OLDER ADULT 

HOUSING

Future Collaborations 

on Housing and 

Health Services 

Should Include 

Relevant Agencies 

and Define Outcomes 

Report to the Ranking Member, 

Committee on Financial Services, 

House of Representatives

April 2018

GAO-18-232

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-18-232, a report to the 

Ranking Member, Committee on Financial 

Services, House of Representatives

April 2018

OLDER ADULT HOUSING

Future Collaborations on Housing and Health 

Services Should Include Relevant Agencies and 

Define Outcomes 

What GAO Found

The Departments of Housing and Urban Development (HUD) and Health and 

Human Services (HHS) have collaborated on older adult housing and health 

issues, but these efforts did not fully demonstrate leading practices GAO 

identified for effective collaboration. 

• The HUD-HHS efforts demonstrated some leading practices. For example, 

the agencies have written agreements for data-sharing projects and have 

leveraged resources to conduct research on older adults.

• The Department of Agriculture (USDA) was not included in the efforts 

although it provides housing assistance to older rural households. GAO

identified the inclusion of all relevant participants as a leading practice. 

According to HUD, the efforts were intended to explore the health of HUDassisted households. However, by not including USDA in future 

collaborations, HUD and HHS may miss opportunities to leverage expertise

and USDA may not be able to benefit from any resulting insights and 

improvements.

• The HUD-HHS collaborative efforts also did not define common outcomes, 

another leading practice GAO identified, likely because their collaboration is

relatively new. Without common outcomes (for instance, focused on recipient 

impact or cost savings), the agencies lack measures against which to 

monitor, evaluate, and report the results of any collaborations.

Future collaborations would benefit from consistent USDA involvement. And by 

defining common outcomes, the agencies would help inform Congress and 

stakeholders of results achieved and strategies or areas on which to focus.

Historical and Projected Population 65 and Older as a Proportion of Total Population, 1900-

2050

View GAO-18-232. For more information, 

contact Daniel Garcia-Diaz at (202) 512-8678 

or garciadiazd@gao.gov.

Why GAO Did This Study

According to the Census Bureau, by 

2030, about 1 in 5 Americans will be 

65 and older. This aging of the 

population presents challenges and 

opportunities for policymakers and 

service providers in helping ensure that 

the older population’s needs—

including housing and health 

services—are met. Federal agencies 

with programs that provide housing 

assistance to low-income older 

households include HUD and USDA. 

Several HHS programs provide those 

households with health services. 

This report assesses the extent to 

which the three agencies collaborated

to address the housing and health 

service needs of older adults living in 

federally assisted housing.

GAO compared agency efforts to

leading collaboration practices it has 

identified (including written 

agreements; roles and responsibilities;

leveraged resources; relevant 

participants; and defined outcomes)

and interviewed HUD, HHS, and USDA 

officials.

What GAO Recommends

GAO is making three 

recommendations (one each to HUD, 

HHS, and USDA). They focus on 

including USDA in collaborations on

older adult housing and health services 

and defining outcomes for the efforts.

The three agencies concurred with 

GAO’s recommendations. HUD stated 

that it had begun examining challenges 

relating to services for low-income rural 

older adults.
Page i GAO-18-232 Older Adult Housing

Letter 1

Background 3

Collaboration on Housing Assistance and Health Services for 

Older Adults Did Not Include USDA or Define Common 

Outcomes 8

Conclusions 15

Recommendations for Executive Action 15

Agency Comments and Our Evaluation 15

Appendix I Comments from the Department of Health and Human Services 18

Appendix II Comments from the Department of Housing and Urban Development 20

Appendix III GAO Contact and Staff Acknowledgments 20

Contents
Page ii GAO-18-232 Older Adult Housing

Abbreviations

FHA Federal Housing Administration

HHS Department of Health and Human Services

HUD Department of Housing and Urban Development

USDA U.S. Department of Agriculture

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

copyrighted images or other material, permission from the copyright holder may be 

necessary if you wish to reproduce this material separately.
Page 1 GAO-18-232 Older Adult Housing

441 G St. N.W.

Washington, DC 20548

April 26, 2018

The Honorable Maxine Waters

Ranking Member

Committee on Financial Services

House of Representatives

Dear Ms. Waters:

The Census Bureau projects that by 2030, about 74 million people (nearly 

21 percent of the U.S. population) will be 65 and older—up from 49 

million (15 percent) in 2016 and 35 million (12 percent) in 2000. This 

growth presents challenges as well as opportunities for policymakers and 

service providers in planning for and helping to address the needs of the 

older population, including housing and health services.1 Researchers 

predict a shortage over the next two decades of housing suitable for the 

needs of older people.

A number of federal programs assist older households with housing. The 

Department of Housing and Urban Development (HUD) and the 

Department of Agriculture (USDA) administer housing programs to assist 

older households through rental subsidies, home loans, loan guarantees, 

and mortgage insurance.2 Many of these programs serve the most 

economically insecure older adults by allowing them access to adequate 

and affordable housing. While it does not administer housing programs, 

the Department of Health and Human Services (HHS) funds health 

services for older adults through the Medicare and Medicaid programs, 

 1

In this report, we use the term “health services” to include long-term services and 

supports that may allow older persons to live independently, such as assistance with 

activities of daily living, and routine wellness or preventive health services.

