Evidence-Based Actions to

Help HUD-Assisted Older

Adults Remain Healthy and

Age in Their Community

Year 2 Report of the Aging in Place Interagency

Agreement between the Department of Housing

and Urban Development (HUD) and the Centers for

Disease Control and Prevention (CDC)

April 2023

Prepared for:

US Department of Housing and Urban Development, Office of Policy Development & Research

Prepared by:

Centers for Disease Control and Prevention, Office of Policy, Performance, and Evaluation

(formerly: Office of the Associate Director for Policy and Strategy)

With the assistance of:

National Network of Public Health Institutes

Georgia Health Policy Center of the Andrew Young School of Policy Studies,

Georgia State University

This project is supported by funding from the Department of Housing and Urban Development

(HUD) to the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health

and Human Services (HHS) through an Interagency Agreement (IAA number 86614621E00002;

Aging in Place Joint Study) totaling $490,000. To complete the work in this report, CDC awarded

financial assistance (NOFO OT18-1802, titled Strengthening Public Health Systems and Services

through National Partnerships to Improve and Protect the Nation’s Health) in the amount of

$485,148 to the National Network of Public Health Institutes. The contents are those of the

author(s) and do not necessarily represent the official views of, nor an endorsement, by HUD,

CDC/HHS, or the U.S. Government.

Acknowledgments

CDC Project Leads: Elizabeth Skillen, PhD, MS; Jennifer Kaminski, PhD

HUD Project Leads: Carol Star, MCP; Jacqueline Bachand, MPH

CDC Project Team: Erin Abramsohn, DrPH, MPH; Samuel Clasp, DrPH, JM, MPH;

Wendy Heaps, MPH; Kai Hong, PhD; Christian Murray, MSc; Andrea Neiman, PhD, MPH;

Richard Puddy, PhD, MPH

National Network of Public Health Institutes Project Team: Leah Ettman, MS, MPH;

Adam Lustig, MS; Ayanna Woolfork, MPH

Georgia Health Policy Center Project Team: Savita Archer, MPH; Fiona Bock, MPH;

James Dills, MUP, MPH; Kristi Fuller, MSW; Glenn Landers, ScD, MHA, MBA; Alyssa Lowe, MPH; Audrey

Price, MPH; Taylor Williams, MPH

CDC Subject Matter Experts: Gwen Bergen, PhD, MPH; David Brown, PhD; Heather Devlin, MA; Christopher

Earl, MPH; Marissa Esser, PhD, MPH; Shannon Griffin-Blake, PhD; Janelle Gore;

Jeff Hall, PhD, MSPH; Christopher Holliday, PhD, MPH; Katherine Irani, MPH, MSW;

Eva Jeffers, MPH; Robin Lee, PhD, MPH; Lisa McGuire, PhD; Ken Rose, MPA; Ayla Schermer, MURP; Patricia Schumacher, MS; Holly Williams

Other Federal Experts: Lori Gerhard (Administration for Community Living); Emily Rosenoff, MPH (Office of the Assistance Secretary for Planning and Evaluation)

TABLE OF CONTENTS

EXECUTIVE SUMMARY .......................................................................................................................................................................................................ii

Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community............2

Context for the Evidence Review ........................................................................................................................................................................................2

Older Adults, Poverty, & Health ........................................................................................................................................................................................................ 3

HUD-Assisted Older Adult Population and Services .................................................................................................................................................... 3

Project-based programs ......................................................................................................................................................................................................................... 3

Tenant-based program ............................................................................................................................................................................................................................. 3

METHODS ....................................................................................................................................................................................................................................6

Literature Review and Environmental Scan ..........................................................................................................................................................................6

Review of Systematic Evidence Reviews ...............................................................................................................................................................................6

Interviews with CDC Subject Matter Experts ......................................................................................................................................................................6

Older Adult Health Data Analysis: Identifying Health Condition Predictors of Housing Transitions ............................... 7

RESULTS .......................................................................................................................................................................................................................................8

Literature Review and Environmental Scan .......................................................................................................................................................................... 8

Review of Systematic Evidence Reviews ................................................................................................................................................................................. 8

SME Insights about the Interventions with Systematic Review Evidence ...............................................................................................12

Older Adult Health Data Analysis: Identifying Health Condition Predictors of Housing Transitions ............................. 13

Synthesis of Results from the Four Methods: Avenues for Potential Evidence-Based Action ............................................ 13

