Older adults may receive federal housing assistance through a number of programs, but only a few programs specifically target older households. To be eligible for those programs, the head of household or spouse must be 62 or older. HUD has two programs specifically targeted to older households—the Supportive Housing for the Elderly (Section 202) program for renters and the Home Equity Conversion Mortgage program for homeowners. HUD’s Section 202 program is the only program that provides supportive housing targeted to very low-income older adults. Supportive housing is defined as non-institutionalized housing that connects residents with the services they need to live independently, such as in-home care, meal delivery, and transportation. Until fiscal year 2012, the Section 202 program funded the development of new units. The Home Equity Conversion Mortgage program, administered by the Federal Housing Administration (FHA), a component of HUD, allows older homeowners to access FHA-insured mortgages to convert some of the equity in their homes into monthly streams of income or lines of credit (reverse mortgage). In addition to being at least 62 years old, borrowers must occupy the property as a principal residence, and any existing lien on the property must be small enough to be paid off at settlement. In a reverse mortgage, the loan balance increases and home equity decreases over time. As the borrower receives payments from the lender, the lender adds the principal and interest to the loan balance, reducing the homeowner’s equity. The homeowner remains responsible for paying insurance and property taxes. The Rural Housing Service has one homeownership program that specifically serves households aged 62 and older. The Section 504 Rural Home Repair and Rehabilitation Grant program finances the removal of health and safety hazards or remodels dwellings to make them accessible for disabled household members. According to USDA officials, grants often are made in conjunction with Section 504 loans that have a 1 percent interest rate. HUD has rental assistance programs that do not target, but serve a significant number of older households. According to HUD officials, HUD’s primary rental assistance programs, including the Housing Choice Voucher, Public Housing, and Project-Based Section 8 programs, serve nearly 1.5 million such households. In addition, FHA’s Section 221(d)(3) and Section 221(d)(4) Multifamily Rental Housing for Moderate-Income Families provide mortgage insurance to finance multifamily properties, some of which may be designated for the elderly. The HOME Investment Partnerships Program provides formula grants to states and localities that communities use to fund a range of activities including building, purchasing, and rehabilitating affordable housing for rent or homeownership or providing direct rental assistance to low-income households. HUD Public Housing Designated for Older Households 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 only by elderly families, by disabled families, or both. HUD refers to this as “designated public housing”. 42 U.S.C. § 1437e. However, HUD officials stated that HUD had fewer than 40,000 units of designated public housing and the majority of elderly persons were not assisted through such housing. Similarly, the Rural Housing Service administers a number of homeownership and rental programs not targeted to older rural households, but that can serve them. They include the Section 502 Rural Direct Home Loan; Section 502 Home Loan Guarantee; Section 504 Rural Housing Repair and Rehabilitation Loan; and the Section 521 Rural Rental Assistance programs. The Section 521 program provides rental subsidies to low-income, elderly, or disabled households living in properties funded by the Section 515 Rural Rental Housing program and others. Finally, the Low-Income Housing Tax Credit, established under the Tax Reform Act of 1986 and administered by the Internal Revenue Service, is the largest source of federal assistance for developing affordable rental housing for low-income households, including elderly households, and as of 2017, had financed about 2.9 million rental units. It provides tax credits to encourage private-equity investment in affordable housing development. Worst-Case Needs for Rental Housing HUD tracks older adults in its biennial Worst Case Housing Needs report. HUD defines households with worst-case needs as very low-income renters who do not receive government housing assistance and paid more than half of their income for rent, lived in severely inadequate conditions, or both. The latest report (2017) indicated that severe housing problems were on the rise among unassisted renter households in 2015. This included older renters, for whom the number and proportion of households with worst-case needs increased from 2013, by 382,000 and 2.6 percentage points, respectively. In 2015, 1.85 million such households experienced worst-case housing needs, including unaffordable rents. The report noted that low- income older households that rely on fixed incomes rather than wages may be less likely to benefit from economic recovery trends that raised incomes for others in recent years. In recent years, HUD and USDA have lost subsidized housing stock. Losses can happen under several scenarios, including when federal rental assistance contracts expire, federally subsidized mortgages reach maturity or are paid off and owners convert the units to market-rate rentals, or units fall into disrepair. In its fiscal year 2014–2018 strategic plan, HUD reported that its public housing stock faced a capital needs backlog, estimated at $26 billion, which would be difficult to meet given federal fiscal constraints. The decreasing supply of adequate affordable housing may affect older low-income renters (see sidebar), who were well represented in HUD- and USDA-assisted housing. In addition to losing housing stock, HUD and USDA have programs that previously added to the supply of