United States 

Department of Housing 

and Urban Development

and 

Japan 

Ministry of Land, Infrastructure, 

Transport and Tourism 

Urban Renaissance Agency

Aging in Place:

U.S. Case Studies
i 

Preface 

 

Since February 2017, the U.S. Department of Housing and Urban Development’s (HUD) Office of 

Policy Development and Research (HUD-PD&R) and the Japan Ministry of Land, Infrastructure, 

Transport and Tourism’s (MLIT) Policy Research Institute (MLIT-PRI), along with the Housing 

Bureau and Urban Renaissance Agency of Japan (UR), have held numerous joint research meetings 

focused on Aging in Place (AIP). The first two meetings were held in Washington, D.C. at HUD 

headquarters in February and June 2017. The third meeting was held at MLIT’s headquarters in 

Tokyo in December 2017. Delegations visited New York City, Baltimore, and Washington, D.C. in 

January 2018. A forum was held in San Francisco in October 2018 and in Los Angeles in June 2019. 

HUD researchers visited MLIT in September 2018. The most recent forum was held in Tokyo in 

February 2020. 

At the June 2017 meeting in Washington, D.C., Secretary Ben Carson of HUD; Minister ISHII Keiichi 

of MLIT; Maren Kasper, Executive Vice President of Ginnie Mae; and NAKAJIMA Masahiro, 

President of UR, signed a Memorandum of Cooperation (hereinafter referred to as the “MOC”). 

The MOC focuses on AIP among elderly citizens in both countries. In Japan, 28 percent of the 

population is age 65 or older with birthrates at an all-time low (7.5 per 1,000 of population in 

2017). In the U.S., 14 percent of the population is age 65 or older, and by 2030 the number is 

expected to increase to 19 percent. Each day in the United States, 10,000 citizens turn 65 years 

old. As in Japan, the United States is also experiencing record low birthrates (11.8 per 1,000 of 

population in 2017), marking the lowest birthrate in 30 years. The aging of the population presents 

both countries with a significant demographic shift and AIP housing challenges. 

In the United States and Japan, older adults prefer to age in place, remaining in their current 

homes or communities. In the United States, Naturally Occurring Retirement Communities 

(hereinafter referred to as the “NORCs”) and Villages are models of actively providing supportive

services for the elderly with organized networks of volunteer, corporate, and governmental 

stakeholders. In Japan, mixed communities with a focus on promoting multi-generational resident 

communities are models of efficient service delivery to the elderly. As such, the MOC’s initial focus 

on AIP and related housing and urban planning policies is an area of joint research that will benefit 

both countries.

To date, HUD-PD&R and MLIT-PRI have implemented joint projects that fully capture the spirit of 

the MOC. These activities described below represent a high level of engagement and evaluation 

exchanges between the MOC partner organizations.

A. Research exchanges at HUD headquarters where HUD-PD&R and PRI-MLIT identified a 

common research topic and began a process of focused exchanges of research and 

evaluation on AIP.

B. HUD-PD&R and MLIT-PRI provided briefings on the housing conditions facing the elderly 

in their respective countries, especially those in subsidized housing. These briefings 
ii

covered current policies regarding housing for the elderly as well as descriptions of 

supportive services delivery models in both countries.

C. Site visits of AIP supported housing and community development projects were 

conducted in the United States and Japan. HUD-PD&R and MLIT-PRI research and policy 

staff participated in site visit exchanges where supportive housing models were being 

implemented across a variety of housing and community contexts. These site visits, 

along with presentations by program staff with an understanding of the social, 

historical, and political context within which these AIP housing models were developed, 

provided both research teams with useful information for assessing their respective 

housing policy for elderly residents who desire to age in place. 

As the United States and Japan continue to engage in an exchange of research and policy 

activities focusing on AIP in their respective countries, each partner has outlined a set of 

activities that are desired for the upcoming year.

For HUD-PD&R:

HUD-PD&R would like to learn more about housing and community development strategies 

MLIT and/or its affiliates (including UR) are undertaking to support AIP.

i. HUD-PD&R would like to receive additional information on community development 

models implemented in Japan to foster AIP. For example, what are MLIT’s 

community planning considerations for AIP? Are there different considerations for 

very low-income elderly compared with low- to moderate-income elderly?

ii. HUD-PD&R would welcome information on the ease of access to services as well as 

the impact of more efficient services delivery on elderly residents in the UR’s “Mixed 

Community” developments that promote multi-generational resident communities 

in suburban rental developments and often include healthcare facilities, health and 

wellness centers, and easy access to high-quality grocery stores.

iii. HUD-PD&R would benefit from information on strategies to promote multigenerational communities. For example, what are the core components of national 

and local housing policy that promote multi-generational community development? 

What approach(es) were taken to garner local support? How was financing handled? 

That is, what role did both national and local government play in financing these 

types of community development projects?

iv. HUD-PD&R is interested in any developments on the Seven Eleven Japan local 

shopping support demonstration approach to supporting the delivery of healthy 

foods to seniors. 
iii

For MLIT and UR:

MLIT and UR would like to learn more about ongoing AIP research projects underway by HUD 

and/or its affiliates.

i. MLIT-PRI would like to receive background information about the U.S.’s NORCs and 

Village models of supportive services for older citizens, as well as the benefits of 

these models on the health and well-being of their members, including any 

research that has been published in peer-reviewed journals. Additionally, it would 

be worthwhile to acquire information about NORCs/Village formation, 

demographics of participants/residents, typical social supportive services provided, 

and membership fees. Finally, MLIT-PRI would appreciate any information about 

how NORCs/Villages are financed, common sustainability models, and forms of 

support from volunteer, corporate, and governmental stakeholders.

ii. MLIT-PRI would welcome updates on the status of PD&R’s Integrated Wellness in 

Supportive Housing (IWISH) demonstration. Ideally, MLIT-PRI would like to receive 

information on the subsidy mechanism, cost sharing, hiring and training process, 

and initial implementation experience.

iii. UR would like to learn more about initiatives in which private sectors (such as 

private enterprises, paid/non-paid volunteers, non-profit organizations) collaborate 

with public sectors (such as local governments and housing authorities) or 

neighborhoods to promote sustainable AIP by focusing on measures such as mutual 

aid and multi-generational interaction or any others, if applicable. UR would 

benefit from information on various concrete examples including the background 

of the initiatives, ideas/practices to sustain the initiatives, and outcomes (both 

positive and negative) of the examples.

iv. The Housing Bureau would welcome information on the status of HUD-PD&R’s 

recently awarded accessibility design grants.

