Under the United States Housing Act of 1937, as amended, Congress created the federal public housing program to provide decent and safe rental housing for eligible low-income families, the elderly, and persons with disabilities. HUD administers federal aid to local public housing agencies that manage housing for low-income residents at rents they can afford. More specifically, 3,150 public housing agencies manage approximately 1.2 million public housing units throughout the nation, of which approximately 1 million are occupied. Public housing comes in all sizes and types, from scattered single-family houses to high-rise apartments. Funding for public housing construction, renovation, or operation can come from a number of HUD programs, as well as other government and private sources. HUD’s Public Housing Capital Fund (Capital Fund) provides funds (distributed by formula) for activities such as redesign, reconstruction, improvement of accessibility, and replacement of obsolete utility systems. The fiscal year 2005 appropriation for the Capital Fund was about $2.4 billion. HUD’s Public Housing Operating Fund (Operating Fund) provides operating subsidies to housing agencies to help them meet operating and management expenses. The fiscal year 2005 appropriation for the Operating Fund was about $2.4 billion. In addition, between fiscal years 1993 and 2005, Congress appropriated $6.8 billion for the HOPE VI program, which HUD awarded to public housing agencies for planning, technical assistance, construction, rehabilitation, demolition, and housing choice voucher assistance. While most of the funds are intended for capital costs, a portion of the revitalization grants may be used for community and supportive services. In addition, public housing agencies use the HOPE VI revitalization grant to leverage additional funds from sources such as other HUD funds, state or local contributions, or public and private loans. In 2002, we reported that housing agencies expected to leverage—for every dollar received in HOPE VI revitalization grants awarded through fiscal year 2001—an additional $1.85 in funds from other sources. We also found that housing agencies that had received revitalization grants expected to leverage $295 million in additional funds for community and supportive services. In addition to leveraging funds from a variety of sources, housing agencies may use Low-Income Housing Tax Credits—which are federal tax credits for the acquisition, rehabilitation, or new construction of affordable rental housing—as well as Medicaid Home and Community-Based Services waivers, which allow flexibility in providing healthcare or long-term care services to Medicaid-eligible individuals outside of an institutional setting. Residents of public housing who are elderly or have disabilities may have more special needs, compared with other residents, due to their age and type of disability. According to a 2002 study by the Housing Research Foundation, elderly public housing residents are more likely to be “frail” or have disabilities, compared with other elderly persons not living in public housing. The researchers reported that more than one in five elderly public housing residents were classified as persons with disabilities, compared with only 13 percent of U.S. elderly persons. In addition, the report found that over 30 percent of elderly public housing residents have at least one functional problem, such as difficulty with cooking, seeing, and hearing, compared with just over 20 percent of all elderly persons. Some elderly persons or persons with disabilities may require assistance with the basic tasks of everyday life, such as eating, bathing, and dressing. In addition, the needs of the elderly or persons with disabilities result in a need for physical features in residences that adequately accommodate physical limitations. According to 2005 HUD data, 64 percent of the approximately 1 million occupied public housing units are occupied by at least one elderly person or a person with a disability, and 50 percent of all heads of public housing households are either elderly (31 percent) or non-elderly persons with disabilities (19 percent), as shown in figure 1. Residents who are elderly or have disabilities live in a variety of public housing settings, including developments that are occupied primarily by elderly residents or residents with disabilities as well as developments that are occupied primarily by families. According to 2005 HUD data, of approximately 500,000 public housing units that are occupied by a head of household who is elderly or has a disability, 47 percent are in developments that are occupied primarily by elderly persons or persons with disabilities, 40 percent are in developments that are occupied primarily by families (family housing developments), and 13 percent are in developments that include buildings that are occupied by families and buildings that are occupied by elderly persons and persons with disabilities (mixed developments). While HUD collects data for several elements describing the physical and social conditions that exist at its public housing developments, the data do not sufficiently establish whether a housing development is severely distressed. Based on survey responses from public housing directors— covering 66 housing developments with indications of potential distress and occupied primarily by the elderly or persons with disabilities—we found that 11 developments exhibited signs of severe physical distress; 12 had signs of severe social distress; and an additional 5 developments had signs of both severe physical and social distress. Although the remainder of the 66 developments had fewer signs of severe distress, the public housing directors we surveyed pointed out several conditions that adversely affected the quality of life for their tenants who are elderly or have disabilities. The factors they most frequently cited were (1) aging buildings and systems, including inadequate air-conditioning; (2) lack of accessibility for residents with disabilities; (3) small studio apartments; (4) tension between elderly residents and non-elderly residents with disabilities; (5) lack of supportive services; and (6) security and crime issues. As previously discussed, Congress expanded the statutory definition of “severely distressed public housing” in 2003 to include, among other factors, housing developments in severe distress because of a lack of sufficient appropriate transportation, supportive services, economic opportunity, schools, civic and religious institutions, and public services. However, HUD data do not indicate whether a development has these kinds of public and other supportive services. HUD collects, maintains, and analyzes data on public housing primarily through a database system and a management center. HUD uses the Public and Indian Housing Information Center (PIC) system—which was designed to facilitate Web-based exchange of data between public housing agencies and local HUD offices—to monitor the housing agencies, detect fraud, and analyze and provide information to Congress and other interested parties. PIC contains a detailed inventory of public housing units and tenant (household) information about occupants. For example, the PIC database maintains information on the number of developments and units, age of the development, extent to which apartment units are accessible for persons with disabilities, and tenant information such as the age, disability status, and income of families who participate in public housing programs. HUD’s Real Estate Assessment Center (REAC) monitors and evaluates the physical condition of public housing and other properties that receive financial assistance from HUD and also assesses their financial condition. For example, the Physical Assessment Subsystem within REAC maintains information about the physical condition of HUD properties, based on on-site physical inspections, which identifies housing developments that are physically deteriorated, have health and safety hazards, or deficiencies such as tripping hazards on sidewalks or parking lots, damaged fences or gates, blocked emergency exits, or inoperable smoke detectors inside apartments. Using the limited data that were available from HUD and other sources, we defined eight measures to indicate potential severe distress for developments: (1) REAC physical inspection results; (2) adjusted physical inspection results provided by the Urban Institute; (3) building age; (4) vacancy rate; (5) total household income by unit; (6) poverty rate for the census tract; (7) accessibility of units to persons with disabilities; and (8) whether developments applied for HOPE VI or were approved for demolition, disposition, or HOPE VI funding. As noted previously, we then developed an “index of distress” to score conditions at public housing developments. We found that 76 (2 percent) of the 3,537 housing developments mainly occupied by the elderly and non-elderly persons with disabilities showed indications of severe distress. In contrast, other developments were more likely to show indications of severe distress. We