Elderly Housing: Federal Housing Programs and Supportive Services
Published: 2005-06-16T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: According to a congressionally established bipartisan commission, decreased investment in affordable housing and an elderly population that is projected to grow from about 12 percent of the population in 2002 to 20 percent by 2030 are likely to increase the number of elderly who must spend large portions of their incomes on housing. Moreover, according to this commission, more than one-third of the elderly tenants of government-subsidized housing require assistance with some type of activity of daily living, such as making a meal or getting in and out of bed. This testimony, which is based on a report issued in February 2005, discusses (1) the federal housing assistance programs requiring that supportive services be made available to elderly residents, (2) other Department of Housing and Urban Development (HUD) programs that assist the elderly in obtaining supportive services, and (3) private partnerships and federal health care programs that may provide supportive services to elderly beneficiaries of federal housing assistance.
section_title: What GAO Found
paragraphs: Of the 23 housing assistance programs GAO reviewed, only 4 require the owners of participating properties to ensure that services such as meals or transportation are available to residents. Three are HUD programs: the Section 202 Supportive Housing for the Elderly Program, which subsidizes multifamily properties for elderly households with very low incomes; the Assisted Living Conversion Program, which subsidizes the conversion of HUD-subsidized multifamily properties into assisted living facilities; and the Section 232 Mortgage Insurance Program, which insures mortgages for licensed facilities that provide varying levels of skilled care and services. USDA's Section 515 Rural Rental Housing Loan program, which makes loans for the construction and rehabilitation of rural multifamily properties, has a Congregate Housing Services subprogram that requires the provision of supportive services. HUD administers four programs that can be used with various housing programs to help the elderly with supportive services: Congregate Housing Services Program, which provides grants for the delivery of meals and nonmedical supportive services to elderly and disabled residents of public and multifamily housing; Neighborhood Networks Program, which encourages the development of computer centers in HUD-supported housing; Resident Opportunities and Self Sufficiency (ROSS) Program, which links public housing residents with services; and Service Coordinator Program, which funds coordinators who help elderly residents access services such as transportation and health care at some multifamily properties. Supportive services may also be available to elderly residents of subsidized housing through partnerships between individual properties and local organizations and through Department of Health and Human Services (HHS) programs. For example, HHS's Public Housing Primary Care Program provides public housing residents with access to affordable primary and preventive health care through clinics that are located in or near the properties. GAO did not obtain data on the extent to which such services are made available.

section_title: Letter
paragraphs: I appreciate the opportunity to be here today as the Committee considers  ways to promote coordination among federal programs that provide  housing and other services to the elderly. According to the report of the  congressionally established Commission on Affordable Housing and  Health Facility Needs for Seniors in the 21st Century, decreased  investment in affordable housing and a burgeoning elderly population that  is projected to grow from about 12 percent of the population in 2002 to 20  percent by 2030 are likely to increase the number of elderly who must  spend large portions of their incomes on housing. Moreover, according to  the Commission, about a third of the elderly tenants of government- subsidized housing required assistance with some type of activity of daily  living, such as preparing meals or getting in and out of bed or a chair.
My statement is based largely on our recent report to the Senate’s Special  Committee on Aging, which requested that we identify federal programs  that provide housing assistance to the elderly and the extent to which  supportive services, such as meals and transportation, were affiliated with  these programs. Beginning in the 1930s, a number of federal housing  programs have subsidized the construction of housing for the poor,  provided rental assistance to tenants in existing privately owned housing,  and insured mortgages for both single- and multifamily properties. Today,  the Department of Housing and Urban Development (HUD) administers  the majority of federal housing assistance programs in urban areas, and  the U.S. Department of Agriculture’s (USDA) Rural Housing Service (RHS)  implements housing programs in rural areas. Among the programs they  administer are a number that either target the elderly specifically or  provide benefits for which the elderly are eligible. My statement discusses  (1) housing assistance programs that serve the elderly and require that  supportive services be made available to elderly residents, (2) other HUD  programs that can be used in conjunction with housing programs to assist  the elderly in obtaining supportive services, and (3) private partnerships  and federal health care programs that may provide some services in  conjunction with federally assisted housing.
In preparing this information, we consulted with HUD and USDA officials  to identify housing assistance programs that benefit the elderly. We  reviewed laws and regulations to determine which of the housing  assistance programs within our scope were required to ensure that  supportive services were available. We identified programs providing  supportive services that could be used with various housing assistance  programs, whether or not such services were required. We reviewed  literature and descriptions of housing assistance programs and  interviewed administrators of the housing assistance programs within our  scope, as well as representatives of advocacy organizations and  professional associations interested in elderly housing issues and  supportive services. We obtained descriptions of the supportive services  programs by interviewing and obtaining documentation from officials  from HUD, USDA, and the Department of Health and Human Services  (HHS). We performed our work in Baltimore, Maryland; Greensboro and  Raleigh, North Carolina; Columbus, Ohio; Oklahoma City and Stillwater,  Oklahoma, and Washington, D.C., between December 2003 and December  2004 in accordance with generally accepted government auditing  standards.
