As people age, their ability to perform routine daily activities, such as eating, bathing, dressing, paying bills, and preparing meals declines (see fig. 1). About 70 percent of those aged 65 and older are likely to need long-term services and supports at some point in their lives, for an average of 3 Family or years. Twenty percent will need that care for at least 5 years.friends often informally assist frail older adults with these daily activities. However, when they have no one to help them informally, or need assistance that family and friends cannot provide, older adults rely on long-term services and supports (LTSS) from paid providers in both institutional and home and community-based settings. In either case, the cost of these services and supports can often be a considerable financial burden for older adults and families. For eligible low-income older adults, state Medicaid programs may cover the cost of institutional long-term services and supports and certain HCBS. According to the Census Bureau, the proportion of the U.S. population aged 65 and over is expected to increase from 13 percent in 2010 to more than 20 percent in 2050 and be more diverse. In 2050, about 22 percent of this group will be 85 and older compared to 14 percent in 2010. As the size of the older population grows, so will the number of older adults needing long-term services and supports, particularly for those 85 and older. 42 U.S.C. § 3012(b). established grants to states for the provision of services and supports. The framework of agencies, programs, and activities established by the act produced what is referred to today as the national aging services network. With support from AoA, within HHS’ Administration for Community Living (ACL), the 56 state units on aging, 618 area agencies on aging (AAA), and 264 Indian tribal and 2 Native Hawaiian organizations as components of the aging services network, are responsible for planning, developing, and coordinating home and community-based services and supports for older adults, nationwide. Community-based organizations (CBO) are public agencies or private nonprofit organizations that represent one or more communities or segments of communities and are engaged in meeting the human services needs of community residents. CBOs can include local or regional governmental or quasi-governmental organizations, as well as private nonprofit organizations. the receipt of, need for, and unmet need for services authorized under Title III of the act. State units on aging are to use their AAAs’ plans as a basis for an overall state plan that they submit to AoA. Five federal agencies across four departments have one or more programs that operate within a system of HCBS and related supports that older adults often require to live as independently as possible in their homes and communities (see table 1). The Older Americans Act is the cornerstone for federal leadership in the development of an HCBS system for older adults. The act authorizes funding to cover the cost of a range of services for older adults provided by local HCBS systems—sometimes referred to as core service delivery activities. HCBS funded under Title III of the act are available to anyone 60 or older, but are to be targeted to those with greatest economic or social need, particularly low-income and low-income minority older adults, and older adults living in rural areas, among others.authorizes funding a variety of aging services network support activities or technical assistance provided to state and local agencies by AoA (see table 2). Appendix II provides funding information for these programs for fiscal years 2010 through 2014. In addition to Older Americans Act funding for nutrition services, four programs within the Department of Agriculture target food assistance, at least in part, to low-income older adults (see table 4). These programs provide nutrition assistance in a variety of forms, ranging from commodities, to prepared meals, to vouchers or other targeted benefits used in commercial food retail locations. Two of these programs are exclusively for low-income older adults. The Commodity Supplemental Food Program provides food to participating states that, in turn, distribute it to older adults. The Senior Farmers’ Market Nutrition Program awards grants to states, territories and Indian tribes to provide coupons to low-income older adults to purchase fresh food at authorized farmers’ markets, roadside stands, and community- supported agricultural programs. Appendix II provides funding information for these two programs for fiscal years 2010 through 2014. 42 U.S.C. § 1766. Other USDA Programs That Provide Nutrition Assistance to Older Adults The Emergency Food Assistance Program (7 U.S.C. §§ 7501-7515) and the Food Distribution Program on Indian Reservations (7 U.S.C. § 2013(b)) also benefit older adults. The Emergency Food Assistance Program helps supplement the diets of low-income Americans, including older adults, by providing them with emergency food and nutrition assistance at no cost. It provides food and administrative funds to states to supplement the diets of these groups. The Food Distribution Program on Indian Reservations Program provides USDA foods to low-income households, including older adults, living on Indian reservations and to Native American families residing in designated areas near reservations and in the state of Oklahoma. According to USDA, fiscal year 2013 obligations for these programs were approximately $266 million and $100 million, respectively. Assistance provided to victims of Hurricane Sandy under the emergency food program in fiscal year 2013 is not included in this amount. of the Child and Adult Care Food Program offers federal funding, administered through state health or aging agencies, for meals at adult day care centers. These centers help elderly and disabled adults remain in their homes and communities and avoid premature institutionalization. According to USDA, this program plays a vital role in improving the quality of day care and making it more affordable for many low-income families. In fiscal year 2014, the program served over 71 million meals to older adults who received care in these centers. SNAP, the largest nationwide nutrition assistance program, enables low- income households to obtain a more nutritious diet by increasing their purchasing power. SNAP provides an electronic benefit transfer card to eligible low-income individuals and families, including older adults, that they can redeem for eligible food items at more than 261,150 stores across the nation authorized to accept SNAP benefits. USDA, close to nine percent of all SNAP participants in 2013 were age 60 or over. According to USDA, participation in SNAP does not interfere with older adults receiving meals free-of-charge at dining facilities that prepare and serve communal meals for older adults. Affordable housing is the nucleus of a system of HCBS and supports for older adults because, without access to affordable housing, care in nursing homes and similar facilities is the only option for low-income, frail older adults. The Department of Housing and Urban Development administers the Supportive Housing for the Elderly (Section 202) program, which plays a critical role in addressing the demand for affordable, supportive housing for older adults in this country. Currently, the program maintains the supply of multi-family housing stock for low- income older adults through renewal of existing rental assistance contracts that cover the difference between a property owner’s HUD- approved operating costs for a project and the tenants’ payments. In addition, Section 202 supports independent living by funding the salaries of nearly 1,300 service coordinators, nationwide, who help residents in Section 202-funded properties find the HCBS and supports they need to continue living in their own homes.program totaled $358 million in fiscal year 2014. Appendix II provides funding information for this program for fiscal years 2010 through 2014. Other HUD Programs That Serve Older Adults In addition to the Section 202 program, several other HUD programs serve older adults. For example, local public housing agencies can apply to HUD for approval to designate public housing developments or portions of developments, such as buildings or floors, for occupancy by only elderly families, only disabled families, or elderly and disabled families. HUD refers to this as “designated public housing”. 