (Analyst-in-Charge), Laurel Beedon, Bernice  Benta-Jackson, John Lack, and Nhi Nguyen, made significant  contributions to all aspects of the work. Also contributing to the report  were Holly Dye, Sheila McCoy, John McGrail, Mimi Nguyen, Cheryl  Peterson, Monica Savoy, Walter Vance, Maria Wallace, Emily Wilson,  and Craig Winslow.

Summary:
Why GAO Did This Study

Research has shown that many older adults want to age in their homes and communities, and their ability to do so often depends on the availability of home and community-based services and other supports. GAO was asked to review the availability of such services.
This report addresses (1) federal programs that fund these services and supports for older adults, (2) how these services and supports are planned and delivered in selected localities, and (3) agencies' efforts to promote a coordinated federal system of these services and supports. GAO reviewed federal program documents and interviewed federal officials. It also visited programs in the Atlanta, Georgia region, Montgomery County, Maryland, and San Francisco California, chosen based on efforts made to enhance their system of HCBS and supports, recommendations from federal agencies and experts, varied governmental jurisdiction, and geographic dispersion.

What GAO Found

Five federal agencies within four departments fund home and community-based services and supports that older adults often require to continue living independently in their own homes and communities. The Administration on Aging (AoA) and Centers for Medicare & Medicaid Services (CMS) in the Department of Health and Human Services (HHS), and the Departments of Housing and Urban Development (HUD), Transportation (DOT), and Agriculture (USDA) provide funds, often through state agencies, to local governments and community-based organizations.
The Older Americans Act of 1965 (the Act) requires AoA to promote and support a comprehensive system of services.
In the three localities GAO visited, local area agencies on aging, assisted by other community-based organizations, took the lead in planning and delivering services and supports for older adults, paid for with a mix of federal, state, and local funding. An Atlanta organization employed home-care aides for older adults and delivered meals. Senior housing developments across the three localities connected more frail residents to in-home services. In San Francisco and Montgomery County, grassroots organizations known as villages provided help with errands. Officials in two localities reported that flat funding of certain state funds, combined with the growing number of older adults, has resulted in waiting lists for affordable housing and in-home services.
The Act requires AoA to facilitate collaboration among federal agencies; however, the five agencies that fund these services and supports for older adults do so, for the most part, independently. GAO's work on interagency collaboration has found that collaboration is important for federal efforts that involve more than one agency. HHS, through AoA, has indicated that competing priorities for its limited resources prevent it from leading development of a cross-agency federal strategy. However, developing such a strategy could help ensure that the five agencies' resources for HCBS and supports are used efficiently and effectively.

What GAO Recommends

GAO recommends that HHS facilitate development of a cross agency federal strategy to ensure efficient and effective use of federal resources for HCBS. HHS concurred and HUD, DOT, and USDA did not comment.