Older adults over the age of 50 who are homeless are oftentimes an overlooked subpopulation. Nicknamed the “invisible population” by many including the Corporation for Supportive Housing (Healthy Aging in Supportive Housing, 2016), their needs differ from the general population of homeless adults, but the existing delivery system and benefits structure are frequently not set up to meet these needs, resulting in an increased likelihood that these individuals are relegated to institutional settings. However, with the right support, existing supportive housing providers are uniquely positioned to adapt their programs to meet the needs of older homeless individuals, allowing them to age in place within the community and thereby supporting the achievement of the Triple Aim of better care for a lower cost resulting in better overall health.
Unique Needs of Older Homeless Adults
Older adults are more likely to have undiagnosed behavioral health conditions than their younger counterparts. The impact of mental health conditions on older adults can be severe, but some conditions like depression are often disregarded as frailty or as an inevitable result of life changes, chronic illness, and disability (NIMH, Older Adults and Mental Health, 2016). Older adults also respond differently to treatment regimens than their younger counterparts. For example, risks of maladaptive antipsychotic side effects such as strokes, fractures, kidney injury, and mortality are greatly increased for older adults when compared to their younger counterparts (Olfson, M., King, M., & Schoenbaum, M., Antipsychotic Treatment of Adults in the United States, 2015).
This is compounded by the fact that homelessness itself can cause premature aging that leads to significantly lower life expectancies than the general population. Homeless adults aged 50+ have rates of chronic illnesses and geriatric conditions similar to or higher than those of housed adults who are 15 to 20 years older, including conditions often thought to be limited to the elderly, such as falls and memory loss (Goldberg, J., Lang, K., & Barrington, V. How to Prevent and End Homelessness Among Older Adults, 2016). Homeless older adults are also more likely to experience difficulty in activities of daily living, like bathing and dressing, at a younger age than the general population. These types of functional impairments occur in 30% of homeless adults in their 50s and early 60s—a prevalence far exceeding that of housed adults who are 20 years older (Goldberg, J., Lang, K., & Barrington, V. How to Prevent and End Homelessness Among Older Adults, 2016).
Delivery System Gaps
Despite this rapid aging process that results in increased functional, physical, and behavioral health impairments, many programs target “seniors” using eligibility criteria that identifies individuals by chronological age rather than by their needs. While 65 —the dominant age of retirement — is the most widely accepted marker of “old age,” it is deficient for later life homelessness given the fact that trajectories across the life course, not just chronological age, define the experience of aging (Grenier, A., Barken, R., Sussman, T., Rothwell, D., & Lavoie, J., Literature Review, Aging and Homelessness, 2013). For example, while homeless individuals ages 50-64 years are not technically old enough to qualify for Medicare, their physical and behavioral health, assaulted by poor nutrition and severe living conditions, may resemble that of a 70-year-old (National Coalition for the Homeless, Homelessness Among Elderly Persons, 2009).
Supportive housing programs are also experiencing a “graying” tenant population that further calls for changes to the way that quality supportive housing is delivered. Indeed, about 40% of supportive housing tenants nationwide are now over age 50 (CSH, Healthy Aging in Supportive Housing, 2016). Although many of these individuals are aging in place, they often experience the same expedited aging and development of functional deficits as homeless individuals given their former homelessness, resulting in increased placement in nursing homes and the like if supportive housing programs do not have the specialized capacity to meet these needs. Unfortunately, this situation occurs too often, as much of New York’s housing programs are designed primarily for working age adults, lacking necessary accessibility features like grab bars and elevators, as well as a comprehensive array of interdisciplinary staff trained to meet the unique needs of older adults (Liu, J. C., Morales, R., Hoffnung, A., Gold, J. S., Morris, D. R., Bardin, R., & Pak, C. M. Senior Housing in New York City: The Coming Crisis, 2013).
Project Renewal’s Solution
There are a few model programs that have effectively transitioned to serving older homeless adults. Project Renewal, Inc. (PRI) operates one such program. Established in 1967, PRI is a nonprofit whose mission is to end the cycle of homelessness by empowering individuals to renew their lives with health, homes and jobs. With over 800 employees, PRI serves more than 16,000 homeless and unstably housed clients each year across its 39 programs, which include shelters, as well as transitional and permanent supportive housing. PRI is particularly adept at coordinating care for clients with multiple physical and/or behavioral health issues, and, for a subset of their aging permanent housing residents, they developed a pilot program nicknamed “Tools for Aging in Place” (TAP) that is currently being implemented at their largest permanent supportive housing program where 57% of the residents are 55 or older.
The TAP pilot is a replicable model for senior supportive housing that supports homeless older adults at risk of nursing home placement to acquire and sustain stable housing and improve their quality of life as they age. TAP includes senior-accessible apartment modifications and support services provided by an interdisciplinary team consisting of not only traditional health and behavioral health providers, but also occupational therapists, occupational therapy interns, and case aides able to specially address health and social challenges related to aging.
The program, initially funded by the NYS Department of Health, has resulted in clear benefits and improved outcomes for participating older adults, including: Significantly increased engagement in healthcare and psychiatric services; enhanced skill sets related to activities of daily living; and improved program satisfaction, social connectivity, and enjoyment.
Moving Forward
Adequate Financing for and attention to the needs of older homeless adults is critical. Despite the program’s significant positive outcomes, sustainable financing has been a challenge. Today, TAP’s enhanced services are mostly funded through grant funding and other private donations, as many of TAP’s clients fall into the eligibility “donut hole” of not being chronologically old enough to qualify for services designed for older adults 65+ but having equivalent functional deficits that require those services. However, given the program’s success in increasing engagement in community services and keeping older homeless adults in the community out of institutional care, the value of such programs is becoming clear. In order to ensure all homeless and unstably housed individuals have the opportunity to age within community-based settings rather than having to move to an institutional setting because the system is not designed to meet their needs, the TAP program and others like it should be viewed as models for replication by supportive housing providers across the state. And critically, to allow the expansion of such programs, supportive housing funders and stakeholders must recognize that when it comes to homeless adults, chronological age is not the equivalent to functional age; therefore, supportive housing policies and rates must support enhanced services for “older adults” who are younger than the traditional 65 years but are living with significant functional deficits.
To learn more about Project Renewal and its TAP program, visit our website www.projectrenewal.org or contact Susan Dan at susan.dan@projectrenewal.org. To learn more about Health Management Associates and its public sector consulting services, visit www.healthmanagement.com/what-we-do or contact Kristan McIntosh at kmcintosh@healthmanagement.com.