affordable housing but no longer do so. One example is HUD’s Section 202 program, which specifically serves very low-income older adults. Except for $10 million in its fiscal year 2017 appropriation that could contribute to capital advances, since fiscal year 2012, the program has primarily funded contract renewals for existing rental assistance and for service coordinators. According to USDA officials, the Section 515 program (direct loans for multifamily housing) had no funds for new construction. They told us that Section 515 funds almost exclusively were being used for unit rehabilitation, and that only the Section 538 loan guarantee program was funding new construction. According to USDA officials, many of the rehabilitated Section 515 properties are described in loan applications as properties serving the elderly, as are some newly constructed properties funded by the Section 538 program. Federal and other entities have reported on a lack of integration among housing and health programs and services and the benefits of closing gaps. In 2002, the congressionally mandated Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century reported that a lack of integration between housing and health care for older adults resulted in inefficiencies, noting that the basis was partly historical differences in policies, funding systems, and regulatory structures. The Commission found that, with few exceptions, older adults obtained their housing from one source and health care and supportive services from a different source. In July 2015, the White House Conference on Aging highlighted the importance of collaboration across sectors and the need to better integrate housing, transportation, health care, and long-term services and supports to encourage healthy aging. It noted that opportunities existed to leverage approaches taken by states and localities to consider how best to serve older adults. In 2016, the Bipartisan Policy Center’s Health and Housing Task Force reported that bridging the current policy gap between housing and health had the potential to provide a number of benefits, including improving health outcomes for older adults, reducing costs incurred by the health care system, and enabling many older adults to age in their own homes and communities. Senior leadership in HUD’s Office of Policy Development and Research recently amplified the discussion about housing and health, noting that the Housing Act of 1937 recognized the linkage between the two. That office also has observed that efforts to better link housing and health services hold promise to improve the ability of older adults to safely, comfortably, and more affordably age in place. Collaborations that were focused on coordinating housing and health services for older adults involved HUD and HHS. While these collaborations demonstrated some leading practices we identified, they did not include USDA (a relevant participant) and did not define common outcomes for these efforts. USDA has collaborated with HUD on two efforts related to housing, and with HUD and HHS on one effort that addressed both housing and health services, although these efforts were not focused specifically on older adults. Officials at HUD and USDA told us that they primarily collaborated on administrative initiatives through the Rental Policy Working Group. For example, in 2016, HUD, USDA, and the Department of the Treasury entered into a memorandum of understanding to formalize the activities of the Rental Policy Working Group, such as reducing duplicative physical unit inspections at properties assisted by one or more of the agencies. While older renter households may benefit from administrative improvements made through the Rental Policy Working Group, its efforts were not intended to focus on any particular household type served by HUD and USDA. Under a 1991 memorandum of understanding, HUD and USDA also are required to coordinate where both agencies’ rental programs could overlap in serving rural families. In 2016, USDA started participating in interagency training intended to help coordinate the provision of home and community-based services and supports to vulnerable populations, including older adults. The training was initiated by HHS, and since 2011, HHS and HUD have conducted it for program staff as part of their efforts to strengthen cross-agency collaboration. In 2017, the 1-day training session focused on housing as a platform for improving the quality of life of persons with disabilities, older adults, and other at-risk populations. USDA participated in a discussion on housing and health collaboration between federal, state, local, and community partners. Representatives of both HUD and HHS said that USDA’s increased participation had been positive. HUD officials also told us that in 2018, the agenda for the 1-day training would focus on housing and health supports for older and disabled persons living in rural areas. Additionally, in 2016, HUD and USDA began coordinating on developing topics for HUD’s research agenda. Specifically, HUD’s Office of Policy Development and Research develops a research agenda with input from external stakeholders, and both HUD and USDA officials told us of efforts to develop rural housing topics for inclusion in HUD’s research. HUD Policy Development and Research officials stated that HUD conducted extensive research in rural areas and was interested in coordinating more with USDA, though this research has not been specific to older adult issues. In response to HUD’s outreach, USDA submitted topics to HUD, some of which were incorporated into HUD’s 2017 research agenda update. They include the relationship between housing, food, and health and the impact of home equity loss on rural homeowners, particularly those who are aging. HUD and HHS have undertaken multiple collaborative efforts that link data on housing and health services and often have focused on older adults. The Support and Services at Home demonstration was