A huge debt of gratitude is owed to Secretary Ben Carson (HUD), former Minister ISHII Keiichi 

and current Minister AKABA Kazuyoshi (MLIT), former Ambassador SASAE, and current 

Ambassador SUGIYAMA for their leadership and support for the ongoing research and policy 

exchange focusing on a topic of important social significance—the promotion of housing and 

community development efforts to support aging-in-place among elderly residents. Without 

their leadership and support, the activities performed under this MOC would not have 

happened with the level of collegial and thoughtful exchanges that have been experienced. This 

partnership has facilitated a knowledge exchange that transcends cultures and supports AIP in 

both the United States and Japan. 

We hope you find the following set of case studies informative. Again, we express our gratitude 

to our senior leadership, as well as collaborators within HUD-PD&R, MLIT, and UR.
iv

We look forward to the ongoing joint research and policy exchanges among HUD, MLIT, 

and UR. 

October 2020 

Mr. Seth Appleton

Assistant Secretary

Policy Development and Research (PD&R)

U.S. Department of Housing and Urban Development (HUD) 

Mr. SUMIMOTO Yasushi

President Policy Research Institute (PRI) 

Ministry of Land, Infrastructure, Transport and Tourism (MLIT) 
1 

Case Study One

Accessible Housing and Technology Research 

and Demonstration Grant Program

The current housing stock in the United States may not meet the needs of a growing and aging 

population. The majority of graying baby boomers desire to live in their homes and remain 

connected to important neighborhood social networks and cultural pastimes where they have a 

sense of belonging, companionship, and familial ties. This country, however, faces a challenge 

with providing housing that is suitable for those with physical impairments. It is often the case 

that homes may not be adaptable for persons with certain types of disabilities. As such, elderly 

persons may find it difficult to perform routine daily activities such as showering and cooking. 

In fact, according to the Centers for Disease Control (CDC), one in four U.S. adults, or about 61 

million Americans, have a disability that impairs their ability to perform daily activities. The 

most common of these disabilities is difficulty walking or climbing stairs. 

Immobility affects one in seven adults. For low-income families, or those with limited 

resources to move or make modifications to their existing homes, the challenge becomes 

that much greater. The following illustration provides the percentage of adults with functional 

disability types.1 

Percentage of Adults by Type of Functional Disabilities 

As more attention is focused on improving housing for seniors and those with disabilities, 

researchers are generating more evidence to demonstrate that the need for accessible housing 

has become urgent. These communities are voicing their concerns to policymakers as well. For 

1 https://www.cdc.gov/ncbddd/disabilityandhealth/infographic-disability-impacts-all.html, (May 8, 2019).
2 

example, in 2011, the American Housing Survey (AHS) included a module on accessibility that 

asked about the presence of 22 accessibility features in housing units and whether those 

features were used. The researchers found that one-third of housing is potentially modifiable, 

but only 0.15 percent is wheelchair accessible. The following exhibit provides a summary of the 

level of accessibility and prevalence.2 

Accessibility and Prevalence

The U.S. Department of Housing and Urban Development (HUD) established the Accessible 

Housing and Technology Research and Demonstration Grant Program in 2015 to address the 

housing needs of people wishing to age in place and for persons with disabilities. Through 

this program, HUD’s Office of Policy Development and Research (PD&R) issued research 

grants to study innovative practices in the design and construction of affordable, accessible, 

and aesthetically pleasing housing. Three grants were awarded in Fiscal Year 2017 to 

explore accessible design strategies for people living with various kinds of disabilities. 

The objective of these grants is for researchers to develop prototypical housing models 

that incorporate aesthetically pleasing design solutions that promote accessibility without 

sacrificing affordability. 

Now in the interim phase of the research, the analysts are currently exploring technological 

adaptations that can be made to existing housing that accommodates persons with various 

types of disabilities. The researchers are testing how well advancements in housing 

technologies respond to the needs of this population. The analysis is limited to the design and 

2 Bo’sher, Luke, Sewin Chan, Ingrid Gould Ellen, Brian Karfunkel and Hsi-Ling Liao. 2015. Accessibility of America’s Housing Stock: Analysis 

of the 2011 American Housing Survey (AHS), Multi-Disciplinary Research Team Report. Washington, DC: U.S. Department of Housing and 

Urban Development, Office of Policy Development and Research. https://www.huduser.gov/portal/publications/mdrt/accessibility-americahousingStock.html. 
3 

retrofitting of non-detached single-family homes, semi-detached townhomes, and structures 

with four or fewer residential units. The ultimate goal is to demonstrate how low-cost physical 

configurations and technological adaptations can be implemented in existing homes so that 

residents can remain in their homes for as long as possible. The modified housing should 

comply with accessible design standards, including the Uniform Federal Accessibility Standards 

or the 2010 Americans with Disabilities Act (ADA) Standards for Accessible Design.3 The total 

value of the Accessible Housing and Technology Research and Demonstration Grant Program 

was $2 million. The awards were given to Auburn University,4 the Home Innovation Research 

Labs,5 and University of Florida, Gainesville.6

Each grantee was required to: (1) conduct a review of the relevant literature, (2) convene an 

interdisciplinary advisory team (IAT) that represents a diversity of skills and expertise in housing 

design, (3) hold focus groups with users and caregivers, and (4) deliver a cost-benefit analysis of 

multiple approaches and designs which would make possible comparison of different 

approaches and methods. Each of the grants will use the information provided by its IAT and 

focus groups to develop affordable, aesthetically acceptable solutions for the common issues 

identified in the proceedings. 