DISCUSSION ............................................................................................................................................................................................................................16

Avenues for Potential Action to Improve the Health of Older Adults Served by HUD Programs .....................................16

CONCLUSIONS .......................................................................................................................................................................................................................18

REFERENCES ..........................................................................................................................................................................................................................19

APPENDIX ................................................................................................................................................................................................................................20

APPENDIX A. STATEMENT OF WORK: AGING IN PLACE JOINT STUDY WITH HHS ..................................................................21

APPENDIX B. CDC SUBJECT MATTER EXPERTS SEMI-STRUCTURED INTERVIEW GUIDE ................................................. 23

APPENDIX C. CDC SUBJECT MATTER EXPERTs INTERVIEWED ........................................................................................................... 25

APPENDIX D. CDC SUBJECT MATTER EXPERT INTERVIEW SUMMARY .........................................................................................26

GLOSSARY OF ACRONYMS ...........................................................................................................................................................................................31

EXECUTIVE SUMMARY

CONTEXT AND BACKGROUND

METHODS

In April 2021, the Department of Housing and Urban

We used four methods of inquiry to characterize and

Development (HUD) and the Centers for Disease

understand the evidence from published intervention

for Control and Prevention’s (CDC) Office of Policy,

literature, systematic reviews, CDC subject matter expert

Performance, and Evaluation (OPPE; then known as the

(SME) interviews, and health data on older adults.

Office of the Associate Director for Policy and Strategy,

Through consideration of the intervention evidence,

OADPS) established a 5-year interagency agreement

the health risk evidence, and subject matter expertise,

(IAA) to build a collaborative relationship to leverage

we identified four avenues for potential evidence-

opportunities and resources in support of shared

based actions: (A) Physical Housing Standards and/or

agency goals and priorities related to aging in place.

Enhancements, (B) Healthcare System Interventions and

The primary aim of the IAA period of performance is

Partnership Opportunities, (C) Programs and Services

to identify sustainable, evidence-informed approaches

HUD Could Offer or Partner to Provide, (D) Existing

for affordable senior housing programs that coordinate

Community Characteristics and Services. Each avenue

health, wellness, and supportive services to help older

contained between two and nine specific evidence-based

adults (defined for the purpose of this IAA as adults

interventions.

aged 62 years and older) remain healthy, age in their

community, and reduce their use of costly health care

CONTEXTUAL CONSIDERATIONS

services. This report details the context, methods, and

Given the diversity of health factors that likely

results of the first two years of the IAA, on the period

contribute to aging in place, multiple interventions

from April 2021 to April 2023.

or avenues may be needed to support HUD’s priority

Annually, HUD serves approximately 9 million individuals,

for this population. SMEs noted the importance of

close to 1.8 million of whom are older adults. In 2022,

considering:

40% of the 4.5 million households who received an

y

Gaps in the available evidence and opportunities

annual subsidy from HUD had a head of household, co-

for future research,

head, or spouse who was aged 62 years or older. Older

y

The potential for “multisolving” interventions

adults with low income reside in all of HUD’s subsidy

that could address multiple health issues,

programs, which serve the same basic function of

y

Potential innovations in identification and

providing a monthly subsidy to make housing affordable

amelioration of risk and connection to the health

to extremely low-income households. HUD’s primary

system,

subsidy programs include: (1) the Housing Choice

y

Barriers to program participation, such as

Voucher Program, (2) Public Housing Program and

perceived value, transportation, affordability, the

(3) the Multifamily Housing Program. Past and current

“digital divide,” and the perception that some

HUD-assisted programs that specifically aim to support

older adult health issues are not preventable,

older adults with very low household income include, but

y

Critical implementation supports (e.g., training

are not limited to, the Section 202 Supportive Housing

and technical assistance) to support fidelity,

for the Elderly Program, the HUD Service Coordinator

y

The possible impact on health equity and

Program, the Assisted Living Conversion Program, and

unintended consequences of interventions, and

the Older Adult Homes Modification Program.

y

Other local, state, and federal agency

HUD is committed to developing innovative strategies

partnerships to support implementation and

to provide older adults who have very low income with

sustainability.