launched in 2011 to connect older residents of affordable housing properties with home and community-based supportive services and promote health care coordination. The latest evaluation report was published in January 2016 and described the program’s ongoing implementation and impact from 2011 through 2014. It found lower rates of growth in Medicare expenditures among program participants than among a comparison group. As of August 2017, HUD representatives told us that the departments were still collaborating on evaluating the demonstration. Data sharing between HUD and HHS on another demonstration program—the Supportive Services Demonstration for Elderly Households in HUD-Assisted Multifamily Housing—began in 2014. Like the Support and Services at Home demonstration, the Supportive Services Demonstration is intended to test aging-in-place models that show potential for delaying or avoiding the need for nursing home care. HUD has been conducting a 4-year, two-part evaluation, which includes an evaluation of the implementation process and an impact evaluation that will match Medicare claims data from HHS’s Centers for Medicare and Medicaid Services and HUD administrative data. HUD and HHS completed a pilot of the data match in 2014, and HUD has submitted two semi-annual reports to Congress on program implementation, the latest in May 2017. HUD officials stated that in October 2017, HUD secured a contract to conduct a full evaluation of the Supportive Services Demonstration, as described above. According to the officials, the demonstration implementation team conducted an in-person, 2-day training event for care coordination teams in November 2017. The National Center for Health Statistics at the Centers for Disease Control and Prevention, also a component of HHS, in 2014 began to link national health survey participant data to HUD administrative data covering HUD’s largest housing assistance programs through 2014. The data linkage is intended to help those agencies and other federal entities and researchers complete independent projects for statistical and research purposes. The first linkage included two household surveys (National Health Interview Survey and National Health and Nutrition Examination Survey) that covered 1999–2012 and it was completed in July 2016. HUD officials told us that HUD and HHS were working on the second data linkage project. HHS confirmed that the second linkage was underway as of February 2018, with an expected completion date of summer 2018. It will add survey years 2013–2016 and administrative data years through 2016. While the project was not focused specifically on older adults, it could include a significant proportion of older adults living in non-institutionalized settings who receive housing assistance from HUD. HHS’s Office of the Assistant Secretary for Planning and Evaluation and HUD completed a study on health care utilization among HUD- assisted older adults in 12 jurisdictions, and published a final report in August 2016. The study, which began in 2009, explored the feasibility of matching administrative data from HUD and HHS’s Centers for Medicare and Medicaid Services to determine if doing so could help track housing and health outcomes, and reliably support future research and policy analysis. More specifically, it linked HUD individual tenant-level data to Medicare and Medicaid beneficiary enrollment, payment, and claims data. In the 2016 report, HHS and HUD found that, controlling for previously identified factors, HUD- assisted dual Medicare-Medicaid beneficiaries were less likely to use some Medicare-covered services such as acute hospital stays, but more likely to use Medicaid-covered home and community-based supportive services. According to the report, the study demonstrated that linking the agencies’ data could inform decisions about future program investment. We found that the collaborative efforts between HUD and HHS (pilot programs and data sharing related to older adults) demonstrated some but not all relevant leading practices we previously identified for effective interagency collaboration. As we reported in 2012, interagency collaborative mechanisms can be enhanced by leading practices, including written guidance and documenting agreements on how the participating agencies will be collaborating, clarifying roles and responsibilities, leveraging resources (such as funding and staffing), including all relevant participants, and clearly defining outcomes. HUD and HHS established interagency agreements or memorandums of understanding for collaborative efforts that focused on or included older adults. For example, HUD and HHS entered into a memorandum of understanding for the National Center for Health Statistics data linkage effort and had contracts for the Support and Services at Home demonstration and other collaborations. Our leading collaboration practices state that agencies articulating their agreements in formal documents can strengthen their commitment to working collaboratively, as long as they are continually updated and monitored. The roles and responsibilities of agencies participating in a collaborative effort may be defined in a number of ways, including through laws, policies, memorandums of understanding, or other requirements. Clarity of roles and responsibilities allows participating agencies to understand and agree on accountability for the joint effort, and a process for making and enforcing decisions. In accordance with their memorandum of understanding, HUD and HHS had clear roles and responsibilities for the National Center for Health Statistics data linkage effort. For example, the agreement documented specific data that HUD was to provide to the National Center for Health Statistics and how the latter would attempt to link HUD’s data to its survey participant data. It also specified both agencies’ roles in data access, storage, and disposition. Collaborating agencies should identify human, information technology, physical, and