Brief descriptions of each grant follow: 

Auburn University: Accessible and Affordable Design for Semi-Detached Housing. Auburn’s

Department of Architecture is partnering with the university’s Center for Disability Research 

and Policy Studies to offer an interdisciplinary team of architects, designers, construction 

professionals, smart home technologists, people with disabilities, and disability research and 

policy specialists. Their goal is to create new and adapted home designs, tested by people with 

certain disabilities. The research team is developing incentive-based policy recommendations 

and preparing tools and strategies for educating the public and the design/construction sector. 

The goal of this effort is to move beyond “study and design” to real change in home design and 

construction practices. 

Home Innovation Research Labs: Research, Prototype Testing, and Evaluation of 

Accessible Design Retrofits for Semi-Detached and Non-Detached Houses. Home Innovation 

Research Lab (Home Innovations) researchers are in the process of developing up to eight 

research-based prototype building configurations, rooms, or room features to be constructed in 

the lab, and design documents. If necessary, typical non-accessible configurations will be built 

first, followed by partial demolition and modification with the pre-determined accessibility 

solution being tested. The least-cost practicable approach will be used, such as a flexible, 

full-scale modeling system that uses moveable walls and non-working proxies for plumbing 

fixtures and accessory items for modification and repeated re-use. The process will be 

documented (notes, photos, video) for analysis of design results, costs and benefits, evaluation, 

training, and dissemination of results.

3 https://www.access-board.gov/guidelines-and-standards/buildings-and-sites/about-the-aba-standards/ufas 4 http://ocm.auburn.edu/newsroom/news_articles/2017/11/architecture,-design-and-construction-interdisciplinary-team-awarded-largest-hudgrant-in-auburn-university-history.php 5 https:/www.homeinnovation.com/hudaccessibilityretrofit/

6 http://www.shimberg.ufl.edu/
4 

University of Florida: Project Re-Envision at UF. The University of Florida’s Shimberg Center for 

Affordable Housing will develop a series of repurposed interior layouts and fixtures of 

prototypical small-scale attached housing (SSAH) for different occupant types to test for 

accessibility, aesthetics, and affordability using multiple assessment tools. Researchers will 

identify prototypical dwelling plans from a systematically gathered inventory of older housing 

stock of public and market-rate SSAHs. Key problematic and efficacious spaces and fixtures 

(S/F) will be identified, informed by a literature review, Housing Enabler (HE), expert focus 

groups, spatial modeling, and human behavior monitoring. Following this research phase, 

digitized 3-D models with enhanced realization will be developed from several designs of 

repurposed S/Fs, targeted to different occupant types. These designs will be tested using 

multiple methods, procedures, and end-users with various types of disabilities. Affordability 

analyses will be conducted on the most successful repurposed layouts and fixtures. Mock-ups 

of different formats (for example, podcasts and brochures) of results and solutions will be 

presented to multiple peer groups for feedback on appeal and utility as an end-user 

communication tool. 

All three research teams have completed their literature review and focus groups. Their findings 

will be used to develop the designs for accessible features. A few key findings are: 

• Several possible deficiencies faced by the resident in their existing home, such as 

deferred maintenance, repairs, and improvement to safety, can be mitigated by testing 

and incorporating accessible design features specific to their needs.

• Home modifications are implemented for a variety of reasons, but primarily for safety 

concerns—to reduce the anxiety of and decrease the rate of injury and falls. 

Modifications need not resemble conventional institutional settings that are often not 

physically appealing. The researchers will present prototypes that are affordable, 

accessible, and aesthetically pleasing. 

• Some external facing modifications can cause safety concerns for the residents. For 

example, installing a ramp in the front of the home is a public announcement of their 

disability. 

• It is important that occupational therapists, nurses, designers, and other important 

stakeholders and providers consult with homeowners prior to any home modification. 

• Homeowners should be involved throughout the home modification process and 

understand how the adaptations will help to improve their lives. 

During the focus group event, participants identified challenges and potential solutions to make 

their homes more livable. Some common issues are listed in exhibit 1. 
5 

Exhibit 1. Challenges and Potential Solutions

Challenges Solutions

Climbing stairs • Handrails on both sides of the stairwell

• Contrast between steps to make the steps more visible

Carrying heavy items • One level that accommodates activities for daily living (ADL) 

Turning knobs • Replace with levers 

Seeing objects • Brighter and better lighting

Hearing • Lighting cues when someone rings the doorbell

Individuals may not use proper 

adaptive equipment, so these 

individuals use the walls or 

bureaus as needed support

• Better education

General Home Navigation • Wider halls allowing for the wheelchairs to turn as needed 

• Marking thresholds with colored tape to limit tripping risk

Problems + Solutions for Bed to Bathroom Transition

Slick/hard to maneuver flooring • Using rubber mats

• Non-slip rugs or floor covers

Problems + Solutions for Kitchen

Inaccessible Kitchen

• Better lighting

• Removing lower kitchen cabinet doors and replacing with 

curtains 

• Converting dining room into makeshift kitchen

• Modify food packing

• Hooks for hanging cups and pans for easy access

• Transparent plastic storage drawers on wheels

Problems + Solutions for Bathrooms

Getting in and out of tub

• Grab bars (more than one)

• Install walk-in/roll-in showers with no lip or raised edge

• Ledge for easy access to toiletries

• Install a secure bench (the shower bench should allow for 

wheelchair-bound residents to easily transfer to and from the 

chair)

• Add a hand handle shower (the shower bench should allow 

for wheelchair-bound residents to easily transfer to and from 

the chair)

Getting on and off the toilet

• Grab bars, preferably on both sides

• Sinks with open bases to allow for wheelchairs to roll 

underneath 

• Easy storage, accessible from all heights
6 

Exhibit 1 represents a small sample of challenges elderly people and people with disabilities 

must deal with as they complete their daily activities. Generally, most homes must provide:

• Sufficient clearance through doorways and hallways to ensure general safety and 

accommodate mobility devices. 

• Safety when using stairs. 

• Independent and safe bathing and use of the toilet. 

• Independent and safe transfers into and out of bed. 

• Safety and full facility in the kitchen. 

• Safe access in and out of the residence. 

