Rental Housing Access & 

Discrimination Experienced by 

People With Multiple Disabilities

Study of Rental Housing 

Discrimination on the Basis 

of Mental Disabilities: 

Short Paper 5

U.S. Department of Housing and Urban Development | Office of Policy Development and Research
RENTAL HOUSING ACCESS & 

DISCRIMINATION EXPERIENCED BY 

PEOPLE WITH MULTIPLE DISABILITIES

STUDY OF RENTAL HOUSING 

DISCRIMINATION ON THE BASIS 

OF MENTAL DISABILITIES: 

SHORT PAPER 5

Prepared by

Joy Hammel

Janet Smith

Jenna Heffron

Alisa Jordan Sheth

University of Illinois at Chicago

Marti Knisely 

Technical Assistance Collaborative

Contributors and Reviewers

Susan Silverstein

AARP Foundation

Katherine McDonald

Syracuse University and Burton Blatt Institute

Charles Dabah

Danbi Lee

University of Illinois at Chicago

Prepared for

U.S. Department of Housing and Urban Development

Office of Policy Development and Research

Submitted by

M. Davis and Company, Inc. 

August 2017
Disclaimer

The contents of this report are the views of the contractor and do not necessarily reflect the views or policies of the U.S. Department 

of Housing and Urban Development or the U.S. government.
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STUDY OF RENTAL HOUSING DISCRIMINATION ON THE BASIS OF MENTAL DISABILITIES: SHORT PAPER 5

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Contents

Abstract.................................................................................. 1

Introduction........................................................................... 2

Methods................................................................................. 4

Results and Findings .............................................................. 5

Incidence Rate of Co-Occurring MI and SUD.................. 5

Incidence of Co-Occurring I/DD and MI......................... 8

Older Adults With Co-Occurring MI and Other 

Disabilities............................................................. 10

Promising Practice Case Studies and Implications To Address 

the Needs of People With MI and I/DD With Multiple 

Disabilities as They Age................................................. 15

The Case of Louisiana: Breaking Down Silos and 

Coordinating Housing With Community-Living 

Supports Across Disability and Aging Systems. ...... 15

Additional Promising Practices Across States and 

Communities......................................................... 16

Synthesis, Conclusions, and Implications for Future 

Housing Research.......................................................... 18

References............................................................................ 20

Additional Reading............................................................... 24

List of Tables

Table 1. Adults With AMI, SMI, and Co-Occurring MI 

and SUD, by Economic Status, 2013 Data.............. 6

Table 2. Conditions Causing Limitation in SSI and SSDI 

Beneficiaries........................................................... 7

Table 3. Physical Health Issues Present at Increased Rates 

in People With SMI................................................ 8

Table 4. Co-Occurring MI in Adults With I/DD................... 8

Table 5. Co-Occurring Conditions (Non MI) in Adults 

With I/DD.............................................................. 9

Table 6. Data on Employment for People With I/DD ........... 9

Table 7. Community Employment for People With I/DD 

Only and People With Co-Occurring I/DD 

and MI. ................................................................ 10

Table 8. Common Contributors to Memory Changes in 

Adults With I/DD................................................. 12

List of Figures

Figure 1. Incidence of AMI and SMI in the Past Year 

Among Adults, by Age, 2013 Data ......................... 5

Figure 2. Incidence of Co-Occurring MI and SUD in the 

Past Year Among Adults, by Age, 2013 Data........... 5

Figure 3. Co-Occurring MI and SUD in the Past Year 

Among Adults, by Employment Status, 

2013 Data .............................................................. 6

Figure 4. Type of Residence, by Diagnosis........................... 10

Figure 5. Older Population by Age, 1900–2050 .................. 11

Figure 6. Type of Residence for People With I/DD, by Age. . 13
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Abstract

Although housing discrimination testing research limits its focus 

to one primary disability, such as serious mental illness or 

intellectual or developmental disability, a significant percentage 

of people are living with multiple disabilities, chronic health 

conditions, and age-related conditions that further complicate 

the search for rental housing as well as housing discrimination 

research. This paper focuses on the demographics of multiple 

disabilities experienced by people with mental disability, specifically focusing on three groups: (1) people with mental illness (MI) 

who also experience a substance use disorder (SUD), physical 

disabilities, and age-related disabilities; (2) people with intellectual or developmental disabilities who also experience MI, 

SUD, and physical or age-related disabilities; and (3) older 

adults who acquire MI, SUD, and other cognitive disabilities, 

such as dementia, as they age. Demographic trends are then 

tied to implications for access to rental housing by these target 

groups. In addition, this paper discusses implications for research 

to examine potential discrimination experienced before, during, 

and after rental housing searches and to study the impact of 

complex housing, disability, and aging policies, systems, and 

programming. Specific issues related to cross-disability and 

housing system coordination and potential promising practices 

to better meet the needs of this growing, multidisability and 

aging group are put forth as examples.
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Introduction

The U.S. Department of Housing and Urban Development 

(HUD) recently completed a pilot study of housing discrimination experienced by people with mental disability (MD).1

The pilot study is specifically focused on documenting housing 

discrimination in the rental market on the basis of MD faced 

by two different subgroups within this population: (1) people 

with a psychiatric disability (PD) or mental illness (MI) and 

(2) people with an intellectual or developmental disability (I/DD). 

To date, these two groups have not been the focus on any largescale housing discrimination-testing research, and this research 

effort sought to actively involve both subgroups in a pilot test 

of rental housing discrimination.

The federal Fair Housing Act (Title VIII of the Civil Rights Act 

of 1968) as amended in 1988 prohibits discrimination in the 

sale, rental, and financing of housing, or other housing-related 

transactions, on the basis of seven protected classes: (1) race, 

(2) color, (3) religion, (4) national origin, (5) sex, (6) familial 

status, and (7) disability. Housing providers are prohibited 

from considering these protected characteristics as the basis 

for rejecting or refusing to negotiate with individuals seeking 

housing or housing-related services, or from misrepresenting 

or limiting housing opportunities based on protected characteristics. People with disabilities have three additional protections: 

(1) multifamily housing with four or more units, built for first 

occupancy after March 13, 1991, must meet specific, if relatively 

modest, accessibility design and construction requirements that 

enable a person using a wheelchair to access and use covered 

units and common areas; (2) housing providers must make 

reasonable accommodations to their rules, policies, practices, 

and services necessary for people with disabilities to equally 

enjoy the property; and (3) housing providers must enable 

residents, at the residents’ expense, to make reasonable 

modifications to physical structures necessary for people with 

disabilities to use and enjoy the property. Although Olmstead2

ruled that any unjustified segregation of persons with disabilities was a violation of Title II of the Americans with Disabilities 

Act, it did not grant any new or specific protections for the 

beneficiaries of this case when leaving an institution.

Testing is an investigative technique that serves as a powerful 

tool for directly observing differences in treatment in the practices 

of housing providers and their agents. Testing can be conducted 

in a variety of configurations, depending on the issues being 

examined, but the most common and effective approach to 

observing differences in treatment based on a protected class is 

matched pair testing. In this type of testing, two testers are assigned profiles that make them similarly situated and qualified 

for the housing being tested, differing only in their membership 

in a protected class. Designing a testing protocol that will detect 

discrimination on the basis of MD, therefore, requires ensuring 

that the testing involves one specific disability group and holds 

all other variables constant (for example, race, age, income, employment status). This requirement makes it challenging to test 

for potential housing discrimination against people with MD 

(MI and I/DD) who also experience co-occurring disabilities, 

including age-related disabilities. Because a significant proportion of people with MD experience other disabilities as well, 

this approach to testing potentially oversimplifies the reality of 

housing discrimination experienced by this population. Some 

of the most common co-occurring categories of disabilities 

these groups experience include—

•	 People with MI who also experience a substance use 

disorder (SUD), physical disabilities, and age-related 

disabilities.

•	 People with I/DD who also experience MI, SUD, and 

physical or age-related disabilities.

•	 Older adults who acquire MI, SUD, and other cognitive 

disabilities, such as dementia, as they age.

The enforcement of fair housing laws is made more challenging 

when people have multiple disabilities. For example, although a 

housing provider cannot legally discriminate against a potential 

tenant on the basis of disability, he or she can do so against 

people who are currently abusing substances and those who 

are deemed to pose a significant danger to others (DOJ, 2004). 

When two or more of these factors (for example, disability, 

1 Mental disability is defined as “(1) having a mental or psychological disorder or condition that limits a major life activity, including working; (2) any other mental 

or psychological disorder or condition that requires special education or related services; (3) having a record or history of a mental or psychological disorder or 

condition which is known to the employer or other entity covered by this part; or (4) being regarded or treated by the employer as having, or having had, any mental 

condition that makes achievement of a major life activity difficult” (Foster v. City of Oakland, 2009 U.S. Dist. LEXIS 70094).