Of 23 federal housing assistance programs that we reviewed, only 4  required property owners to ensure that services such as meals or  transportation were available to their residents. Three are HUD programs:  the Section 202 Supportive Housing for the Elderly Program, which  subsidizes the development and operating costs of multifamily properties  for elderly households with very low incomes; Assisted Living Conversion  Program, which subsidizes the conversion of HUD-subsidized multifamily  properties into assisted living facilities; and Section 232 Mortgage  Insurance Program, which insures mortgages for licensed facilities that  provide varying levels of skilled care and services. In addition, USDA’s  Section 515 Rural Rental Housing Loan program, which makes loans for  the construction and rehabilitation of rural multifamily properties, has a  Congregate Housing Services subprogram that requires the provision of  supportive services.
HUD administers four service-related programs that can be used in  conjunction with various housing programs to assist the elderly in  obtaining supportive services: the Congregate Housing Services Program,  which provides meals and other services in public and multifamily housing  properties; the Neighborhood Networks Program, which provides  resources for establishing computer networks at these sites; and the  Resident Opportunities and Self Sufficiency (ROSS) and Service  Coordinator programs, which link residents with services in the  community.
Supportive services may also be available to elderly residents of  subsidized housing through partnerships between individual properties  and local organizations and through programs provided by HHS. For  example, HHS’s Public Housing Primary Care Program provides public  housing residents with access to affordable comprehensive primary and  preventive health care through clinics that are located either in or near  public housing properties.
subsections: section_title: Background
paragraphs: Beginning in the 1930s, a number of federal housing programs have  provided assistance to low-income renters and homeowners, including  rent subsidies, mortgage insurance, and loans and grants for the purchase  or repair of homes. Housing developments can be assisted by multiple  programs. For example, a loan or mortgage on a multifamily property may  be insured through a HUD or USDA program, and the property may have  tenants that receive rental assistance from these agencies. In our earlier  report, we identified a total of 23 federal housing programs that target or  have special features for the elderly. Of these programs, 2 are intended for  the elderly only, 3 target the elderly and disabled, and another 18 have  special features for the elderly, such as income adjustments that lower  elderly households’ rental payments. Appendix I lists these housing  assistance programs.
In general, both HUD and USDA programs target families at lower income  levels. HUD programs target families with incomes that are extremely low  (no more than 30 percent of an area’s median), very low (no more than 50  percent of an area’s median), and low (no more than 80 percent of an  area’s median). USDA programs also target families with incomes that are  very low and low. In addition, some USDA programs target families with  moderate incomes (no more than 115 percent of an area’s median).  However, these programs do not reach all needy households, and waiting  lists for many types of subsidized housing, including housing for the  elderly, are often long.
HUD has specific goals for increasing housing opportunities for the  elderly, including one goal specifically related to supportive services. As  outlined in its fiscal year 2004 Annual Performance Plan, these goals  include (1) increasing the availability of affordable housing for the elderly,  (2) increasing the number of assisted-living units, (3) increasing the  number of elderly households living in privately owned, federally assisted  multifamily housing served by a service coordinator, and (4) increasing  elderly families’ satisfaction with their Section 202 units. USDA does not  have specific goals related to the elderly in its fiscal year 2004 Annual  Performance Plan.
As GAO has previously reported, virtually all the results that the federal  government strives to achieve require the concerted and coordinated  efforts of two or more agencies. This shared responsibility is an outgrowth  of several factors, including the piecemeal evolution of federal programs  and service delivery efforts. Achieving results on public problems, such as  the potentially large service needs of a growing elderly population,  increasingly calls for effective interagency coordination. However, our  work has shown that a number of barriers inhibit coordination among  agencies. For example:  In reporting on the coordination of programs for the homeless, we noted  that the federal government’s system for providing assistance to low- income people is highly fragmented. Each federal assistance program  usually has its own eligibility criteria, application, documentation  requirements, and time frames; moreover, applicants may need to travel to  many locations and interact with many caseworkers to receive assistance.
A review of federally assisted transportation services for “transportation- disadvantaged” seniors (who are more likely to have difficulty accessing  transportation due to physical ailments) found that 5 federal agencies  administer 15 programs. Service providers told GAO that certain  characteristics of federal programs, such as what the providers view as  burdensome reporting requirements and limited program guidance, can  impede the implementation of practices that enhance senior mobility.