2

The Department of Health and Human Services (which has primary responsibility for 

programs serving the aging population) uses “older adults” to refer to individuals aged 65 

and older. However, 62 is the age of eligibility for most federal housing programs 

designated for elderly households.

Letter
Page 2 GAO-18-232 Older Adult Housing

and a range of home and community-based services through the Older 

Americans Act of 1965 and Medicaid.3

At the same time that the older population is growing, programs that 

target or serve a significant number of older adults are challenged in a 

number of ways. For example, housing assistance programs have lost 

housing stock. In addition, a significant number of federally assisted units 

are occupied by older households that often receive health care and other 

services from different agencies than those providing the housing 

assistance. In this context, programs may face challenges with planning, 

researching, and collaborating across multiple agencies.

Under the authority of the Comptroller General, this report assesses the 

extent to which selected federal agencies collaborate to address the 

housing needs of an aging population living in federally assisted housing. 

This is the first of two reports that examine issues related to housing for 

older adults, including those who are low-income. The second report will 

address future demand for housing by older households and older adults’

housing-related needs.

For this report, we examined housing programs that target or serve a 

significant number of older adults and are administered by HUD and 

USDA’s Rural Housing Service, two agencies that provide housing 

assistance to renters and homeowners.4 We reviewed program 

regulations; our prior reports; Congressional Research Service reports; 

other agency documents; and reports and studies related to housing a 

growing older population. According to research studies, housing can 

serve as a platform for overall well-being and for health services for older 

adults, and access to health services can be integral to aging in place.5

Thus, we reviewed documentation on relevant collaborations involving 

HUD, USDA, and HHS. We compared the efforts to leading collaboration 

 3

Home and community-based services funded under Title III of the Older Americans Act 

are available to anyone 60 or older, but are to be targeted to those with greatest economic 

or social need. In 2015, we reported on funding for and delivery of home and communitybased services and supports to older adults. See GAO, Older Adults: Federal Strategy 

Needed to Help Ensure Efficient and Effective Delivery of Home and Community-Based 

Services and Supports, GAO-15-190 (Washington, D.C.: May 20, 2015). 

4

The Rural Housing Service is a component of USDA’s Rural Development.

5

The Centers for Disease Control and Prevention defines aging in place as the ability to 

live in one’s own home and community safely, independently, and comfortably, regardless 

of age, ability, or income.
Page 3 GAO-18-232 Older Adult Housing

practices identified in our prior work.6 To describe any goals related to 

older adults, we reviewed HUD’s and USDA’s strategic plans for fiscal 

years 2014–2018, and an HHS (Administration for Community Living) 

strategic plan for fiscal years 2013–2018.7 We also interviewed and 

obtained documentation from HUD, USDA, and HHS officials on their 

programs, goals, and ongoing collaborations.

We conducted our work from April 2015 to April 2018 in accordance with 

generally accepted government auditing standards. Those standards 

require that we plan and perform the audit to obtain sufficient, appropriate 

evidence to provide a reasonable basis for our findings and conclusions 

based on our audit objectives. We believe that the evidence obtained 

provides a reasonable basis for our findings and conclusions based on 

our audit objectives.

Older adults may receive federal housing assistance through a number of 

programs, but only a few programs specifically target older households. 

To be eligible for those programs, the head of household or spouse must 

be 62 or older.

HUD has two programs specifically targeted to older households—the 

Supportive Housing for the Elderly (Section 202) program for renters and 

the Home Equity Conversion Mortgage program for homeowners.

• HUD’s Section 202 program is the only program that provides 

supportive housing targeted to very low-income older adults.8

Supportive housing is defined as non-institutionalized housing that 

 6

GAO, Managing for Results: Key Considerations for Implementing Interagency 

Collaborative Mechanisms, GAO-12-1022 (Washington, D.C.: Sept. 27, 2012).

7

This is the first strategic plan for the Administration for Community Living, which HHS 

created in 2012. The two major components within the Administration for Community 

Living are the Administration on Aging and the Administration on Intellectual and 

Developmental Disabilities.

8

According to HUD officials, Section 202 properties reserve a limited number of units for 

disabled persons under age 62. Prior to HUD’s Supportive Housing for Persons with 

Disabilities (Section 811) program being established, low-income disabled persons 

became eligible to participate in the Section 202 program.

Background

Federal Housing 

Programs That Assist 

Older Adults

Programs Targeting Older 

Households
Page 4 GAO-18-232 Older Adult Housing

connects residents with the services they need to live independently, 

such as in-home care, meal delivery, and transportation.9 Until fiscal 

year 2012, the Section 202 program funded the development of new 

units.10

• The Home Equity Conversion Mortgage program, administered by the 

Federal Housing Administration (FHA), a component of HUD, allows 

older homeowners to access FHA-insured mortgages to convert some 

of the equity in their homes into monthly streams of income or lines of 

credit (reverse mortgage). In addition to being at least 62 years old, 

borrowers must occupy the property as a principal residence, and any 

existing lien on the property must be small enough to be paid off at 

settlement. In a reverse mortgage, the loan balance increases and 

home equity decreases over time. As the borrower receives payments 

from the lender, the lender adds the principal and interest to the loan 

balance, reducing the homeowner’s equity.11 The homeowner 

remains responsible for paying insurance and property taxes.