found that 958 (12 percent) of 7,932 family housing developments and 69 (15 percent) of 466 mixed housing developments showed indications of severe distress. In addition, some public housing directors we interviewed reported that family housing developments, near or adjacent to their developments occupied primarily by elderly residents and residents with disabilities, were more likely to be in worse condition or afflicted by neighborhood crime or illicit activities. According to HUD’s data, the following characteristics describe the 76 housing developments that were occupied by mostly elderly persons and non-elderly persons with disabilities: 21 had been approved for demolition, disposition, or HOPE VI 72 had a building that was more than 30 years old; 64 had few units (less than 5 percent) that met accessibility standards; 24 had a physical inspection score under 60 percent; 41 were in a census tract with a poverty rate greater than 35 percent; 26 had households with a total median income under $7,000. Responses to our survey of public housing directors indicated that some of the 76 public housing developments occupied primarily by elderly persons and non-elderly persons with disabilities were severely distressed and that, among those that were not, certain characteristics nevertheless adversely affected the quality of life for their residents. We received responses covering 66 of these 76 developments and found that 11 showed signs of severe physical distress, 12 had signs of severe social distress, and five others had signs of both physical and social distress. In developments where survey data indicated signs of severe distress, housing directors reported deterioration and obsolescence in key systems. However, housing directors described the condition of the physical structures at 34 developments as either, “not at all deteriorated” or “a little deteriorated” (see fig. 2). Indicators of severe social distress that the directors reported include inadequate supportive services, such as transportation, assistance with meals, and problems with crime. Even though not necessarily indicative of severe distress, a number of factors were reported by many public housing agency directors as adversely affecting living conditions for the elderly and persons with disabilities. Among the most frequently cited characteristics or conditions were aging buildings, lack of accessibility for residents with disabilities, small size of apartments, mixing elderly and non-elderly residents with disabilities, the lack of supportive services, and crime. To varying extents, the survey respondents also cited these factors as challenges in providing public housing (see fig. 3). Eleven surveyed housing agency directors mentioned that aging buildings posed maintenance and other challenges for their housing agencies—nearly all (96 percent) of the developments that we surveyed were more than 30 years old. Some buildings had deteriorating structures, as shown in figure 4. In addition, several public housing agency officials further noted during our site visits and in our survey that because of their age, the developments were “functionally obsolete.” That is, many of the design features were outdated and did not meet the needs of residents. For example, 11 of the survey responses cited lack of adequate air-conditioning as a condition that most adversely affected the elderly and persons with disabilities. The building manager at one development said that during the summer months some elderly tenants who have heart conditions face increased health risks because their apartments do not have air-conditioning. At another development, an antiquated steam system provided heating. The public housing agency official whom we spoke with said this contributed to exorbitant utility bills. In addition to outdated systems, housing agency officials also cited outdated building designs as affecting the quality of life. For example, we visited two high-rise buildings that were more than 30 years old and constructed with exterior walkways, which residents had to use to access their apartments. During the winter months residents were routinely exposed to extremely cold weather and snow (see fig. 5). In addition, one public housing agency official whom we spoke with said that high-rise buildings limit social interactions among elderly residents. Due to the age of the buildings, public housing agency directors who responded to our survey reported that most of the 66 developments were undergoing, or will need, demolition, replacement, renovation, or rehabilitation (see fig. 6). Of the 66 developments for which we received responses, 11 were or are going to be demolished or replaced; and 21 had building systems (such as air-conditioning and elevator systems) that were recently or currently are being renovated; while 28 developments will require renovation to building systems within 3 years, according to housing agency directors. Respondents most frequently indicated that plumbing and sewer systems, elevators, and exterior building doors required near-term replacement or renovation. Other systems or features that were cited nearly as frequently were site lighting, parking lots, and heating and hot water systems. (Because our survey targeted developments that were most likely to be distressed, these conditions may not be representative of public housing for the elderly and persons with disabilities in general.) Public housing agency directors reported that a lack of accessibility throughout their developments was one condition that most adversely affected the quality of life for the elderly and persons with disabilities. For example, directors reported that 13 developments had elevators that were not large enough to allow a person in a wheelchair to easily turn around (see fig. 7). Our survey results also found that some developments did not have entrance and lobby doorways wide enough to allow passage for a person in a wheelchair or power scooter. We visited one housing development that had hallways on the main floor that were too narrow for modern power scooters to pass one another. According to a public housing agency official from this development, narrow halls are a problem because about one-third of the residents at the housing development use power scooters. This development also had a wheelchair ramp at the building’s entrance that was too narrow for power scooter users to easily navigate, and we observed power scooter users making difficult three-point turns on the narrow ramp. Additionally, six developments we surveyed did not have ramps of any kind for persons using wheelchairs or power scooters. Moreover, according to our survey, 23 developments had entrance and lobby hallways without grab bars. According to professionals knowledgeable about the housing needs of the elderly and persons with disabilities, grab bars or hand-rails in hallways are important because they help prevent falls, which are potentially disabling or fatal events. Based on our survey responses, housing agency directors for 32 developments indicated less than 5 percent of their units were accessible. During our visit to one housing development, the building manager told us that none of the apartment units were accessible to persons with disabilities; therefore, prospective residents with special needs were referred to another building within the housing agency’s portfolio. Housing directors reported that small studio apartments adversely affected the quality of life at six developments for the elderly and persons with disabilities and represented a major challenge for five housing agencies. One of the building managers that we interviewed noted that elderly residents who live in studio apartments sometimes do not have enough room for a lifetime’s worth of possessions and often have difficulty finding space for other family members, such as grandchildren, for whom the residents may serve as primary caregivers. In response to our survey, 17 public housing agency directors reported that a mixed population of elderly residents and younger residents with disabilities represented a challenge at their developments. During our visits to housing developments, housing agency officials and building managers told us that the mixed resident population sometimes led to tension because residents from each group often lead different lifestyles. In addition, many of the elderly residents that we interviewed told us that younger residents were more likely to have late-night visitors, play loud music, and lead active lifestyles, while they preferred quieter activities. Resident leaders at one development we visited told us that some elderly residents did not spend time in the common areas because they feared younger residents. Another elderly resident told us that some younger residents in his development robbed and terrorized the older residents. Further, officials that we interviewed also said that younger residents with disabilities sometimes have mental health conditions the housing agencies were not equipped to address. More specifically, building managers and residents told us that residents with mental