stable, affordable housing that enables them to remain

in their homes as they age. To support this goal, CDC

KEY FINDINGS: AVENUES FOR

partnered with the National Network of Public Health

POTENTIAL EVIDENCE-BASED

Institutes (NNPHI) and the Georgia Health Policy Center

(GHPC) in Georgia State University’s Andrew Young

ACTION TO IMPROVE THE HEALTH

School of Public Health to identify evidence-informed

OF OLDER ADULTS SERVED BY

policies and practices related to aging in place, and

HUD PROGRAMS

offer guidance about what is most needed, relevant, and

immediate for HUD-assisted older adult tenants at

The two avenues with the strongest published and

this time.

contextual evidence to support their consideration for

possible action by HUD and partners from the health

system, communities, and other federal agencies are:

ii | Executive Summary

´ Healthcare System Interventions and Partnership

Opportunities for management of existing chronic

health conditions among older adults and reduce

risk for falls, and

´ Programs and Services HUD Could Offer or Partner

to Provide to promote health and reduce the risk of

chronic physical and mental health conditions that

contribute to transitions out of independent living.

Among the identified Healthcare System Interventions

and Partnership Opportunities, the specific interventions

with systematic review evidence on key health outcomes

to support older adults’ aging in place were:

´ Case-managed Care for Community-Dwelling

Frail Elders or Integrated Long-term Care for

Community-dwelling Frail Elders, Chronic Disease

Management Programs,

´ Risk Assessments & Personalized Approaches

to Fall Prevention among Older Adults or Multi-

component Fall Prevention Interventions for Older

Adults,

´ Team-based Care to Improve Blood Pressure

Control, and

´ Home-Based Depression Care Management.

Of the identified Programs and Services HUD Could

Offer or Partner to Provide for HUD Residents, the

specific interventions had systematic review evidence

on key health outcomes to support older adults’ aging in

place were:

´ Service-enriched Housing,

´ Interventions Engaging Community Health Workers

or Combined Diet and Physical Activity Promotion

Programs to Prevent Type 2 Diabetes Among

People at Increased Risk, and

´ Activity Programs for Older Adults.

The other two avenues for potential action (Physical

Housing Standards and/or Enhancements, and Existing

Community Characteristics and Services) appear to have

less potential for effectiveness based on current evidence.

Further research or exploration might be valuable to

identify which specific physical standards, enhancements,

or characteristics of housing and communities support

aging in place among older adults.

Evidence-Based Actions to

Help HUD-Assisted Older

Adults Remain Healthy and

Age in Their Community

Context for the Evidence Review

In April 2021, the Department of Housing and Urban Development (HUD) and the Centers for

Disease Control and Prevention’s (CDC) Office of Policy, Performance, and Evaluation (OPPE; then

known as the Office of the Associate Director for Policy and Strategy, OADPS) established a 5-year

interagency agreement (IAA) to build a collaborative relationship to leverage opportunities and

resources in support of shared agency goals and priorities related to aging in place. The primary

aim of the IAA period of performance is to identify sustainable, evidence-informed approaches

for affordable senior housing programs that coordinate health, wellness, and supportive services

to help older adults (i.e., adults aged 62 years and older) remain healthy, age in their community,

and reduce their use of costly health care services. The broader vision beyond the IAA is an

ongoing, collaborative partnership between HUD, CDC, and other agencies to intentionally advance

shared priorities related to health and housing. More information about the Purpose, Tasks, and

Deliverables of the IAA are provided in Appendix A.

.The specific goals set forth in the IAA were to:

• Identify evidence-informed policies and practices related to aging in place.

• Narrow the scope to what is needed, relevant and immediate for HUD-assisted tenants

at this time.

• Convene HHS and HUD partners to explore opportunities to align the array of existing HHS

collaborations and investments to increase access to community and clinical services for

wellness and care coordination for low-income older adult populations.

• Convene Department of Health and Human Services (HHS) and HUD to jointly assess

learnings from environmental scans, convening, and interim findings from the Integrated

Wellness in Supported Housing (IWISH) demonstration to inform future directions for scaling

aging-in-place models in HUD-assisted housing.

• Inform the design, research questions, and evaluation for HUD to develop, implement, and

evaluate pilot tests based on research design in HUD sites; and

• Identify appropriate ways to scale-up evidence-informed policies and practices to improve

the health of the nation’s low-income population.

The focus of the HUD-CDC collaboration begins with, but will not be limited to, the nation’s older

adult population. This report details the context, methods, and results of the first two years of

this agreement (from April 2021 to April 2023) in service of the first two goals of the IAA: identify

evidence-informed policies and practices related to aging in place; and narrow the scope to what is

needed, relevant, and immediate for HUD-assisted tenants.