The Rural Housing Service has one homeownership program that 

specifically serves households aged 62 and older. The Section 504 Rural 

Home Repair and Rehabilitation Grant program finances the removal of 

health and safety hazards or remodels dwellings to make them accessible 

for disabled household members. According to USDA officials, grants 

often are made in conjunction with Section 504 loans that have a 1 

percent interest rate.

 9

HUD also funds supportive service programs for residents of HUD-assisted properties 

who are either elderly or disabled. They are the Congregate Housing Services, Multifamily 

Housing Service Coordinator, and Resident Opportunity and Self-Sufficiency programs.

10HUD’s Section 202 program was established by Section 202 of the Housing Act of 1959. 

Pub. L. No. 86-372, § 202, 73 Stat. 654, 667 (1959) (codified as amended at 12 U.S.C. 

1701q). Since 1991, the program has provided capital advances and rental assistance to 

private nonprofit organizations to build housing that is affordable to very low-income 62-

and-over households. In fiscal year 2011, Congress appropriated approximately $100 

million for new units, a reduction from previous years’ appropriations of more than $500 

million. From fiscal years 2012 through 2016, appropriations were primarily for renewing 

existing properties’ rental assistance and service coordinator contracts. However, in fiscal 

year 2017, Congress provided $10 million of the program’s annual appropriation to be 

used for capital advance and project-based rental assistance awards or for incremental 

senior preservation rental assistance contracts. According to HUD officials, as of March 

2018, HUD was in the process of finalizing a spending plan for the funds, which would 

include issuing a Notice of Funding Availability for competitive grant awards.

1112 U.S.C. § 1715z-20.
Page 5 GAO-18-232 Older Adult Housing

HUD has rental assistance programs that do not target, but serve a 

significant number of older households. According to HUD officials, 

HUD’s primary rental assistance programs, including the Housing Choice 

Voucher, Public Housing, and Project-Based Section 8 programs, serve 

nearly 1.5 million such households. In addition, FHA’s Section 221(d)(3) 

and Section 221(d)(4) Multifamily Rental Housing for Moderate-Income 

Families provide mortgage insurance to finance multifamily properties, 

some of which may be designated for the elderly. The HOME Investment 

Partnerships Program provides formula grants to states and localities that 

communities use to fund a range of activities including building, 

purchasing, and rehabilitating affordable housing for rent or 

homeownership or providing direct rental assistance to low-income 

households.12

Similarly, the Rural Housing Service administers a number of 

homeownership and rental programs not targeted to older rural 

households, but that can serve them. They include the Section 502 Rural 

Direct Home Loan; Section 502 Home Loan Guarantee; Section 504 

Rural Housing Repair and Rehabilitation Loan; and the Section 521 Rural 

Rental Assistance programs. The Section 521 program provides rental 

subsidies to low-income, elderly, or disabled households living in 

properties funded by the Section 515 Rural Rental Housing program and 

others.13

Finally, the Low-Income Housing Tax Credit, established under the Tax 

Reform Act of 1986 and administered by the Internal Revenue Service, is 

the largest source of federal assistance for developing affordable rental 

housing for low-income households, including elderly households, and as 

of 2017, had financed about 2.9 million rental units. It provides tax credits 

to encourage private-equity investment in affordable housing 

development.

 1242 U.S.C. § 12701 et seq. HUD also administers block grant programs, including the 

Community Development Block Grant and Indian Housing Block Grant, which states and 

metropolitan cities and Native American tribes, respectively, may use to address 

affordable housing and other economic or community development priorities. 42 U.S.C. § 

5301 et seq.; 42 U.S.C. § 4101 et seq.

13Section 515 provides direct loan financing for family, elderly, congregate, or group home 

properties. In addition to Section 515 residents, the Section 521 program also subsidizes 

rental assistance for residents of properties funded by USDA’s Section 514 and Section 

516 Farm Labor Housing loan and grant programs, respectively. According to USDA 

officials, Farm Labor Housing properties can house retired farm workers.

Other Programs That Can 

Serve Older Households

HUD Public Housing Designated for Older 

Households

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 only 

by elderly families, by disabled families, or 

both. HUD refers to this as “designated public 

housing”. 42 U.S.C. § 1437e. However, HUD 

officials stated that HUD had fewer than 

40,000 units of designated public housing and 

the majority of elderly persons were not 

assisted through such housing.

Source: Department of Housing and Urban Development 

(HUD). | GAO-18-232
Page 6 GAO-18-232 Older Adult Housing

In recent years, HUD and USDA have lost subsidized housing stock. 