financial resources needed to initiate or sustain their collaborative effort. And it is important that the agencies leverage sufficient resources to accomplish their objectives. HUD’s and HHS’s written agreements generally included a description of how they would leverage each agency’s resources, including staffing, funding, and data. For the Support and Services at Home demonstration, HUD provided resources to help evaluate the program model, while HHS funded a wellness nurse who worked with a service coordinator to perform such tasks as assessing residents’ needs; identifying and coordinating service delivery; monitoring receipt and follow-through of services; and building and sustaining partnerships with providers. HUD and HHS, including their component agencies and offices, were the main participants in these collaborative efforts. HUD officials stated that USDA was not included because these collaborative efforts were pilots originally intended to better understand the health of households assisted by HUD. But no current plan exists to include USDA in such collaborative efforts in the future. As these collaborative efforts mature, USDA, which provides assistance to low-income older adults in rural areas, may benefit from inclusion. Effective collaborative efforts benefit from having participants with the necessary knowledge, skills, and abilities to contribute to the outcomes of the collaboration. Officials at HUD and HHS said they were open to greater collaboration with USDA in the future. And while HUD has a presence in rural communities, USDA’s participation would allow the Rural Housing Service to provide input on and help address challenges that may be unique to rural older adults. By not including USDA in future collaborative efforts on older adult housing and health services, HUD and HHS may miss opportunities to identify and respond to the changing needs of some older adults living in federally assisted housing—such as by drawing on the experience and resources of the Rural Housing Service in serving rural populations. In addition, USDA may miss opportunities to benefit from lessons learned or programmatic improvements that HUD and HHS might undertake as a result of their collaborations. Although HUD and HHS have established specific objectives for their various evaluations and data-sharing initiatives, they have not defined common outcomes for these collaborative efforts. For example, while some of these efforts were expected to explore the housing and health relationship and inform more evidence-based program decisions, the agencies have not defined common outcomes for their interagency efforts as a whole. We reported that collaborating entities should determine whether they have clearly defined short-term and long-term outcomes, can track their progress, and whether they each have collaboration- related performance standards against which to evaluate individual performance. Such common outcomes could include both quantitative and qualitative information. For example, a set of measures against which to track and monitor their collaborations (including demonstrations, data matching, and studies) might include the extent to which hospital stays were reduced, as noted for the Support and Services at Home and Supportive Services demonstrations, or program costs saved. Monitoring and reporting such measures would provide greater transparency to agency and congressional decision makers about how these collaborative efforts have resulted in potential cost savings and other benefits across agency lines. A more long-term common outcome could include developing proposals for programmatic improvements that would leverage the lessons learned from the collaborative efforts. Senior leadership at HUD has said that HUD considers the nexus of housing and health to be a priority for future work, and that federal agencies needed to continue finding ways to move beyond their programmatic scope to engage in more comprehensive, cross-cutting efforts. The official pointed to data-matching efforts with HHS as low-cost initiatives that could enhance HUD’s knowledge about the health status of assisted households and potentially inform cost-saving policies. Because many of their collaborative efforts began in the last 5 years and some remain ongoing, HUD and HHS may not have prioritized developing common outcomes that relate both to older adult housing and health services. In contrast, HUD and HHS have developed broader goals that relate to how they serve older adults.However, without defined common outcomes to help guide ongoing and future efforts, HUD and HHS (and potentially USDA) lack measures against which to monitor, evaluate, and report the results of their collaborative efforts. Federal agencies, particularly HUD and HHS, have found opportunities to collaborate in meaningful ways on services provided to older adults. But collaborative federal efforts to address the housing needs of older adults and tie into health services would benefit from consistent USDA involvement and from defining common outcomes. Greater USDA participation would result in a better nationwide assessment of the housing and health needs of older Americans who live in all federally assisted housing and leverage USDA’s expertise and resources in serving rural populations. Outcome information would help the agencies articulate to stakeholders and Congress the results the collaborations achieved; activities, strategies, or areas on which to focus in the future; and how scarce federal resources were leveraged and managed. We are making a total of three recommendations (one recommendation each to HUD, HHS, and USDA): The Secretary of Housing and Urban Development should work with HHS and USDA’s Rural Development to define common outcomes and identify opportunities to include USDA in future collaborative efforts on older adult housing and health services. (Recommendation 1) The Secretary of Health and Human Services should work with HUD and USDA’s