In June 2019, the three research grantees will travel to HUD headquarters to deliver an interim 

presentation of these and other study findings. The final reports will expand on the preliminary 

and interim findings and deliver to HUD policy recommendations that will inform the 

Department on accessible design for persons with disabilities. The grantees are expected to 

deliver these final reports in September 2020. 
7 

Fully Accessible Kitchen 
8 

Case Study Two

U.S. Department of Housing and Urban Development 

Supportive Services Demonstration and Evaluation

Abstract

The HUD Supportive Services Demonstration (SSD), also referred to as Integrated Wellness in 

Supportive Housing (IWISH), leverages HUD’s properties as a platform for the coordination and 

delivery of services to better address the interdependent health and supportive service needs 

of its older residents. The IWISH model funds a full-time Resident Wellness Director (RWD) 

(that is, enhanced service coordinator) and part-time Wellness Nurse (WN) to work in HUDassisted housing developments that either predominantly or exclusively serve residents aged 62 

or over. The RWD and WN are implementing a formal strategy for coordinating services and 

liaising with providers to help meet residents’ needs, including the use of standardized 

assessments, individual and community healthy aging plans, partnerships with providers, and 

bringing in evidence-based programming. The 3-year demonstration (October 2017–September 

2020) is being implemented in HUD-assisted multifamily properties in California, Illinois, 

Maryland, Massachusetts, Michigan, New Jersey, and South Carolina. HUD has designed a 

cluster-randomized controlled trial to evaluate the model: eligible HUD-assisted properties that 

applied for the demonstration were randomly assigned to one of three groups: a “treatment 

group” that received grant funding to hire a RWD and WN and implement the IWISH model (40 

properties); an “active control” group that will participate in the evaluation and continue 

business-as-usual (40 properties); and a “passive control” group that received neither grant 

funding nor is actively participating in the evaluation, but for which administrative data will be 

used (44 properties). A process study will assess fidelity to the IWISH model, successes and 

challenges to implementation, and answer questions related to resident health, well-being, and 

housing. The impact evaluation will use HUD administrative data linked with Medicare and 

state Medicaid claims data to assess the impact of IWISH on healthcare utilization.

Background 

HUD currently assists over 1.6 million low-income senior households age 62 or older through its 

housing programs. These housing programs use a variety of mechanisms to provide subsidized 

rental housing for the elderly, including public housing, tenant- and project-based vouchers, 

and privately-owned multifamily housing. HUD’s Office of Multifamily Housing (Multifamily) 

Section 202 Supportive Housing for the Elderly Program is one of the main vehicles for 

subsidizing multifamily housing for low-income senior adults and to date has developed over 

400,000 units for low-income seniors, and the Congress has also appropriated an additional 

$161 million in fiscal years 2017, 2018, and 2019 for new construction of additional units. 

Multifamily also subsidizes elderly designated and elderly restricted properties through its 

Section 221(d)(3), Section 236, and Section 8 project-based rental assistance programs.

Many Section 202 and other elderly-restricted Multifamily properties also connect residents 

with supportive services, particularly through the on-site resident service coordinators. Service 
9 

coordinators are typically funded via the operating budget, rental subsidies, or HUD’s Office of 

Multifamily Housing Service Coordinator Grant Program, which provides grants for the 

employment of service coordinators in HUD-assisted multifamily housing for the elderly and 

persons with disabilities. The role of service coordinators varies widely among properties, but 

HUD-funded service coordinators typically work onsite at each property to provide information 

and refer residents to supportive services available in the community—such as transportation 

and meal services—to facilitate continued independent living.

The health-service needs of HUD-assisted seniors are primarily supported by Medicare and 

Medicaid insurance programs; an estimated 70 percent of HUD-assisted seniors are covered by 

both Medicare and Medicaid (often referred to as “dual-eligible beneficiaries” or “duals”). For 

dual-eligible beneficiaries, Medicare is the primary payer of primary and specialty care, 

inpatient and outpatient acute care, and post-acute skilled-level care. Medicaid may provide 

support to cover Medicare premiums and other services, such as long-term services and 

supports. Historically there has been poor coordination and alignment between the provision of 

housing, social, and health services; the two have operated as separate, distinct sectors to 

address what have been considered non-overlapping needs. The intent of the Supportive 

Services Demonstration is to better integrate assisted housing with health and social services, 

such that assisted housing properties can be used as a platform for improved health and 

housing outcomes.

Previous Research

To better understand the health of HUD-assisted older adults, and explore the potential to 

better align and coordinate social and health services, HUD conducted three research initiatives 

that have direct bearing on the demonstration: In 2010, HUD and the Department of Health 

and Human Services (HHS) contracted The Lewin Group to develop design options for a 

demonstration of coordinated housing and long-term services and supports for low-income 

seniors. Following an extensive scan of best practices, the report recommended a model 

comprising an on-site enhanced service coordinator and nurse team that helps residents 

address their social and health needs. In this model, the service coordinator assumes a 

proactive role to conduct assessments, develop and monitor individual healthy aging plans, and 

encourage resident engagement in programs and activities. The on-site nurse works in 

conjunction with the enhanced service coordinator and performs health and function 

assessments, answers health-related questions, provides one-on-one and group health 

education, liaises with healthcare providers, and monitors transitions home following an 

emergency department or hospital visit. The model was also designed such that it can build 

directly upon the existing service coordinator program already present in many HUD-assisted 

properties. Many of the recommendations are included in the current demonstration.

As part of the same contract, HUD and HHS engaged The Lewin Group to pilot an administrative 

data match that linked HUD administrative and Centers for Medicare and Medicaid Services 

(CMS) Medicare and Medicaid claims data. The goals of this study were to explore the feasibility 

of linking HUD and CMS administrative data, determine the extent to which these linked data 

could track health and housing outcomes, and assess whether this approach could support 
10 

future research. The study found that HUD-assisted dual beneficiaries had more chronic 

conditions, greater healthcare utilization, and higher healthcare costs than similar unassisted 

beneficiaries residing in the community.7 Importantly, this pilot linkage has provided the basis 

for the data collection and analysis portion of the impact evaluation of the Supportive 

Services Demonstration.