Losses can happen under several scenarios, including when federal 

rental assistance contracts expire, federally subsidized mortgages reach 

maturity or are paid off and owners convert the units to market-rate 

rentals, or units fall into disrepair. In its fiscal year 2014–2018 strategic 

plan, HUD reported that its public housing stock faced a capital needs 

backlog, estimated at $26 billion, which would be difficult to meet given 

federal fiscal constraints.14 The decreasing supply of adequate affordable 

housing may affect older low-income renters (see sidebar), who were well 

represented in HUD- and USDA-assisted housing.15

In addition to losing housing stock, HUD and USDA have programs that 

previously added to the supply of affordable housing but no longer do so. 

One example is HUD’s Section 202 program, which specifically serves 

very low-income older adults. Except for $10 million in its fiscal year 2017 

appropriation that could contribute to capital advances, since fiscal year 

2012, the program has primarily funded contract renewals for existing 

rental assistance and for service coordinators.16 According to USDA 

officials, the Section 515 program (direct loans for multifamily housing) 

had no funds for new construction. They told us that Section 515 funds 

almost exclusively were being used for unit rehabilitation, and that only 

the Section 538 loan guarantee program was funding new construction.17

According to USDA officials, many of the rehabilitated Section 515 

 14Department of Housing and Urban Development, Strategic Plan 2014-2018

(Washington, D.C.: April 2014). 

15According to HUD, in 2016, 32 percent of HUD-assisted rental units (1.6 million) were 

occupied by 62-and-older households. This number includes older households assisted by 

eight multifamily housing programs that HUD tracks in its Picture of Subsidized 

Households dataset, including the Section 202, Project-Based Section 8, and Housing 

Choice Voucher programs. In 2016, according to USDA, 20.7 percent of USDA-assisted 

rental units (89,183) were occupied by 62-and-older households. This number includes 

older households assisted by the Section 521 Rural Rental Assistance program.

16In 2016, we reported on HUD’s oversight of efforts by Section 202 properties to link

older residents to services. See GAO, Elderly Housing: HUD Should Do More to Oversee 

Efforts to Link Residents to Services, GAO-16-758 (Washington, D.C.: Sept. 1, 2016).

17The Section 538 program provides a loan guarantee to finance multifamily housing for 

low- and moderate-income households in rural areas. According to USDA officials, some 

Section 538 properties may be designated as elderly or family properties, and as of 

September 30, 2017, 260 loans had been made on elderly designated properties under 

the Section 538 program.

Supply of Federally 

Assisted Housing

Worst-Case Needs for Rental Housing

HUD tracks older adults in its biennial Worst 

Case Housing Needs report. HUD defines 

households with worst-case needs as very 

low-income renters who do not receive 

government housing assistance and paid 

more than half of their income for rent, lived in 

severely inadequate conditions, or both. The 

latest report (2017) indicated that severe 

housing problems were on the rise among 

unassisted renter households in 2015. This 

included older renters, for whom the number 

and proportion of households with worst-case 

needs increased from 2013, by 382,000 and 

2.6 percentage points, respectively. In 2015, 

1.85 million such households experienced 

worst-case housing needs, including 

unaffordable rents. The report noted that lowincome older households that rely on fixed 

incomes rather than wages may be less likely 

to benefit from economic recovery trends that 

raised incomes for others in recent years.

Source: Department of Housing and Urban Development 

(HUD). | GAO-18-232
Page 7 GAO-18-232 Older Adult Housing

properties are described in loan applications as properties serving the 

elderly, as are some newly constructed properties funded by the Section 

538 program.

Federal and other entities have reported on a lack of integration among 

housing and health programs and services and the benefits of closing 

gaps.

• In 2002, the congressionally mandated Commission on Affordable 

Housing and Health Facility Needs for Seniors in the 21st Century 

reported that a lack of integration between housing and health care for 

older adults resulted in inefficiencies, noting that the basis was partly 

historical differences in policies, funding systems, and regulatory 

structures.18 The Commission found that, with few exceptions, older

adults obtained their housing from one source and health care and 

supportive services from a different source.

• In July 2015, the White House Conference on Aging highlighted the 

importance of collaboration across sectors and the need to better 

integrate housing, transportation, health care, and long-term services 

and supports to encourage healthy aging. It noted that opportunities 

existed to leverage approaches taken by states and localities to 

consider how best to serve older adults.19

• In 2016, the Bipartisan Policy Center’s Health and Housing Task 

Force reported that bridging the current policy gap between housing 

and health had the potential to provide a number of benefits, including 

improving health outcomes for older adults, reducing costs incurred by 

the health care system, and enabling many older adults to age in their 

own homes and communities.20

• Senior leadership in HUD’s Office of Policy Development and 

Research recently amplified the discussion about housing and health, 

noting that the Housing Act of 1937 recognized the linkage between 

 18Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st 

Century, A Quiet Crisis in America (Washington, D.C.: June 30, 2002).

19The 2015 White House Conference on Aging, Final Report (Washington, D.C.: 2015).

20Bipartisan Policy Center, Healthy Aging Begins at Home (Washington, D.C.: May 2016).

Reports on Integration of 

Housing and Health 

Services
Page 8 GAO-18-232 Older Adult Housing

the two.21 That office also has observed that efforts to better link 

housing and health services hold promise to improve the ability of 

older adults to safely, comfortably, and more affordably age in place.

