Mitigating Homelessness Among Older Adults: Adapting the Permanent Supportive Housing Model

Abstract:

Homeless older adults have a unique constellation of needs, including early onset of geriatric conditions and a disproportionate prevalence of behavioral health disorders. Studies demonstrate numerous benefits of permanent supportive housing (PSH) for homeless people, but those studies have primarily been conducted among younger formerly homeless people. Recent studies of older adults living in PSH suggest that housing alone is not enough to address geriatric conditions in this population and to improve their ability to age in place. This article discusses four models that hold promise for interweaving care and housing for unhoused older adults. More study is needed to evaluate the effectiveness of these promising programs.

Key Words:

permanent supportive housing, homeless, unhoused, models, evaluation

The median age of the adult homeless population is increasing as the U.S. population ages. While in 1990 homeless adults ages 50 and older made up 11 percent of the single adult homeless population (Hahn et al., 2006), today they comprise approximately half of that population (Culhane et al., 2019). Recent research suggests this upward trend is due largely to a cohort effect. Individuals born in the second half of the post-World War II baby boom have an elevated risk of homelessness; thus, as they age, the median age of individuals experiencing homelessness rises (Culhane et al., 2019).

As this trend is expected to continue, the population of homeless adults ages 55 and older in Boston and New York City is now predicted to increase between 2017 and 2030 two- to three-fold. A core challenge facing our country is how to mitigate the growing problem of homelessness among older adults, preventing precariously housed individuals from becoming unhoused and helping those who are unhoused to obtain safe and secure permanent housing.  

Many homeless older adults face a unique combination of comorbid conditions, underscoring the need to interweave housing, health, and social care services targeted to their specific needs. In this article, we argue that the solution lies in evolving our often-siloed housing, health, and social care systems into a better integrated system of care for vulnerable older adults at-risk for or homeless.

The Complex Health Challenges of Homeless Older Adults

In the general population, adults ages 50 to 64 are considered middle-age and have a lower prevalence of chronic conditions compared to older adults, defined as those ages 65 years or older. However, homeless adults ages 50 and older experience premature aging, including rates of geriatric syndromes and chronic conditions similar to or higher than housed adults 15 to 20 years older (Brown et al., 2012). Homeless adults also experience premature mortality, with an average age of death of approximately 50 years (Hwang, 2000; Baggett et al., 2013). For these reasons, homeless adults are considered to be “older” at age 50, 15 years earlier than in the general population (Brown and Kushel, 2021). The juxtaposition of the increasing proportion of homeless older adults in the United States and the accelerated aging they experience highlights the need for effective models of care for this population.  

Homeless older adults have a unique constellation of needs, including early onset of aging-related conditions. A substantial percentage of homeless older adults experience difficulty performing basic activities of daily living such as bathing, dressing, and transferring (33 percent), difficulty performing instrumental activities of daily living such as managing medications and taking public transportation (60 percent), falls (50 percent), cognitive impairment (25 percent), hearing impairment (33 percent to 50 percent), visual impairment (20 percent), and urinary incontinence (50 percent).

Many of these geriatric conditions are risk factors for adverse outcomes, including hospitalization and nursing home admission (Brown et al., 2013b). Homeless older adults also experience a high prevalence of chronic medical conditions, with 75 percent having at least one condition such as hypertension, arthritis, asthma or chronic obstructive pulmonary disease, and 50 percent having two or more (Brown et al., 2012).  

In addition to the early onset of geriatric syndromes and chronic illnesses, homeless older adults face conditions that are less common among older adults in the general population, including a disproportionate prevalence of substance use disorders and mental health conditions. Almost 75 percent of homeless older adults reported one or more psychiatric conditions, including depression (34 percent to 60 percent), anxiety disorder (19 percent), and posttraumatic stress disorder (12 percent to 34 percent) (Brown and Kushel, 2021).  

This unique combination of comorbid conditions underscores the need for models of care for homeless older adults that combine housing plus care targeted to their specific needs.

Consider the case of Mr. N, a 59-year-old man living in a homeless shelter. Along with diabetes, which required insulin, he also suffered from severe arthritis, for which he used a cane. Mr. N faced multiple difficulties related to managing his diabetes, including the risk of having his medications stolen while staying in the shelter and the need to keep his insulin cold. During the summer months, the latter challenge sometimes resulted in him staying on the local beach, where he could dig a hole in the sand to store the insulin and keep it cold. He also faced significant issues due to his arthritis. He not only risked having his cane lost or stolen while staying in the shelter, but also faced several social and environmental obstacles.