More generally, we have noted the range of barriers to coordination that  agencies often face, including missions that are not mutually reinforcing or  that may even conflict; concerns about protecting jurisdiction over  missions and control over resources; and incompatible procedures,  processes, data, and computer systems.
section_title: Four Housing Assistance Programs Require That Supportive Services Be Made Available to Elderly Residents
paragraphs: Generally, HUD and USDA’s housing assistance programs are not required  to provide supportive services to the elderly. Of the 23 housing assistance  programs that target or include the elderly among potential beneficiaries,  only 4 require the owners of properties developed under the programs to  ensure that supportive services are available. Appendix II provides  summaries of the four programs, which include:    HUD’s Section 202 program, which subsidizes the development and  operating costs of multifamily properties for elderly households with very  low incomes. It is the only federal housing program that targets all of its  rental units to very-low-income elderly households. Applicants for Section  202 funding must demonstrate that services will be available at the  development or in the community where new construction is proposed.
HUD’s Assisted Living Conversion Program, which provides private  nonprofit owners of eligible properties with grants to convert some or all  of their units into assisted living facilities for the frail elderly. The  reconfigured facilities must include enough community space to  accommodate a central kitchen or dining area, lounges, and recreation and  other multiple-use areas. The facilities must provide supportive services  such as personal care, transportation, meals, housekeeping, and laundry.
HUD’s Section 232 Mortgage Insurance Program, which provides mortgage  insurance for the construction or substantial rehabilitation of nursing  homes (facilities that provide skilled nursing care and have 20 or more  beds); intermediate care facilities (those that provide minimum but  continuous care and have 20 or more beds); board and care homes  (facilities that provide room, board, and continuous protective oversight  and have at least 5 accommodations); and assisted living facilities (those  with 5 or more units designed for frail elderly persons who need  assistance with at least 3 activities of daily living). All insured facilities  must provide supportive services, but these services vary according to the  type of facility.
USDA’s Section 515 Program, which provides loans to construct or to  purchase and substantially rehabilitate multifamily rental or cooperative  housing and recreational facilities in rural communities. Tenants eligible  to live in program properties may also receive rental assistance through  HUD or USDA programs. The Congregate Housing subprogram funds the  development of assisted, group living environments that must provide  meals, transportation, housekeeping, personal services, and recreational  and social activities.
Generally, HUD and USDA do not provide funding for the services  required under these housing programs. The property owners typically  obtain other funds, either from federal programs, local charities, and civic  groups to provide supportive services or must ensure that appropriate  services are available in the community.
section_title: Other HUD Programs Can Assist the Elderly in Obtaining Supportive Services
paragraphs: HUD administers four service-related programs that can be used in  conjunction with subsidized housing programs: two programs that provide  supportive services to residents of public and multifamily properties  developed under HUD programs, and two that link residents to supportive  services. None of these programs are targeted exclusively to the elderly,  but they either can be used in properties designated for the elderly or offer  funding specifically for services for the elderly.
The Congregate Housing Services Program provides grants for the delivery  of meals and nonmedical supportive services to elderly and disabled  residents of public and multifamily housing, including USDA’s Section 515  housing. While HUD provides up to 40 percent of the cost of supportive  services, grantees must pay at least 50 percent of the costs, and program  participants pay fees to cover at least 10 percent. Like the  Elderly/Disabled Services Coordinator Program under ROSS, the  Congregate Housing Services Program has provided no new grants since  1995, but Congress has provided funds to extend expiring grants on an  annual basis.
The Neighborhood Networks program encourages property owners,  managers, and residents of HUD-insured and -assisted housing to develop  computer centers. Although computer accessibility is not a traditional  supportive service for the elderly, a senior HUD official noted that having  computers available enhances elderly residents’ quality of life. HUD does  not fund each center’s planned costs but encourages property owners to  seek cash grants, in-kind support, and donations from sources such as  state and local governments, educational institutions, private foundations,  and corporations.
The ROSS grant program links public housing residents with appropriate  services. This program differs from the Service Coordinator Program in  that it is designed specifically for public housing residents. The ROSS  program has five funding categories, including the Resident Service  Delivery Models for the Elderly and Persons with Disabilities (Resident  Services) and the Elderly/Disabled Service Coordinator Program. Resident  Services funds can be used to hire a project coordinator; assess residents’  needs for supportive services and link residents to federal, state, and local  assistance programs; provide wellness programs; and coordinate and set  up meal and transportation services. The Elderly/Disabled Service  Coordinator Program has not provided new grants since 1995 but still  services existing grants.