health disabilities often disturbed other residents if they did not take proper medication. We found that at 29 of the developments for which we received survey responses, elderly residents made “very frequent” or “somewhat frequent” complaints about younger residents with disabilities. Conversely, at 59 of the developments, younger residents with disabilities made complaints about elderly residents “a little” or “not at all.” Thirteen surveyed public housing agency directors mentioned that providing adequate supportive services was a challenge. Most of the developments we visited and surveyed had some on-site supportive services, which assist with activities of daily living and are intended to help the elderly and persons with disabilities remain independent and in their communities (see fig. 8). However the array of supportive services varied and often could not be characterized as meeting the needs of residents. According to a HUD report on housing needs for the elderly, residents’ needs for greater assistance, such as that offered by a nursing home, may increase as a result of inadequate supportive services. Many of the building managers and residents that we interviewed told us that residents who moved out of the public housing development often moved in with family or to a nursing home because the development lacked sufficient supportive services. According to data from one public housing agency director, of 21 residents who relocated from one of the public housing developments during the 2004 calendar year, 6 moved into a nursing home. Although 28 of the developments from which we received survey responses had some type of on-site medical or health services, these varied from development to development because not all of the developments with health services offered assistance with medication. According to professionals knowledgeable about the housing needs of the elderly and non-elderly persons with disabilities, having a nurse or healthcare professional at the development to help residents manage their medications is beneficial. The elderly and non-elderly persons with disabilities also often need assistance with housekeeping, personal care, and meals. One building manager at a development we visited told us that the residents without nearby family often needed assistance with housekeeping. During one of our visits, we observed a resident receiving assistance with housekeeping. At another development, the housing agency officials told us that residents appreciated the services from an on-site hair salon. According to our analysis of our survey data, 34 developments offered on-site meal preparation services. One building manager at a development we visited told us that on-site lunch programs were often the only hot meal of the day for some residents. Building managers at other developments indicated that many of their residents can no longer safely cook. According to our analysis of survey responses, most of the developments offered recreational activities for the elderly or non-elderly persons with disabilities. Furthermore, residents we interviewed reported that recreational activities, such as outings, or organized potluck dinners, were important to their quality of life. One public housing agency official with whom we spoke said that many elderly residents do not have family nearby and without planned activities at the housing development many would never leave their apartments. According to one study on public housing for the elderly, up to a third of elderly residents living in public housing in New York almost never left their apartments. During our visits to 25 housing developments, we observed on-site activities such as arts and crafts workshops and sewing and computer classes. Many of the buildings also had libraries, television rooms, and exercise rooms. According to knowledgeable professionals, elderly residents need physical activities incorporated into their daily lives to maintain their health. At some developments we visited, residents said they had events such as bingo or pancake breakfasts, but lacked activities involving physical exercise. According to our survey responses, we also found that 25 housing developments offered job training or placement services for their residents. Public housing agency directors reported that in 55 of the developments some kind of scheduled or on-demand door-to-door transportation service was available. Door-to-door transportation includes vans or buses that pick up residents at the housing development and take them to destinations such as grocery stores, banks, or to medical appointments. However, survey responses from eight developments indicated that accessing any form of transportation was “not very easy,” nor were grocery stores or other services located near these developments, which increased the isolation of residents. Several of the residents at the housing developments that we visited said a lack of accessible transportation affected their quality of life because they could not easily get to a grocery store or doctors’ appointments. According to our survey results, 26 housing developments provided access to a service coordinator at least 20 days per month, while 19 had no service coordinator, and 11 had one available less than 5 days per month (see fig. 9). According to HUD, a service coordinator assists elderly residents and non-elderly residents with disabilities of federally assisted housing to obtain needed supportive services from community agencies, thereby preventing premature and inappropriate institutionalization. For example, a service coordinator might find a public housing resident with a disability someone to help with housekeeping, enabling the resident to remain independent. Service coordinators also help elderly residents and non-elderly residents with disabilities determine if they qualify for government services. According to the 2002 Housing Research Foundation Report cited above, 83 percent of elderly residents in public housing live alone, and therefore may not have a support network to help them access services or fill out paperwork. While service coordinators are an important aspect to improving the quality of life for the elderly and non-elderly persons with disabilities who reside in public housing, some developments provided access to service coordinators on a less frequent basis. For example, one housing agency we visited had one service coordinator for 2,500 units occupied by elderly persons and non-elderly persons with disabilities. According to the housing director, this staffing level was not sufficient to meet resident needs. In another case, two service coordinators were responsible for all of the housing agency’s 20,000 residents. Survey data indicated that 38 developments had at least some problems with crime in surrounding neighborhoods, while 24 developments had at least some problems with crime inside the development (see fig. 10). A few developments that we visited were adjacent to family public housing developments, which in general—according to our analysis of HUD data and interviews with housing agency directors—tend to be in worse condition than public housing occupied by the elderly and non-elderly persons with disabilities. Housing directors stated that, as a result, crime was more of a problem at those family-adjacent developments. Some elderly residents and non-elderly residents with disabilities told us that they did not feel safe in their neighborhoods or, sometimes, in their developments. At one housing development, one resident told us that young people from the neighborhood loitered in and around their development, which made the elderly residents feel uncomfortable. At two other housing developments we visited, public housing agency officials and residents identified tenants who sold drugs from their apartments, which attracted unwanted outsiders into the development. Residents at one development said they stopped participating in recreational activities because they feared someone would break into their apartments if they left. When problems with crime and vandalism peaked at another housing development, residents told us that they formed their own security group to monitor the activity at the building. According to officials whom we surveyed and interviewed, various strategies have been used to improve both physical and social conditions to better address the special needs of the elderly and non-elderly persons with disabilities. Methods to deal with physical distress included capital improvements such as renovating or modernizing buildings, systems, and units or, in extreme cases, demolishing or selling a development. Methods to reduce the level of social distress include a range of actions to address the needs of the elderly and non-elderly persons with disabilities, such as designating developments as “elderly only” for reasons of safety, converting developments into assisted living facilities, and working with other agencies, such as nonprofit and religious organizations, to provide in-home supportive services to residents. To improve physical conditions at public housing developments, 