42 U.S.C. § 1437e. According to HUD, older adult tenants generally are well represented in HUD’s major rental assistance programs and as of December 2014, 42.5 percent of project- based Section 8 units and 31 percent of Public Housing units (42 U.S.C. § 1437b) were rented by older adult households, while 22 percent of Housing Choice Vouchers assisted older adult households. Section 8 units refer to low-income housing units under section 8 of the United States Housing Act of 1937 (Pub. L. No. 75-412, 50 Stat. 888 (as added by the Housing and Community Development Act of 1974, Pub. L. 93-383, 88 Stat. 633, 662-66, (codified as amended at 42 U.S.C. § 1437f)). Under the project-based Section 8 program, HUD contracts with property owners that receive rental subsidies for units rented to low-income tenants. The Federal Housing Administration (FHA), a component of HUD, also administers the Home Equity Conversion Mortgage program. 12 U.S.C. § 1715z-20. The program allows older adult homeowners access to FHA- insured reverse mortgages to convert the equity in their homes into monthly streams of income and/or lines of credit. According to HUD, in fiscal year 2013, FHA endorsed more than 60,000 of these loans nationwide. Up until fiscal year 2012, the Section 202 program also provided capital advances to private, nonprofit organizations (sponsors) to finance the construction, rehabilitation, or acquisition of new affordable rental housing units for very low-income older adults. According to HUD officials, appropriations for capital advances were discontinued beginning in fiscal year 2012 as a result of the Consolidated and Further Continuing Appropriations Act of 2012. They also indicated that, for fiscal year 2015, the department proposed to Congress adding rental assistance contracts and funding for service coordinators to units set aside for older adults in developments funded through the Low-Income Housing Tax However, according to HUD officials, no Credit and other programs.funds for new Section 202 rental assistance contracts were appropriated in fiscal year 2015. The Department of Transportation’s Enhanced Mobility of Seniors and Individuals with Disabilities program mainly supports projects that improve mobility for seniors and people with disabilities in four ways.program funds, public transportation projects planned, designed, and carried out to meet the special needs of these targeted groups when public transportation is insufficient, inappropriate, or unavailable; public transportation projects that improve access to fixed-route service and decreased reliance on complementary paratransit; public transportation projects that exceed the requirements of the Americans with Disabilities Act (ADA); and alternatives to public transportation, such as volunteer driver programs, accessible and/or senior friendly taxi services and other transportation options. The Federal Transit Administration (FTA) within DOT operates this program, which provides formula grants to states that typically award this funding to eligible local human services agencies to, for example, purchase accessible vehicles (e.g., vehicles with lifts) to provide transportation to older adults or persons with disabilities for a range of purposes. At least 55 percent of program funds must be used for public transportation capital, which includes the purchase or lease of buses, mobility management, and other expenses. Obligations for this program totaled $240 million in fiscal year 2014. To qualify for funding, the Enhanced Mobility program requires recipients to develop coordinated public transit human services plans with other organizations that have a stake in their local transit systems. Recipients also are required to contribute matching funds to their projects. Only projects that are part of a locally coordinated human services transportation plan are to be approved for this funding. In addition to promoting well-coordinated transit systems, the Enhanced Mobility program’s planning requirement also facilitates coordination of resources across federal programs. According to AoA officials, coordination between this program and AoA’s HCBS program under Title III of the Older Americans Act, for example, has led to an agreement between FTA and AoA that the funding AAAs receive under Title III can be used as matching funds for local projects receiving Enhanced Mobility program funding. Federal funds for HCBS and other supports for older adults typically are targeted to local governments, other community-based organizations, and service providers. Figure 3 illustrates federal funding streams for HCBS and other supports for older adults. While HUD provides funding directly to nonprofit sponsors, AoA, CMS, USDA, and DOT direct their funding to state agencies that, in turn, allocate them to state or local governments, CBOs, and other service providers. Formula grants under the Older Americans Act, for example go to each state unit on aging, which distributes this funding among their AAAs. AAAs have key local planning and service delivery responsibilities and some degree of latitude in determining what HCBS to provide for older adults in their service areas. CMS pays a share of each state Medicaid agency’s medical assistance expenditures for HCBS; state Medicaid agencies pay the service providers that deliver the care. In San Francisco, California; Montgomery County, Maryland; and the Atlanta, Georgia region, similar steps were taken to plan HCBS and related supports for the growing population of older adults in their communities. To assist in planning, every AAA is required to have an advisory council. The Montgomery County Commission on Aging serves as the Montgomery County AAA’s advisory council. Each year the commission conducts a summer studies program through which its members engage outside experts and county officials to examine issues such as care giving, senior transportation, and greater representation of older adults in county decision making. According to commission members, the AAA’s new senior transportation mobility manager was hired in part because of their recommendations. In addition to reporting on community needs and activities, the Advisory Committee on Aging, within Atlanta’s AAA, promoted public awareness of resources for older adults, and assisted municipalities, educational institutions, private businesses, and nonprofit organizations in developing older adult programs and services. The AAA operated by the Atlanta Regional Commission is the largest AAA in Georgia and serves 10 of the 29 counties in the Atlanta metropolitan region. sources served as the basis for the area plan each AAA submitted to its state unit on aging. In the three localities we visited, HCBS and related supports for older adults were delivered through a broad network of CBOs and programs. In each locality, these services and supports primarily relied on funding from federally-supported programs, state and local government programs, and from private sources such as foundation