The communal shower introduced the risk of victimization by other shelter residents, and climbing into upper bunkbeds at the shelter placed him at risk for falls and injuries. In addition, to obtain food during the day, Mr. N had to navigate a complex web of food programs that involved traveling throughout the city, even in harsh weather conditions. Mr. N faced a unique combination of challenges resulting from his underlying chronic health conditions that were exacerbated by social and environmental factors related to experiencing homelessness.

Existing Permanent Supportive Housing Interventions Hold Promise, But Need Adaptations

Permanent supportive housing (PSH) was devised as solution to homelessness for the most vulnerable chronically homeless people. PSH provides permanent housing via rental assistance or indefinite leasing, paired with supportive services to help people who are experiencing homelessness to achieve housing stability. In existing PSH models, these supportive services often include programs to address wellness and nutrition, mental health conditions, and/or substance use disorders. However, PSH sites are usually not geriatrics-focused and do not incorporate services to promote aging in place, such as long-term services and supports or home safety evaluations to assess the need for environmental adaptations.

Nevertheless, studies have demonstrated numerous benefits of PSH for people experiencing homelessness. These include improving their ability to become and remain housed, their overall well-being, health outcomes for those living with HIV, and housing status for those with mental illness and substance use disorders (National Academies of Sciences, Engineering, and Medicine, 2018). PSH also has also been shown to decrease emergency department use and hospital stays for those with high medical needs.

But most prior studies (including those listed above) primarily have been limited to younger homeless people. Randomized controlled trials have not yet examined the impact of PSH on outcomes that are particularly relevant to older adults, including risk of functional decline, falls, and nursing home admission. Two observational studies suggest that standard PSH alone is not sufficient to adequately address geriatric syndromes and allow for safely aging in place.

One study examining the impact of obtaining housing on health outcomes among homeless older adults found no change in several key geriatric syndromes that are risk factors for nursing home admission, including activities of daily living (ADL) impairment, instrumental activities of daily living (IADL) impairment, and urinary incontinence (Brown et al., 2015). Similarly, a study among older adults living in PSH found that longer housing tenure was not associated with improved functional status (Henwood et al., 2019). These findings suggest that among homeless older adults, PSH as currently conceived may be successful in stabilizing function over short time periods, but remains insufficient for addressing geriatric syndromes. This compromises the ability of homeless older adults to effectively age in place.

Consequently, it is vital that we develop effective models that interweave geriatrics-focused care with housing for this population. While this is still an emerging area, several programs and pilot studies demonstrate promising models of care, melding lessons from the fields of geriatrics and gerontology with those from homelessness and housing services literature. Below we discuss four such models that use different care interventions to augment PSH for formerly homeless older adults (see Table 1, below).

Table 1. Emerging PSH Models Adapted for Formerly Homeless Older Adults

Model Number One: PSH + CAPABLE

A University of Southern California (USC) pilot study is testing an intervention to introduce a geriatrics-focused model of care, Community Aging in Place–Advancing Better Living for Elders (CAPABLE) (Johns Hopkins School of Nursing, 2021) in PSH settings. To conduct the study, USC partnered with a local PSH provider, the Skid Row Housing Trust (“the Trust”). The Trust is a Los Angeles nonprofit organization that provides PSH to promote stable, safe, healthy lives among people who have experienced homelessness, prolonged poverty, poor health, disabilities, mental illness, and/or addiction. The Trust develops, manages, and operates twenty-six apartment buildings as PSH sites for more than 1,800 formerly homeless individuals in Los Angeles (Skid Row Housing Trust, 2021).

The CAPABLE program initially was created for older adults who were returning to independent living after hospitalization. CAPABLE is a home-based program that provides the services of an occupational therapist (approximately six visits), a nurse (approximately four visits), and a handyperson (approximately one to two visits) to clients in their home across six months. Visits are spaced throughout the six-month time period so that older adults are able to practice newly learned strategies, culminating in a “graduation,” by which time the older adult will understand how to use and apply their new skills.

The aims of the PSH + CAPABLE pilot study are two-fold: to evaluate the impact of this combination of services on client outcomes and to identify adaptations needed for successful implementation. The study uses a pre-/post-design (no control group) for the impact evaluation and a Dynamic Adaptation Process implementation approach for the determination of needed modifications (U.S. National Library of Medicine, 2021).

Based on the latest publicly available data, the study plans to enroll 100 tenants of the Trust. Tenants must be ages 50 and older and experiencing difficulty with performing ADL, but have either no or only mild cognitive impairment. Primary outcome measures include change from baseline to one year in ADL, instrumental functioning, falls, frailty or physical functioning, depression, and hand strength.