The Service Coordinator Program provides funding for managers of  multifamily properties designated for the elderly and disabled to hire  coordinators to assist residents in obtaining supportive services from  community agencies. These services, which may include personal  assistance, transportation, counseling, meal delivery, and health care, are  intended to help the elderly live independently and to prevent premature  and inappropriate institutionalization. Service coordinators can be funded  through competitive grant funds, residual receipts (excess income from a  property), or rent increases. According to HUD’s fiscal year 2003  Performance and Accountability Report, service coordinators were  serving more than 111,000 units in elderly properties.
section_title: Private Partnerships and Federal Health Care Programs May Provide Some Supportive Services
paragraphs: Elderly residents of public and federally subsidized multifamily housing  can also receive supportive services through partnerships between  property owners and local organizations and through programs provided  by HHS. For example, property owners can establish relationships with  local nonprofit organizations, including churches, to ensure that residents  have access to the services that they need. At their discretion, property  owners may establish relationships that give the elderly access to meals,  transportation, and housekeeping and personal care services. Although  GAO did not obtain data on the extent to which such services are made  available at all public and federally subsidized multifamily housing, in site  visits to HUD and USDA multifamily properties, we found several  examples of such partnerships:  In Greensboro, North Carolina, Dolan Manor—a Section 202 housing  development—has established a relationship with a volunteer group from  a local church. The volunteer group provides a variety of services such as  transportation for the residents.
In Plain City, Ohio, residents of a Section 515 property called Pleasant  Valley Garden receive meals five times a week in the community’s senior  center (a $2 donation is suggested). A local hospital donates the food and  a nursing home facility prepares it. Volunteers, including residents, serve  the meals. The senior center uses the funds collected from the lunch for its  activities. In addition, local grocery stores donate bread products to the  senior center daily. The United Way provides most of the funding for the  senior center.
In Guthrie, Oklahoma, Guthrie Properties—also a Section 515 property—  has established a relationship with the local Area Agency on Aging. The  agency assists residents of Guthrie Properties in obtaining a variety of  services, including meals and transportation to a senior center.
Some elderly residents of public and federally subsidized housing may also  obtain health-related services through programs run by HHS. For example,  HHS’s Public Housing Primary Care Program provides public housing  residents with access to affordable comprehensive primary and preventive  health care through clinics that are located either within public housing  properties or in immediately accessible locations. The program awards  grants to public and nonprofit private entities to establish the clinics. The  organizations must work with public housing authorities to obtain the  physical space for the clinics and to establish relationships with residents.  Currently, there are 35 grantees, 3 of which are in rural areas. According to  a program administrator, although clinics are not specifically geared  toward public housing designated for the elderly, they can be established  at such properties.
Elderly residents of federally subsidized housing may also be eligible for  the Medicaid Home and Community-Based Services (HCBS) Waiver  Program, which is administered by HHS’s Centers for Medicare and  Medicaid Services. Through this waiver program, individuals eligible for  Medicaid can receive needed health care without having to live in an  institutional setting. HUD has identified these waivers as an innovative  model for assisting the frail elderly in public housing.
In addition, eligible elderly residents of federally subsidized housing may  receive health care through the Program of All-Inclusive Care for the  Elderly (PACE), which is also administered by the Centers for Medicare  and Medicaid Services. Like the HCBS waiver program, this program  enables eligible elderly individuals to obtain needed services without  having to live in an institutional setting. The program integrates Medicare  and Medicaid financing to provide comprehensive, coordinated care to  older adults eligible for nursing homes. Figure 1 provides information on  the housing assistance programs that can use federally funded supportive  services programs that assist the elderly.
Mr. Chairman, this concludes my prepared statement. I would be happy to  answer any questions at this time.
section_title: Contacts and Acknowledgements
paragraphs: For further information on this testimony, please contact David G. Wood  at (202) 512-8678. Individuals making key contributions to this testimony  included Emily Chalmers, Natasha Ewing, Alison Martin, John McGrail,  Marc Molino, Lisa Moore, John Mingus, Paul Schmidt, and Julianne  Stephens.
section_title: Appendix I: Housing Programs Targeted to or with Special Features for the Elderly
paragraphs: USDA Section 502 Rural Housing Loans (Direct)
Section 502 Direct Housing Natural Disaster Loans Section 502 Guaranteed Rural Housing Loans Section 504 Rural Housing Repair and Rehabilitation Loans Section 515 Rural Rental Housing Loans Section 521 Rural Rental Assistance Section 538 Guaranteed Rural Rental Housing Loans Project-based Rental Assistance (Section 8 and Rent Supplement) (inactive)
Section 8 Moderate Rehabilitation (inactive)
Section 207 Mortgage Insurance for Manufactured Home Parks Section 207/223(f) Mortgage Insurance for Existing Multifamily Properties Section 213 Mortgage Insurance for Cooperatives Section 221(d)(3) Below-Market Interest Rate (inactive)
Section 221(d)(3)/(d)(4) Mortgage Insurance Section 236 Mortgage Insurance and Interest Reduction Payments (inactive)
Before fiscal year 1992, the Section 202 program also supported the development of housing for the  disabled.
The Section 515 program’s Congregate Housing subprogram requires properties to provide  supportive services.