The third key piece of research is the evaluation of the Support and Services at Home (SASH) 

program. SASH is designed to connect older adults living in affordable senior housing properties 

in Vermont with community-based healthcare and supportive services to promote greater care 

coordination, improve health status, and slow the growth of healthcare expenditures. Each 

SASH panel consists of up to 100 participants served by a full-time SASH coordinator and a 

quarter-time wellness nurse, typically using HUD-assisted or other nonprofit affordable housing 

properties as the locus for coordination. Under contract from HHS and HUD, RTI International 

and the LeadingAge have been evaluating the SASH program to examine program 

implementation and assess health outcomes and service utilization of SASH participants. Many 

of the promising practices from the SASH model have been incorporated into the Supportive 

Services Demonstration model design.

Implementation

The Fiscal Year (FY) 2014 Consolidated Appropriations Act provided authority for HUD to test 

housing with services models that have the potential to allow elderly persons to successfully 

age in place. In January 2016, HUD announced the availability of a funding opportunity (Notice 

of Funding Availability or NOFA) under the Supportive Services Demonstration for Elderly 

Households in HUD-Assisted Multifamily Housing, which aims to promote aging in place and 

improve housing stability, well-being, health outcomes, and reduce unnecessary or avoidable 

healthcare utilization associated with high healthcare costs. It made available approximately $15 

million in 3-year grants to owners of multifamily properties to implement the demonstration.

Eligible applicants were owners of elderly designated or restricted multifamily properties 

with at least 50 assisted housing units occupied by eligible tenants (households consisting of

one or more persons of whom one is at least 62 years of age or older); up to 10 percent of 

the units could be occupied by a person with a disability under the age of 62. Properties with 

and without current resident service coordinators could apply. Eligible HUD-assisted housing 

types included housing assisted under Section 202 of the Housing Act of 1959, housing with 

project-based Section 8 assistance (including USDA Section 515 rural housing projects), 

housing insured under Section 221(d)(3), and housing assisted under Section 236 of the 

National Housing Act. Awardees consisted of properties in seven states: California, Illinois, 

Massachusetts, Maryland, Michigan, New Jersey, and South Carolina. 

HUD contracted The Lewin Group—with the support of subcontractors LeadingAge and the 

WellHome Network—to refine the demonstration model and fully implement the Supportive 

7 U.S. Department of Health and Human Services Assistant Secretary for Planning and Evaluation Office of Disability, Aging and Long-Term 

Care Policy. 2014. “Picture of Housing and Health: Medicare and Medicaid Use Among Older Adults in HUD-Assisted Housing,” Washington, 

DC: HHS. http://aspe.hhs.gov/daltcp/reports/2014/HUDpic.pdf.
11

Services Demonstration. The team developed the model known as Integrated Wellness in 

Supportive Housing, or IWISH. The IWISH model relies upon a housing-based Resident 

Wellness Director (RWD) and a part-time Wellness Nurse (WN) who implement a formal 

strategy for coordinating services to help meet residents’ needs. The RWD engages with all 

residents (who decide to participate) in a proactive, comprehensive, and ongoing manner and 

works closely with the WN to implement the six components of the IWISH model:

1. Formal partnerships with appropriate local health and social service providers;

2. Formal resident engagement and roll out strategy to maximize resident recruitment 

and retention;

3. Standardized assessment with all participants after program enrollment and 

periodically throughout demonstration;

4. Individual health aging plan (IHAP) for each participant and community health aging 

plan (CHAP) for each property to guide service and program planning;

5. Centralized, web-based platform where properties can enter assessment and 

tracking information for report generation, tracking sentinel events, and service 

planning and coordination; and

6. Implementation of appropriate evidence-based wellness and health education.

Implementation officially began in October 2017, and the demonstration will run through 

September 2020. The location of the 40 properties implementing the IWISH model can be 

found in exhibit 1.
12 

Exhibit 1. Location of Properties Implementing the IWISH Model

Location map created by Abt Associates, Inc.

In November 2017, the implementation team hosted a two-day, in-person training for all 

the RWDs and WNs on staff at the time. The initial training, focused on staff roles and 

responsibilities, the IWISH model, and working with residents. To date, the 

implementation team has hosted over 30 webinars on a wide variety of topics to help train 

and support staff, including strategies for relationship building and supporting behavior 

change, teamwork, privacy, assessing resident and community needs, trauma informed 

care, working with serious mental health challenges, and conflict resolution. The 

implementation team also has regular check-ins with sites and provides technical 

assistance and support on an ongoing basis.

Evaluation

In an effort to fully evaluate the IWISH model and demonstration, HUD is also funding an 

independent evaluation conducted by Abt Associates, with the major goal of producing 

reliable, credible, quantitative evidence for Congress and stakeholders about the impact of 

IWISH on healthcare utilization and transitions to nursing home care. Eligible HUD-assisted 

properties that applied for the demonstration were randomly assigned to one of three 

groups: a “treatment group” that received grant funding to hire an RWD and a WN and 

implement the IWISH model (40 properties); an “active control” group that did not receive 

grant funding but received a stipend to participate in the evaluation (40 properties); and a 

“passive control” group that received neither grant funding nor a stipend (44 properties). 

The random assignment enables an evaluation that quantifies the impact of the IWISH 

model by comparing outcomes at the 40 treatment group properties to outcomes at the 

84 properties in the active and passive control groups.
13 

The evaluation consists of a process study and impact evaluation. The process study will 

assess fidelity to the IWISH model, successes and challenges to implementation, and 

answer important questions related to resident health, well-being, and housing. The 

impact evaluation will use HUD administrative data linked with Medicare and state 

Medicaid claims data to quantitatively assess the impact of IWISH on healthcare utilization 

by comparing those participating in IWISH and those in the control groups. The impact 

evaluation is focused on four main questions:

1. What is the impact of IWISH on utilization of Medicare and Medicaid covered 

unplanned hospitalizations and other acute care?

2. What is the impact of IWISH on utilization of Medicare and Medicaid covered 

primary care and other non-acute healthcare services?