grants, charitable donations, and fees for services. The AAA in each locality played a key role in determining what HCBS programs and related supports would receive funding from the Older Americans Act as well as other sources. Each locality’s system of HCBS and related supports for older adults provided information and referral, nutrition and in-home services, as well as affordable housing and transportation services. There were some differences, however, in how these services and supports were funded and delivered in each locality. While a variety of CBOs provided information and referral services to help older adults find appropriate available HCBS and related supports in each locality, each AAA’s Aging and Disability Resource Center served as the primary referral service in each locality. In San Francisco, the AAA responded to the city’s multi-lingual population by creating 12 ADRC “outstations” throughout the city. These outstations provide services in multiple languages, such as English, Spanish, Mandarin, and American Sign. In Atlanta, the AAA also developed a referral database containing more than 25,000 registered providers of aging and long-term care services, covering nutrition services, housing options and services, and transportation assistance. This database was accessible, through subscription, to CBOs throughout the region that worked with older adults. In Montgomery County and San Francisco, “villages” of older adults served as important sources of information and referral for HCBS and related supports for their members. In addition to providing information and referral services, San Francisco Village is trying to diversify its membership in terms of socio-economic status. While the majority of its members are considered “middle-income,” the Village has received a grant from the San Francisco AAA to subsidize membership for low- income older adults. Subsidized memberships fees are $100 per individual or $150 per household, as compared to regular membership fees of $600 and $750, respectively. The San Francisco village, one of two we spoke with, also provided companionship visits and assistance with errands. The “Village” Model for Aging in Place Villages are grassroots, community-based membership organizations that facilitate access to HCBS and strengthen social supports for older adults as they age in their homes and communities. They are created and funded primarily by older adults and rely heavily on members volunteering to help other members. Usually governed by an advisory council or board, villages are operated by volunteers or by some mix of paid staff and volunteers. A recent report, based on a survey of 69 villages in the United States, found that villages largely consist of older adults of middle to high socio-economic status, who are most likely between ages 65 and 74. The average annual membership fee was $431 for an individual and $587 for a household, but approximately two-thirds of the villages charging fees offered discounted memberships based on income. Villages focus on providing access for their members to social and non-medical supports, emphasizing transportation, technology assistance, and home repair and maintenance. Many also negotiate with outside service providers for discounted fees for their members. The report found that approximately half of the villages were receiving at least 45 percent of their funds from membership fees. And, half of the villages received at least 20 percent of their budgets from fund-raising and charitable donations. Government funding and contributions from nonprofit organizations each accounted for 5 percent or less of village budgets. Currently, over 200 villages belong to the national Village to Village Network, an organization that helps establish and manage villages. The five report authors represented four universities: Rutgers, the State University of New Jersey, New Brunswick; the University of California, Berkeley; the University of Michigan, Ann Arbor; and the University of Maryland, Baltimore. Service programs in naturally occurring retirement communities (NORC) were also important sources of information and referral for older adult residents of certain communities in the Atlanta region, including the service programs in the East Point and Toco Hills NORCs. In all three localities, each AAA’s ADRC program was the primary entry point for older adults into the system of HCBS and related supports. As such, the ADRC was the first point of contact for older adults seeking publicly-funded in-home services, such as personal care and homemaker services. In each locality, ADRC program staff assessed the individual needs and financial resources of older adults seeking such services, developed service plans for them, and referred them to providers for in- home services that, in some cases, were funded under the Older Americans Act. In Montgomery County, for example, the Senior Care program provided in-home services funded by the state. Older adults who were determined to be eligible for Medicaid HCBS under the state Medicaid program were referred to the county Department of Health and Human Services for care. In addition to Medicaid and Older Americans Act funding, CBOs relied on other sources of financial support to cover the cost of in-home services for older adults. Senior Connections, a CBO in Atlanta, employed certified home-care aides to assist homebound older adults and those with It charged for its services, other than meals, physical limitations.according to a sliding scale, based on an individual’s income. Senior Connections also relied on financial support from the county, United Way, private donations, and fundraisers to subsidize the cost of services to its clients in need. As a part of HCBS, meals for older adults can be provided in a congregate setting away from recipients’ homes or delivered to their homes. Four of the CBOs we visited across the three localities provided meals, and we observed some differences in their delivery and funding in each locality. For example, Senior Connections in Atlanta offered congregate and home-delivered meals for older adults at a per meal and package price, with meals available to those who qualified based on income, age, and county of residence at no-cost or subsidized with Older Further, Senior Connections delivered meals to Americans Act funding.senior facilities, opened its congregate meals to residents at area housing complexes and workers at businesses, at a cost to the latter, and offered nutrition counseling. There was also a senior multipurpose facility in Atlanta that offered congregate meals daily, and membership dues for the facility covered the cost of these meals. Staff at two CBOs we visited told us that they also referred the low- income older adults they served to SNAP and helped them complete the required paperwork. Despite the options USDA has provided states for making their SNAP application process simpler, according to some CBOs we contacted in two of the three localities, older adults continue to consider the annual recertification process in their states burdensome, especially considering that their anticipated monthly benefit could be as low as $16. We consistently heard in each locality that housing options and transportation were among the services most in demand by older adults. Among the five Section 202 properties we visited across our three localities, services and amenities provided for their older adult residents, include service coordinators who connected especially frail residents to the supportive services they needed (see appendix III for a description of the Section 202 properties we visited). For example, a service coordinator in a Montgomery County Section 202 property assessed residents’ needs and referred them to various community resources. This coordinator also helped establish support networks and volunteer services for residents. At one Atlanta property, the service coordinator was in charge of organizing education and wellness programs, such as stroke awareness, healthy eating on a budget, and music therapy, as well as making referrals and providing residents with information about outside services. According to some of the sponsors of Section 202 housing properties we interviewed, the program’s service coordinators save federal dollars because they delay older adults’ reliance on federally funded nursing home care. At one of the Section 202 properties we visited, staff expressed concern over the suspension of federal funding for construction of housing units for low-income older adults under the Section 202 program. Further, some sponsors of existing Section 202 housing told us that using low- income housing tax credits for older adults may not be realistic because households with extremely low incomes may not be able to afford the rents that would be charged even under a tax credit program. Some CBOs and local governments we contacted across our three localities provided transportation services for older adults that received funding under the federal Enhanced Mobility program. For example, Dekalb County, Georgia collaborated with CBOs to operate a senior shuttle service that provided county residents who were 60 and older with curb-to-curb rides. Similarly, the Montgomery County transportation project we contacted coordinated transportation services for older adults in Montgomery County and was funded with Enhanced Mobility funds. San Francisco used a DOT, Federal Transportation Administration grant to provide peer escorts to accompany older adults with dementia. According to AAA and CBO officials, the growing population of older adults, in conjunction with constraints on federal, state, and local government funding, made it difficult to meet older adults’ needs for affordable housing, in-home and nutrition services, and transportation. In addition, the growing diversity of the older adult population—differences in language, culture, and customs—compounded these challenges. Some CBOs also indicated that as funding from public programs has remained flat in recent years, they were finding it difficult to secure funds from other sources to sustain the HCBS and supports they provide to older adults. In all three localities that we visited, we were told that there were lengthy waiting lists—one consequence of funding constraints—for a number of HCBS and supports. AAA officials in Atlanta and Montgomery County reported that while Medicaid funding for HCBS has been increasing in recent years, hundreds of older adults referred to Medicaid for in-home services under state Medicaid waiver programs were ending up on waiting lists because their state Medicaid agencies had not met their funding match. In one locality, there was concern that the state Medicaid program may have chosen to devote a higher percentage of state Medicaid resources to nursing home care than to HCBS. In Montgomery County, an AAA official said that of the 23,000 people, statewide, who were on Maryland’s waiting list for the state’s Medicaid Community First Choice option, about 10 to 12 percent were Montgomery County residents. In Atlanta, the AAA director said that there were 800 people in the region who were eligible for services under one of the state’s Medicaid 1915(c) waiver programs and on a waiting list because the program was closed due to lack of state Medicaid matching funds. According to the Atlanta AAA director, applicants would be assessed for eligibility for Medicaid funded in-home services as soon as more state funds became available. Only older adults who are low-income are eligible for Medicaid-funded HCBS, and in Atlanta and Montgomery County, AAA officials described a mix of Older Americans Act, state, and local funds that they used to serve older adults who were not eligible for Medicaid. In the Atlanta region and Montgomery County, officials reported that there were also waiting lists for Older Americans Act-funded HCBS. CBO officials also reported waiting lists for affordable senior housing. Among the Section 202 properties that reported information on waiting lists, waiting periods ranged from 6 months to 10 years, indicating that the existing supply of affordable units available to older adults under Section 202 and other programs was not meeting the demand. Further, Section 202 is no longer producing new units. Congress did not approve new rental assistance contracts through the Section 202 demonstration funded in fiscal year 2014 and there was no funding for new units in fiscal year 2015. Given the increasing size of the older adult population and projections that many will need assistance with their housing costs, the demand for affordable housing for older adults will likely continue to exceed the supply. The demand for nutrition services has also grown in recent years. Two CBO officials noted shortfalls in meeting the demand for nutrition services in their communities. Senior Connections representatives, who provided meals for older adults in several Georgia counties, told us that one county had more than 200 individuals on its waiting list, mainly for meals and in- home care. In a previous study, we reported that officials told us that requests for home-delivered meals were increasing as older adults were remaining in their homes longer rather than moving into assisted living facilities or nursing homes. Moreover, complicated application requirements may be impeding their access to food assistance through SNAP, which USDA and HHS officials told us may be used by the participant as a voluntary contribution toward the cost of congregate and home delivered meals for older adults, if the provider is authorized by USDA to accept SNAP benefits for this purpose (e.g. is an authorized SNAP retailer). Three USDA initiatives--the Combined Application Project, Standard Medical Deduction, and the Elderly Simplified Application Project--to allow states to simplify the application and recertification requirements for older adults have been adopted by 17, 16, and 6 states, respectively. According to a USDA official, all three initiatives include evaluation and reporting requirements, due to their status as demonstration projects, that can be viewed as burdensome by state agencies. According to the official, those evaluation and reporting requirements may deter states from applying to operate a project. CBOs in each locality also reported high demand for transportation services for older adults, but one we visited, which assisted older adults with different modes of transportation, had temporarily suspended its transportation voucher program until new funding was made available through a DOT grant. Further, local officials said that flexibility was critical in providing older adults with the right type of transportation assistance to address their needs. For example, a San Francisco mobility program manager noted that an increasing number of baby boomers living at home had dementia. She stated that there were day programs for older adults available at senior centers, but these individuals needed transportation to the centers. Some older adults who did not meet the specific requirements for paratransit required assistance that was not available through the fixed-route bus system even when subsidies made trips more affordable to them. Further, those with dementia needed more hands-on assistance in transit than was available through paratransit. To respond to this need, local officials in San Francisco said that in July 2014 the city launched