2

 The Olmstead Decision of the United States Supreme Court in Olmstead v. L.C. in 1999 held that, under certain circumstances, public entities must provide 

community-based services to people with disabilities.
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SUD, and posing a direct threat to others) coexist, it can be 

extremely difficult to determine whether a housing provider’s 

differential treatment toward a potential tenant is legal or illegal.

People with multiple disabilities must navigate multiple and 

complex systems to search for, pay for, and maintain long-term 

community living, cutting across housing, medical and health 

care, and long-term community-living support systems. Each 

of these critical systems has differing policies, rules, and regulations that consumers must coordinate in order to successfully 

live in the community and maintain rental housing. This paper 

focuses on these system-level needs and issues that these 

groups face.

This paper reviews research in an area that is critical to rental 

housing access and discrimination but that cannot be addressed 

in pilot housing discrimination testing because of the numerous 

and complex variables presented. Findings provide an overview 

of how multiple disabilities affect the housing search, retention 

of housing, and the complexities of coordinating rental housing 

supports for those with multiple disabilities. The paper concludes with examples of promising practices in programming 

and policy systems change efforts designed to respond to housing access and discrimination issues that this population faces. 

As such, the findings and the cases also point to implications 

for future housing access and discrimination research to document the lived experiences of these groups.
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Methods

Two methods were used in this paper: (1) a critical appraisal 

of existing research and (2) accompanying promising practice 

case studies. The critical appraisal of the literature (Curtin and 

Fossey, 2007; Guba, 1981; Guyatt et al., 2011) was done across 

disability, aging, housing, and legal sources to examine and 

provide a preliminary overview of current trends and patterns 

related to how the housing search, retention of housing, and 

coordination of rental housing supports are affected by the 

experience of multiple co-occurring MD.

To achieve this aim, researchers collected recently published 

national surveys and reports related to MD and housing and 

conducted an online database search for recently published 

research on this topic. Researchers then conducted a critical 

appraisal review of literature and data sources to be used in this 

paper. For each data source used, researchers assessed several 

factors, including whether the study addressed a focused issue 

specific to these subgroups, the appropriateness of the research 

design to address the aims of the research, rigor of data analysis 

and interpretations, clarity of reported findings, and value of the 

research to this paper’s aim to highlight housing access and discrimination issues. The data sources used in this paper included 

well-recognized and validated sources of data from United States 

public and governmental agency documents and reports, including the Survey of Income and Program Participation from the 

U.S. Census Bureau, the National Survey on Drug Use and Health: 

Mental Health Findings from the Substance Abuse and Mental 

Health Services Administration (SAMHSA), and the National 

Core Indicators from the National Association of State Directors 

of Developmental Disabilities Services and Human Services 

Research Institute. Researchers then identified data from within 

these documents relevant to people with MD (MI and I/DD) 

who experience co-occurring disabilities that may also become 

exacerbated as they age.
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Results and Findings

In 2003, the President’s New Freedom Commission on Mental 

Health declared that recovery from MI is possible, but that 

fragmented and inadequate support services often stand in the 

way of this recovery. Recovery, which means living, working, 

learning, and fully participating in the community regardless 

of the presence or absence of symptoms, is contingent on 

obtaining and maintaining accessible, affordable, integrated 

housing and appropriate supports (President’s New Freedom 

Commission on Mental Health, 2003).

People with PD-MI and I/DD who experience co-occurring 

multiple disabilities often need to navigate multiple systems 

and policies to obtain accessible, affordable, and integrated 

rental housing in the community, and they experience numerous challenges within these systems. Coordinating housing 

rental supports for people with multiple disabilities can be 

quite complex, and this process can be experienced differently 

depending on disability types, severity, and other factors, including education level, employment status, economic status, 

and criminal history.

The following sections highlight what we currently know about 

people with multiple disabilities and their access to rental 

housing: (1) incidence rates of MI and co-occurring disabilities,

(2) housing issues experienced by this population, (3) incidence 

rates of I/DD and co-occurring disabilities, and (4) housing 

issues frequently experienced by this population.

Incidence Rate of Co-Occurring MI 

and SUD

In 2013, an estimated 43.8 million adults age 18 and older 

were living with MI in the United States, making up 18.5 percent of the population (SAMHSA, 2014). Of these 43.8 million 

adults, 10 million had a serious mental illness (SMI), which is 

defined as one that substantially limits at least one major life 

activity. More people age 26 to 49 experienced MI or SMI in 

2013 than did individuals in any other age bracket (SAMHSA, 

2014). At a time when more and more Americans are living in 

rental market housing, the greatest increase is among people 

age 25 to 54, and particularly among people age 30 to 39 (JCHS, 

2013). Therefore, adults with MI and SMI may represent a significant portion of the rental housing market. Figure 1 shows 

incidence rates of MI and SMI in 2013, broken down by age.

In 2013, approximately 7.7 million people reported experiencing 

co-occurring MI and SUD in the past year (SAMHSA, 2014). Put 

Figure 1. Incidence of AMI and SMI in the Past Year 

Among Adults, by Age, 2013 Data

AMI = any mental illness. SMI = serious mental illness.

Source: SAMHSA (2014)

another way, approximately 17.5 percent of people with MI 

also experienced co-occurring SUD that year. Individuals ages 

18 to 25 and 26 to 49 experience co-occurring MI and SUD at 

the highest rates (6.0 percent and 4.5 percent, respectively). 

This relatively large proportion of people living with co-occurring MI and SUD also overlaps with the age brackets in which 

increasing numbers of adults are seeking rental housing in the 

community (see Figure 2).

Lack of appropriate housing supports and services can lead 

people with MI and co-occurring disabilities to land in institutions such as nursing homes or institutions for mental disease, 

to become homeless, or to rotate between these two systems. 

According to HUD’s 2014 Annual Homeless Assessment Report, 

in January 2014, approximately 578,000 people were homeless 

Figure 2. Incidence of Co-Occurring MI and SUD in 

the Past Year Among Adults, by Age, 2013 Data

MI = mental illness. SUD = substance use disorder.

Source: SAMHSA (2014)
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on any given night, and, of this number, slightly more than 

84,000 people were identified as chronically homeless (HUD, 

2014b). In addition, data from HUD’s homeless assistance 

programs identified approximately 234,000 people served who 

were homeless and also had SMI or chronic SUD (HUD, 2014a). 

People with disabilities make up most of the chronically homeless population, including people with SMI, SUD, physical disability, chronic disease, or two or more of these co-occurring 

conditions (Burt, 2001; Byrne et al., 2014).

Co-Occurring MI and SUD, by Level of Education, 

Employment, and Economic Status

Education level, employment, and economic status often go 

hand in hand, both for people with and without MI. For people 

with MI and co-occurring disabilities, however, these factors 

can play a particularly large role in the struggle to obtain and 

maintain rental housing in the community. Regarding level of 

education, MI prevalence was higher among adults with some 

college who did not obtain a degree (20.2 percent) and those 

who did not complete high school (20.0 percent) than it was 

for college graduates (17.7 percent) and adults with a high 

school degree (17.0 percent) (SAMHSA, 2014). Similarly, 

college graduates were less likely to have co-occurring MI and 

SUD (2.8 percent) than their counterparts who had attended 

some college but did not earn a college degree (4.1 percent) 

(SAMHSA, 2014). This trend resembles that of employment 

status among adults with MI and co-occurring SUD. In 2013, 

more unemployed adults (22.8 percent) and part-time employed 

adults (20.3 percent) experienced any type of MI than did 

their counterparts who were employed full time (15.4 percent; 

SAMHSA, 2014). Similarly, more unemployed adults (6.6 percent) experienced SMI than did those who were employed 

either part time (4.8 percent) or full time (2.7 percent), with 

full-time workers having the lowest rate of SMI among the 

three groups (SAMHSA, 2014). This same trend was evident 

for adults with co-occurring MI and SUD, in that the percentage of unemployed adults who had co-occurring MI and SUD 

(6.8 percent) was higher than those who were employed part 

time (4.0 percent) or full time (3.0 percent) (SAMHSA, 2014; 

see Figure 3).

Economic status follows suit with both education and employment for people with MI and co-occurring SUD, in that in 

2013, 26.1 percent of adults whose family income was below the 

federal poverty level experienced any mental illness (AMI) in the 

past year (SAMHSA, 2014; see Table 1). Further, adults whose 

family income was 100 to 199 percent or 200 percent or more 

of the federal poverty level also experienced significant levels 

of MI (20.9 percent and 16.0 percent, respectively) (SAMHSA, 

2014). Similarly, the percentage of adults who experienced 

Figure 3. Co-Occurring MI and SUD in the Past Year 

Among Adults, by Employment Status, 2013 Data 

MI = mental illness. SUD = substance use disorder.