18 of the 43 responding public housing agency directors said they had ongoing or planned actions, such as modernizing building structures, upgrading accessibility features, and installing new building systems such as air conditioning and electrical systems. During our site visits, public housing agency officials whom we interviewed also described current or planned renovations to improve the physical conditions of their developments. For example, at one development the housing agency had recently improved its lobby and exterior with new paint, tiles, and landscaping. Building managers at this location told us that these renovations improved living conditions for residents and made the development more marketable. The housing agency also converted some of the first-floor units to be accessible to persons with disabilities and installed new appliances in the units. Other actions taken by housing agencies to improve physical conditions include planned or implemented elevator upgrades, which in some cases have made elevators more accessible to elderly residents or residents with disabilities. In addition, at one development we visited that had exterior walkways, the housing agency was undertaking large-scale renovations, which included enclosing the exposed areas to protect residents from inclement weather. At five developments we visited, public housing agencies had recently added central air-conditioning. Lastly, at three locations we visited, public housing agencies had previously converted, or planned to convert, studio apartments into one-bedroom units to better meet the needs of residents. Housing agency directors we interviewed during our site visits said that their housing agencies use public funding from federal, state, and local sources, and funding from private sources to address physical conditions. Public housing agency directors whom we surveyed made similar comments, with 17 citing HUD’s Capital Fund as a funding source to implement building modernizations or to renovate building components, including actions to accommodate the needs of persons with disabilities. The Capital Fund provides housing agencies with funds based on a formula that takes into account the size, location, and age of developments, along with the need for modernization, among several other characteristics. Public housing agency directors also reported using Low-Income Housing Tax Credits to make large-scale improvements or for new construction. Public housing agencies have also entered into partnerships with private-sector firms to implement a variety of improvements, such as building upgrades and comprehensive renovations. According to a housing agency official responsible for three large housing developments we visited, public housing agencies often lack development experience; thus, a partnership with private developers can bring valuable resources to improve public housing developments. Public housing agencies also undertook more comprehensive improvement programs to address difficulties at developments that are associated not only with physical deterioration, but also with the overall deterioration of the surrounding neighborhood. For example, in St. Petersburg, Florida, the housing agency received a $27 million HOPE VI grant in 1998, which it used to tear down and rebuild all housing at the Historic Village development and the accompanying family housing development, Jordan Park. The housing agency made physical improvements to the development and individual apartments, such as improving accessibility for persons with disabilities and adding air-conditioning. Before the redevelopment, Jordan Park had a high concentration of poverty and a reputation as being a haven for criminal activity. Building managers told us that the incidence of crime in the area has since gone down. The HOPE VI grant made up about 40 percent of the funding necessary for the $70 million improvements at Historic Village and Jordan Park. Low-Income Housing Tax Credits and a combination of state and local sources made up the rest of the funding. According to St. Petersburg housing agency officials, the large-scale improvements at Historic Village reduced vacancy rates and lowered the crime rate in the surrounding area, which is one of the goals of the HOPE VI program. However, at the Graham Park development, the housing agency in St. Petersburg determined that modifications necessary to improve accessibility were not feasible or cost effective because widening the narrow hallways would affect the structural integrity of the building. As a result, the housing agency submitted an application to sell Graham Park and use the proceeds to acquire or develop alternative affordable housing. Furthermore, the housing agency will offer current residents Section 8 housing vouchers so they can rent housing elsewhere. Some survey respondents also reported that they were planning to or were in the process of replacing some of their developments. For example, eight housing agency directors reported that they were considering or were implementing actions to demolish or dispose of existing developments in order to acquire or build new housing for the elderly and non-elderly persons with disabilities. Public housing agency officials we contacted mentioned a variety of strategies to improve social conditions at housing developments for the elderly and non-elderly persons with disabilities. For example, 28 housing agency directors who responded to our survey mentioned actions they have taken or plan to take to address social conditions for elderly persons and persons with disabilities who reside in public housing. For instance, 12 housing directors reported that they have taken actions to resolve problems associated with having elderly and non-elderly residents in the same development, such as designating their developments as “elderly only.” In particular, a number of housing directors cited safety concerns caused by young persons with mental health disabilities. Housing agency directors also reported that they have added security features and established programs to reduce crime and increase security. At one development for example, the housing agency partnered with the local police department to establish a community watch program. Thirteen survey respondents also reported taking other actions to address the needs of the elderly and persons with disabilities, including in-home health and nutrition assistance and other supportive services. In particular, one public housing director reported that the housing agency created its own senior resident advisor, who provides an array of supportive services to address the needs of its elderly residents. To improve social conditions on a larger scale, the housing agency in Allegheny County completely revitalized the Homestead Apartments outside of Pittsburgh, Pennsylvania. The housing agency built space on-site for two nonprofit elder care service providers in addition to remodeling the buildings. One provider met the needs of the frailest residents with complete nursing services, meals, and adult day care. The other provider operates a walk-in wellness center that provides Homestead’s more independent residents with blood pressure checks, assistance with medication, and service coordination and referrals. Housing officials whom we interviewed at Homestead estimated that the services provided at the adult day care center prevented nursing home-eligible residents from prematurely entering nursing homes. This resulted in a monetary savings for the state because, according to a Pennsylvania Department of Public Welfare director, the cost of care for those enrolled in the adult day center was only 85 percent of the cost of caring for them at a nursing home. Much of the new development at Homestead was financed with Low-Income Housing Tax Credits. In another large-scale effort, the Miami-Dade Housing Agency converted Helen Sawyer Plaza into an assisted living facility. Twenty-four hour nursing care, meals, and recreational activities are now provided on-site. According to the building manager, the conversion eliminated high vacancy rates at the development, created a sense of community among the residents, and prevented residents from prematurely entering nursing homes. The housing agency uses Medicaid Home and Community-Based Services waivers to obtain federal funding for the assisted-living care of residents at Helen Sawyer. Such Medicaid waivers offer states the flexibility to pay for nursing services delivered outside of institutional settings. In addition, officials we interviewed at Helen Sawyer asserted that conversions to assisted living facilities are cost-effective options, in part, because public housing agencies own the property on which the public housing is built. As a result, housing agencies do not have to assume the mortgage or lease payments that comparable private assisted living facilities often have. Based on our survey results and information from housing officials whom we interviewed, housing agencies partnered with outside agencies, such as community-based nonprofits or churches, to provide supportive services for the