Collaborations that were focused on coordinating housing and health 

services for older adults involved HUD and HHS. While these 

collaborations demonstrated some leading practices we identified, they 

did not include USDA (a relevant participant) and did not define common 

outcomes for these efforts.

USDA has collaborated with HUD on two efforts related to housing, and 

with HUD and HHS on one effort that addressed both housing and health 

services, although these efforts were not focused specifically on older 

adults. Officials at HUD and USDA told us that they primarily collaborated 

on administrative initiatives through the Rental Policy Working Group.22

For example, in 2016, HUD, USDA, and the Department of the Treasury 

entered into a memorandum of understanding to formalize the activities of 

the Rental Policy Working Group, such as reducing duplicative physical 

unit inspections at properties assisted by one or more of the agencies. 

While older renter households may benefit from administrative 

improvements made through the Rental Policy Working Group, its efforts 

were not intended to focus on any particular household type served by 

HUD and USDA. Under a 1991 memorandum of understanding, HUD and 

 21Department of Housing and Urban Development, Office of Policy Development and 

Research, “Health, Housing, and Data Matching,” PD&R Edge (Washington, D.C.: Dec. 

11, 2017), accessed on January 9, 2018, at https://www.huduser.gov/portal/pdredge/pdredge-frm-asst-sec-121117.html.

22The Rental Policy Working Group was established in 2010 by the White House 

Domestic Policy Council. Its participants include the Domestic Policy Council, HUD, 

USDA, Treasury, the National Economic Council, and the Office of Management and 

Budget. We previously discussed the Rental Policy Working Group as one of four federal 

interagency groups that exhibited some of the practices that we identified can enhance 

and sustain collaboration. See GAO-14-220.

Collaboration on 

Housing Assistance 

and Health Services 

for Older Adults Did 

Not Include USDA or 

Define Common 

Outcomes

USDA, HUD, and HHS 

Collaborated on Some 

Housing and Health 

Service Efforts That Did 

Not Focus on Older Adults
Page 9 GAO-18-232 Older Adult Housing

USDA also are required to coordinate where both agencies’ rental 

programs could overlap in serving rural families.23

In 2016, USDA started participating in interagency training intended to 

help coordinate the provision of home and community-based services and 

supports to vulnerable populations, including older adults. The training 

was initiated by HHS, and since 2011, HHS and HUD have conducted it 

for program staff as part of their efforts to strengthen cross-agency 

collaboration. In 2017, the 1-day training session focused on housing as a 

platform for improving the quality of life of persons with disabilities, older 

adults, and other at-risk populations. USDA participated in a discussion 

on housing and health collaboration between federal, state, local, and 

community partners. Representatives of both HUD and HHS said that 

USDA’s increased participation had been positive. HUD officials also told 

us that in 2018, the agenda for the 1-day training would focus on housing 

and health supports for older and disabled persons living in rural areas.24

Additionally, in 2016, HUD and USDA began coordinating on developing 

topics for HUD’s research agenda. Specifically, HUD’s Office of Policy 

Development and Research develops a research agenda with input from 

external stakeholders, and both HUD and USDA officials told us of efforts 

to develop rural housing topics for inclusion in HUD’s research. HUD 

Policy Development and Research officials stated that HUD conducted 

extensive research in rural areas and was interested in coordinating more 

with USDA, though this research has not been specific to older adult 

issues.25 In response to HUD’s outreach, USDA submitted topics to HUD, 

some of which were incorporated into HUD’s 2017 research agenda 

update. They include the relationship between housing, food, and health 

and the impact of home equity loss on rural homeowners, particularly 

those who are aging.

 23According to HUD officials, HUD and USDA housing assistance typically overlapped 

only when HUD provided rental assistance to households living in developments funded 

by USDA’s Section 515 program. They said that HUD also had funded community 

buildings such as a computer lab at USDA-funded developments. HUD officials told us 

that, as of August 2017, HUD was providing project-based Section 8 rental assistance to 

approximately 50,000 households living in properties funded by USDA’s Section 515 

program.

24Other federal entities such as the U.S. Interagency Council on Homelessness and the 

Department of Justice have attended the training sessions.

25USDA’s principal research entities, the Agricultural Research Service and Economic 

Research Service, generally do not conduct housing studies. 
Page 10 GAO-18-232 Older Adult Housing

HUD and HHS have undertaken multiple collaborative efforts that link 

data on housing and health services and often have focused on older

adults.

• The Support and Services at Home demonstration was launched in 

2011 to connect older residents of affordable housing properties with 

home and community-based supportive services and promote health 

care coordination. The latest evaluation report was published in 

January 2016 and described the program’s ongoing implementation 

and impact from 2011 through 2014. It found lower rates of growth in 

Medicare expenditures among program participants than among a 

comparison group.26 As of August 2017, HUD representatives told us 

that the departments were still collaborating on evaluating the 

demonstration.

• Data sharing between HUD and HHS on another demonstration 

program—the Supportive Services Demonstration for Elderly 

Households in HUD-Assisted Multifamily Housing—began in 2014. 