OLDER ADULTS, POVERTY, & HEALTH

Housing programs, such as Project Based Section 8,

Section 811, and Section 202. In HUD’s sole tenant-based

Nearly 56 million people aged 65 and over live in the

housing program, the Housing Choice Voucher program,

U.S., representing almost 17% of the total population

the subsidy is tied to the household. The Housing Choice

in 2021 (US Census Bureau, n.d.). This proportion is

Voucher program is thus unique to the other HUD

expected to grow to over 21% by 2040 (Administration

programs in that Housing Choice Voucher households

for Community Living (ACL), 2021). While the poverty

can enter the private housing market and have a greater

rate within this group declined in the past fifty years,

choice in terms of the unit they select

the number of older adults experiencing poverty

to rent.

increased, growing from 3.1 million to 5.8 million since

1974 (Congressional Research Service, 2022). Among

Project-based programs

older adults, people living alone faced higher rates of

´ The Public Housing Program provides decent and poverty than those living with families; Hispanic and

safe rental housing for eligible low-income families,

African American women who lived alone saw the

the elderly, and persons with disabilities.

highest poverty rates among older adults (ACL, 2021).

The distribution of poverty varies by geography as well.

´ The Multifamily Housing Program facilitates the In 2018, the Kaiser Family Foundation reported on the

construction, substantial rehabilitation, purchase,

percent of people aged 65 years and older in each of the

and refinancing of multifamily properties and

50 US states and Washington, D.C.; percentages ranged

administers subsidized housing programs that

from 5.9% to 15.5% based on the official poverty measure,

provide rental assistance to low-income families,

and from 6.9% to 27.3% based on the supplemental

the elderly, and those with disabilities, as well as

poverty measure (Cubanski et al., 2018). As with other

the preservation and recapitalization of assisted

age groups, older individuals with lower incomes are at

affordable housing.

higher risk for functional limitations, compared to those

Tenant-based program

with higher incomes (Minkler et al., 2006).

´ The Housing Choice Voucher Program allows

HOUSING AND HEALTH

families with very low income to choose and lease

or purchase safe, decent, and affordable privately

A 2018 Health Affairs policy brief provided an overview

owned rental housing.

of the literature on housing and health (Taylor, 2018),

The populations of interest specified in the IAA are older

concluding that strong evidence exists for the effects

adult populations with very low income served by HUD

of housing on health outcomes and health care costs.

residing in multifamily or single-family housing, whether

Four pathways were characterized connecting housing

private market or federally subsidized. According to data

and health. The Stability pathway is based on evidence

from HUD administrative databases (Public and Indian

showing the detrimental health outcomes of not having

Housing (PIH) Information Center (PIC) and the Tenant

stable housing (and thus the health benefits of having

Rental Assistance Certification System (TRACS)), HUD

stable housing). The Affordability pathway describes the

provided annual rental assistance to 1.8 million older

impact of housing on health in the context of a family’s

adult households in 2022. Almost half (47%) of these

income needing to cover housing costs and other

households have one or more heads of household with

health promoting and healthcare expenditures – thus,

a disability, and 3.1% of households contain one or more

when a family has to spend more for adequate housing,

other members who have a disability. The percentage

less household income is available for other needs.

of HUD households with a head of household, co-head,

HUD’s primary mission of providing affordable housing

or spouse who was aged 62 years or older has risen

addresses both of those pathways directly. The remaining

over time, from 33% in 1996 to 40% in 2022. Forty-three

two pathways involve safety and quality of housing and

percent of HUD older adult households in 2022 had been

the neighborhood in which people live. Evidence for

in HUD-assisted housing for more than 10 years. The

interventions in both of those pathways are considered

median income for older adult residents in 2022

in this review, in addition to the contributions of health-

was $11,964.

specific interventions.