elderly and non-elderly persons with disabilities. In some cases, the agencies paid for the services; but in some cases, housing agencies also used federal grants. A building manager for one development that we visited said they partnered with a nearby church to provide a van to take residents shopping once a week. Local churches also provided food assistance to elderly residents and residents with disabilities who were not able to leave their apartments at this development. At another housing development we visited in Miami, Florida, Catholic Charities, a community-based organization, provided lunches on a daily basis to residents and assorted grocery items such as bread, fruit, and cereal on a weekly basis. We also observed a partnership in Seattle, Washington, where the housing agency partnered with a community-based organization to provide an on-site elderly community center where residents had access to meals, social activities, and assistance with filling prescriptions. Residents at this development also had access to an on-site health clinic. In addition, based on responses to our survey, five housing agency directors cited HUD’s Resident Opportunities and Self Sufficiency (ROSS) grant program as a means to provide supportive services such as assistance with health, activities of daily living, and transportation. Finally, public housing officials at two locations we visited also reported that ROSS grants funded door-to-door transportation for residents, assistance with housekeeping, and service coordinators, among other services. The extent to which public housing developments for the elderly and non-elderly persons with disabilities is severely distressed cannot be determined definitively with existing data, which are insufficient regarding factors that contribute to distress. Moreover, much of the data that are available are at the development level, rather than the individual building or unit level. These limited data, along with information from housing agency directors, suggest that severe distress in public housing developments primarily occupied by elderly residents and residents with disabilities was less prevalent than in developments occupied primarily by other types of residents. However, our work indicates that a number of developments primarily occupied by the elderly and non-elderly persons with disabilities are physically and/or socially distressed. Further, our site visits and survey of selected public housing directors indicate that, even in developments that may not be considered distressed, a number of physical and social factors can negatively affect the quality of life for public housing residents who are elderly or have disabilities. The directors’ agencies have implemented several strategies to address a variety of factors that contribute to problematic conditions for both elderly and non-elderly residents with disabilities, such as improving accessibility to persons with disabilities, addressing problems associated with mixing elderly and non-elderly disabled persons, and undertaking larger scale efforts to provide supportive services. Nevertheless, our work indicated that a significant number of the 66 developments covered by our survey will need replacement, renovation, or rehabilitation in the future and that the array of supportive services has often not met the needs of residents. These findings suggest that continued efforts will be needed to improve the quality of life for residents who are elderly, increasingly frail, or have disabilities. We provided a draft of this report to HUD for its review and comment. We received oral comments from officials in HUD’s Office of Public and Indian Housing indicating general agreement with the report. As a general comment, one official stated that the draft report underrates the adverse impact of the lack of accessibility of units for persons with disabilities. The official also noted that as elderly residents continue to age in place, their accessibility needs will increase. We did not attempt to determine a correlation between the extent of accessibility in public housing units and the percent of residents with disabilities. However, our report notes that public housing residents who are elderly or have disabilities may have more special needs, compared with other residents, due to their age and type of disability and that elderly public housing residents are more likely to be “frail” or to have disabilities, compared with other elderly persons. HUD also suggested that the report should contain additional discussion on how public housing agencies use HOPE VI funds to provide supportive services to the elderly. We did not insert additional information because in this report, as well as previous reports cited herein, we have provided information on the use of HOPE VI as a funding source for community and supportive services. Finally, one official expressed agreement with the public housing directors who, in responding to our survey, indicated that one method of reducing social distress is working with governmental and nonprofit organizations to provide supportive services. HUD also provided technical clarifications, which we incorporated as appropriate. We are sending copies of this report to the HUD Secretary and other interested congressional members and committees. We will make copies available to others upon request. In addition, this report will also be available at no charge on our Web site at http://www.gao.gov. If you or your staff have questions about this report, please contact me at (202) 512-8678 or Woodd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Key contributors to this report are listed in appendix IV. The objectives of this report were to examine (1) the extent to which public housing developments occupied primarily by the elderly and non-elderly persons with disabilities were severely distressed and (2) the ways in which the stock of severely distressed public housing for the elderly and non-elderly persons with disabilities could be improved. We analyzed tenant and development characteristic data from the Department of Housing and Urban Development’s (HUD) Public and Indian Housing Information Center (PIC) database and physical inspection data from the Real Estate Assessment Center (REAC) database. We obtained data from HUD in January 2005 for both databases. For purposes of this report, we sought to use PIC data to describe the number of households headed by elderly persons or persons with disabilities and to identify developments occupied primarily by elderly persons or persons with disabilities that were potentially severely distressed. To assess the reliability of data from the PIC database, we reviewed relevant documentation, interviewed agency officials, including contractors who worked with these databases, and conducted electronic testing of the data, including frequency and distribution analyses. Our assessment showed that some tenant and development characteristic data for the 28 housing agencies that are Moving to Work (MTW) sites were outdated by as many as 6 years because, at the time of our data collection, HUD had not yet implemented a system that allowed PIC to accept MTW data. For the purposes of this report, we sought to identify developments that were potentially distressed; therefore, we determined these data to be sufficiently reliable for use in our first index. However, for the developments that we surveyed, we asked housing agencies to verify data for the six fields we used from PIC to identify developments that were potentially distressed. When we compared the updated data that were received through our survey to the data contained in PIC, we found that 39 of 62 developments had decreased vacancy rates, compared with the PIC data, while 8 had increased vacancy rates. In a few cases, we found that developments that had been demolished were reported in the PIC system as existing developments. Similarly, we found a few instances where developments had been approved for sale but remained in the PIC system as part of a public housing agency’s current housing portfolio. To assess the reliability of the data from the REAC database and the adjusted REAC data from the Urban Institute, we reviewed relevant documentation, interviewed knowledgeable officials, including contractors who worked with the database, and conducted electronic testing of the data, including frequency and distribution analyses. We determined the data to be sufficiently reliable to identify developments that were potentially distressed. However, we also asked housing agency directors to verify their physical inspection score that we obtained from REAC. We compared the updated data received through our survey with the data contained in REAC and found that in 6 of 62 cases, the two data points differed by more than 15 percent. A possible reason for these discrepancies is that REAC scores can be volatile based on the nature of the problems identified in the rating. For example, an updated REAC score that was markedly better than the previous one could have resulted from the remedying of easily fixable items. Had HUD possessed current