its peer escort transportation service. According to the mobility manager, in this instance, the city was able to use FTA grant funds to acquire vehicles for the peer escort service, but had to find another grant to fund a small stipend for the escorts. Several transportation service providers across the localities expressed a need to reduce restrictions on the use of federal transportation grant funding. For example, CBO and local government officials told us that they would like to spend more transportation grant funds to transport older adults to recreational events. They said that some programs allowed funding for older adult transportation to hospital and other non-emergency medical appointments, but not recreational transportation, even though this was important to older adults’ quality of life. This is consistent with our findings in a previous report that when flexible transportation services exist and are accessible, older adults can more comfortably age in place in their homes and communities. In the three localities, a diverse older adult population has compounded the task of meeting increasing demand for HCBS and supports, and challenged CBOs to find ways to accommodate differences in language, culture, and customs. Representatives of a Montgomery County village told us that they served individuals who represented more than 57 countries of origin and shared a common characteristic—many were first generation Americans. One Section 202 property in the Atlanta region relied on its collaboration with an Asian community center to meet the social needs of its Korean residents, who represented 20 percent of all residents. The property had also hired a part-time language interpreter to facilitate communications with these residents. At the same time that Older Americans Act funding has been essentially flat in recent years, some local CBOs reported finding it difficult to secure from non-federal sources the funds they need to sustain the services they provide to older adults. For example, the mobility manager at the CBO which suspended its transportation voucher program told us that local fundraising was challenging in the low-income community where the CBO was located. Moreover, in addition to constraints on Older Americans Act funding, our 2014 analysis of state and local budgets suggests that states and local governments will continue to face fiscal challenges in the coming years absent substantial policy changes. Further, HHS budget documents note that states, tribes, and localities that depend on federal funds for these services have limited options to offset losses of federal funding. Developing the capacity to compete in new markets for HCBS and opportunities may be a strategy for AAAs and CBOs to address these challenges. For example, the San Francisco AAA is taking advantage of the business acumen learning collaborative formed by ACL’s Center for Consumer Access and Self-Determination. As one of the sites selected to participate in the learning collaborative in 2013, San Francisco’s AAA convened a network of 15 CBOs. The stated outcome for network members is to build their organizational capacity to contract with managed health care entities. The goal was that future contracts with health plans and managed care providers would provide revenue to the CBOs that were part of the AAA’s network. ACL’s business acumen learning collaborative is in line with the Older Americans Act, which requires AoA to provide technical assistance designed to assist state units on aging (SUA), AAAs, and service providers in serving older individuals with the greatest economic and social needs. The act also requires the establishment, directly or through AoA grants or contracts, of national technical assistance programs to fund technical assistance to SUAs, AAAs, and CBOs funded under the act in implementing home and community-based long-term care systems.federal funding is constrained, local entities may be best served by having greater opportunities for technical assistance that could help them form strategic networks and identify additional sources of non-federal financial support. Local partnerships between service providers could in turn facilitate the type of care coordination that would benefit older adults. AoA, within HHS, is the principal agency designated to carry out the provisions of the Older Americans Act. As we reported in table1 earlier, AoA and CMS fund a range of HCBS for older adults while the other agencies that fund home and community based services—HUD, DOT, and USDA, do so in their respective areas. AOA funds HCBS and related supports and has reached out to the other agencies to collaborate on selected projects. However, AoA has not yet brought all five agencies together to develop a cross-agency federal strategy for home and community-based services and related supports. The Older Americans Act directs AoA to facilitate, in coordination with CMS and other federal agencies as appropriate, the provision of services and supports in the home and community. However, AoA, CMS, HUD, DOT, and USDA fund programs that deliver HCBS and supports to older adults through individual agency efforts, for the most part. While AoA has formed collaborative projects with each of the five agencies that fund HCBS for older adults, most of the collaborative arrangements reported are between AoA and one or two other federal agencies. Table 5 below lists the HCBS and support programs for older adults covered in this report. ADRCs are located in communities. The ADRC program seeks to improve older adults’ access to HCBS. Three of the programs include projects that one of the participants has identified as an interagency collaboration, AoA has worked with USDA to allow state distribution of USDA foods in lieu of all or part of their cash allotments under the Nutrition Services Incentive Program to supplement the home-delivered and congregate meal programs funded by the Older Americans Act. AoA collaborates with CMS in implementing the ADRC program, previously discussed. The AoA officials we interviewed identified the ADRC program as the focus of the agency’s effort to improve older adults’ access to HCBS at the local level. AoA is currently working to implement the no wrong door system—the updated model of the ADRC program—throughout the aging services network.officials also reported that they collaborate with AoA in the ADRC program. DOT According to DOT officials, DOT changed its requirements to allow other federal funds to be used as the local match for DOT funds.Under the revised requirement, local agency recipients of Section 5310 grant funds could use grant funds from AoA as a match for FTA Section 5310 funds. However, as table 5 shows, the five agencies administer most of the programs independently, without involvement by other agencies at the federal level. In addition to these programs that fund HBCS for older adults, agency officials reported collaboration on projects in which AoA and one or more other agencies participate. These projects, including a housing demonstration project, development of a data base, and specification of standards for an electronic HCBS record, focus mainly on federal program development tasks, rather than front line service delivery, AoA participates in DOT’s Coordinating Council on Access and Mobility, which is a federal interagency council for transportation services, established by Executive Order. The Council oversees activities and makes recommendations intended to simplify customer access to transportation and improve the efficiency of services using existing resources. While the five agencies that fund HCBS are represented on this council, their discussions focus on better coordinating transportation funding