* Other = students, people keeping home or taking care of children full 

time, retired or disabled people, or others not in the labor force.

Source: SAMHSA (2014)

Table 1. Adults With AMI, SMI, and Co-Occurring MI 

and SUD, by Economic Status, 2013 Data

Economic Status

Percent With

AMI SMI MI and SUD

Family income below federal poverty level 26.1 7.7 4.8

Family income at 100–199% of the federal 

poverty level

20.9 5.1 4.0

Family income at 200% or more of the 

federal poverty level

16.0 3.2 2.6

AMI = any mental illness. MI = mental illness. SMI = serious mental 

illness. SUD = substance use disorder.

Source: SAMHSA (2014)

SMI in 2013 was highest among those whose family income was 

below the poverty line (7.7 percent), followed by those whose 

family income was 100 to 199 percent of the poverty level (5.1 

percent), and those whose family income was 200 percent or 

more of the 

poverty level (3.2 percent) (SAMHSA, 2014). Following this same 

trend, 4.8 percent of adults whose family income was below the 

federal poverty line had a co-occurring MI and SUD. Only 2.6 

percent of adults whose family income was at least 200 percent 

of the federal poverty line had co-occurring MI and SUD in 2013 

(SAMHSA, 2014). These findings clearly point to the complexity 

of MI, SMI, SUD, and income/poverty rates in the United States, 

all of which significantly affect market-rate rental housing and 

potential discriminatory treatment related to accessing housing.

Work can be vital to health, recovery, and social inclusion for 

people with MI (Boardman et al., 2003), both as a meaningful 

activity and as a means of improving economic status and 

securing any type of market-rate rental housing. Most adults 

with MI want to work (McQuilken et al., 2003) and, when given 
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the appropriate support, an estimated 60 percent may be able 

to maintain employment (Marshall et al., 2014). Employment, 

however, does not guarantee economic stability, nor does it 

guarantee the ability to access and maintain rental housing in 

the community (Cook, 2006). For example, Fair Market Rent 

(FMR) for both one-bedroom and efficiency units consistently 

represent more than the entire monthly income of someone who 

receives Supplemental Security Income (SSI) payments (TAC, 

2007). In fact, the most recent statistics show that, on average, 

renting a one-bedroom unit at FMR costs 104 percent of the 

monthly income of people with disabilities who receive SSI payments (TAC, 2012). This fact is particularly relevant, considering 

that adults with MI are the second largest population among 

SSI and Social Security Disability Insurance (SSDI) beneficiaries 

and are the largest population among people receiving either 

SSI only or concurrent SSI and SSDI (SSA, 2009; see Table 2).

In addition, even if a person is able to afford rental housing, he 

or she may encounter stigma when trying to obtain and maintain this housing. Preliminary research shows that the general 

public may be less likely to lease an apartment to someone who 

they perceive to have MI (Bahm and Forchuk, 2009; Bordieri 

and Drehmer, 1986; Corrigan and Penn, 1999). People with MI 

may be more susceptible to this type of rental housing discrimination than their peers without MI, and people who report a 

co-occurring MI and physical disability may potentially face more 

discrimination than those with MI alone (Bahm and Forchuk, 

2009; Gouvier and Coon, 2002). Further, Bahm and Forchuk 

(2009) found that perceived discrimination/stigma was positively 

correlated with MI severity and negatively correlated with selfreported health, emotional well-being, and life satisfaction. 

Although not done on a large-scale rigorous discriminationtesting basis, these findings support the link between multiple 

disabilities and the potential for increased discrimination in the 

rental housing market. It also helps to elucidate the negative 

effect that housing discrimination may have on the health and 

lives of people with multiple disabilities and the importance of 

reducing housing discrimination for this population.

MI and Physical Health Issues

In addition to adults who live with SUD, adults who live with MI 

also struggle with physical health conditions. Of adults living 

with MI, 68 percent also experience co-occurring medical conditions (Robert Wood Johnson Foundation, 2011). People with 

SMI are particularly vulnerable to experiencing co-occurring 

physical health disabilities and chronic conditions, as presented 

in Table 3. MI, physical health, and SUD are reciprocally linked; 

that is, they often influence each other, but they also share some 

of the same risk factors (Lando et al., 2006; Office of Disease 

Prevention and Health Promotion, 2014; Robert Wood Johnson 

Foundation, 2011). MI, SUD, and physical health issues, particularly when co-occurring, can make it very difficult to maintain 

any type of residential stability (National Coalition for the 

Homeless, 2009a, 2009b).

Table 2. Conditions Causing Limitation in SSI and SSDI Beneficiaries

Condition Causing Limitation

Beneficiaries Reporting Condition (%)

All

Beneficiaries

SSDI-Only

Beneficiaries

Concurrent

Beneficiaries

SSI-Only

Beneficiaries

Musculoskeletal 36 43 26 30

Mental illness 33 29 34 39

Circulatory system 21 25 15 17

Nervous system 17 18 15 15

Endocrine/nutrition 16 19 15 13

Injury or poisoning 11 14 7 9

Respiratory system 8 7 7 11

Sensory 9 9 11 9

Intellectual/developmental disability 7 3 14 10

Other 35 34 38 34

No conditions limit activities 6 5 7 8

SSDI = Social Security Disability Insurance. SSI = Supplemental Security Income.

Source: SSA (2009)
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Table 3. Physical Health Issues Present at Increased Rates in People With SMI

Disease Category Physical Diseases With Increased Frequency

Bacterial infections and mycoses Tuberculosis*

Viral diseases HIV,** Hepatitis B/C*

Neoplasms Obesity-related cancer*

Musculoskeletal diseases Osteoporosis/decreased bone mineral density*

Stomatognathic diseases Poor dental status*

Respiratory tract diseases Impaired lung function*

Urological and male genital diseases Sexual dysfunction*

Female genital diseases and pregnancy complications Obstetric complications**

Cardiovascular diseases Stroke, myocardial infarction, hypertension, other cardiac and vascular diseases**

Nutritional and metabolic diseases Obesity,** diabetes mellitus,* metabolic syndrome,** hyperlipidemia**

SMI = serious mental illness.

* good evidence for increased risk. ** very good evidence for increased risk.

Source: De Hert et al. (2011)

Incidence of Co-Occurring I/DD and MI

The most recent census information reports approximately 1.2 

million adults or 0.5 percent of the U.S. adult population have 

an I/DD, with an additional 944,000 adults reporting having 

other developmental disabilities (Brault, 2012). These data do 

not include those adults with I/DD living in institutionalized 

settings, however, which was estimated to be nearly 57,000 in 

2010 (Larson et al., 2013). Recent estimates of the prevalence 

of developmental disabilities, including intellectual disability, 

among children measured nearly 10 million, or 15 percent of 

children less than age 17 in the United States, showing a 17-

percent increase from data gathered a decade earlier (Boyle, 

et al., 2011). The authors pinpoint the increase was largely 

because of the rise in diagnoses of autism and attention deficit 

hyperactivity disorder, which are in turn likely because of increased awareness and service provision for these diagnostic 

groups. As these children age, they represent a significant disability group within the MD category whose needs related to 

independent living and rental housing have yet to be studied. 

The largest and most extensive survey on disability in the United 

States, the National Health Interview Survey on Disability, was 

conducted in 1994 and 1995 and provided widely reported 

and cited statistics on prevalence rates of I/DD. This survey has 

not been replicated since, however, thus limiting any meaningful updates (Hendershot et al., 2005).

According to the National Core Indicators annual reports (NCI, 

2014), approximately 35 percent of adults 18 years of age and 

older with I/DD have a co-occurring MI diagnosis, including mood 

disorder (22 percent), behavior challenges (15 percent), anxiety 

disorders (16 percent), and psychotic disorders (10 percent), 

with respondents potentially living with more than one diagnosis 

at the same time (see Table 4). Rates of co-occurring chemical 

dependency, however, were reported as less than 1 percent. 

This result may be because of more restricted living situations 

and life choices for these individuals, or it may represent an 

issue of underreporting SUD for this population, or it may 

be related to issues of access to accessible communication for 

people with I/DD to report such issues.

Table 4. Co-Occurring MI in Adults With I/DD

Co-Occurring MI Condition 

in Adults With I/DD

NCI National 

Average

(%)

Mood disorder 22

Anxiety disorder 15

Behavior challenges 16

Psychotic disorder 10

Other MI diagnosis 6

I/DD = intellectual or developmental disability. MI = mental illness. 