PIC and REAC data on all developments, our first index may have identified some developments that were different from those identified in this report; this was the reason that we sought corroboration on these data through survey questions. We have noted these limitations in our report when appropriate. We focused our analysis on housing “developments” because much of the available data were at the development rather than the individual building or unit level. (A development can be a collection of buildings, located near each other or scattered geographically, or an individual building.) As a result, our analysis does not necessarily include all public housing units that are occupied by elderly persons or non-elderly persons with disabilities, because such units may be located in developments that are occupied primarily by other types of residents. To determine criteria for defining public housing as primarily occupied by elderly persons and non-elderly persons with disabilities, we consulted with officials from HUD and reviewed relevant studies. We decided to identify public housing developments as primarily those occupied by elderly persons or non-elderly persons with disabilities if they met the following criteria: There were at least 10 occupied units in the development; and 50 percent of head of households were elderly persons (aged 62 or older); or 50 percent of head of households were non-elderly persons with disabilities; or 80 percent of head of households were either elderly persons or non-elderly persons with disabilities. Based on our analysis of PIC data, we categorized public housing developments as either (1) developments occupied primarily by elderly persons or non-elderly persons with disabilities if they met the above criteria, (2) family developments if they did not meet the above conditions, and (3) developments that were mostly family housing but contained buildings with a concentration of elderly persons or persons with disabilities. To determine the criteria for a severely distressed development occupied primarily by elderly persons and non-elderly persons with disabilities, we interviewed HUD officials, knowledgeable individuals from social research organizations, and reviewed relevant laws and literature. To determine if HUD’s developments occupied by elderly persons or non-elderly persons with disabilities were severely distressed, we identified eight indicators of severe distress from the PIC and REAC systems and data from other sources. For each development we used (1) physical inspection score; (2) adjusted physical inspection score provided by the Urban Institute; (3) building age; (4) percent of units deemed accessible to persons with disabilities; (5) vacancy rate; (6) household income; (7) percent of population in census tract below poverty line; and (8) status of the development regarding application for HOPE VI funding or approval for demolition, disposition, or revitalization. For the “adjusted physical inspection score,” the Urban Institute edited HUD’s REAC physical inspection scores to avoid heavily penalizing developments for deficiencies that were easily correctable. For example, HUD deducts many points for inoperable smoke detectors, a serious but easily fixable problem. The Urban Institute deducted fewer points for these defects, so the “adjusted score” puts more weight on the soundness of the physical structures. Although we used the eight indicators to identify potentially severely distressed developments, these indicators had some limitations. For example, we used a high vacancy rate as one indicator of severe distress. However, in some instances, a development had a high vacancy rate because some of the units were being taken out of the available housing stock for purposes such as redesign, but still were categorized in HUD’s database as available. Moreover, we used the age of the building as an indicator of physical distress. However, in some cases, we found that housing developments recently had undergone renovation. In these cases, building age was not a good indicator of physical distress. For each development, we obtained data for each of the eight indicators of severe distress. We then examined the distributions of the data for each of the eight indicators, and scaled each indicator from 0 to 10. We then calculated a composite score for each development by computing an average for each development from their scores on the eight indicators. Based on the distribution of the composite scores, and judgment as to what constituted distress, we established a threshold score to indicate potential severe distress and potential moderate distress. We eliminated from the scoring developments that were missing data from three or more of the indicators. From our analysis, we found a total of 11,935 developments in the 50 states and the District of Columbia that had at least 10 occupied units and data available on at least six of the eight indicators of distress. We determined that 3,537 of these developments met our criteria as “primarily occupied by elderly persons or non-elderly persons with disabilities.” Of these 3,537 developments, we identified 76 developments (administered by 46 public housing agencies) that were potentially severely distressed. We conducted site visits to 25 of these developments, interviewed building managers, resident leaders, and local public housing agency officials, and observed the physical and social conditions at the sites. We selected housing agencies to visit based on factors such as diversity of size, geographic location, and number of potentially distressed developments. We then surveyed the 46 public housing agencies that manage the 76 potentially severely distressed developments to collect data describing their physical and social conditions. In developing the survey questions, we utilized our literature review on distressed public housing and the special needs of the elderly and non-elderly persons with disabilities, conducted interviews with representatives of advocacy organizations and professional associations interested in issues affecting the elderly and non-elderly persons with disabilities, and reviewed our field work conducted at several public housing developments. Through this research, we identified supportive services and housing features that are needs of the elderly and non-elderly persons with disabilities that reside in public housing and structured survey questions, accordingly. HUD staff located in the Office of Public and Indian Housing and the Office of Policy Programs and Legislative Initiatives reviewed the survey questionnaire and provided comments. Knowledgeable individuals from the National Association of Housing and Redevelopment Officials and the American Association of Service Coordinators also provided feedback on the survey. We pretested the survey with the directors of six housing agencies located in California, Connecticut, Hawaii, New Jersey, and Indiana. Lastly, four independent social scientists reviewed the survey for soundness. We mailed the survey (questionnaire) to each public housing agency on June 10, 2005. In the survey, we asked the local housing agency to verify, update, or correct the data we obtained from HUD on percent of units that were occupied by elderly persons or non-elderly persons with disabilities and data on five of our eight indicators of distress. Questions covered the following topics: physical deterioration, systems requiring renovation or modernization, the neighborhood environment in which the development was located, accessibility features, access to social and public services, and actions to remedy housing challenges (see www.gao.gov/cgi- bin/getrpt?GAO-06-205SP for a copy of the survey). Each questionnaire contained a set of specific questions about the identified development and a set of general questions about public housing for the elderly and non- elderly persons with disabilities. In the 11 cases where the housing agency managed more than one of the identified 76 developments, respondents were asked to provide separate answers—in response to the specific questions—for each of the identified developments. For the 35 public housing agencies with one development, we also asked the local housing agencies whether they had other developments or buildings occupied primarily by elderly persons or non-elderly persons with disabilities that did not score above our distress threshold, but had conditions comparable to or worse than the developments we identified. In a few cases, public housing agencies indicated that they did have other developments comparable or worse than the ones we identified. This indicates that the eight indicators we used to identify potentially distressed developments did not always capture cases of potential distress in developments occupied primarily by elderly persons or non-elderly persons with disabilities. Participants could return the questionnaire by mail or fax. To increase the response rate, we conducted three sets of follow-up telephone calls to offices that had not responded to our survey by the initial deadline. Collection of survey data