Like the Support and Services at Home demonstration, the Supportive 

Services Demonstration is intended to test aging-in-place models that 

show potential for delaying or avoiding the need for nursing home 

care. HUD has been conducting a 4-year, two-part evaluation, which 

includes an evaluation of the implementation process and an impact 

evaluation that will match Medicare claims data from HHS’s Centers 

for Medicare and Medicaid Services and HUD administrative data. 

HUD and HHS completed a pilot of the data match in 2014, and HUD 

has submitted two semi-annual reports to Congress on program 

implementation, the latest in May 2017. HUD officials stated that in 

October 2017, HUD secured a contract to conduct a full evaluation of 

the Supportive Services Demonstration, as described above. 

According to the officials, the demonstration implementation team 

conducted an in-person, 2-day training event for care coordination 

teams in November 2017.

• The National Center for Health Statistics at the Centers for Disease 

Control and Prevention, also a component of HHS, in 2014 began to 

link national health survey participant data to HUD administrative data 

covering HUD’s largest housing assistance programs through 2014. 

The data linkage is intended to help those agencies and other federal 

 26Department of Health and Human Services, Support and Services at Home (SASH) 

Evaluation: Second Annual Report (Washington, D.C.: January 2016).

HUD and HHS Have Had 

Several Collaborations on 

Services and Data Sharing 

for Older Adults
Page 11 GAO-18-232 Older Adult Housing

entities and researchers complete independent projects for statistical 

and research purposes. The first linkage included two household 

surveys (National Health Interview Survey and National Health and 

Nutrition Examination Survey) that covered 1999–2012 and it was 

completed in July 2016. HUD officials told us that HUD and HHS were 

working on the second data linkage project. HHS confirmed that the 

second linkage was underway as of February 2018, with an expected 

completion date of summer 2018. It will add survey years 2013–2016 

and administrative data years through 2016. While the project was not 

focused specifically on older adults, it could include a significant 

proportion of older adults living in non-institutionalized settings who 

receive housing assistance from HUD.

• HHS’s Office of the Assistant Secretary for Planning and Evaluation 

and HUD completed a study on health care utilization among HUDassisted older adults in 12 jurisdictions, and published a final report in 

August 2016.27 The study, which began in 2009, explored the 

feasibility of matching administrative data from HUD and HHS’s

Centers for Medicare and Medicaid Services to determine if doing so 

could help track housing and health outcomes, and reliably support 

future research and policy analysis. More specifically, it linked HUD 

individual tenant-level data to Medicare and Medicaid beneficiary 

enrollment, payment, and claims data. In the 2016 report, HHS and 

HUD found that, controlling for previously identified factors, HUDassisted dual Medicare-Medicaid beneficiaries were less likely to use 

some Medicare-covered services such as acute hospital stays, but 

more likely to use Medicaid-covered home and community-based 

supportive services. According to the report, the study demonstrated 

that linking the agencies’ data could inform decisions about future 

program investment.

We found that the collaborative efforts between HUD and HHS (pilot 

programs and data sharing related to older adults) demonstrated some 

but not all relevant leading practices we previously identified for effective 

interagency collaboration. As we reported in 2012, interagency 

collaborative mechanisms can be enhanced by leading practices, 

including written guidance and documenting agreements on how the 

participating agencies will be collaborating, clarifying roles and 

 27Department of Health and Human Services, Picture of Housing and Health Part 2: 

Medicare and Medicaid Use among Older Adults in HUD-Assisted Housing, Controlling for 

Confounding Factors (Washington, D.C.: August 2016).

Select Collaborations Did 

Not Include USDA or 

Define Common 

Outcomes
Page 12 GAO-18-232 Older Adult Housing

responsibilities, leveraging resources (such as funding and staffing), 

including all relevant participants, and clearly defining outcomes.28

HUD and HHS established interagency agreements or memorandums of 

understanding for collaborative efforts that focused on or included older 

adults. For example, HUD and HHS entered into a memorandum of 

understanding for the National Center for Health Statistics data linkage 

effort and had contracts for the Support and Services at Home 

demonstration and other collaborations. Our leading collaboration 

practices state that agencies articulating their agreements in formal 

documents can strengthen their commitment to working collaboratively, 

as long as they are continually updated and monitored.

The roles and responsibilities of agencies participating in a collaborative 

effort may be defined in a number of ways, including through laws, 

policies, memorandums of understanding, or other requirements. Clarity 

of roles and responsibilities allows participating agencies to understand 

and agree on accountability for the joint effort, and a process for making 

and enforcing decisions. In accordance with their memorandum of 

understanding, HUD and HHS had clear roles and responsibilities for the 

National Center for Health Statistics data linkage effort. For example, the 

agreement documented specific data that HUD was to provide to the 

National Center for Health Statistics and how the latter would attempt to 

link HUD’s data to its survey participant data. It also specified both 

agencies’ roles in data access, storage, and disposition.

Collaborating agencies should identify human, information technology, 

physical, and financial resources needed to initiate or sustain their 

collaborative effort. And it is important that the agencies leverage 

sufficient resources to accomplish their objectives. HUD’s and HHS’s 

written agreements generally included a description of how they would 

leverage each agency’s resources, including staffing, funding, and data. 