While this pilot study is ongoing, the original CAPABLE intervention targeting older adults with low incomes, has already shown promising results. These include halving difficulties in function, reducing depression symptoms, improving motivation in older adults, and yielding more than a six-fold return on financial investment (Johns Hopkins School of Nursing, 2021). CAPABLE has been widely adopted by more than twenty-five organizations, including Accountable Care Organizations, PACE programs, a Meals on Wheels agency, and Medicaid waiver programs, and has the potential to be extended to a broader range of organizations.

Model Number Two: PSH + Geriatrics-Focused Services and Care

Founded in 1991, Hearth is a Boston nonprofit organization dedicated to ending homelessness among older adults. Hearth employs a two-part strategy for addressing homelessness in this population: outreach, focused on preventing and addressing homelessness among at-risk and homeless older adults, and provision of PSH for formerly homeless older adults. This article focuses on Hearth’s model of PSH.

Hearth operates five affordable supportive housing sites and one assisted living facility with a total of 174 units (all occupied) in the Greater Boston area and, in the coming year, will add an additional fifty-four PSH units. All residences are wheelchair accessible due to high rates of disability and mobility impairment among residents. An interdisciplinary team—composed of site directors, licensed social workers, registered nurses, resident assistants, and personal care homemakers—works together at each residence to help residents age in place. To address geriatric syndromes and chronic illnesses prevalent in their clients, for example, staff members help coordinate medical appointments and transportation so clients have access to medical care.

Social isolation is addressed by group activities and by offering shared (or common) living spaces; individuals with substance use disorders are supported through on-site substance awareness groups and counseling; and behavioral and mental health issues are addressed by check-ins with social workers and client-centered, personalized plans developed by a team that includes nursing, social work, and substance use counseling staff (Brown et al., 2013a). Preliminary findings from a recent pre-post evaluation of the Hearth housing model impact show that residents living in Hearth housing achieve long-term housing stability and reductions in total medical expenses and healthcare use over time (publication under review).

Model Number Three: PSH + Healthcare

As the population of homeless veterans ages, there is a growing need for geriatrics-focused care in addition to complex medical and psychosocial care. The U.S. Department of Housing and Urban Development–VA Supportive Housing (HUD–VASH) Program provides critical resources for ending homelessness among veterans. However, as the number of homeless older veterans grows, this program should be augmented with geriatrics-focused care to help promote older veterans’ ability to aging in place (Veterans Affairs Office of Health Equity, 2019).

A novel multiagency collaboration led by Dr. Anne Fabiny at the San Francisco VA Medical Center seeks to address this gap. Working with a diverse coalition of partners including the San Francisco VA HUD–VASH program, San Francisco VA Health Care System, Health Plan of San Mateo County, the Public Housing Authority of San Mateo County, Mercy Housing, Brilliant Corners, the Town of Colma, and the Archdiocese of San Francisco, Dr. Fabiny implemented an intensive PSH model for formerly homeless older veterans: The Colma Veterans Village (Veterans Health Administration Office of Health Equity Cyberseminar, 2019).

Importantly, the Colma Veterans Village model fully integrates housing and healthcare for this vulnerable population. The apartment building, sited on a two-acre property, was built by Mercy Housing, a large, national, affordable housing organization working to eliminate housing insecurity and homelessness for people with low incomes. Mercy Housing owns and operates the property, which includes sixty-six units for formerly homeless veterans, thirty-three of which were dedicated for older, frailer, HUD-VASH eligible veterans; all units are Americans With Disabilities Act (ADA) adaptable and 15 percent are ADA accessible.

At this housing site, healthcare is provided by a team of VA clinicians, including a primary care team consisting of a nurse, psychiatric nurse practitioner, and a primary care provider. The standard staffing plan also includes a HUD-VASH social worker and an on-site Resident Service Advisor, while the enhanced staffing plan includes VA-employed social work case managers and peer support specialists (Veterans Health Administration Office of Health Equity Cyberseminar, 2019).

Evaluation of this model is in progress using two approaches. In the first, the team is using a difference-in-difference analysis to compare healthcare use among residents of the Colma Veterans Village to a control group of two HUD-VASH sites that do not have the augmented on-site team-based model; utilization measures include primary care, subspecialty care, emergency department care, and inpatient admissions. In the second approach, the team is using a quality improvement evaluation with a Plan-Do-Study-Act cycle to understand the medical, functional, and social needs of veterans living at Colma Veterans Village and to determine how they are being connected to services.

Model Number Four: PSH + PACE

In 2008, St. Paul’s PACE, which serves older adults with low incomes, became the first nonprofit organization to bring PACE (Program of All-Inclusive Care for the Elderly) to San Diego County. St. Paul’s PACE currently provides PACE services, including medical, social, nutrition, transportation, and home care services, to more than 2,000 low-income older adults in the area (St. Paul's PACE, 2021).