ended on August 30, 2005. We had 43 housing agencies return the survey, providing a response rate of 93 percent, and representing 66 of the 76 developments. We did not attempt to verify the respondents’ answers against an independent source of information; however, we used two techniques to verify the reliability of questionnaire items. First, we used in-depth cognitive interviewing techniques to evaluate the answers of pretest participants. Interviewers judged that all the respondents’ answers to the questions were correct. Second, we compared some responses with observations made during site visits; again, observers concluded that responses to these items were correct. The practical difficulties of conducting any survey may introduce certain types of errors, commonly referred to as nonsampling errors. For example, differences in how a particular question is interpreted, the sources of information available to respondents, or the types of people who do not respond can introduce unwanted variability into the survey results. Steps such as pretesting and follow-up contacts to increase response rates serve to minimize nonsampling errors. In addition, to further reduce errors, we performed statistical analyses to identify inconsistencies and used a second independent reviewer for the data analysis. We edited for consistency before the data were entered into an electronic database. All survey data were 100-percent verified, and a random sample of the surveys was further verified for completeness and accuracy. We analyzed responses to close-ended questions using statistical software. One analyst reviewed and categorized responses to open-ended questions, which was then independently verified by a second trained analyst. Because the developments selected for our survey were not based on a random sample, the results are not generalizable to all public housing for the elderly and non-elderly persons with disabilities. To identify the developments with the greatest indications of severe social or physical distress based on survey responses we developed “distress indexes.” See appendix II for more detail. To examine the ways in which the stock of severely distressed public housing for the elderly and non-elderly persons with disabilities could be improved, we reviewed relevant laws and regulations, and reports by federal agencies and research organizations. We also interviewed residents of public housing and public housing agency directors. We analyzed the interview responses and developed a summary of the most frequently reported strategies. Finally, we included questions in our survey to the public housing agency directors that operate the 76 developments that we identified as potentially severely distressed. We analyzed the responses from the survey and developed a summary of the most frequently reported strategies (see www.gao.gov/cgi-bin/getrpt?GAO-06-205SP for a copy of the survey and aggregated results). We conducted our work in Washington, D.C.; Miami and St. Petersburg, Florida; Homestead, New Castle, and Pittsburgh, Pennsylvania; Evansville, Indiana; St. Louis, Missouri; Seattle, Washington; and Oakland and San Francisco, California, between November 2004 and October 2005 in accordance with generally accepted government auditing standards. To identify the developments with the greatest indications of severe social or physical distress based on survey responses, we developed “distress indexes.” To create the indexes, we assigned points to individual survey questions based on their level of importance and impact on the quality of life for the elderly and non-elderly persons with disabilities. We used evidence from interviews with individuals knowledgeable of the housing needs of the elderly and non-elderly persons with disabilities to determine how to weight the questions. The nature of some topics, and thus the number of items about that topic, reflect the relative importance of that topic in determining distress. For example, we asked nine questions about which supportive services are available to residents, reflecting how significantly supportive services can affect conditions for residents of public housing. We assigned points to survey response items that indicated conditions of physical or social distress, giving higher points to responses that indicated more distress and no points to responses that indicated little distress. For example, one of the survey questions asked about the extent to which the physical structures at the development were deteriorated. We assigned 20 points to the physical distress index score if the respondent answered, “extremely deteriorated,” 15 points if the answer was “very deteriorated,” 10 points if “somewhat deteriorated,” 5 points if “a little deteriorated,” and no points if the answer was “not at all deteriorated.” We then summed the points for all questions for each development, which resulted in overall physical and social distress index scores. Each development could score up to 139 points on the physical distress index and up to 205 points on the social distress index. We analyzed the results for each of the 66 developments for which we had survey responses to determine the total scores for both physical and social distress. We determined that developments that had a score of 50 percent or more of the total points for either index had signs of severe physical or severe social distress. We were able to verify that a score of 50 percent or more indicated severe distress because we visited some of these developments and made detailed observations on their condition. See table 1 for the specific points assigned to each indicator of physical and social distress. We visited both the Homestead Apartments and Helen Sawyer Plaza developments and interviewed public housing agency officials and building managers. We also interviewed residents at the Homestead Apartments. The following describes in more detail the approaches used by the housing agencies to provide housing and services to its elderly residents at these developments. Allegheny County housing agency officials successfully renovated the Homestead Apartments near Pittsburgh, Pennsylvania, and made improvements to provide supportive services. The housing agency chose to renovate the Homestead Apartments because of the high concentration of elderly residents and because two of Homestead’s high-rise buildings were the oldest buildings in the housing agency’s portfolio. To renovate the apartments at Homestead, the housing agency partnered with a private real estate development firm that specialized in residential housing and community development. The interior portions of each of the development’s four high-rise buildings were replaced, and the housing agency added or built updated features. As part of the renovation, the housing agency converted 350 units into 240 apartments, with two- bedroom apartments and lounges added to every floor. Previously, the apartments were exceptionally small and had kitchen and bath configurations that would not accommodate persons with disabilities. Further, the housing agency reconfigured 5 percent of the units, and all of the laundry areas and lounges, to be accessible to persons with disabilities. To improve common areas of the development, the housing agency also installed large windows in the hallways to increase levels of natural light. A primary goal of the Homestead revitalization was to provide enhanced supportive services to elderly residents, in particular frail elderly residents. The housing agency in Allegheny County surveyed Homestead residents to determine how best to provide services and based on their responses, developed three categories according to the level of care they needed. The first group included the “most frail” residents, who had medical or functional frailties. The second group consisted of “at-risk” residents, who may have needed occasional services. The third group was made up of residents who were healthy and rarely used any of the available services. According to the health care staff at these facilities, residents typically progress through these three stages as they age. The housing agency then partnered with several non-HUD entities to improve services for the elderly and colocate an assisted living type of facility at the development. To help the most frail elderly residents, the housing agency partnered with a nonprofit organization—Community LIFE (Living Independently for Elders)—which offers complete nursing services, meals, and physical therapy (see fig. 13) to Homestead residents who are enrolled in the program. The LIFE Center also has a beauty salon that enrollees can use once a month for free. These services are modeled after the Program of All-Inclusive Care for the Elderly (PACE). For most participants, these comprehensive services permit them to continue living at home. Homestead residents represent about 40 percent of the LIFE Center’s enrollees. For at-risk residents, who do not require the level of care provided at the LIFE Center, the housing agency partnered with the University of Pittsburgh Medical Center (UPMC) to provide on-site services in