3. What is the impact of IWISH on housing exits and resident tenure? 

4. What is the impact of IWISH on transitions to long-term institutional care?

The interim report is expected in the fall of 2019 and the final, comprehensive report is 

expected in the spring of 2022.
14 

Case Study Three

Naturally Occurring 

Retirement Community and Villages

Naturally Occurring Retirement Community (NORC) and Villages are neighborhood/community 

supportive services program models that promote independent living arrangements among 

elderly populations. NORCs form “naturally” as residents in a neighborhood, an 

apartment/condominium building, or cluster of apartment/condominium buildings in close 

proximity age and account for a sizeable share of the population within the defined geography. 

NORCs are typically run by non-profit organizations that establish relationships with community 

healthcare providers and social service organizations to facilitate healthy independent living 

among elderly residents. Services are typically delivered onsite with social events and 

programming occurring both onsite and offsite. Villages are typically membership organizations 

for elderly residents whereby supportive services and social events are arranged and 

coordinated for Village members. Village membership is available to elderly residents 

irrespective of their place of residence. Based on the needs of Village members, Village staff 

members coordinate a range of services provided by trusted vendors (for example, home 

repairs, landscaping, wellness groups, exercise classes, meal preparation, social and cultural 

excursions) and ensures that members are satisfied with the quality of these services. Village 

staff are often paid and rely heavily on support from local volunteer organizations. 

As residents within a community begin to age, it is inevitable that Villages in communities with 

high concentrations of elderly residents might become Village NORCs—blending the two 

models to support independent living and combat social isolation among the elderly. Whether 

these services are provided by NORCs, Villages, or Village NORCs, the primary objective remains 

the same—supporting healthy aging in the community.

In the section below, I describe the Hamilton-Madison House NORC Supportive Services 

Program and the Hotel Oakland Village. Because Hamilton-Madison House SSP is an example of 

a “classic NORC” or “vertical NORC” (apartment building or set of apartment buildings within a 

development) and the Hotel Oakland Village was established within a large multifamily 

property (converted hotel), the reader will notice similarities in the location where services are 

delivered but differences in the range of services offered between the two. It is worth noting 

that NORCs and Villages are uniquely tailored to the needs of their residents. So, it is possible to 

observe a NORC and Village with a similar set of services and activities for its 

residents/members. 
15 

Naturally Occurring Retirement Community

The Hamilton-Madison House NORC Supportive Services Program (HMH NORC SSP) is in the 

Lower Eastside of Manhattan and is near the Alfred E. Smith NORC and the Knickerbocker 

Village NORC. The HMH NORC SSP services 3,500 apartments with more than 8,000 residents 

(majority seniors). The HMH NORC SSP is mostly publicly funded, receiving three-quarters of its 

funding from the New York City Department on Aging. The programs offered by HMH NORC SSP 

are based on a community needs assessment and includes early feedback from residents, 

health and human services providers, and other community support organizations in the 

program development phase. This process ensures that services deemed by elderly residents 

to be necessary for independently living and promotion of social engagement are included in 

program activities. Additionally, HMH NORC SSP develops relationships with philanthropic 

organizations, businesses, and other community sponsors to support their NORC 

programming efforts.

The New York State Legislature has specific legislation to support NORCs. Specifically, New York 

state law defines NORC and includes provisions for the delivery of supportive services within a 

NORC. As defined under Article 2 Title 1 Section 209 (Elder Law), the Hamilton-Madison House 

NORC SSP is a “classic NORC:” 

Exterior Elevation of HMH NORC SSP site 

location.
16 

“an apartment building or housing complex which: (1) was not predominantly built for 

older adults; (2) does not restrict admissions solely to older adults; (3) (A) at least forty 

percent of the units have an occupant who is an older adult; and (B) in which at least 

two hundred fifty of the residents of an apartment building are older adults or five 

hundred residents of a housing complex are older adults; and (4) a majority of the older 

adults to be served are low or moderate income, as defined by the United States 

Department of Housing and Urban Development.”

As part of NORC programming, HMH NORC SSP delivers services that promote independent 

living, improve the quality of life for its residents, and slow the rate of emergency care 

utilization as well as transition to assisted and nursing care facilities. Residents within HMH 

NORC SSP access services in the following areas: service coordination and casement 

management for healthcare assessments and follow-up linkages and preventive interventions, 

in-home care, counseling, housekeeping/chores, congregate meal, exercise, transportation, 

shopping, recreational activities, and social excursions. These services are considered 

supplements to existing onsite and community-based health and well-being efforts—not 

replacement thereof.

The following table provides basic demographics of the residents serviced by HMH NORC SSP. 

Although roughly a third of NORC residents are elderly, half of households served by the NORC 

have at least one elderly household member. And given the age distribution among elderly 

residents, the NORC has supportive services to address elderly residents’ needs as they 

continue to “age in place.”

Alfred E. Smith 

NORC

Knickerbocker Village 

NORC

Year Founded 1953 1934

Total Units 1,931 1,589

Number of Residents 4,316 3,720

% Elderly Residents (age 60+) 33 28

% Households with at least one Elderly Resident 54 51

Age Categories:

% age 60 to 69

% age 70 to 79

% age 80 to 89

% age 90 or older

47

36

15

2 

43

35

18

4 

Note: Twenty percent of NYCHA residents are age 62 or older (similar to nationwide estimates 

for HUD-assisted residents).
17 

The Village

Hotel Oakland Village

Originally opened in 1912 as a luxury hotel that hosted past United States Presidents, movie 

stars, and dignitaries from around the globe, Hotel Oakland experienced tough economic times 

during the 1930’s. Shortly thereafter, the hotel was taken over by the military and converted to 

military hospital (Oakland Area Station Hospital) and later became a VA hospital. Between 1963 

and 1978, the hotel laid dormant and averted a series of demolition attempts by the city.

In 1979, real estate investor Bill Langelier and his partners purchased the landmark hotel and 

converted it to affordable senior housing. Their goal was to provide 400 quality affordable units 

to low-income seniors. After observing limited social engagement amongst residents and 

understanding the impact of social isolation on the health of seniors, Langelier decided to 

establish health education groups co-managed by residents with a focus on promoting social 

engagement around health and wellness topics. In July 2011, he and his team established the 

Hotel Oakland Village.

