How Cross-Sector Partnerships Can Develop Solutions for Aging Americans

Milbank State Leadership Network The Health of Aging Populations

Most aging Americans wish to remain in their homes and age in place as long as possible. Yet, there are barriers to aging in place, such as the lack of affordable and accessible housing, access to quality community-based supportive services, and coordination of services. Low-income seniors and seniors who experience housing instability face even more challenges to aging in place as they often receive additional services from multiple uncoordinated systems, only some of which are under state management. Moreover, these challenges disproportionately impact people and communities of color.

For the past 30 years, the supportive housing sector has been working to align systems of financing and practice and develop place-based solutions for the most vulnerable. As a result, lessons for cross-sector partnerships are emerging that federal, state, and local officials can apply to help low-income, older Americans age in place.

The Fundamental Challenge: System Misalignment

Today, most older adults with complex needs face a patchwork of health coverage and services that are difficult to navigate. While Medicare provides coverage for health care services, home- and community-based services (HCBS) are paid for by Medicaid. Other federal aging programs are funded via the Older Americans Act (OAA) and overseen by the Administration for Community Living (ACL), a part of the federal US Department of Health and Human Services (HHS). These programs offer services that meet social and nutritional needs, such as senior centers or Meals on Wheels. ACL also supports community Area Agencies on Aging, called the “Triple As,” the Aging and Disability Resource Centers (ADRCs) and the Centers for Independent Living (CIL). These networks are common entry points for community members and their families to access HCBS and other programs that serve older adults. The federal Department of Housing and Urban Development (HUD) funds multiple programs that may also serve older low- income Americans (see Figure 1).

These state-based aging services systems are not structurally aligned at the national level. Eligibility criteria for programs vary and providers have data systems with limited interoperability. As a result, seniors have to answer the same questions and provide the same documentation at multiple sites. Many systems are moving online, but some seniors, particularly those without family supports have trouble navigating the process and technology. Overall, the burden to coordinate care and services falls on the individual or family.

The community-based agencies also receive funding in a non-coordinated manner, with some funds (Medicare) flowing directly to providers, others (Medicaid, aging) to states and then to providers, and still others (housing) directly from federal to local government or agencies. In addition, the funding agencies do not commonly coordinate with community nonprofit organizations outside their networks.

The Solution: Aligning Systems to Create Place-Based Solutions

Some states are intentionally aligning systems by building cross-sector partnerships that blend funding across sectors, such as housing, health care, and aging, to address the needs of low-income older adults who want to live in the community.

Options for financing include using low-income tax credits for affordable housing or Medicaid waiver funding for home modifications or supportive housing services. State officials are also exploring contract requirements or value-based payment models that require or incentivize managed care to make housing-related investments. HUD has a number of programs focused on senior housing development, including the HUD 202 program, service-enriched housing, and the I-WISH demonstration. The HUD 202 program offers developers funding for both affordable housing and on-site service coordination. Vermont’s Support and Services at Home (SASH) program braids housing funding, such as HUD 202, and services funding, such as state and Medicaid dollars. Research on SASH shows the positive impact of a place-based solution that combines housing and onsite coordination of health and social services on diabetes, high blood pressure, and social isolation.

Lessons from Supportive Housing’s Place-Based Solutions

The following are key lessons for cross-sector solutions based on the supportive housing sector’s experience.

Shared Purpose Matters

Developing a shared purpose — among state health and housing departmental leaders, aging and disability leaders, and sometimes elected officials — is critical to achieving success in cross-sector work. Jointly creating shared goals can include level-setting for all parties, ensuring shared terms and language and developing a purpose statement that can support cross-sector teams through the process.

Timing Matters

Clear deadlines, often set by political leadership, ensure that funding, award cycles. and timelines align with shared expectations. Cross-sector partners often have no idea how long implementing a Medicaid waiver, negotiating a Medicaid managed care organization contract, or housing construction can take.

Developing Joint Processes Matters

Collaborative referral processes, joint metrics, and joint reporting all are critical components of these efforts. State leaders often turn to academic partners or technical assistance firms to help develop these measures. Partnerships flourish when all partners know their strengths, resources, knowledge, and gaps in each area.

State Leaders Matter

State leaders have a variety of essential roles to play in creating and sustaining cross-sector partnerships, including the following:

  • Setting clearly defined priorities. Clearly defined priorities set by political or cross-sector leadership form a touchstone that helps to keep cross-sector teams on course. Examples include helping older adults age in place or decreasing nursing home or congregate care placements due to the impact of COVID -19.
  • Allocating flexible resources. State leaders can make flexible, unallocated resources available as this approach usually works best when states begin a cross-sector process to determine regulations and requirements. Ensuring teams understand the red lines defined by federal funders (e.g., Medicaid will not pay for housing) and locally determined implementation rules are also crucial to success.
  • Engaging in communication activities. Cross-sector efforts need momentum. Celebrating efforts through various communications channels can boost team morale and affirm the importance of their actions.
  • Establishing accountability. State leaders should ask for measures including timelines, process metrics, and projected impact at the start of the process.

Aging and Thriving

Creating cross-sector partnerships and understanding the factors that contribute to their success will be essential to addressing the needs of aging, low-income Americans. States are beginning to analyze their health care and housing data through an equity frame, and those analyses should help drive state leaders to build the cross-sector efforts needed for all Americans to thrive as they age.