NCI = National Core Indicators.

Source: NCI (2014)

I/DD and Other Co-Occurring Disabilities and 

Conditions

Statistics indicate that 24 percent of adults with I/DD use some 

type of physical mobility aid or technology, such as a walker or 

wheelchair (NCI, 2014). Other more common co-occurring 

conditions for adults with I/DD include seizure disorder (25 

percent), cerebral palsy (14 percent), autism spectrum disorder 

(12 percent), and vision or hearing impairment (10 percent) 

(see Table 5). Physical or sensory impairments can further affect 

and compound housing access issues for adults with I/DD, 

including the need for physical accessibility to entrances and 

bathrooms for wheelchair and walker users and adapted alarms 

and other safety devices for those with vision, hearing, and 

sensory impairments.
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Table 5. Co-Occurring Conditions (Non-MI) in Adults 

With I/DD

Co-Occurring Condition

NCI National 

Average

(%)

Moves with aids or independent wheelchair user 15

Nonambulatory or moves with dependent assist 9

Autism spectrum disorder 12

Cerebral palsy 14

Brain injury 3

Seizure disorder 25

Vision and/or hearing impairment 10

Alzheimer’s disease or dementia 2

Down syndrome 9

I/DD = intellectual or developmental disability. MI = mental illness. 

NCI = National Core Indicators.

Source: NCI (2014)

I/DD and Education

Access to and participation in higher education is an important 

indicator to obtaining competitive employment and the financial resources needed to access independent living and rental 

housing in the community (Migliore, Butterworth, and Hart, 

2009). Although the Individuals with Disabilities Education 

Act ensures that people with I/DD both with and without cooccurring conditions are able to receive public elementary and 

secondary education services, rates of post-secondary education 

for young adults with I/DD are among the lowest rates of any 

disability group. A study in 2007 showed that, of all young 

adults with I/DD accessing vocational rehabilitation services, 

only 3.4 percent attended any kind of post-secondary education, 

and only 1.5 percent completed any program through an educational institution (Migliore, Butterworth, and Hart, 2009).

Transition and Postsecondary Programs for Students with Intellectual Disabilities, awarded through the Office of Postsecondary 

Education and funded through the reauthorization of the Higher 

Education Act in 2008, led to the creation and expansion of 

higher education opportunities for people with I/DD (Grigal 

et al., 2013). Results from this initiative show that 54 percent 

of participants leaving the programs after 2 years earned some 

type of credentials, with 48 percent of these participants engaging in competitive employment or other career development 

activities, 30 percent reporting paid employment, and 82 percent reporting wages at or above the minimum wage (Grigal 

et al., 2013).

I/DD and Employment

Employment is recognized as a major factor in helping people 

with I/DD make the transition from institutional to community-based housing and in providing residential stability (U.S. 

Senate, 2013), because it provides more financial resources and 

subsequent options for renting or owning a home. Most adults 

with I/DD are not employed in the community, however, despite 

an interest in pursuing work opportunities (NCI, 2014; see 

Table 6).

Although adults with I/DD and co-occurring MI have similar 

rates of community employment than that of the general I/DD 

population, they tend to have lower hourly wages than those 

without MI (NCI, 2011b; see Table 7). The most recently available National Core Indicators data reported that only 15 percent 

of respondents with I/DD had paid work in the community. For 

those respondents who did have community employment, only 

one-third of people reported having competitive employment 

(NCI, 2014).

Table 6. Data on Employment for People With I/DD

Community Employment Issue Community Employment Status NCI National Average (%)

Has a paid job in the community Yes 15

No 85

Wants a paid job in the community Yes 49

In-between 7

No 44

Type of paid employment in the community (average hourly wage) Individually supported ($8.48)a 35

Group supported ($6.44) 32

Competitive ($8.15) 33

I/DD = intellectual or developmental disability. NCI = National Core Indicators.

a

 NCI definitions for employment status are community-based setting: integrated place where most people do not have disabilities; individually 

supported: individuals are receiving public-funded support/services to get/maintain their job, and the job is one that is primarily done by people 

without disabilities; group supported: individuals are receiving public-funded supports/services to get/maintain their job, and the job is one that is 

primarily done by people with disabilities; competitive: individuals are not receiving any public-funded supports/services to get/maintain their job, 

and the job is one that is primarily done by people without disabilities.

Source: NCI (2014)
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Table 7. Community Employment for People With I/DD Only and People With Co-Occurring I/DD and MI

Hours Worked

in 2 Weeks

Amount Earned

in 2 Weeks

($)

Hourly Wage

($)

Earning at or

Above Minimum Wage

(%)

Months at Current Job

I/DD only 31.5 201.00 6.40 43 66 

Dual diagnosis 30.6 170.00 5.81 35 56

I/DD = intellectual or developmental disability. MI = mental illness.

Source: NCI (2011b)

Given the increasing focus on ensuring access to equitable education and employment for people with I/DD, increasing numbers of people with I/DD and those with I/DD and co-occurring 

MI and physical disabilities will also be looking for market-rate 

rental housing in the communities in which they work.

I/DD and Housing

The Research and Training Center on Community Living (2012) 

estimates that 56 percent of adults with I/DD live in their family 

home, 23 percent live in congregate settings of four or more 

people (including institutions and nursing homes), 11 percent 

live in a group or foster home setting, and 10 percent live in 

their own home or apartment and not with family (Larson et 

al., 2014). Although housing trends indicate that most adults 

with I/DD live in a family member’s home, people with I/DD 

and co-occurring MI are much less likely to live with family and 

more likely to live in group homes, institutions and nursing 

facilities, or other situations, which may include rental housing 

(NCI, 2011b; see Figure 4).

As illustrated in Figure 4, less than 20 percent of adults with I/

DD with or without co-occurring diagnoses live independently 

in a home or rental apartment. The Arc (2015) identified five 

factors contributing to these low levels of home rental or ownership, including lack of affordable and available housing, 

Figure 4. Type of Residence, by Diagnosis 

I/DD = intellectual or developmental disability.

Source: NCI (2011)

accessibility issues for those also experiencing physical or sensory 

impairments, lack of supports to prevent institutionalization 

or homelessness, caregiver aging issues, and potential housing 

discrimination for this population.

The Technical Assistance Collaborative (2012) reported that 

people with disabilities who rely solely on SSI for income are 

priced out of nearly every rental market in the United States 

unless they have permanent subsidy assistance, with many rents 

for studio and one-bedroom apartments exceeding the entire 

monthly SSI benefit. In 2010, nearly 600,000 adults with I/DD 

nationwide received Medicaid Home and Community-Based 

Services (HCBS) Waivers, which in some states can be used to 

obtain housing within the community; however, the level of 

funding and availability of supports to be used toward housing 

expenses vary significantly by state (Larson et al., 2013). The 

population of people with I/DD, however, who are now making 

the transition to least-restrictive community-living options in 

response to Olmstead Decision lawsuits and systems changes 

is growing. Therefore, we can expect to see this population 

increasingly trying to access market-rate rental housing.

Older Adults With Co-Occurring MI 

and Other Disabilities

The rate at which adults are living to old age in the United 

States is steadily increasing. The U.S. Department of Health 

and Human Services Administration on Aging (HHS, 2013), 

using data from the 2008 census, reported that the number of 

Americans age 65 and older is expected to reach 20 percent of 

the total population by 2040 and continue to increase thereafter 

(HHS, 2013; see Figure 5).

In 2013, nearly 5.3 million people (12.2 percent) age 65 and 

older in the United States experienced MI (SAMHSA, 2014). 

The percentage increases to 20.4 percent when neurological 

disabilities like dementia are included (Karel, Gatz, and Smyer, 

2012). Depressive disorders and dementia-related symptoms 

are identified as most common MI related issues among older 

adults, with SUD also being of concern (Institute of Medicine, 

2012). Up to 19 percent of adults 65 and older experience 
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Figure 5. Older Population by Age, 1900–2050

Source: HHS (2013)

depression (NAMI, 2009a), which is often experienced as a 

secondary condition, co-occurring with other physical and 

emotional health conditions such as diabetes, Parkinson’s 

disease, and chronic pain (Cahoon, 2012). The World Health 

Organization (WHO, 2013) reported that mental health and 

physical health frequently affect one another reciprocally. For 

example, older adults with heart disease experience depression 

at higher rates than those who do not have physical health 

conditions, and, similarly, untreated depression can exacerbate 

the effects of heart disease in older individuals (WHO, 2013). 

Alzheimer’s disease and other forms of dementia are also significant co-occurring diagnoses in older adults, with 5 million 

Americans age 65 and older living with Alzheimer’s disease as 

of 2014 (Alzheimer’s Association, 2015).