For the Support and Services at Home demonstration, HUD provided 

resources to help evaluate the program model, while HHS funded a 

wellness nurse who worked with a service coordinator to perform such 

tasks as assessing residents’ needs; identifying and coordinating service 

delivery; monitoring receipt and follow-through of services; and building 

and sustaining partnerships with providers.

 28GAO-12-1022. 

Written Guidance and 

Agreements

Roles and Responsibilities

Leveraging Resources
Page 13 GAO-18-232 Older Adult Housing

HUD and HHS, including their component agencies and offices, were the 

main participants in these collaborative efforts. HUD officials stated that 

USDA was not included because these collaborative efforts were pilots 

originally intended to better understand the health of households assisted 

by HUD.29 But no current plan exists to include USDA in such 

collaborative efforts in the future.

As these collaborative efforts mature, USDA, which provides assistance 

to low-income older adults in rural areas, may benefit from inclusion. 

Effective collaborative efforts benefit from having participants with the 

necessary knowledge, skills, and abilities to contribute to the outcomes of 

the collaboration. Officials at HUD and HHS said they were open to 

greater collaboration with USDA in the future. And while HUD has a 

presence in rural communities, USDA’s participation would allow the 

Rural Housing Service to provide input on and help address challenges 

that may be unique to rural older adults. By not including USDA in future 

collaborative efforts on older adult housing and health services, HUD and 

HHS may miss opportunities to identify and respond to the changing 

needs of some older adults living in federally assisted housing—such as 

by drawing on the experience and resources of the Rural Housing Service 

in serving rural populations.

30 In addition, USDA may miss opportunities 

to benefit from lessons learned or programmatic improvements that HUD 

and HHS might undertake as a result of their collaborations.

Although HUD and HHS have established specific objectives for their 

various evaluations and data-sharing initiatives, they have not defined 

common outcomes for these collaborative efforts. For example, while 

some of these efforts were expected to explore the housing and health 

relationship and inform more evidence-based program decisions, the 

agencies have not defined common outcomes for their interagency efforts 

as a whole. We reported that collaborating entities should determine 

whether they have clearly defined short-term and long-term outcomes, 

 29As previously stated, HUD may provide rental assistance to rural households, including 

those living in properties financed by USDA.

30HHS’s Administration on Aging and USDA’s Rural Development established a 

memorandum of understanding in 1990 to support joint efforts to improve coordination of 

programs serving the housing and service needs of rural elderly people. According to 

USDA officials, the agreement was intended to encourage field staff and networks to 

share information to better serve the elderly population in rural areas, and those efforts 

continue at a local level, with local aging resource agencies referring older homeowners to 

USDA for assistance. 

Relevant Participants

Outcomes
Page 14 GAO-18-232 Older Adult Housing

can track their progress, and whether they each have collaborationrelated performance standards against which to evaluate individual 

performance.

31

Such common outcomes could include both quantitative and qualitative 

information. For example, a set of measures against which to track and 

monitor their collaborations (including demonstrations, data matching, 

and studies) might include the extent to which hospital stays were 

reduced, as noted for the Support and Services at Home and Supportive 

Services demonstrations, or program costs saved. Monitoring and 

reporting such measures would provide greater transparency to agency 

and congressional decision makers about how these collaborative efforts 

have resulted in potential cost savings and other benefits across agency 

lines. A more long-term common outcome could include developing 

proposals for programmatic improvements that would leverage the 

lessons learned from the collaborative efforts.

Senior leadership at HUD has said that HUD considers the nexus of 

housing and health to be a priority for future work, and that federal 

agencies needed to continue finding ways to move beyond their 

programmatic scope to engage in more comprehensive, cross-cutting 

efforts. The official pointed to data-matching efforts with HHS as low-cost 

initiatives that could enhance HUD’s knowledge about the health status of 

assisted households and potentially inform cost-saving policies.32

Because many of their collaborative efforts began in the last 5 years and 

some remain ongoing, HUD and HHS may not have prioritized developing 

common outcomes that relate both to older adult housing and health 

services. In contrast, HUD and HHS have developed broader goals that 

relate to how they serve older adults.33However, without defined common 

 31GAO-12-1022.

32Department of Housing and Urban Development, Office of Policy Development and 

Research, “The Housing and Health Connection from the Data Side,” PD&R Edge

(Washington, D.C.: Sept. 8, 2014), accessed on January 11, 2018, at 

https://www.huduser.gov/portal/pdredge/pdr_edge_frm_asst_sec_090814.html.

33HUD implemented a new strategic goal of using housing as a platform to improve quality 

of life, and promoting health and housing stability among vulnerable populations was an 

objective under that goal. HUD officials noted that HUD was deliberate in including older 

adults as a vulnerable population. HHS’s Administration for Community Living has a 

strategic goal of enabling people with disabilities and older adults to live in the community 

through available and accessible high-quality, long-term services and supports.
Page 15 GAO-18-232 Older Adult Housing

outcomes to help guide ongoing and future efforts, HUD and HHS (and 

potentially USDA) lack measures against which to monitor, evaluate, and 

report the results of their collaborative efforts.