streams, programs, and transportation services. AoA also collaborated with HUD and HHS’ Office of the Assistant Secretary for Planning and Evaluation to develop design options for a demonstration of publicly assisted rental housing coordinated with health and long-term care services and support for low-income older adults. The goal is a sustainable, collaborative system between housing and human services agencies. HUD officials also told us that AoA and HUD support contractors who are developing a database that links demographic health status and health service utilization data for older adult residents of public housing. AoA, HUD, and CMS collaborate on a housing and supportive services project known as the Housing Capacity Building Initiative for Community Living. This initiative is a series of projects that focus on strategies for providing supportive services to older adults and individuals with disabilities who live in the community. Thus far, most of the projects focus on individuals with disabilities. CMS has an agreement with the HHS Assistant Secretary for Planning and Evaluation to develop standards for an electronic record for HCBS, according to CMS officials. CMS also is working with HUD’s 10 regional offices to examine what is required to integrate Section 202 developments into the larger community. In the past year, conversations have centered on HUD’s challenge with Section 202 developments that are more isolated from other community elements. Of the three collaborations identified in table 5 earlier, plus the six described above, three involve three or more of the agencies that fund HCBS for older adults. However, only DOT’s Coordinating Council on Access and Mobility included all five agencies. While these projects represent steps toward interagency collaboration, they do not allow all five agencies to consider jointly the broad implications of their independent initiatives for older adults, their common target population. For example, three CMS programs provide incentives for state Medicaid Programs to reduce the use of institutionally-based long-term services and supports in the community. At the same time, Congress eliminated funding for capital advances under the Section 202 program. According to HUD officials, HUD is encouraging localities to look to existing affordable housing resources in the community in the absence of funding for housing construction under the Section 202 program. AoA is collaborating with HUD and CMS by helping to determine how best to provide services to older adults in multifamily housing in the community. However, as we previously discussed, while attributable not only to changes in the Section 202 program, the demand for older adult affordable housing will likely continue to exceed the supply. One implication of these simultaneous developments is that, if there is no housing available, older adults may be unable to receive services unless they reside in an institutional setting. Collaboration to develop mutually reinforcing or joint strategies could help ensure that federal resources for HCBS and supports are used efficiently and effectively. Others also have pointed out the potential consequences of the lack of collaboration among the agencies that administer programs for older adults. For example, a 2014 report prepared for the Department of Health and Human Services noted that the disconnects among Medicare, Medicaid, acute and chronic health care providers, affordable housing programs, aging programs, and home and community based services may lead to lower-quality care, premature institutionalization, and higher costs for public and private health and long term care. This study reported that the factors contributing to higher costs were premature transfers to nursing homes and residential care facilities, repeated trips by emergency medical technicians to an individual’s home, repeated trips to hospital emergency rooms, and frequent hospitalizations. Officials we interviewed at AoA, DOT, HUD, and CMS all voiced support for interagency collaboration. The AoA officials we interviewed stated that the agency believes that collaboration with other federal agencies is necessary to build a comprehensive system of home and community- based services and has taken steps to formalize some of the agency’s collaborative relationships. HUD officials also thought that all of the HHS, HUD, DOT, and USDA programs and resources directed to older adults should be aligned to better serve them, especially because of the changing demographics of the older adult population. DOT officials emphasized that all federal agencies that fund HCBS for older adults should reach beyond barriers to coordination at the federal level. They suggested that the transportation services that community based organizations operate should be connected to locally coordinated planning organizations, such as a metropolitan council of governments. They said that they hope AoA will promote the message that joint planning is needed. CMS officials reported a positive experience collaborating with ACL and HUD. They said that they were unaware of any challenges to collaboration and found that any differences in the participating agencies’ organizational cultures that exist often enhance collaboration. When asked at what point AoA plans to coordinate a more comprehensive, cross-agency approach to administering the federal programs that fund HCBS, an AoA representative said that the agency does not have adequate resources to cover the cost of such a collaborative process. While we recognize that AoA is a small agency and faces many competing priorities for its resources, our recent work on interagency collaboration found that most collaborative groups in government are not directly funded, but leverage the existing resources of the participating agencies in order to operate. As part of our work on collaboration, we previously reported on key practices to enhance and sustain interagency collaboration. In that work, we broadly defined collaboration as any joint activity that is intended to produce more public value than could be produced when the We also described how agencies can enhance and agencies act alone.sustain their collaborative efforts by engaging in eight practices, including, define and articulate a common outcome; establish mutually reinforcing or joint strategies; identify and address needs by leveraging resources; agree on roles and responsibilities; establish compatible policies, procedures, and other means to operate develop mechanisms to monitor, evaluate, and report on results; reinforce agency accountability for collaborative efforts through agency plans and reports; and reinforce individual accountability for collaborative efforts through performance management systems. These practices can serve as a framework for collaboration among the five agencies that administer HCBS that would allow them to consider and establish a cross-agency federal strategy for administering HCBS. For example, as the five agencies collaborate, CMS officials might contribute lessons learned by state Medicaid agencies that would help develop joint strategies for using HCBS to prevent frequent use of emergency medical services by older adults. More specifically, using the eight practices for collaborative efforts, a cross agency federal strategy could help the federal agencies address some of the challenges associated with funding and delivery of HCBS in the localities we visited. For example, Officials at AoA and local officials said that federal rules governing the use of funds for transportation for older adults could be more flexible or subsidize transportation for older adults for different purposes, including health care and recreation. AoA, DOT, HUD, CMS, and