For the purposes of this report, HUD-assisted programs

HUD-ASSISTED OLDER ADULT

for older adults with very low household income include

POPULATION AND SERVICES

a varied set of programs that fall mainly within HUD’s

Multifamily Housing Programs and the Office of Healthy

HUD programs can be broadly classified into two

Homes and Lead Hazard Control. Specific programs

categories: project-based and tenant-based housing. In

include, but are not limited to:

project-based housing, the subsidy is tied to a physical

unit. HUD programs that are project-based include the

public housing program and a variety of Multifamily

Page 3

Multifamily Housing Programs

this study reported their health as either fair

or poor, a proportion considerably higher than

´ Section 202 Supportive Housing for the Elderly

among unassisted renters with low income and the

Program, which provides capital advances general adult population. The majority of HUD-to finance the construction, rehabilitation, or

assisted adults represented by these data were

acquisition with or without rehabilitation of

overweight or obese and more than one-half of

structures that will serve as supportive housing for

them lived with a disability at the time of their

very low-income elderly persons, including the frail

health interview. Relative to unassisted renters

elderly, and provides rent subsidies for the projects

with low income and the general adult population,

to help make them affordable

HUD-assisted adults reported greater prevalence

´ HUD Service Coordinator Program, which

for all included 10 health conditions and diagnoses,

provides funding for the employment of Service

including serious chronic ailments such as heart

Coordinators (i.e., a social service staff person

disease, diabetes, and asthma.

hired or contracted by the owner or management

´ Picture of Housing and Health: Medicare and

company) in insured and assisted Multifamily

Medicaid Use among Older Adults in HUD-

Housing designed for the elderly and persons

Assisted Housing presented analyses of linked with disabilities

administrative records from HUD older adult

´ Assisted Living Conversion Program, which

assisted housing and data from Medicare/

provides private, nonprofit owners of eligible

Medicaid claims in 12 jurisdictions across the

developments with a grant to convert some or all

country in 2008. HUD-assisted Medicare/Medicaid

of the dwelling units in the project into an Assisted

Enrollees (MMEs) in this analysis had more chronic

Living Facility or Service-Enriched Housing for

conditions (55% of HUD-assisted MMEs had 5

elderly residents aging in place; this program

or more compared to 43% of unassisted MMEs),

is not currently funded to support new awards,

which translated into higher health care utilization

but previously funded projects continue to serve

and costs than unassisted MMEs in the community.

current residents

HUD’s priority for the approximately 1.8 million

Office of Healthy Homes and Lead Hazard Control

older adults they serve annually is to provide stable,

affordable housing that enables individuals to remain

´ Older Adult Homes Modification Program, which

in their homes as they age. Based on this priority, HUD

assists experienced nonprofit organizations,

seeks to focus on preventing transitions out of the

state and local governments, and public housing

community setting and into institutional settings. To

authorities in undertaking comprehensive

support this priority, CDC partnered with the National

programs that make safety and functional home

Network of Public Health Institutes (NNPHI) and the

modifications and limited repairs to meet the

Georgia Health Policy Center (GHPC) in Georgia State

needs of low-income elderly homeowners

University’s Andrew Young School of Policy Studies

HUD publications have documented the health

to identify evidence-informed policies and practices

challenges faced by the older adult population served.

related to aging in place, and offer guidance about

For example:

what is most needed, relevant, and immediate for HUD-

assisted older adult tenants at this time.

´ A Health Picture of HUD-Assisted Adults, 2006

–2012 was an analysis of linked administrative records from HUD adult and older-adult assisted

housing and data from the National Center for

Health Statistics’ National Health Interview Survey.

More than one-third of HUD-assisted adults in

Page 4 | Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community

Page 5

METHODS

We used four separate methods of inquiry (Figure 1) in

reviewing websites that provide recommendations

service of identifying evidence-based actions that HUD

pertaining to evidence-based health promotion

and partners could take to address the most critical

interventions. NCOA’s Evidence-Based Program search

health threats to older adult residents’ ability to remain in

tool and ACL’s Aging and Disability Evidence-Based

their communities as they age. These four methods were

Programs and Practices initiative provide listings of

pursued sequentially, with the results of each informing

specific evidence-based intervention programs. The

the next stage.

Community Preventive Services Task Force (“Community

Guide”) and County Health Rankings & Roadmaps

LITERATURE REVIEW AND

(CHR&R) What Works for Health from the University of

ENVIRONMENTAL SCAN

Wisconsin Population Health Institute provide results of

systematic reviews of broader categories of intervention

The first method of inquiry was intended to identify the

approaches. We identified for inclusion the interventions

available evidence for effective programs, policies, and

that directly address or could support aging in place in a

practices that support healthy aging in place. GHPC

community-based setting, align with HUD’s mission, and first conducted a broad literature review using search

target adults. In many cases, the intervention programs

terms related to housing, aging, and health. The search

listed on the NCOA and ACL registries were examples

was restricted to English-language articles published in

that would be subsumed in the broader intervention

the past ten years on US-focused studies. The searches

categories reviewed in the Community Guide and CHR&R

were conducted in PubMed, AgeLine, Web of Science,

reviews. In total, we reviewed 31 broad intervention

ProQuest Social Services, and Google Scholar, and

categories and 8 other specific intervention programs.