When MI co-occurs, or perhaps even occurs for the first time 

for older adults, everyday function can be significantly disrupted, which, in turn, disrupts housing and community-living 

status. In some cases, this co-occurrence may cause older 

adults to leave their long-term homes and consider options 

such as market-rate rental, independent living, supported or 

assisted living, or nursing home situations. In the market-rate 

rental scenario, trying to find and apply for rental housing 

as an older adult with MI and concomitant physical health 

conditions represents a difficult challenge that a significant and 

growing percentage of older adults face.

Older Adults and Substance Use Disorder

Up to 700,000 older adults were diagnosed with alcohol use 

conditions in 2010, and another 100,000 were diagnosed with 

drug use conditions that year (Institute of Medicine, 2012). 

These numbers may be even higher, given that MI and SUD 

problems are often overlooked, underreported, misdiagnosed, 

and undertreated in this population because of stigma associated with MI and the potential threat to maintaining independent 

living (CDC/NACDD, 2008; De Mendonça Lima, 2004; WHO, 

2013).

Older Adults With Multiple Disabilities and 

Housing

The U.S. Census Bureau’s 2013 American Housing Survey 

(sponsored by HUD) shows that approximately 35 percent of 

owner-occupied older adult households (65 years and older) 

include at least one disabled person, and 8 percent include a 

person with an MD. Because many, if not most, of these homeowners purchased their homes before acquiring age-related disabilities and chronic conditions, their homes may no longer be 

accessible to them and they may be forced to consider moving, 

including moving to market-rate rental housing such as senior 

independent living complexes. In addition, these older adults 

may need in-home personal assistance and accessibility features 

in their home and in their community, adding a component of 

reasonable accommodation to their rental housing needs (U.S. 

Census Bureau, 2005; U.S. Census Bureau, 2013).

Not all older adults with MI have owned their own homes, 

however, and may be at risk for losing existing market-rate 

rentals. In fact, 47 percent of older adult households who reside 

in rental units include at least one person with a disability, 

and 13 percent include a member with an MD (U.S. Census 

Bureau, 2013). Further, there are more people ages 65 to 79 

and 80 and older who have disabilities than there are accessible 

housing units (JCHS, 2014). Further, adults age 80 and older 

are two times more likely to have a disability than they are 

to live in homes that have at least three accessibility features 

(JCHS, 2014). These individuals may need to endure long 

waiting lists of several years or more to obtain affordable senior 

housing, which may or may not be adequately accessible. In 

addition, senior housing sites may be hesitant to accept or have 

policies restricting tenants who have a history of MI or SUD, 

even though both occur together for a significant portion of 

older adults (HHS, 2003). Systemic and financial issues, such 

as the delay in obtaining affordable housing and the inability to 

afford rental housing, and individual or societal issues related to 

disclosing MI and SUD, can lead to homelessness or institutionalization for many of these older adults (HHS, 2003).

I/DD and Aging

The life expectancy for adults with I/DD has steadily increased 

during the past several decades, with individuals with mild I/DD 

seeing life expectancy on par with the general population and 

those with moderate to severe I/DD often living into their 50s 
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and 60s (Bittles et al., 2002). With this increasing life expectancy 

has also come an increasing incidence of aging related issue 

within this population, including Alzheimer’s disease, dementia, and other sources of memory changes (Moran et al., 2013; 

Perkins and Moran, 2010; see Table 8).

Recent research has indicated that the incidence of dementia in 

adults with I/DD more than 65 years of age is five times that of the 

general population (Strydom et al., 2013). In addition, adults 

Table 8. Common Contributors to Memory Changes 

in Adults With I/DD

Condition Presentation

Sensory deficits Hearing loss

Vision loss, low vision, depth-perception 

changes

Metabolic disturbances Electrolyte abnormalities

Hypoglycemia/hyperglycemia

B12 or folate deficiencies

Undetected thyroid dysfunction

Anemia

Toxic medication levels

Toxic adverse medication effects

Coexisting mood 

disorder

Either newly detected or subacute 

worsening of baseline mood disorder

Pharmacologic concerns Polypharmacy

Drug-drug interactions

Altered pharmacokinetic properties

Sleep problems Sleep apnea

Other undetected sleep disorders

Seizures Undetected or worsening seizure disorders

Pain Undiagnosed or undertreated pain

Mobility problems Mobility disorders and loss of functionality

Psychosocial or 

environmental 

stressors

Changes in routine at home or work

Death or impairment of close family and 

friends

Reactions to threatening situations

Other conditions 

associated with 

cognitive deficit

Chronic subdural hematoma

Brain tumors

Multiple sclerosis

HIV/AIDS

Cryptococcal infection

Considerations for adults 

with Down syndrome

Early development of cataracts

Increased risk of keratoconus

Conductive hearing deficits

Thyroid dysfunction

Obstructive sleep apnea

Celiac disease

Atlantoaxial instability

Spinal stenosis

Osteoarthritis

I/DD = intellectual or developmental disability. 

Source: HHS (2013)

with Down Syndrome typically experience even higher rates of 

Alzheimer’s disease with earlier onset because of genetic factors. 

(Livingston and Strydom, 2012; Strydom et al., 2010). The 

National Task Group on Intellectual Disabilities and Dementia 

Practices (NTGIDDP, 2012) estimates that at least 54,000 older 

adults with I/DD are living with dementia in the United States, 

although no current national statistics more accurately determine the incidence.

Aging Adults with I/DD also experience higher rates of heart 

disease, high blood pressure, high cholesterol, diabetes, stroke, 

arthritis, asthma, and obesity, which can lead to premature 

death or poorer health when aging (Reichard, Stolzle, and Fox, 

2011). In a survey of adults with I/DD age 65 and older, 44 percent 

of respondents reported co-occurring MI, 21 percent a physical disability, 11 percent legally blind, 9 percent hearing loss, and 7 percent 

having Alzheimer’s or dementia (NCI, 2011a). Any, or all, of these 

co-occurring disabilities can significantly influence rental housing access and discrimination issues, particularly as this population lives longer and also has aging caregiver issues that may 

threaten their ability to stay in family homes.

The increase in care demands associated with developing agerelated conditions for adults with I/DD often comes as families, 

particularly parents, are less able to provide direct care, often 

because of their own aging issues (Heller and Factor, 2008; Livingston and Strydom, 2012). Compounded with this increase in 

care needs, families of people with I/DD often have few formal 

supports and poor access to services (Heller, 2008; NTGIDDP, 

2012). Although older adults with I/DD experience many of 

the same physical changes and age-related chronic diseases as 

the general aging population, they are more likely to experience 

inadequate or poorly managed health care, unrecognized health 

conditions, and poor coverage of health promotion and preventative care (Perkins and Moran, 2010). Health outcomes for 

older adults with I/DD are often poorer than that of the general 

population, and thus can exacerbate rental housing access and 

potential discrimination.

Older Adults With I/DD and Housing

With the increased rates of dementia and chronic diseases that 

can affect physical heath and functioning of people aging with 

I/DD, paired with increasing support needs that family caregivers often have difficulty meeting, adults with I/DD more than 

65 years of age are more likely to live outside the family home 

and also more likely to live in an institution or nursing facility 

than those less than 65 years of age (see Figure 6). Although 

many older adults with I/DD continue to live at home throughout their lives (NTGIDDP, 2012), many families seek alternative 
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Figure 6. Type of Residence for People With I/DD, 

by Age

I/DD = intellectual or developmental disability. 

Source: HHS (2013)

housing as caregivers experience age-related declines, primary 

caregivers die, and caregiving needs for older adults with I/DD 

increase. Individuals with I/DD who were living independently 

in the community may also face challenges to remaining in their 

housing because they experience common age-related cognitive 

and physical declines and increased difficulty obtaining health 

care, because outlined in the previous section.

Housing Policy Issues Across Multiple Disability 

Populations

As described in the previous section, people with co-occurring 

MI and SUD may have multiple disability-related needs that can 

complicate the process of obtaining and maintaining market-rate 

rental housing (National Coalition for the Homeless, 2009a).

Federally funded public and subsidized rental housing—both 

tenant- and project-based—provides housing for different populations, including people with disabilities. Across all programs, 

1,175,636 “disability families” are either currently living in public housing, in private sector housing with a housing choice 

voucher or in some type of federally subsidized housing (HUD, 

2015).3

 In recent years, changes in the different programs 

have expanded opportunities for integrated accessible housing 

through both development of housing units and designated 

housing choice vouchers. The exact number of units designated 

for people with disabilities is unknown, as is how many may 

be occupied by people with multiple disabilities. What we 

do know is that several subsidy programs target people with 

disabilities; however, no program is solely intended to benefit 

people with MD or people with multiple disabilities.