Based on its successful implementation of the PACE program, in 2013 St. Paul’s PACE piloted a new initiative in which PACE was combined with PSH for eleven homeless older adults at one housing site. As the new model proved to be a success, it was gradually expanded to additional housing sites built and funded by community housing organizations such as Bridge Housing (new building with sixty-three dedicated units), Wakeland Housing and Development Corporation (new building with fifty-nine dedicated units), and the San Diego Housing Commission/Housing Development Partners (retrofitted motel with forty-seven dedicated units). As of 2021, more than 200 formerly homeless older adults have been served by this PACE + PSH model (St. Paul's PACE, 2021).

Individuals housed in these settings receive PACE services. PACE is a unique program funded via capitated payments from the Centers for Medicare & Medicaid Services (CMMS). To be eligible to enroll in PACE, individuals must be dually eligible for Medicare and Medicaid, housed, ages 55 and older, living in the service area of a PACE organization, needing nursing home–level care, and being able to live safely in the community with help from PACE. However, the program does not provide or pay for housing. This housing requirement had previously been a barrier for homeless older adults to access PACE services, but, as noted above, St. Paul’s PACE was able to overcome this challenge by forming strategic partnerships: collaborating housing developers provide housing, while St. Paul’s PACE enrolls homeless older adults in, and provides, PACE services.

Access to PACE is crucial in providing geriatrics-focused care for formerly homeless older adults served by St. Paul’s PACE. PACE covers numerous Medicaid and Medicare services, including adult daycare, dentistry emergency services, home care, hospital care, laboratory/X-ray services, meals, medical specialty services, nursing home care, nutritional counseling, occupational therapy, physical therapy, prescription drugs, primary care, recreational therapy, social services, social work counseling, and transportation. The provider team is interdisciplinary, consisting of a dietician, driver, home care liaison, nurse, occupational therapist, PACE center supervisor, personal care attendants, physical therapist, primary care physician, recreational therapist or activity coordinator, and social worker. Teams meet regularly to monitor the status of enrolled adults and ensure that their medical and social needs are met.

This model has the potential for broad replicability, given the widespread accessibility of PACE. As of August 2020, there were 272 PACE centers in thirty-one states. Nationally, the program has a total of 53,000 enrollees with an average age of 77, 85 percent of whom are ages 65 or older. Results indicate that the program leads to improved preventive care, decreased healthcare use (i.e., reductions in emergency room visits, hospital admissions, rehospitalizations, and nursing home admissions), decreased cost to states, and reduced family caregiver burden (National PACE Association, 2020).

Next Steps: Suggestions to Better Address Homelessness Among Older Populations

We know that homeless older adults have unique needs compared to their younger counterparts due to the early onset of aging-related conditions, plus a disproportionate prevalence of substance use disorders and mental health conditions. This population requires targeted solutions. But while PSH provides several benefits for people experiencing homelessness, they are usually not geriatrics-focused, and research suggests that more services are needed to effectively facilitate aging in place. A recent study of formerly homeless older adults living in PSH made three key recommendations to better meet the needs of an increasing homeless older population:

• PSH requires additional support services tailored to the unique needs of homeless older adults, such as occupational therapy to assess home safety, physical therapy consultations for appropriate assistive devices, and substance use counseling;
• PSH staff members need training on recognizing and addressing geriatric conditions; and
• The physical characteristics of PSH housing need to be modified to match older adults’ capacities and needs (Henwood et al., 2019).

The four approaches to integrating health and social care services with PSH described in this article address these recommendations in a number of ways. They vary in their context (e.g., research study versus nonprofit-led initiative), the subset of formerly homeless older adults served (e.g., qualifications such as Veteran status or ability to perform ADL), and intervention design (e.g., incorporating CAPABLE vs. PACE).

However, all have one common feature: they emphasize a person-centered philosophy with housing as the platform. Each approach employs an innovative strategy to adapt permanent supportive housing to better meet the individual capacities and needs of formerly homeless older adults. Each of these models (and others not included in this article) work well in theory and show promise to different degrees. However, more evidence-based research is needed to rigorously evaluate their individual and comparative effectiveness, as well as to inform specific recommendations for how to effectively integrate housing and health so that this population can successfully age in place.