the form of a walk-in wellness center. The services include blood pressure checks, glucose tests, assistance with medication, social service coordination, and space for visiting physicians. The UPMC facility also had two registered nurses on staff. All Homestead residents are free to take advantage of the services offered at the UPMC facility, which is colocated at the development and easily accessible to residents. UPMC also operates an exercise room in the Homestead Apartments, which has become popular among residents. According to the housing agency officials at Allegheny County, the renovation and colocation of supportive services were made possible by an innovative coordination of efforts and use of mixed financing. Approximately 67 percent of the funding for the Homestead renovation was based on Low-Income Housing Tax Credits. Under this program, states are authorized to allocate federal tax credits as an incentive to the private sector to develop rental housing for low-income households. After the state allocates tax credits to developers, the developers typically offer the credits to private investors, who use the tax credits to offset taxes otherwise owed on their tax returns. Other funding sources included state and local grants, a federal loan, and a $2.5 million dollar HOPE VI grant. According to the Allegheny County officials, the award of the HOPE VI grant helped to ensure potential investors that the project was viable. In addition, the LIFE Center was developed during renovation, thereby facilitating the colocation of this supportive service. To maintain the LIFE Center over the long-term, the housing agency was able to offer an attractive low-cost lease to Community LIFE because the agency already owned the land on which the facility was built. In addition, residents who are enrolled in the LIFE Center are eligible for Medicare or Medicaid, so Community LIFE receives payment through those programs. Proceeds from the LIFE Center’s lease with the housing agency are used to fund UPMC services. The Miami-Dade Housing Agency converted Helen Sawyer Plaza into an assisted living facility to enable elderly residents to “age in place” and avoid often costly institutional alternatives such as nursing homes. According to officials at Helen Sawyer, prior to conversion, the facility suffered from a high vacancy rate, and some of the building systems were outdated. Helen Sawyer residents now receive a variety of supportive services, which were made available as part of the assisted living conversion. For example, residents receive 24-hour nursing care and three hot meals per day in the dining room. A hairdresser and manicurist visit the development twice weekly. The development offers 30 hours of activities weekly, including aerobics, dancing, cultural events, and arts and crafts. Residents also have access to door-to-door transportation and a weekly shuttle for grocery shopping. Staff on-site offer or coordinate other supportive services such as podiatry, assistance with taking prescribed medications, and adult day care. An additional benefit of the conversion is that married residents can continue to live together in their apartments, even when one spouse requires assisted living care. To improve physical conditions at the eight-story Helen Sawyer Plaza, the building was modernized and apartments were made more spacious, which made the development more attractive to elderly residents. The development now has 104 apartments, including 83 studio apartments and 21 one-bedroom apartments. The studio units are 450 square feet while the one-bedroom units are 600 square feet. Security features at the development include perimeter iron fencing with card-access entry and individual emergency alarm systems for each apartment. Amenities now include a lobby, public restrooms, commercial kitchen, resident dining room, and community room. The housing agency also added grab bars throughout common areas and made improvements to more easily accommodate wheelchairs or motorized scooters. Helen Sawyer Plaza’s conversion into an assisted living facility was a multiphase process that required coordination among several organizations. For example, the housing agency contracted with a consultant who had expertise on assisted living facilities, obtained HUD modernization funding, and borrowed money to rehabilitate the building, obtained a license from the State of Florida to operate as an assisted living facility, and petitioned the Florida Department of Elderly Affairs for a Medicaid Home and Community-Based Services waiver. The waiver essentially allows the housing agency to receive money from the state to cover the cost of caring for residents at Helen Sawyer. The Miami-Dade officials also pointed out that funding from Medicaid waivers can be an incentive to convert a public housing development to an assisted living facility. For example, 65 Helen Sawyer Plaza residents receive Medicaid waivers that reimburse up to $28 per day for services. The Miami-Dade Housing Agency also coordinated with the city of Miami and Dade County to revitalize abandoned buildings in the neighborhood and offer transportation service at Helen Sawyer Plaza. In addition to the contact named above, Paul Schmidt, Assistant Director; Isidro Gomez; Robert Marek; Alison Martin; Marc Molino; Don Porteous; Linda Rego; Barbara Roesmann; and Michelle Zapata made key contributions to this report.

Summary: In 2003, Congress reauthorized HOPE VI, a program administered by the Department of Housing and Urban Development (HUD) and designed to improve the nation's worst public housing. In doing so, Congress required GAO to report on the extent of severely distressed public housing for the elderly and non-elderly persons with disabilities. "Severely distressed" is described in the statute as developments that, among other things, are a significant contributing factor to the physical decline of, and disinvestment in, the surrounding neighborhood; occupied predominantly by very low-income families, the unemployed, and those dependent on public assistance; have high rates of vandalism and criminal activity; and/or lack critical services, resulting in severe social distress. In response to this mandate, GAO examined (1) the extent to which public housing developments occupied primarily by elderly persons and non-elderly persons with disabilities are severely distressed and (2) the ways in which such housing can be improved. HUD officials provided oral comments indicating general agreement with the report. Available data on the physical and social conditions of public housing are insufficient to determine the extent to which developments occupied primarily by elderly persons and non-elderly persons with disabilities are severely distressed. Using HUD's data on public housing developments--buildings or groups of buildings--and their tenants, GAO identified 3,537 developments primarily occupied by elderly residents and persons with disabilities. Data from HUD and other sources indicated that 76 (2 percent) of these 3,537 developments were potentially severely distressed. To gather more information on the 76 developments that were potentially distressed, GAO surveyed public housing agency directors responsible for these developments. GAO received responses covering 66 of the 76 developments (the survey and aggregated results are available in GAO-06-205SP). These responses indicated the following: (1) eleven developments had signs of severe physical distress, such as deterioration of aging buildings and a lack of accessible features for persons with disabilities; (2) another twelve developments had signs of severe social distress, which included a lack of appropriate supportive services such as transportation or assistance with meals; and (3) an additional five developments had characteristics of both severe physical and social distress. Nevertheless, many of the directors GAO surveyed reported that numerous factors adversely affected the quality of life of elderly persons and non-elderly persons with disabilities residing in their developments. The factors cited most frequently were (1) aging buildings and systems, including inadequate air conditioning; (2) lack of accessibility for persons with disabilities; (3) small size of apartments; (4) the mixing of elderly and non-elderly residents; (5) inadequate supportive services; and (6) crime. To better address the special needs of the elderly and non-elderly persons with disabilities, public housing agency officials GAO surveyed or contacted have used various strategies to improve both physical and social conditions at their developments. Strategies to reduce physical distress include capital improvements such as renovating buildings, systems, and units or, in extreme cases, relocating residents and demolishing or selling a development. Methods to reduce the level of social distress include a range of actions, such as designating developments as "elderly only," converting developments into assisted living facilities, and working with other governmental agencies and nonprofit organizations to provide supportive services to residents.