USDA might define common outcomes for local transportation for older adults that took into account different transportation modes and the range of transportation purposes, and incorporate these objectives into their grant awards. AoA and the Center for Consumer Access and Self-Determination, also within ACL, have taken the initiative to help develop AAAs’ and other community-based organizations’ capacity to contract with healthcare entities to provide HCBS. AoA, HUD, DOT, and USDA, could help ensure that HCBS such as affordable housing, non- medical transportation, and additional nutrition assistance are provided at the community level by first defining common outcomes for these services. AoA, HUD, DOT, and CMS also could develop lessons learned for the local networks that AAAs and CBOs form to provide these services that could contribute to efficient and effective use of federal resources. As previously discussed, although HUD provides older adults with project rental assistance for units in existing multifamily housing developments, HUD did not anticipate any new funding for Section 202 capital advances to construct new housing after 2012. On the other hand, in each locality we visited, we were told that there were lengthy waiting lists for affordable housing for older adults. Defining common outcomes for affordable housing construction and rental assistance with supportive social services, including transportation and nutrition services, by HUD, CMS, AoA, DOT, and FNS could help develop strategies for leveraging limited resources for housing construction. The diversity of the older adult population presents challenges to meeting the needs of all older adults. Cross-agency goal setting by the five federal agencies with a focus on meeting the needs of diverse populations could help AAAs and community based organizations serve their clientele more effectively. In our work on interagency collaboration, we have found that when federal support in a particular area cuts across federal agencies, as it does with regard to HCBS and supports for older adults, agency collaboration is important to ensuring that federal efforts, overall, achieve meaningful results. Each of the five agencies that fund home and community-based services and supports for older adults, however, for the most part does so independently. While AoA is well-positioned to lead federal agencies in planning a cross-agency federal strategy for the provision of home and community-based services and supports for older adults, an AoA representative indicated that the many competing priorities it has for its limited resources prevent it from doing so. Development of a cross-agency federal strategy could help provide assurance that federal resources are used efficiently and effectively to help communities meet the demand for HCBS and supports for older adults. As the older population continues to grow, communities will find it increasingly difficult to meet the demand for the HCBS and supports many older adults will need to age in their own homes and communities. Based on recent trends, federal funding at AoA, HUD, and DOT for HCBS and supports is not likely to keep pace with demand for these services and supports, making it important to ensure that the federal resources available for this purpose are used effectively and efficiently. Development of a cross-agency federal strategy could better position the federal agencies to assist area agencies on aging and community-based organizations with providing HCBS and supports in the most efficient and effective manner. Under the Older Americans Act, AoA is responsible for facilitating the provision of home and community-based services and supports for older adults in this country, in coordination with CMS and other federal agencies. As a result, AoA is well-positioned to lead collaboration among the five federal agencies covered in our review. However, because of increases in Medicaid spending and emphasis on the role of HCBS in supporting health care patients, CMS has become an even more important partner to AoA in meeting older adults’ expected demand for HCBS. Thus, it may be most appropriate for the HHS Secretary to take the initiative in developing such a cross-agency federal strategy. The Secretary of the Department of Health and Human Services should facilitate development of a cross-agency federal strategy to help ensure that federal resources from ACL, CMS, USDA, HUD, and DOT are effectively and efficiently used to support a comprehensive system of HCBS and related supports for older adults. Through such a strategy the agencies could, for example, define common outcomes for affordable housing with supportive services, non-medical transportation, and nutrition assistance at the federal level; develop lessons learned for the local networks that area agencies on aging and community-based organizations are forming; and develop strategies for leveraging limited resources. We provided a draft of this report to HHS, DOT, HUD, and USDA. HHS provided general comments that are reproduced in appendix IV. All four departments provided technical comments which we incorporated as appropriate. HHS concurred with our recommendation and stated that HHS leadership agrees with the need to continue to coordinate services to address the often complex conditions of older adults with long term services and support needs. HHS also stated that the department continually strives to improve its strategic coordination and described ways that it facilitates cross agency strategic efforts, including a community-living initiative with HUD and an interagency workgroup on Olmstead requirements.also described collaboration by HHS and HUD on policy research projects concerning housing and supportive services for older adults, including a comparison of health service utilization by older adults who live in assisted housing with those who do not and an evaluation of a demonstration in Vermont that provides services and supports to residents of HUD-assisted housing. We continue to encourage HHS to engage all five agencies—the Administration on Aging and Centers for Medicare and Medicaid Services in HHS, HUD, DOT and USDA--in development of a cross agency federal strategy for administering home and community-based services for older adults. Using the eight practices to enhance and sustain interagency collaboration that we have identified in prior work could help the five agencies address some of the challenges associated with funding and delivery of home and community-based services to older adults in the communities where they live. We are sending copies of this report to the appropriate congressional committees, the Secretaries of the Departments of Health and Human Services, Housing and Urban Development, Transportation, Agriculture, and other interested parties. We will also make copies available to others on request. In addition, the report will be available at no charge on GAO’s website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7215 or brownke@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs can be found on the last page of this report. GAO staff who made major contributions to this report are listed in appendix V. Appendix I: Community Based Organizations Contacted, by Locality and Type Benson Manor (Department of Housing and Urban Development (HUD) Section 202) Dekalb County Senior Transportation Services (Department of Transportation Enhanced Mobility) East Point Naturally Occurring Retirement Community (NORC) Gwinnett Christian Terrace (HUD Section 202) Chevy Chase at Home Village Homecrest House (HUD Section 202) Muslim Community Center Senior Program Victory Oaks (HUD Section 202) Village Rides (Department of Transportation Enhanced Mobility) Armstrong