At the same time, it is important to consider the relative importance of individual-level and cost outcomes. As discussed in a recent perspective piece in the New England Journal of Medicine, not only is evidence for cost-savings related to PSH often variable and flawed, but there also are significant issues with imposing a financial lens on the issue of housing interventions: expecting cost savings creates a double standard that does not apply to other health and social services, and a focus on savings could compromise attention to other important metrics of success (Kertesz et al., 2016). A program that achieves its primary objective to provide effective care may be unfairly deemed unsuccessful if no net savings are demonstrated. Thus, even if the model does not achieve neutral cost-savings or better, it still impacts a key person-centered outcome: giving individuals a home and an improved quality of life.

As the number of homeless older adults continues to rise, we must develop and test housing plus care models to meet the unique needs of this population. While PSH research often focuses on younger populations and outcomes primarily based on housing status, several models—including the four detailed in this article—provide novel approaches to interweave housing plus geriatrics-focused care for formerly homeless older adults.

Next steps include evaluating the effectiveness and replicability of these care interventions for impacting person-centered outcomes, which are especially relevant to older adults, including functional status, quality of life, hospitalization, and nursing home admission. By building this evidence base, we will be poised to help the growing population of homeless older adults achieve housing stability and age in place successfully in the coming decades.

Sonia Gupta Pandit, MPH, MBA, is a post-baccalaureate student at the University of Pennsylvania in Philadelphia. She may be contacted at pandits@upenn.edu. Rebecca T. Brown, MD, MPH, is an assistant professor of Medicine at the Perelman School of Medicine of the University of Pennsylvania and an attending physician at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia. She may be contacted at rebecca.brown@pennmedicine.upenn.edu.

References

Baggett, T. P., et al. 2013. “Mortality Among Homeless Adults in Boston: Shifts in Causes of Death Over a 15-year Period.” JAMA Internal Medicine 173(3): 189–95.

Brown, R. T., et al. 2012. “Geriatric Syndromes in Older Homeless Adults.” Journal of General Internal Medicine 27(1): 16–22.

Brown, R. T., et al. 2013a. “Meeting the Housing and Care Needs of Older Homeless Adults: A Permanent Supportive Housing Program Targeting Homeless Elders.” Seniors Housing and Care Journal 21(1): 126–35.

Brown, R. T., et al. 2013b. “Use of Acute Care Services Among Older Homeless Adults.” JAMA Internal Medicine 173(19): 1831–4.

Brown, R. T., et al. 2015. “Health Outcomes of Obtaining Housing Among Older Homeless Adults.” American Journal of Public Health 105(7): 1482–8.

Brown, R., and Kushel, M. 2021. “Effects of Homelessness & Housing Instability on Older Adults.” In L. C. Walter, et al., eds., Current Diagnosis & Treatment Geriatrics, 3e. New York: McGraw-Hill Education.

Centers for Medicare & Medicaid Services. “Program of All-Inclusive Care for the Elderly (PACE).” Retrieved February 1, 2021.

Culhane, D., et al. 2019. “The Emerging Crisis of Aged Homelessness in the US: Could Cost Avoidance in Health Care Fund Housing Solutions?” International Journal of Population Data Science 4(3).

Hahn, J. A., et al. 2006. “Brief Report: The Aging of the Homeless Population: Fourteen-year Trends in San Francisco.” Journal of General Internal Medicine 21(7): 775–8.

Henwood, B. F., et al. 2019. “Geriatric Conditions Among Formerly Homeless Older Adults Living in Permanent Supportive Housing.” Journal of General Internal Medicine 34(6): 802–3.

Hwang, S. W. 2000. “Mortality Among Men Using Homeless Shelters in Toronto, Ontario.” JAMA 283(16): 2152–7.

Johns Hopkins School of Nursing. 2021. “Community Aging in Place–Advancing Better Living for Elders (CAPABLE).” Retrieved February 1, 2021.

Kertesz, S. G., et al. 2016. “Permanent Supportive Housing for Homeless People—Reframing the Debate.” New England Journal of Medicine 375(22): 2115–7.

National Academies of Sciences, Engineering, and Medicine. 2018. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington, DC: National Acadmies Press.

National PACE Association. 2020. “PACE by the numbers.” Retrieved February 1, 2021.

Skid Row Housing Trust. 2021. “Our Buildings.” Retrieved April 15, 2021.

St. Paul's PACE. 2021. “Supportive Housing Partnerships.” Retrieved February 1, 2021.

U.S. National Library of Medicine. 2021. “Implementing CAPABLE.” Retrieved February 1, 2021.

Veterans Affairs Office of Health Equity. 2019. “Addressing the Housing Needs of Homeless Veterans.” Retrieved February 1, 2021.

Veterans Health Administration Office of Health Equity Cyberseminar. 2019. “Addressing the Housing Needs of Homeless Veterans.” Retrieved February 1, 2021.