resulted in 179 unique articles. Relevant interventions

From the relevant programs and approaches, the project

published outside of scientific journals were also

team extracted narrative information regarding the level

identified by an environmental scan of key websites,

of evidence, the population served, and the documented

including CDC, HHS, HUD, the National Council on Aging

health outcomes.

(NCOA), Administration for Community Living (ACL),

and the Aging and Disability Business Institute (ADBI).

INTERVIEWS WITH CDC SUBJECT

From the set of retrieved published and unpublished

MATTER EXPERTS

sources, a total of 147 interventions relevant to older

adult health were identified. The project team extracted

As a third method of inquiry, GHPC conducted subject

narrative information on each intervention, including

matter expert (SME) interviews to elicit contextual and

descriptions of the intervention, population, type of

implementation expertise, identify gaps in the evidence,

intervention, and tested health outcomes.

and identify emerging evidence and opportunities for

innovation. Prior to the interviews, SMEs were provided

REVIEW OF SYSTEMATIC

with background information regarding the IAA and a

EVIDENCE REVIEWS

spreadsheet of information regarding the interventions

with a high level of systematic review evidence pertaining

To complement information from the environmental

to their areas of expertise. The full interview guide is

scan and identify the interventions with the most robust

presented in Appendix B. Semi-structured interviews

evidence base, the second method of inquiry involved

were one hour each in length, conducted via Zoom by an

Figure 1. Four Methods of Inquiry to Inform Evidence-

Based Actions to Improve the Health of HUD-Assisted

Older Adults

Page 6 | Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community

experienced facilitator from the GHPC. Staff from NNPHI

analyses of this type based on data from the 1992-

and CDC attended the interviews as schedules allowed.

1998 waves of the Medicare Current Beneficiary Survey

A total of nine interviews were conducted with CDC

(MCBS), which is a multi-stage probability sample from

SMEs between April 2022 and January 2023. In addition,

107 sampling units representing the 50 U.S. states, the

one SME’s Division submitted comments via email in

District of Columbia, and Puerto Rico. More information

response to the discussion guide. The list of SME topics

about the MCBS can be found elsewhere (Centers for

and names are provided in Appendix C.

Medicare & Medicaid Services (CMS), 2021). The sample

Six members of the GHPC team, including the facilitator,

is constructed to represent the entire beneficiary

participated in data analysis. All interviews were

population and the populations in each of seven age

recorded with permission from the interview participants,

groups. The analyses of greatest relevance for our project

submitted to a third-party transcription service, coded

were the multivariate analyses predicting transitions out

following published approaches for qualitative data

of independent living from respondent health conditions;

(DeCuir-Gunby et al., 2011; Marshall & McCulloch, 2011;

results were presented separately in that report for

Lincoln & Guba, 1985; MacQueen, et al., 1998; Ryan

transitions into nursing homes and transitions into other

& Bernard, 2003), and analyzed using the software

assisted living facilities.

package NVivo 12 (Lumivero, 2017). When seven of the

We sought to conduct similar analyses using more recent

interviews were complete, a member of the analysis team

MCBS data (2015–2019), with two changes. We analyzed

drafted an initial set of data-driven codes drawn from

risk for any transition out of independent living (i.e., to

the transcripts and shared the information with the team

nursing home or assisted living), and we included only

for feedback. Through conversations among the analysis

participants who were dually eligible for Medicare and

team, the initial codes and definitions were edited, and

Medicaid to more closely resemble the HUD-assisted

additional structural codes were added. Using the a priori

population. As in Waidmann and Thomas (2003), we

codes, the analysis team coded one interview transcript.

included the following health condition variables in the

The analysis team met to review areas with lower levels

multivariate model: Alzheimer’s disease, broken hip,

of agreement (based on an NVivo coding comparison

cancer, diabetes, emphysema, heart disease (including

query) and identify areas for codebook revision.