Place (HUD Section 202) Bayview Hunters Point Multipurpose Senior Services Inc. Home & Community-Based Supportive Services Aging and Disability Resource Centers (ADRC) Aging and Disability Resource Center (Mandatory) Aging and Disability Resource Center (MIPPA) 1915(c) HCBS Waivers 1915(i) HCBS: State Plan Options Balancing Incentive Program (BIP) Money Follows the Person Demonstration (MFP) Community First Choice (CFC) Senior Farmers’ Market Nutrition Program Supportive Housing for the Elderly (Section 202)-Capital Advance and New Project Rental Assistance Contracts (PRAC) Supportive Housing for the Elderly (Section 202)-Renewals and Amendments PRACs Supportive Housing for the Elderly (Section 202) -Service Coordinators Enhanced Mobility of Seniors and Individuals with Disabilities (Sections 5310) An obligation is a legally binding agreement that results in outlays, immediately or in the future. According to Congressional Research Service, the Aging Network Services Activities program funds declined starting in fiscal year 2012 because some activities supporting older adults that were previously included under the Aging Network Support Activities program were moved to separate line items in fiscal year 2011. These included the Senior Medicare Patrol Program, ADRCs, the National Center on Elder Abuse, and the National Long-Term Care Ombudsman Resource Center. Expenditures for Medicaid programs for fiscal years 2007 – 2014 were provided by CMS from the Medicaid Financial Management Reports. Appropriations of $10 million for FY 2010 through FY 2014 for ADRCs were made under the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §2405 124 Stat. 119, 305. Area Agencies on Aging, ADRCs and State Health Insurance programs receive funding through MIPPA to help Medicare beneficiaries apply for the Medicare Part D Extra Help/Low-income Subsidy and the Medicare Savings Program. According to USDA, obligations for the Commodity Supplemental Food Program in fiscal year 2010 were $182 million and for fiscal year 2013, $186 million. Appropriations for capital advances for fiscal years 2012-2014 were for administrative expenses related to the Capital Advance Program. No appropriations for new capital advances were made that year. Amount is significantly higher in fiscal year 2013 and beyond due to the incorporation of the former New Freedom program into the Enhanced Mobility of Seniors and Individuals with Disabilities program. Amenities and activities: HUD-funded service coordinator (and activities director), part-time language interpreter, laundry facility, 24-hour surveillance and overnight security, twice weekly shopping trips, bus excursions, terrace room (for movies, gaming, and special events), book club, free weekly swap meet, sewing and craft clubs, bingo, wellness and exercise room, fitness classes, worship services and Bible study, resident gardens, combined library and computer room. Homecrest House is a nonprofit, nondenominational community formed when HUD awarded the first Section 202 grant in 1976. This sponsor operates two Section 202 properties in Maryland. Two adjoining properties by the same sponsor opened for occupancy in 1979 and 1985, respectively. There are 235 total units. Amenities and activities: Kitchen, outdoor patio, laundry facility, community room, vending machines, wellness room, fitness center, computer room, library, sunroom, 24-hour security, and health education meetings. Bridge Housing Corp. is a San Francisco- based nonprofit housing developer formed in 1983. This sponsor operates five Section 202 properties in California. Property opened for occupancy in 2011 and has116 units (23 designated for homeless older adults) Amenities and activities: Community room with kitchen, laundry facility, assigned covered parking, courtesy patrol, landscaped courtyard and picnic area. HUD refers to community-based organizations that receive Section 202 funding to provide affordable housing to older adults as sponsors. Project H.A.N.D.S. is a Canada-based international nonprofit organization that helps needy communities through projects such as outreach clinics and education funding. In addition to the contact named above, Clarita Mrena (Assistant Director), Sara Edmondson (Analyst-in-Charge), Laurel Beedon, Bernice Benta-Jackson, John Lack, and Nhi Nguyen, made significant contributions to all aspects of the work. Also contributing to the report were Holly Dye, Sheila McCoy, John McGrail, Mimi Nguyen, Cheryl Peterson, Monica Savoy, Walter Vance, Maria Wallace, Emily Wilson, and Craig Winslow.

Summary: Research has shown that many older adults want to age in their homes and communities, and their ability to do so often depends on the availability of home and community-based services and other supports. GAO was asked to review the availability of such services. This report addresses (1) federal programs that fund these services and supports for older adults, (2) how these services and supports are planned and delivered in selected localities, and (3) agencies' efforts to promote a coordinated federal system of these services and supports. GAO reviewed federal program documents and interviewed federal officials. It also visited programs in the Atlanta, Georgia region, Montgomery County, Maryland, and San Francisco California, chosen based on efforts made to enhance their system of HCBS and supports, recommendations from federal agencies and experts, varied governmental jurisdiction, and geographic dispersion. Five federal agencies within four departments fund home and community-based services and supports that older adults often require to continue living independently in their own homes and communities. The Administration on Aging (AoA) and Centers for Medicare & Medicaid Services (CMS) in the Department of Health and Human Services (HHS), and the Departments of Housing and Urban Development (HUD), Transportation (DOT), and Agriculture (USDA) provide funds, often through state agencies, to local governments and community-based organizations. The Older Americans Act of 1965 (the Act) requires AoA to promote and support a comprehensive system of services. In the three localities GAO visited, local area agencies on aging, assisted by other community-based organizations, took the lead in planning and delivering services and supports for older adults, paid for with a mix of federal, state, and local funding. An Atlanta organization employed home-care aides for older adults and delivered meals. Senior housing developments across the three localities connected more frail residents to in-home services. In San Francisco and Montgomery County, grassroots organizations known as villages provided help with errands. Officials in two localities reported that flat funding of certain state funds, combined with the growing number of older adults, has resulted in waiting lists for affordable housing and in-home services. The Act requires AoA to facilitate collaboration among federal agencies; however, the five agencies that fund these services and supports for older adults do so, for the most part, independently. GAO's work on interagency collaboration has found that collaboration is important for federal efforts that involve more than one agency. HHS, through AoA, has indicated that competing priorities for its limited resources prevent it from leading development of a cross-agency federal strategy. However, developing such a strategy could help ensure that the five agencies' resources for HCBS and supports are used efficiently and effectively. GAO recommends that HHS facilitate development of a cross agency federal strategy to ensure efficient and effective use of federal resources for HCBS. HHS concurred and HUD, DOT, and USDA did not comment.