The Non-Elderly Persons with Disabilities (NED) vouchers enable families with a person with a disability to locate and secure 

suitable and accessible housing on the private market. Although 

NED vouchers are like regular housing choice vouchers, the 

public housing authority (PHA) will provide the voucher holder 

a list of known accessible units to help in the housing search 

process, and when, and if, the voucher is returned, it must go 

to another NED family. Furthermore, NED Category 2 vouchers 

were issued specifically to help facilitate the transition of nonelderly people with disabilities currently residing in nursing 

homes or other healthcare institutions into the community. 

The 5-year Mainstream tenant-based voucher program funded 

through Section 811 is specifically for people with disabilities. 

As with NED, Mainstream vouchers are required to continue to 

be used by people with disabilities upon turnover.

In a similar arrangement, in the HUD-Veterans Affairs Supportive Housing (HUD-VASH) program, HUD provides the rental 

assistance and the U.S. Departments of Veterans Affairs 

provides case management and clinical services via its medical 

centers and other community resources. Although not intended 

to move people with disabilities into the community, HUDVASH can help veterans with disabilities who are homeless and 

keep others from being institutionalized.

To date, more than 400 PHAs have been awarded approximately 55,000 vouchers specifically for nonelderly disabled families. 

Although a newer program, HUD-VASH has nearly 60,000 

vouchers. By comparison, the 5-year Mainstream voucher is a 

much smaller program with less than 7,000 vouchers. In total, 

these targeted vouchers represent about 6 to 7 percent of the 

total voucher program in the United States, which is at about 

2.1 million households assisted. By comparison, it is estimated 

that about 29 percent of nonelderly households with someone 

who has a disability—about 627,000 households—were using 

vouchers (TAC, 2014). This percentage is closer to 50 percent 

when elderly disabled households are included (Center on Budget and Policy Priorities, 2015). In either case, most households 

that include one or more people with disabilities are not using 

vouchers from these special programs.

3

 A disabled family, according to HUD, means a family whose head, spouse, or sole member is a person with a disability. It may include two or more people with 

disabilities living together, or one or more people with disabilities living with one or more live-in aides.
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In the past 10 to 15 years, a small portion of PHAs have been 

permitted to designate as “elderly only” buildings that had previously been for people who were “elderly” or with disabilities 

regardless of age (NAMI, 2014). Currently, 128 PHAs across 

the United States have plans approved that designate 63,806 

housing units specifically for people with disabilities or for 

senior families (at least one person must be 62 years of age or 

older). Most of these are one bedroom or studios (96 percent) 

and most are for senior families (91 percent). By current estimates, 2,553 public housing units are solely for people with 

disabilities, another 3,190 units are for both senior families and 

people with disabilities, and 58,603 units are for senior families 

that may include people with disabilities older than age 62. This 

designation has also been permitted in HUD-assisted multifamily housing where about one-fourth of the units are now 

designated for elderly people only, but only 5 percent are 

designated for people with disabilities (NCD, 2010).4

In addition, although Section 811 has effectively created housing for people with disabilities and the Melville Act of 2010 has 

incentivized more integrated housing approaches (for example, 

no more than 25 percent of units in the Section 811 property 

under the Project Rental Assistance [PRA] approach can be designated for people with disabilities) (TAC, 2011), most housing 

built under this program in the past continues to be segregated.

Further, some state budgets put funding for services and statefunded housing assistance programs (SFHAPs) in competition 

with one another, making funding allocations to one at the expense of the other (TAC, 2014). Finally, although SFHAPs have 

been useful for many people with MI, they are not without 

limitations. For example, because of difficulties in meeting the 

demand for SFHAPs, many states have enacted strict eligibility 

criteria developed to meet population-specific priorities. Of the 

77 SFHAPs profiled in TAC’s State Funded Housing Assistance 

Programs report (TAC, 2014), only only 8 target people with 

disabilities of any kind, and 23 specifically target people with 

SMI. In addition, although 52 of these SFHAPs are considered 

“Subsidy Programs” in that they provide long-term assistance 

for housing costs rather than one-time or short-term assistance 

to address an immediate housing crisis, many struggle to transition recipients to a more permanent form of federal housing 

assistance (TAC, 2014). This approach can affect the fluidity of 

the intended program and limit the number of households that 

can take advantage of this form of assistance. Together, these 

issues may leave many adults with MI and co-occurring MI and 

SUD without the services and supports they need to apply for, 

obtain, and maintain rental market housing long term.

4

 Although it is not possible to correlate any changes in population using aggregated data, we did find that, according to the most current HUD data, 344,692 

households in public housing are considered a disability family (HUD, 2015). Of this population, 201,205 are nonelderly and 143,487 are elderly, and most do 

not have children (85 percent). Comparing these data with the National Council on Disability report (NCD, 2010), we found 210,760 nonelderly households and 

135,218 elderly households with a disability living in public housing (NCD, 2010). What has also changed slightly is the overall proportion in public housing based 

on distribution by age of householder: in 2008, nonelderly-headed households were 22 percent of the total in public housing and now are 21 percent, while elderlyheaded households were 11 percent in 2008 compared with 15 percent now (HUD, 2015; NCD, 2010).
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Promising Practice Case Studies and Implications To 

Address the Needs of People With MI and I/DD With 

Multiple Disabilities as They Age

As demonstrated in this critical appraisal, a significant and 

potentially growing population of people with PD-MI and I/DD 

are experiencing multiple disabilities that may interfere with 

and affect access to rental housing and potential discrimination 

related to obtaining this housing and staying in it over time. 

Much of this research points to specific system and policy 

implications that involve cross-coordination of housing and 

community-living supports across different disability and aging 

systems and programming. This section highlights several 

examples of promising practices in state and regional/local 

communities that address this complexity and coordination. 

These cases also highlight how different strategies can be used 

in different communities to customize this coordination of 

housing and supports, yet still contribute to potential increased 

housing access and opportunities for these populations.

The Case of Louisiana: Breaking 

Down Silos and Coordinating Housing 

With Community-Living Supports 

Across Disability and Aging Systems

Louisiana began developing a 3,000 cross-disability permanent 

supportive housing (PSH) initiative in 2007 and 2008 in the 

Gulf Opportunity Zone (southern Louisiana) as part of the state’s 

recovery plan to the natural disaster Hurricane Katrina in 2005. 

PSH combines deeply affordable rental housing with voluntary, 

flexible, and individualized community-based services to assist 

people with the most severe and complex disabilities5 to live 

successfully in the community. State-level partnerships among 

the Louisiana Housing Corporation (LHC), the Office of Community Development’s Disaster Recovery Unit, and the Department of Health and Hospitals (DHH) provided the framework 

for leveraging hurricane recovery resources to reach the 3,000-

unit PSH goal.

Nearly 1,200 PSH units were created as a result of innovative 

state policies incorporating small set-asides of PSH units in 

affordable rental properties financed through the Low-Income 

Housing Tax Credit (LIHTC) program, Housing Trust Fund, 

Small Rental Repair, and Piggy Back Programs. Permanent rental 

subsidies awarded by Congress ensured the remaining units were 

secured in the private rental market through a mix of scatteredsite leasing and PSH projects, and the affordability of all 3,000 

units for those with the lowest incomes.

The Louisiana Public Housing Authority, a program of the LHC, 

manages the program and the 3,000 subsidies. Because the 

Community Development Block Grant (CDBG) program was 

designated only as a “startup” for services, the state modified 

their Medicaid (HCBS and 1915[i]) programs and other state 

and federal programs so tenant services can be sustained overtime. The program has successfully housed more than 2,480 

households with disabilities across the Louisiana Gulf Coast, of 

whom 42 percent were homeless, with good housing retention 

rates and average monthly Medicaid cost reductions among those 

served. More than 70 percent of the households have multiple 

or co-occurring disabilities and most qualify for Medicaid and 

SSI or SSDI.

State officials, disability and homeless advocates and stakeholders used this opportunity to create one state-driven PSH system 

that could help accomplish two policy goals—end chronic homelessness and reduce reliance on expensive and unnecessary institutional settings within the context of the Olmstead Decision.

The PSH leaders gave priority to access for the most vulnerable 

people with disabilities. They did not place readiness criteria or 

restrictions based on the severity of individual’s disabilities. By 

doing this, they took steps to overcome access and discrimination barriers that often accompany targeting this population.

The leaders adopted a cross-disability Housing First6 community 

support team service model directly linked to the PSH units; 

service providers do not manage or operate housing. People 

have the opportunity to move to another unit when preferred 

or as a deterrent to eviction and most owners/property managers remain in the program over time. Service providers serve as 

5

 The tenants must have one or more of the following disabling conditions—MI, SUD, developmental disability, chronic health condition, or physical disability—and 

must be in need of permanent supportive housing.

