AGESPAN AND PARTNERS BRING 

HOUSING AND 

SERVICES TOGETHER 

I

n northeastern Massachusetts, AgeSpan pursues solutions that bring together housing and 

supportive services. Why? Many older adults and people with disabilities not only need afordable 

and accessible housing, but also supportive services that enable them to be as independent as possible. 

Assistance with nutrition, transportation, personal care, medication management, and chore services 

are just a few examples of these critical services. Opportunities for social engagement are also vital to 

well-being. When housing and services are coordinated, older adults and people with disabilities are 

better able to live well in the community. 

As an Area Agency on Aging (AAA), AgeSpan1 

engages in innovative partnerships with housing 

providers through the Massachusetts Supportive 

Housing Program (MSHP). Working with 

property managers at designated local housing 

sites, AgeSpan places staf as resident service 

coordinators (RSCs). Te RSCs deliberately build 

strong, trusting relationships with residents, 

ofering a daily touchstone that greatly improves 

quality of life. As noted by Martha Leen, 

AgeSpan Director of Community Programs/ 

Area Agency Planner, “When RSCs came into 

housing sites, residents felt an improved sense 

of connectedness simply because someone in 

the building was regularly checking on them 

and making an efort to engage them.” Tis 

investment in developing trust enables RSCs to 

quickly identify and resolve issues according to 

each individual’s priorities. 

Moreover, because the RSCs are highly trained 

AgeSpan employees, they know how to 

arrange and coordinate services, assist with 

enrollment in programs and public benefts, 

and support many other aspects of residents’ 

well-being and independence. Tis robust 

model of service coordination, coupled with 

the AAA’s capabilities, brings essential services 

into housing for older adults and people with 

disabilities. Together, AgeSpan and its local 

housing partners utilize the MSHP to improve: 

. Access to, and use of, both health 

care and home and communitybased services, 

. Housing stability, 

. Food security, 

. Social connectedness, and 

. Community cohesion. 

For the residents of these communities, the 

combination of housing and services helps 

them remain in their homes instead of 

potentially becoming homeless or needing 

to move into a nursing home. 

1 https://agespan.org/ 
2 

STATE PROGRAM CATALYZES LOCAL PARTNERSHIPS FOR HOUSING AND SERVICES 

Because housing and service systems often 

operate independently, state programs can 

catalyze community-driven eforts that 

coordinate housing and service providers. Te 

Massachusetts Supportive Housing Program is 

led by both the Executive Ofce of Elder Afairs 

and Department of Housing and Community 

Development. Te program advances health 

equity by combining housing with services for 

two populations that have been historically 

underserved: older adults and people with 

disabilities who live in state-funded public 

housing. 

In Massachusetts, the Aging Services Access 

Point network is comprised of nonproft 

agencies, including AgeSpan, that provide 

direct and protective services to people age 60 

and older. Te MSHP funds a suite of services 

that includes on-site RSCs, 24/7 emergency 

response, group meals for residents who 

choose to join, and social activities. Tese 

services enable residents to maintain their 

independence, and the shared support creates 

a sense of community. Te program works 

because each Aging Service Access Point 

sustains close ties and dynamic partnerships 

with service providers in its designated region. 

AgeSpan possesses a deep understanding of 

the needs of older adults and people with 

disabilities in its service area, which consists 

of 28 towns and cities. For decades—and like 

AAAs across America—AgeSpan has supported 

the health and independence of people they 

serve by creating and ofering nutrition, 

transportation, housing preservation, home 

modifcation, home care, evidence-based 

health programs, and other services that help 

enable independent living. Some of these 

supports are provided directly by the AAA, 

and others come from AgeSpan’s network 

of service providers. Also, AgeSpan provides 

many evidence-based programs to help adults 

of all ages manage diabetes and other chronic 

health conditions, prevent falls, stay physically 

active, deal with depression, and more. When 

unmet needs are identifed in its service area, 

AgeSpan works with stakeholders to develop 

and implement solutions. 

RESIDENT SERVICE COORDINATORS AND TRUST 

To improve how AgeSpan reaches low-income 

community members, the agency is developing 

a broad array of housing partnerships. 

Overviews of two of these partnerships can be 

found in “Innovative Partnerships that Provide 

Support to Live at Home” (on the next page). In 

addition, AgeSpan became a MSHP partner and 

now works onsite with residents of eight statefunded public housing communities for older 

adults and adults of all ages with disabilities. To 

improve housing stability, a goal of the MSHP, 

AgeSpan leverages its AAA service network to 

provide home and community-based services 

based on a comprehensive assessment of each 

individual’s needs and choices. Improved wellbeing, another MSHP goal, is also enhanced by 

building relationships. 
3 

 

“AgeSpan stafs on-site RSCs who are a 

keystone of program success,” said Leen. 

Residents are more likely to access supports 

and services and engage in programming 

when they are encouraged to do so by a 

trusted person. RSCs cultivate that trust by 

building rapport as they see residents daily. 

When RSCs notice a resident’s condition has 

changed, they are able to quickly respond 

by tapping into AgeSpan’s direct services, 

its network of community partners, and 

its systems. 