Rural Development to define common outcomes and identify opportunities to include USDA in future collaborative efforts on older adult housing and health services. (Recommendation 2) The Assistant to the Secretary for Rural Development should work with HUD and HHS to define common outcomes and identify opportunities to include USDA in future collaborative efforts on older adult housing and health services. (Recommendation 3) We provided a draft of this report for review and comment to HHS, HUD, and USDA. HHS and HUD provided written comments that are reproduced in appendixes I and II, respectively. USDA provided technical comments, which we incorporated as appropriate. All three agencies concurred with our recommendations. The Deputy Administrator of Multifamily Housing Programs provided USDA’s concurrence in an e-mail dated April 11, 2018. In its comment letter, HUD stated that our recommendation to include an additional agency in housing and health demonstrations is consistent with direction provided by the Senate Committee on Appropriations in fiscal year 2016. The committee directed HUD to partner with other federal agencies to pursue a service coordination demonstration in non- metropolitan areas. HUD noted that the committee advised it not to delay existing demonstration efforts while a non-metropolitan component was being designed. HUD also stated that it convened an expert panel to better understand challenges to service coordination for low-income older adults in rural areas, and summarized the findings in a report. HUD said further action on the panel report was contingent on funding availability and direction from appropriations committees. HUD stated that, in regard to our recommendation that additional federal agencies might benefit from data-linkage projects similar to its project with the National Center for Health Statistics, it would be pleased to offer assistance, guidance, and insights to other agencies. Our recommendation is that HUD work with HHS and USDA’s Rural Development to define common outcomes and identify opportunities to include USDA in future collaborative efforts on older adult housing and health services. This would include data sharing, service demonstrations, research, and other collaborations. Ongoing housing and health collaborations among HUD, HHS, and USDA would benefit from greater USDA involvement, which also would serve to enhance assessments of the housing and health needs of older Americans in federally assisted housing. We are sending copies of this report to the appropriate congressional committees, the Secretary of Agriculture, the Secretary of Health and Human Services, the Secretary of Housing and Urban Development, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-8678 or garciadiazd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III. In addition to the contact named above, Paul Schmidt (Assistant Director), Bernice Benta-Jackson (Analyst in Charge), Abigail Brown, Stephen Brown, William Chatlos, Charles Culverwell, Kirsten Lauber, John McGrail, Marc Molino, Dae Park, Nadine Garrick Raidbard, Barbara Roesmann, Joseph Silvestri, and Jeff Tessin made key contributions to this report.

Summary: According to the Census Bureau, by 2030, about 1 in 5 Americans will be 65 and older. This aging of the population presents challenges and opportunities for policymakers and service providers in helping ensure that the older population's needs—including housing and health services—are met. Federal agencies with programs that provide housing assistance to low-income older households include HUD and USDA. Several HHS programs provide those households with health services. This report assesses the extent to which the three agencies collaborated to address the housing and health service needs of older adults living in federally assisted housing. GAO compared agency efforts to leading collaboration practices it has identified (including written agreements; roles and responsibilities; leveraged resources; relevant participants; and defined outcomes) and interviewed HUD, HHS, and USDA officials. The Departments of Housing and Urban Development (HUD) and Health and Human Services (HHS) have collaborated on older adult housing and health issues, but these efforts did not fully demonstrate leading practices GAO identified for effective collaboration. The HUD-HHS efforts demonstrated some leading practices. For example, the agencies have written agreements for data-sharing projects and have leveraged resources to conduct research on older adults. The Department of Agriculture (USDA) was not included in the efforts although it provides housing assistance to older rural households. GAO identified the inclusion of all relevant participants as a leading practice. According to HUD, the efforts were intended to explore the health of HUD-assisted households. However, by not including USDA in future collaborations, HUD and HHS may miss opportunities to leverage expertise and USDA may not be able to benefit from any resulting insights and improvements. The HUD-HHS collaborative efforts also did not define common outcomes, another leading practice GAO identified, likely because their collaboration is relatively new. Without common outcomes (for instance, focused on recipient impact or cost savings), the agencies lack measures against which to monitor, evaluate, and report the results of any collaborations. Future collaborations would benefit from consistent USDA involvement. And by defining common outcomes, the agencies would help inform Congress and stakeholders of results achieved and strategies or areas on which to focus. GAO is making three recommendations (one each to HUD, HHS, and USDA). They focus on including USDA in collaborations on older adult housing and health services and defining outcomes for the efforts. The three agencies concurred with GAO's recommendations. HUD stated that it had begun examining challenges relating to services for low-income rural older adults.