6

 Housing First is an approach of providing permanent supportive housing to single homeless adults with MI and co-occurring SUD.
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a clinical home with linkages to the other needed community 

and support services focused on the tenant’s housing-related 

access and support needs. Formal liaison functions, including 

an eviction-prevention process, were created, with responsibilities assigned to services managers, supportive housing 

authority management staff, and property managers.

One hallmark of the program has been the flexibility of the 

program’s leadership to evolve and make adjustments as it has 

grown and faced challenges. Initially the DHH entered into 

agreements with six organizations, primarily local human service authorities to manage outreach, referrals, waiting lists, and 

contract for supportive services. This model worked well initially as the organizations were embedded in their communities 

and they were able to get their program up and running in a 

timely manner. Because the program funding was shifting with 

supportive services being reimbursed by fund sources other 

than CDBG, the state and managed care organizations have 

been taking over more of the management responsibilities. 

The work in Louisiana is far from finished; below are lessons 

learned from this program highlighting housing access and 

discrimination issues.

•	 Mandating PSH as a set-aside in the LIHTC and small 

rental repair programs and assistance from a Piggyback 

program helped launch the PSH program; the PSH 

program prioritized a quick staff response approach to 

property managers’ concerns while advocating for and 

assisting tenants to become self-advocates.

•	 Cross-agency collaboration, including establishing 

liaison responsibilities, helped increase access and reduce 

evictions long term.

•	 The Louisiana PHA has given high priority to monitoring 

tenant selection and requesting property managers to accept 

tenants with challenging credit and criminal histories.

•	 Supportive service providers and referring agencies have 

given a great deal of attention to unit selection, matching 

locations to prospective tenant’s expressed choices and 

concerns.

•	 The program has had more success with larger rather than 

smaller property owners.

•	 Some supportive services providers were challenged with 

adapting to the Housing First model especially serving 

individuals who were chronically homeless or those who 

had been institutionalized for a long period of time or 

repeatedly over time.

•	 Service providers were able to adapt their practice to provide 

supportive services to people across the range of disabilities 

although meeting Medicaid requirements was more challenging. The program has offered continuous technical 

assistance, training and coaching to assist providers to 

coordinate across services and programs in a consumerdirected manner.

•	 Individuals referred directly from institutions were less 

likely to access the program because the time needed to 

make transition arrangements and decisions often exceeded 

the time available units could remain vacant. This timing 

issue in coordinating transition out of institutions using 

housing voucher, bridge subsidies or other housing assistance, remains a key cross-systems policy issue to tackle.

Additional Promising Practices Across 

States and Communities

Pennsylvania and North Carolina both have developed small 

set-asides of units in affordable rental properties financed 

through their LIHTC program for people with extremely low 

incomes to give people with disabilities more access to quality 

integrated rental housing. In North Carolina, the set-asides are 

explicitly set aside for people with disabilities; in Pennsylvania, 

owners are required to enter into an agreement with appropriate 

referring entities (including those supported by the Commonwealth’s Department of Human Services) to assure that sufficient 

referrals are received from households who are income eligible 

and in need of the accessibility features.

North Carolina has implemented the Department of Health and 

Human Services (DHHS)/ Housing Finance Agency Targeting

Program, a state-driven PSH initiative. Today more than 2,000 

multifamily rental units are provided across the state through a 

mandate that 10 percent of the units in every new federal LIHTC 

property be reserved for PSH tenants. The DHHS and local lead 

agencies (LLAs) assist people who have extremely low incomes 

and multiple disabilities and who may be homeless to gain access 

to and maintain permanent independent housing in apartment 

communities participating with the Targeting Program.

The Pennsylvania Housing Finance Agency (PHFA) LIHTC 

Qualified Allocation Plan (QAP) has included a threshold requirement for developers to make a subset of their low-income 

units affordable to people at or below 20 percent of the area 

median income, adjusted for family size. In their 2015 QAP, the 

PHFA required a LIHTC application financing plan that evidences 

that at least 10 percent of the low-income units in urban areas 
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and 5 percent of the low-income units in suburban/rural areas. 

Through 2014, 843 units have been set aside for this purpose. 

The Department of Human Services supports LLAs in single or 

multiple counties to enter into an agreement with a developer 

to make referrals to the 20 percent units and to assure services 

are available to tenants to sustain their tenancy long term. The 

DHS requests LLAs enter into agreements with referring and 

services organizations across the full spectrum of agencies serving people with a range of disabilities, including people with 

multiple disabilities. LLAs manage the referral process, tenant 

selection, assist with housing search, tracks referrals, and assist 

with tenancy disputes. The LLAs also manage the 2013 awarded 811 PRA (in startup phase) program referral process that, 

in Pennsylvania, gives priority to individuals referred directly 

from institutional settings.

In Philadelphia, a single clearinghouse in the Office of Supportive Housing manages tenant selection and referrals for people 

with multiple disabilities to rental housing that is subsidized by 

five different funding sources. This requires the clearinghouse 

to not only help provide choices for housing search but also 

manage what types of subsidy an individual may be entitled to 

at the time of their referral. The city’s goals in combining these 

functions into one clearinghouse are to provide more integrated 

housing options to people across multiple disabilities, reduce 

management redundancies and improve timeliness of referrals 

and allocate more attention to working with landlords and property managers. Clearinghouse staff are skilled in negotiating 

with owners and can assist prospective tenants and their service 

providers with eligibility determinations and move-in challenges.

The New Jersey Housing Mortgage and Finance Agency (NJ 

HMFA) and the Department of Human Services (DHS) have 

recently entered into a new agreement for the NJ JMFA to operate 

a housing clearinghouse, Supportive Housing Connection (SHC). 

The SHC will manage an array of existing and new state-funded 

housing subsidies and the 811 PRA rental subsidies (should 

New Jersey be awarded 811 PRA subsidies) for people with 

behavioral health disorders and people with I/DD, coordinating services across these different groups. DHS has also 

centralized the oversight of housing, tenant selection, and referrals for these two populations into an Office of Housing. DHS 

initiated this agreement to (1) meet their goals for giving priority 

and expanding choices for individuals who are exiting institutions, and (2) separating housing and services so choice of 

housing is not dependent on required services but instead on 

a consumer-driven choice model. To manage rental subsidies 

and deliver services under a single contract, 45 providers are 

under contract with the DHS behavioral health division. This 

agreement maximizes resources but more importantly is being 

designed to reduce the time between people being referred and 

getting access to quality housing units, establishing priorities 

and giving people more choices of providers and housing. The 

NJ HMFA has the ability to attract more quality private rental 

resources because of their role in financing affordable housing.

Other states and local communities are taking steps to provide 

better housing access to individuals across multiple disability 

groups. Washington State is focusing their 811 PRA subsidies 

on individuals being identified through their Money Follows 

the Person (MFP) program and Maryland is demonstrating 

how strong state leadership can be the driving force to create 

a strong coordinated outreach system to improve access to 

private market housing.

The Georgia Department of Community Affairs (DCA) took a 

major step to prioritize its fair marketing approach. Using its 

QAP as a tool and policy, DCA is requiring each project selected 

for an award of LIHTCs to submit and have approved an Affirmatively Furthering Fair Housing marketing plan, outlining 

how each new LIHTC project will market units to underserved 

tenants, including tenants with multiple disabilities. The marketing plans must adhere to a number of requirements, including 

(1) outreach efforts to each service provider, homeless shelter 

or local disability advocacy organization in the county in which 

the project is located; (2) a strategy to establish and maintain 

relationships between the management agent and community 

service providers; (3) a referral and screening process that will 

be used to refer tenants to the housing, and to make reasonable 

accommodations to facilitate the admittance of people with disabilities and the homeless into the program; and (4) marketing 

of properties to underserved populations 2 to 4 months before 

occupancy to ensure a quicker and smoother transition.

All these promising practices have the potential to improve 

housing access and decrease housing discrimination with people 

with PD-MI and I/DD, specifically with people who are experiencing multiple disabilities and aging in place at the same time. 

These programs and sites also offer a rich groundwork for future 

housing access and discrimination research projects to compare 

the effectiveness and effect of these innovative programs with 

other sites that have not yet implemented these changes.
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Synthesis, Conclusions, and Implications for Future 

Housing Research

This critical appraisal of existing disability and aging research 

highlights the housing access needs and potential discrimination 

of a growing and significant population of people with PD-MI 

and I/DD who are living and aging with multiple disabilities 

and chronic conditions. This population includes three major 

groups.