INNOVATIVE PARTNERSHIPS THAT PROVIDE SUPPORT TO LIVE AT HOME 

AgeSpan has established and nurtures additional partnerships that serve the needs of older 

adults and people with disabilities. Among others, these collaborations address housing 

stability and wellness. 

Partnerships with Accountable Care Organizations stabilize housing situations. 

Housing stability plays a key role in health and well-being. AgeSpan and the Northeast 

Independent Living Program (a Center for Independent Living) teamed up to lead a network 

of community-based organizations that is contracting with Medicaid Accountable Care 

Organizations (ACOs) to ofer housing-related services, such as pre-tenancy support, tenancy 

preservation, and home modifcations. To learn more, read Partnership Profle: Elder Services of 

the Merrimack Valley and North Shore and My Care Family Accountable Care Organization2 from 

USAging’s Aging and Disability Business Institute. 

An onsite wellness nurse prevents emergency room visits and ambulance calls. 

AgeSpan collaborates with Winn Managed Properties, which receives funding from the U.S. 

Department of Housing and Urban Development, to provide supportive services to residents 

of the Alice G. Winn & Family Heritage House. At this community for older adults, AgeSpan’s 

on-site wellness nurse is available to residents by appointment or drop-in for at-home 

services, health and prescription consultation, and more. AgeSpan also provides a resident 

service coordinator focused on engaging programming, education, and care coordination for 

residents. In the program’s frst year, all 111 Heritage House residents received services, at 

least 14 emergency room visits were avoided, and 42 percent of residents participated in at 

least one of the evidence-based programs ofered to help them stay healthy and engaged. 

2 https://www.aginganddisabilitybusinessinstitute.org/elder-services-of-the-merrimack-valley-and-north-shore-and-my-care-family-accountable-care-organization/ 
4 

PROGRAM HIGHLIGHTS: PERSON-CENTERED SUPPORT AND CONSUMER CHOICE 

In partnership with the property managers, 

AgeSpan provides both individualized and 

group services in these independent living 

settings, chiefy by using funding from the 

MSHP and the Older Americans Act. AgeSpan 

uses a person-centered approach—meaning they 

focus on supporting residents’ independence 

and ability to make their own choices. As 

AgeSpan employees, RSCs can readily provide 

an extensive array of support tailored to each 

individual and routinely perform the following 

services in keeping with residents’ choices by 

providing: 

. Person-centered assessments of 

individual residents’ health and 

social needs and the development 

of individual plans based on their 

priorities and goals. 

. Direct connections and referrals 

to community agencies that 

provide needed health care and 

home and community-based 

services. Tese might range from 

home care to veterans’ services, to 

transportation, and many others. 

RSCs also monitor service use and 

support communications with 

service providers. 

. Enrollment assistance for 

benefts such as Medicaid and 

the Supplemental Nutrition 

Assistance Program (SNAP) as well 

as difcult-to-access services such 

as behavioral health assistance and 

dental insurance. 

. Education to residents about 

options such as Programs of AllInclusive Care for the Elderly3 

(PACE, a program that provides 

participants with comprehensive 

medical and social services) and 

Senior Care Options4

 (a health plan 

that provides a combination of 

health services and social support 

services). RSCs also ofer assistance 

with enrolling and follow up to 

assure ft and coordinate with 

PACE case managers for residents 

enrolled in the program. 

. Support to residents with Money 

Follows the Person, a federal 

Medicaid program that supports 

access to home and communitybased services for individuals who 

have returned to the community 

after leaving institutions such as 

nursing homes. 

. Easy access to State Health 

Insurance Assistance Program (SHIP) 

counselors, who can help with 

understanding Medicare options. 

. Assistance with fnding jobs, 

transportation, clothing, 

household goods, durable medical 

equipment, and other necessities. 

. Individualized counseling and case 

management for residents who 

need more intensive assistance with 

accessing and coordinating supports. 

3 https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Ofce/PACE/PACE 

4 https://www.mass.gov/service-details/senior-care-options-sco-overview 
5 

Other services promote housing stability and 

tenancy preservation. RSCs, as a trusted resource, 

can mediate conficts residents may have 

with other residents, the landlord, or housing 

authority staf. In cases of hoarding, RSCs initiate 

team meetings of case managers, providers, and 

housing authority staf to identify supports and 

services to preserve tenancy. All discussions are 

confdential and centered in consumer choice 

and control. For example, RSCs support residents 

when concerned family members believe they 

can no longer live independently and pressure 

the resident to move to a more restrictive setting. 

RSCs also advocate with housing authority staf 

on residents’ behalf. During changes in residency, 

the RSC assists with move-ins and move-outs. 