Federal agencies, particularly HUD and HHS, have found opportunities to 

collaborate in meaningful ways on services provided to older adults. But 

collaborative federal efforts to address the housing needs of older adults 

and tie into health services would benefit from consistent USDA 

involvement and from defining common outcomes. Greater USDA 

participation would result in a better nationwide assessment of the 

housing and health needs of older Americans who live in all federally 

assisted housing and leverage USDA’s expertise and resources in 

serving rural populations. Outcome information would help the agencies 

articulate to stakeholders and Congress the results the collaborations 

achieved; activities, strategies, or areas on which to focus in the future; 

and how scarce federal resources were leveraged and managed.

We are making a total of three recommendations (one recommendation 

each to HUD, HHS, and USDA):

The Secretary of Housing and Urban Development should work with HHS 

and USDA’s Rural Development to define common outcomes and identify 

opportunities to include USDA in future collaborative efforts on older adult 

housing and health services. (Recommendation 1)

The Secretary of Health and Human Services should work with HUD and 

USDA’s Rural Development to define common outcomes and identify 

opportunities to include USDA in future collaborative efforts on older adult 

housing and health services. (Recommendation 2)

The Assistant to the Secretary for Rural Development should work with 

HUD and HHS to define common outcomes and identify opportunities to 

include USDA in future collaborative efforts on older adult housing and 

health services. (Recommendation 3)

We provided a draft of this report for review and comment to HHS, HUD, 

and USDA. HHS and HUD provided written comments that are 

reproduced in appendixes I and II, respectively. USDA provided technical 

comments, which we incorporated as appropriate. All three agencies

concurred with our recommendations. The Deputy Administrator of

Conclusions

Recommendations for 

Executive Action

Agency Comments 

and Our Evaluation
Page 16 GAO-18-232 Older Adult Housing

Multifamily Housing Programs provided USDA’s concurrence in an e-mail 

dated April 11, 2018.

In its comment letter, HUD stated that our recommendation to include an 

additional agency in housing and health demonstrations is consistent with 

direction provided by the Senate Committee on Appropriations in fiscal 

year 2016.34 The committee directed HUD to partner with other federal 

agencies to pursue a service coordination demonstration in nonmetropolitan areas. HUD noted that the committee advised it not to delay 

existing demonstration efforts while a non-metropolitan component was 

being designed. HUD also stated that it convened an expert panel to 

better understand challenges to service coordination for low-income older 

adults in rural areas, and summarized the findings in a report. HUD said

further action on the panel report was contingent on funding availability 

and direction from appropriations committees. HUD stated that, in regard 

to our recommendation that additional federal agencies might benefit from 

data-linkage projects similar to its project with the National Center for 

Health Statistics, it would be pleased to offer assistance, guidance, and 

insights to other agencies. Our recommendation is that HUD work with 

HHS and USDA’s Rural Development to define common outcomes and 

identify opportunities to include USDA in future collaborative efforts on 

older adult housing and health services. This would include data sharing, 

service demonstrations, research, and other collaborations. Ongoing 

housing and health collaborations among HUD, HHS, and USDA would 

benefit from greater USDA involvement, which also would serve to 

enhance assessments of the housing and health needs of older 

Americans in federally assisted housing.

 34S. Rep. No. 114-75, at 132 (2015).
Page 17 GAO-18-232 Older Adult Housing

We are sending copies of this report to the appropriate congressional 

committees, the Secretary of Agriculture, the Secretary of Health and 

Human Services, the Secretary of Housing and Urban Development, and 

other interested parties. In addition, the report is available at no charge on 

the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact 

me at (202) 512-8678 or garciadiazd@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix III.

Sincerely yours,

Daniel Garcia-Diaz

Director, Financial Markets and Community Investment
Appendix I: Comments from the Department of 

Health and Human Services

Page 18 GAO-18-232 Older Adult Housing

Appendix I: Comments from the Department 

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

Health and Human Services

Page 19 GAO-18-232 Older Adult Housing
Appendix II: Comments from the Department 

of Housing and Urban Development

Page 20 GAO-18-232 Older Adult Housing

Appendix II: Comments from the Department 

of Housing and Urban Development
Appendix II: Comments from the Department 

of Housing and Urban Development

Page 21 GAO-18-232 Older Adult Housing
Appendix II: Comments from the Department 

of Housing and Urban Development

Page 22 GAO-18-232 Older Adult Housing
Appendix II: Comments from the Department 

of Housing and Urban Development

Page 23 GAO-18-232 Older Adult Housing
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 24 GAO-18-232 Older Adult Housing

Daniel Garcia-Diaz, (202) 512-8678 or garciadiazd@gao.gov

In addition to the contact named above, Paul Schmidt (Assistant Director), 

Bernice Benta-Jackson (Analyst in Charge), Abigail Brown, Stephen 

Brown, William Chatlos, Charles Culverwell, Kirsten Lauber, John McGrail, 

Marc Molino, Dae Park, Nadine Garrick Raidbard, Barbara Roesmann,

 Joseph Silvestri, and Jeff Tessin made key contributions to this report.

Appendix III: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(100096)
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