1. People with PD-MI who have concurrent SUD, cognitive, 

physical, and age-related conditions and disabilities.

2. People with I/DD who have concurrent MI, SUD, physical, 

and age-related conditions and disabilities.

3. Adults older than age 60 who have the same set of concurrent disabilities and who are now aging with them 

and/or who newly acquire these disabilities after they 

become seniors.

The presence of multiple disabilities has been shown to influence overall function and independent living status, and ergo, 

also affect housing status, choice, and need for reasonable 

accommodations and supports within that housing. Although 

at the same time, given the Olmstead Decision and system policy changes emanating from it, these people represent the very 

groups whose rights to least restrictive community-living options with supports should be protected. This least restrictive 

community-living mandate is difficult to implement, however, 

particularly when it involves cross-cutting coordination of 

housing AND community-living supports across systems and 

policies which have traditionally been “siloed” or cordoned 

off to specific disability and age groups. In reality, this review 

shows the need for coordination among mental health, developmental disability, physical disability, and aging services, 

given the significant number of people who experience one 

or more of these functional issues and conditions at the same 

time. Of critical significance is the need for coordination 

across—

•	 Disability and age-related systems.

•	 Medicare and Medicaid Home and Community-Based 

Services Waivers and other community-living support 

programs.

•	 Affordable, accessible, and integrated housing systems and 

programs.

In addition, findings show that other key factors further complicate housing for people with multiple disabilities, including 

concurrent SUD or history of SUD, incarceration or criminal 

history, poor socioeconomic status and history of subsidized 

income, and homelessness. For a significant portion of the 

population of people with MD, these concurrent issues make 

rental housing access and potential discrimination related to it a 

very difficult challenge; however, we can expect to see growing 

numbers of people from this population attempting and wanting to move into integrated rental housing in the community. 

Therefore, this issue merits focused research to document 

the lived experiences of individuals with multiple disabilities, 

specifically related to accessing rental housing and expanding to 

also include home ownership.

To date, housing discrimination testing has not addressed the 

complex needs of these groups. As appropriate to the science, 

housing discrimination testing initially has focused on one 

specific disability group and held other variables constant, including age, socioeconomic status, and race/ethnicity, or has 

excluded individuals with multiple disabilities, SUD, or history 

of incarceration. Such a focus also increases the rigor of findings 

relative to legal issues of discrimination. As we move forward 

in studying the effect of housing on community living, health, 

participation, and quality of life, however, so too should the 

research also reflect the complexity of the lived experiences of 

people with multiple disabilities as they age and attempt to age 

in place in a community-living and housing situation of choice. 

More sophisticated multivariate group testing methodologies 

could begin to examine significant research questions related 

to the effect of multiple disabilities and related circumstances 

(for example, poverty, access to a housing voucher or home 

and community-based waiver, SUD history) on access to 

market-rate rental housing. For example, studies that compare 

the housing access and discrimination issues experienced by 

the following groups would appear to be indicated, given the 

statistics related to their occurrence.

1. People with PD-MI with and without SUD history.

2. People with I/DD with and without co-occurring PD-MI.

3. People with PD-MI and I/DD who experience physical and 

age-related disabilities and conditions as they age or as 

after they become older adults.
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4. People with PD-MI and I/DD who have adequate income 

to obtain market-rate rental housing compared with the 

same group who come in using housing vouchers or HBC 

waivers or compared with those who have none of these 

resources and attempt to go into rental housing living on 

subsidies or in poverty.

5. People with PD-MI and I/DD who receive coordinated

housing and community-living supports or who participate 

in demonstration and other systems change initiatives in 

their states and communities compared with those who 

live in communities that have not yet implemented these 

initiatives.

In addition to getting in the door[misplaced modifier; this sentence says that “research” is getting in the door—please rewrite 

for sense], research that documents the effect of coordinated 

housing and community-living supports on long-term maintenance of rental housing over time for people with PD-MI and I/

DD with multiple disabilities is also needed and may also document different discrimination issues that surface only in the 

long term or in light of emergencies, exacerbations, major life 

events, and aging. These issues and longitudinal qualitative and 

quantitative research related to them may also inform strategies 

to decrease premature or unwanted institutionalization, nursing 

home placement, and homelessness, societal issues that are 

experienced by a significant proportion of people with PD-MI 

and I/DD.
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STUDY OF RENTAL HOUSING DISCRIMINATION ON THE BASIS OF MENTAL DISABILITIES: SHORT PAPER 5

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Additional Reading

Corrigan, Patrick W., Vetta Thompson, David Lambert, Yvette 

Sangster, Jeffrey G. Noel, and Jean Campbell. 2003. “Perceptions 

of Discrimination Among Persons With Serious Mental Illness,” 

Psychiatric Services 54 (8): 1105–1110.

Fontaine, Jocelyn, and Jennifer Biess. 2012. Housing as a 

Platform for Formerly Incarcerated Persons. Washington, DC: 

Urban Institute, What Works Collaborative. http://www.urban.

org/uploadedpdf/412552-housing-as-a-platform-for-formerlyincarcerated-persons.pdf.

Forchuk, Cheryl, Geoffrey Nelson, and G. Brent Hall. 2006. 

“It’s Important To Be Proud of the Place You Live In: Housing 

Problems and Preferences of Psychiatric Survivors,” Perspectives 

in Psychiatric Care 42 (1): 42–52.

Jokinen, Nancy, Matthew P. Janicki, Seth M. Keller, Philip McCallion, Lawrence T. Force, and the National Task Group on 

Intellectual Disabilities and Dementia Practices. 2013. “Guidelines for Structuring Community Care and Supports for People 

With Intellectual Disabilities Affected by Dementia,” Journal of 

Policy and Practice in Intellectual Disabilities 10 (1): 1–24.

National Alliance on Mental Illness (NAMI). 2014a. “NAMI 

Housing Fact Sheet.” http://www.nami.org/Template.

cfm?Section=Issue_Spotlights&Template=/TaggedPage/

TaggedPageDisplay.cfm&TPLID=5&ContentID=15943.

———. 2014b. “State Mental Health Legislation 2014: 

Trends, Themes and Effective Practices.” http://www.nami.

org/getattachment/About-NAMI/Publications-Reports/PublicPolicy-Reports/2014NAMIStateLegislationReport.pdf.

National Alliance to End Homelessness. 2014. “Poor Health 

and Homelessness.” http://www.endhomelessness.org/pages/

mental_physical_health.

National Council on Disability (NCD). 2008. “Inclusive Livable 

Communities for People With Mental Illness.” http://www.ncd.

gov/publications/2008/03172008.

Newman, Sandra, and Howard Goldman. 2009. “Housing 

Policy for Persons With Severe Mental Illness,” Policy Studies 

Journal 37 (2): 299–324.

Rhine, Sarah S. 2009. “Criminalization of Housing: A Revolving 

Door That Results in Boarded Up Doors in Low-Income Neighborhoods in Baltimore, Maryland,” University of Maryland Law 

Journal of Race, Religion, Gender, and Class 9 (2): 333–371. 

https://litigation-essentials.lexisnexis.com/webcd/app?action=

DocumentDisplay&crawlid=1&doctype=cite&docid=

9+RRGC+333&srctype=smi&srcid=3B15&key=

aa675bd8892a4286400aaeb4b05a9bc2.

Roman, Caterina G. 2009. Moving Toward Evidence-Based 

Housing Programs for Persons With Mental Illness in Contact With 

the Justice System. Washington, DC: Center for Mental Health 

Services National GAINS Center, Substance Abuse and Mental 

Health Services Administration. http://gainscenter.samhsa.gov/

pdfs/ebp/MovingTowardEvidence-BasedHousing.pdf.

Substance Abuse and Mental Health Services Administration 

(SAMHSA). 2006. Transforming Housing for People With Psychiatric Disorders Report. Washington, DC: Substance Abuse and 

Mental Health Services Administration.

U.S. Department of Health and Human Services. 2013. 

“Results From the 2012 National Survey on Drug Use and 

Health: Mental Health Findings.” http://www.samhsa.gov/

data/sites/default/files/2k12MH_Findings/2k12MH_Findings/

NSDUHmhfr2012.htm#sec2-1.

Weisman, Robert L., J. Steven Lamberti, and Nancy Price. 2004. 

“Integrating Criminal Justice, Community Healthcare, and Support Services for Adults With Severe Mental Disorders,” Psychiatric Quarterly 75 (1): 71–85. http://link.springer.com.proxy.

cc.uic.edu/article/10.1023/B%3APSAQ.0000007562.37428.52.

World Health Organization (WHO). 2012. “Dementia Fact 

Sheet.” http://www.who.int/mediacentre/factsheets/fs362/en/.