To ensure social engagement and communitybuilding programming aligned with residents’ 

preferences, AgeSpan conducts an annual 

resident survey to inform community 

programming. Some popular social activities 

are community cofee hours, movie screenings, 

speakers, fantasy football, trivia contests, 

and hands-on activities such as gardening 

and woodworking. When residents requested 

fresh fruits and vegetables, AgeSpan recruited 

a local farmer to provide in-season farmers’ 

markets at the housing sites, allowing residents 

to choose their own foods. To address food 

insecurity, residents also have the opportunity 

to obtain bags of groceries with shelf-stable 

and fresh items from an AgeSpan partnership 

with the Greater Boston Food Bank. To meet 

the MSHP requirement that sites ensure that 

all residents have access to at least one meal 

per day, AgeSpan uses Older Americans Act 

funding to provide one group meal per day that 

is available to all residents. 

AgeSpan engages in health-related activities 

such as providing vaccines and conducting 

blood pressure checks. Te AgeSpan Healthy 

Living Center of Excellence brings on-site 

evidence-based workshops such as A Matter 

of Balance for falls prevention and Healthy 

Ideas to reduce depression. By ofering these 

programs, AgeSpan helps reduce emergency 

room visits and the need for more intensive 

care while also giving residents ways to make 

additional interpersonal connections. AgeSpan 

also provides a 24/7 response service with its 

MSHP resources. 

WHAT ARE HOME AND COMMUNITY-BASED SERVICES? 

Tese are health and social services provided in someone’s home or community rather than 

in institutions such as hospitals or nursing homes. Tese services support the everyday 

activities of older adults and people with disabilities, and help them live independently in 

their own homes. Examples include personal care assistance, homemaker services, case 

management, caregiver training, home health, and more. 
6 

HOW THE PARTNERSHIP WORKS 

Maintaining a successful partnership requires 

the housing authority and AgeSpan to 

work together on behalf of the residents. 

Before initiating services at a housing site, 

the two partners create a memorandum of 

understanding that specifes the roles and 

responsibilities of each agency. 

In general, the housing authority provides the 

facility, and AgeSpan provides the support. 

In most cases, the housing authority is 

responsible for a no-cost on-site ofce space; 

property maintenance, safety features, and 

24-hour access; kitchen, cooking, and dining 

facilities for group meals; and coordination 

with the RSC on how best to meet residents’ 

needs. In addition to providing the RSC and 

group services, AgeSpan arranges for a home 

care services provider that also ensures 24/7 

emergency assistance to residents. 

Partners hold regular meetings to coordinate 

on communication with residents and 

changes in group programming that may have 

implications for building maintenance. Tese 

meetings also foster coordination of solutions 

for problems afecting residents’ well-being, 

such as excessive clutter or noise issues. 

OUTCOMES 

Together, AgeSpan and its housing partners 

improved housing stability directly and 

through the following accomplishments that 

are described below. 

. Tenancy support: Te partnership 

preserved tenancy for residents 

who may have been at risk of 

eviction or institutionalization 

and created a confict-resolution 

process to resolve conficts 

between housing authorities and 

residents and between residents. 

. Increased access to needed 

services and resources: Once 

residents gained access to 

AgeSpan’s programs and services, 

referrals to its community partners 

increased. Accordingly, residents 

have benefted from caregiver 

support programs, transportation, 

behavioral health services, 

assistive technology, Medicare 

counseling and assistance, and 

more. Residents also received 

encouragement and support, as 

needed, to enroll in the SNAP and 

other public beneft programs. 

. Increased engagement in 

health and wellness: Residents 

participated in on-site health 

and wellness programs, including 

evidenced-based programming 

through the AgeSpan Healthy 

Living Center of Excellence. Tese 

programs empowered participants 

to manage their health and 

avoiding falls. 
7 

. Improved food security: 

Communal and brown-bag meals 

alleviated hunger. 

. Reduced social isolation: Residents 

had better access to community 

resources—such as senior centers, 

public libraries, and faith-based 

institutions—and interactions with 

their staf or volunteers. 

. Increased community cohesion: 

Trough this shared experience, 

residents established bonds with 

RSCs and developed stronger 

relationships with one another. As 

a result, they had a secure sense of 

well-being. 

Maintaining a successful partnership 

requires the housing authority and AgeSpan 

to work together on behalf of the residents. 

HOUSING AND SUPPORTIVE SERVICES PARTNERSHIPS IMPROVE QUALITY OF LIFE 

Te outcomes from the AgeSpan partnership 

with the MSHP and housing sites show 

the potential of combining housing with 

supportive services, delivered with a personal 

touch. Trough strong, trusting relationships 

with residents, RSCs readily assess residents’ 

needs, priorities, and goals. As AgeSpan Area 

Agency on Aging staf, the RSCs have an array 

of supportive services at their fngertips for 

individuals to promote independence and to 

enrich residents’ access to social engagement, 

opportunities brought in from partners from 

across the greater community, health and 

wellness programs, and a caring environment. 

By forming a community-driven approach 

to bring services into afordable housing, 

partners can enhance housing stability and 

optimize independence, well-being, and 

health of older adults and people with 

disabilities across the lifespan. 
AUGUST 2022 

Tis publication was supported by the U.S. Administration for Community Living through a contract with Mission Analytics Group, Inc. 

(Contract number HHSP233201500060I) which subcontracted the work to USAging. Te views expressed do not necessarily 

represent the positions or policies of the Administration for Community Living/Department of Health and Human Services.