Exterior Elevation of Hotel Oakland – Early 1900's. 

Source: LocalWiki.org
18 

Essentially, the Hotel Oakland Village was established to address the impact of social isolation 

on the health and wellness of the Village’s resident. With nearly 400 elderly residents, many 

whom are “active,” Hotel Oakland Village seized the opportunity to develop programming 

addressing social isolation while also attending to the healthcare needs of its residents. During 

the early years, Langelier and his management team facilitated the creation of 8 resident comanaged health education groups. As resident participation increased, so did the number of 

health education groups – from 8 groups in 2011 to 15 groups in 2016. Health education groups 

promote social engagement among residents who might otherwise be at risk of living an 

isolated life with little social interaction within their immediate community [or “with limited 

social interaction with their neighbors”]. These resident co-managed groups provide healthcentered social engagements for residents with a focus on informing and building healthy 

habits that support independent living. [The collection of information delivery and healthy habit 

building activities is expected to extend residents’ ability to live independently while avoiding 

negative healthcare events.]

Resident Managed Health Group

Hotel Oakland Village’s health groups provide residents with access to services that are comanaged by their fellow residents. These health groups promote social engagement within the 

Village and healthy independent living. By partnering with residents to delivery peer-led health 

education groups covering medical diagnoses most common to Village residents, residents are 

engaging their neighbors on healthy independent living practices and lowering the walls of 

social isolation.

The following table is a selection of health education groups co-managed by Village residents.

Exterior Elevation of Hotel Oakland – 2000’s. 
19 

Falls Prevention • Increases awareness of risk of falling and promotes a 

culture of falls prevention

• 15-member Resident Advisory Board

Healthy Eating • Provides insight on personal nutrition and healthy 

eating habits

• Cooking classes and shared learning

Healthy Minds • Seminars on cognitive disorders and the conditions 

they create

• Promotion of brain stimulation activities

Neighbor Helping Neighbors • Neighbors taken on the role of supporting neighbors 

in their time of need

• Two ‘Floor Captains’ on each floor

Personal Safety • Covers crime prevention and safety issues

• Organized walks and errand groups

Health and Wellness Connection

In February 2016, Hotel Oakland Village began “Village Health and Wellness Connection.” As 

part of Village Health and Wellness Connection, a comprehensive long-term wellness plan is 

developed for each resident. In partnership with the onsite Wellness Director, residents are 

connected to onsite services to address elements outlined in the wellness plan. Resident who 

experience similar health ailment meet regularly to support each other in addressing the 

health ailment. 

With ongoing monitoring of adherence to the wellness plan and support with implementing the 

plan, Hotel Oakland Village’s approached this partnership with a focus on providing supportive 

services that allow residents to transition from independent living to assisted living to skilled 

nurse supported living without having to leave the facility. This model is a well-designed 

housing with supportive services program that is committed to supporting seniors who desire 

to age in place.

The following groups have been established with 100 percent of residents participating in at 

least one group. 

Heart Problems Stomach Problems Arthritic Problems

Three High (high blood 

pressure, high cholesterol, 

and high sugar)

Emotional Well-Being Music Therapy

Chore Provider

Hong Fook

In addition to onsite services provided to residents, Hotel Oakland Village offers two Hong Fook 

community-based adult services centers (CBAS) that support health living among the broader 
20 

community’s elderly and disabled adult populations at risk of institutional care. CBAS centers 

are funded by Medi-Cal. CBAS centers provide nursing care, chronic disease management, 

dietitian and rehabilitative services, social services, and stimulating cognitive and recreational 

activities. These services are offered onsite to community residents and are also made available 

to Hotel Oakland Village residents through a referral from the Village’s Wellness Director. For 

Village residents, the wellness plan is the focus of engagement. The additional CBAS services 

expand the types of service providers available to Village residents to include speech therapist, 

occupational therapist, physical therapist, dietician and nutritionist, social workers, and 

activities coordinator.
21 

Case Study Four

Volunteerism in the United States:

Case Study for the US-Japan Aging in Place Research Project

Volunteering in the United States has become a classic tradition. Many Americans start 

volunteering at an early age and continue this practice throughout their lives. Numerous 

venues to participate in voluntary projects are available, including education, youth clubs, and 

religious-affiliated groups. 

Example of Religious Groups and Volunteering

Religious congregations offer a variety of opportunities for volunteers of all ages. Some of these 

tasks include ushering in members as they join the service, helping with administrative tasks, 

cleaning the church, or doing yard maintenance. Children learn the value in serving others as 

they volunteer their time and energy helping maintain the church building and assisting elderly 

church members.

Example of Youth Club

The Boy Scouts of America and the Girl Scouts of the United States of America are very large 

organizations within the United States that offer a wide variety of volunteer opportunities. 

There are 2.4 million youth participants and nearly 1 million adult volunteers participating in 

the Boys Scouts. In addition, there are 1.7 million youth members and 750,000 adult volunteers 

in the Girl Scouts. These Scout programs are educational, after-school programs that teach 

children a variety of skills through the merit badge program. Once a Scout accomplishes a task, 

he/she is awarded a badge that is sewn on a sash, which the child proudly wears to their 

scouting meetings. These merit badges include badges for community service. 

The highest status for a Boy Scout is the rank of Eagle Scout, which is usually not attained until 

high school. This scouting milestone requires an additional 21 merit badges including several 

that are focused on community services such as Citizenship in the Community, Citizenship in 

the Nation, Emergency Preparedness, Lifesaving, and Environmental Science or Sustainability. 

The Eagle Scout candidate must choose a community project that shows their engagement in 

the greater community, focused on volunteerism. 

Examples of Education Institutions 

College admissions are highly competitive in the United States, especially at the top tier 

universities and colleges. High school students know that community service and volunteerism 

can give them the edge over other similarly qualified students. Colleges are looking for young 

people who are committed to not only attaining a high level of education through superior 

grades but also to their community and to making the world a better place. 
22 

Parents also encourage their teenage children to pursue international volunteer projects. There 

are numerous web sites solely devoted to helping parents and students find an international 

volunteer project. Through those projects, students not only have an opportunity to learn 

a new culture and travel abroad, but they will also receive a sense of accomplishment 

and purpose. 

Many high schools across the United States make performing community service a requirement 

for graduation. Some schools require as many as 40 hours of volunteer time to complete their 

degree. Many grade schools will also organize a volunteer day at least once during the 

academic year. Students perform some sort of volunteer service project on those days, such as 

cleaning up a park or recreation area, collecting canned goods for a food drive, or perhaps 

organizing a clothing drive for the needy. 

Community service and volunteering have always been a part of the American society, and this 

sense of community spirit is part of the culture of growing up in the United States. 

U.S. Government Involvement in Promoting Volunteerism

The U.S. Government created the Corporation for National and Community Service (CNCS) with 

the National and Community Service Trust Act of 1993. The agency’s mandate is to support the 

American culture of citizenship, service, and responsibility through the following volunteer 

programs: AmeriCorps, Learn and Serve America, Senior Corps, and other national service 

initiatives. CNCS supports volunteerism through grants and is the nation’s largest annual grant 

maker for supporting community service and volunteering. In fiscal year 2019, the agency’s 

budget was $1.08 billion, which included operating costs and also provided for grants to 

encourage volunteerism. 
23 

The Senior Corps program is targeted at those who are 55 and over by matching them with the 

right volunteer organization. One program, Senior Companions, pairs volunteers with two to 

four adults who are aging in place in their homes but need volunteers to help with chores and 

other tasks. This service connects volunteers to the elderly who need a senior companion. 

Senior Corp programs are available across the country.

The Senior Corps program, however, helps more than just elderly people. Senior Corps’ RSVP 

program was created to help those over 55 find specific service opportunities that may include:

• Organizing neighborhood watch programs.

• Tutoring and mentoring disadvantaged or disabled youth.

• Renovating homes.

• Teaching English to immigrants.

• Assisting victims of natural disasters.

CNCS is able to provide volunteer matching on a national scale through local state offices, 

however, there are many other volunteer matching services available.

Examples of Nonprofit Organization Promoting Local Volunteerism 

HandsOn Bay Area in San Francisco, CA is a nonprofit organization that acts as a broker to 

connect organizations that need volunteers with people looking for a volunteer opportunity 

who are not sure how to find a good match. HandsOn Bay Area also works with local companies 

to plan and organize corporate volunteer days. In 2017, they organized more than 25,000 

volunteers, resulting in more than 76,000 hours of service to more than 280 schools, parks, and 

nonprofits across the Bay Area. The projects included education and literacy, youth 

development, health and aging, homelessness, and environmental projects. 

Example of a Private Nonprofit Working in Collaboration with Volunteers Using 

Government Funding 

Meals on Wheels America is an excellent example of a nationwide nonprofit group that relies 

on both volunteers and paid employees to provide services for preparing and delivering meals. 
24 

In order to qualify for a free meal from Meals on Wheels, the recipient must be housebound 

and 60 years or older. Recipients must also meet income limitations of no more than $1,218 

per month. Meals on Wheels America provides one meal delivery a day, often large enough 

for a full day of food. Some delivery drivers are paid but many are volunteers, including those 

who prepare the food and those administering the program. Meals on Wheels America noted 

that, in 2018, “millions of volunteers enabled 225 million meals to be delivered to 2.4 

million seniors.” 

Meals on Wheels America is funded through a number of income streams, mostly private, but 

the organization receives 38 percent of their funding through the Older Americans Act. This 

grant pool is administered by the U.S. Department of Health and Human Services (DHHS). In 

2016, DHHS dispersed $590 million to local Meals on Wheels America organizations. The 

remaining 62 percent of funding is through other sources including private donations and 

foundation grants. Private foundation, corporate philanthropy, and community foundation 

funding of aging and senior services is less than 2 percent of total giving for Meals on Wheels. 

This amount is an incredibly low share of overall philanthropy and demonstrates the need for 

volunteers. Without volunteers, this organization could not exist.

2018 Volunteering in America Report 

CNCS recently released the 2018 Volunteering in America report. Their research found that 

77.34 million adults (30.3 percent) volunteered through an organization in 2017. Americans 

volunteered nearly 6.9 billion hours, worth an estimated $167 billion in economic value, based 

on the Independent Sector’s estimate of the average value of a volunteer hour for 2017. Other 

key findings from the report (quoted):

• Americans in Utah report the highest rate of volunteering (51 percent), holding the top 

spot among states, followed by Minnesota (45.1 percent). Oregon (43.2 percent) 

climbed from the 13th-ranked state to the third; and is joined by Iowa (41.5 percent) 

and Alaska (40.6 percent), which are both also new to the top five.

• Among cities, Minneapolis-St. Paul (46.3 percent) once again ranks first, with Rochester, 

NY (45.6 percent), Salt Lake City (45 percent), Milwaukee, WI (44.6 percent), and 

Portland, OR (44.3 percent) trailing slightly behind.

• Parents volunteer at rates nearly 48 percent higher than non-parents, and working 

mothers give more time than any other demographic, with a volunteer rate of 

46.7 percent.

• Generation X has the highest rate (36.4 percent) of volunteering, whereas Baby 

Boomers give more hours of service (2.2 billion). Millennials are stepping up to do more 

in Utah and the District of Columbia.
25 

• Americans most frequently gave their time to religious groups (32 percent), one-fourth 

volunteered most often with sports or arts groups (25.7 percent), with another nearly 

20 percent supporting education or youth service groups.

• One in three volunteers raises funds for nonprofits (36 percent). Additional volunteer 

activities include food donation and meal preparation (34.2 percent), transportation and 

labor support (23 percent), tutoring young people (23 percent), serving as a mentor 

(26.2 percent), and lending professional and management expertise (20.5 percent).

• Nearly 80 percent of volunteers donated to charity, compared with 40 percent of 

non-volunteers. Overall, one-half of all citizens (52.2 percent) donated to charity this 

past year.

Conclusion 

These numbers are remarkable and show that, without volunteers, far fewer services would be 

offered to our nation’s most needy, including our elderly. 
26 

October 2020