myocardial infarction, angina pectoris, or any other heart

conditions), “mental retardation,” osteoarthritis (non-

Each interview transcript and the written comments

rheumatoid arthritis), paralysis, Parkinson’s disease,

were then reviewed and independently coded by two

psychiatric/mental disorders, rheumatoid arthritis, and

members of the analysis team. The GHPC team met to

stroke. We calculated the percent of individuals in the

discuss the key research questions, ideas for the next

dual-eligibility sample with each condition, to estimate

steps in the analysis, and feedback regarding draft cross-

how many dually eligible adults are affected by each

cutting themes. Two team members divided the research

condition. We also used a Cox proportional hazards

questions and determined initial codes for reviewing

model to estimate risk of transition into a nursing home

themes and completed the analysis with the support

or assisted living facility of each condition, holding

of two additional team members. The themes were

other variables in the model constant (including other

collaboratively developed by the four team members

health conditions, age, gender, race/ethnicity, income,

using a digital form of the cutting and sorting technique

education, family structure, US region, rurality, and

(Lincoln & Guba, 1985; Ryan & Bernard, 2003). The

numbers of Activities of Daily Living, Instrumental

themes were organized, summarized, and presented

Activities of Daily Living, and Functional Limits). To

with selected key research questions framing the

guide our decision-making, we focused on health

results section.

conditions with resultant hazard ratios ≥ 1.20 (i.e., a

20% increase in risk of transition associated with having

OLDER ADULT HEALTH DATA

that condition) as potentially meaningful contributors

ANALYSIS: IDENTIFYING HEALTH

to our deliberations. Because hazard ratios do not take

CONDITION PREDICTORS OF

into account the underlying population prevalence of a

HOUSING TRANSITIONS

condition, we used hazard ratios and prevalence of the

health conditions in the sample to inform prioritization

To provide additional information for using in prioritizing

of interventions.

potential actions, CDC sought to identify significant

health condition predictors of transitioning from

independent living to assisted living, as a fourth method

of inquiry. Waidmann and Thomas (2003) reported

Page 7

RESULTS

LITERATURE REVIEW AND

ENVIRONMENTAL SCAN

Our review and discussion of the extracted data from

the first method of inquiry, the literature search and

environmental scan, revealed that although there are

interventions specifically intended to support older

adults with low income as they age in the community

(e.g., HUD’s Integrated Wellness in Supportive Housing

(IWISH) demonstration), there is also a sizable literature on interventions that may improve health or prevent

impairment in older adults such that they can live

independently longer. However, that literature comprises

a wide range of intervention types, populations studied,

and health outcomes for which the interventions show

efficacy or effectiveness. For example, some interventions

focus on very specific populations and health outcomes

(e.g., glycemic index among individuals with Type 2

diabetes), while others aim to influence more distal

outcomes in a larger population (e.g., availability of

fruits and vegetables in the community). This variability

limits comparisons or prioritizations across the 147

intervention studies identified in the literature search and

environmental scan.

REVIEW OF SYSTEMATIC

EVIDENCE REVIEWS

In absence of adequate time and resources to conduct

an empirical meta-analysis of intervention effects

(which would allow for comparison of a wide range of

outcomes), we progressed to our second method of

inquiry and examined findings from the four existing

evidence-based review websites: Community Guide,

CHR&R, ACL, and NCOA. Two of those four review

rubrics assign a level of evidence label to intervention

approaches, based on the quality of available research

and strength of outcomes. As we sought to identify

evidence-based approaches, we considered only relevant

interventions that were rated in the top two tiers of

evidence: Recommended (strong) or Recommended

(sufficient) by Community Guide, or Scientifically

Supported or Some Evidence by CHR&R. This filtering

resulted in 24 broad categories of interventions with

sufficient/some or strong evidence pertinent to the

health of older adults. However, this shorter list of 24

interventions with systematic review evidence still

reflected a variety of interventions, populations, and

health outcomes (Tables 1a and 1b). We thus sought

additional implementation and contextual information to

guide decision-making.

Page 8

Table 1a. Interventions Relevant to Older Adult Health with Systematic Review Evidence Rated “Recommended (Strong Evidence)” by Community Guide or “Scientifically Supported”

Intervention and Link to

Intervention Type

Evaluated

Evaluation Outcomes

Evidence Summary

and Description

Population

Activity Programs for

Programs offer educational, social,

Older adults

Health outcomes

Older Adults

creative, musical, or physical activities in

Mental health Isolation

group settings that encourage personal

Quality of life

interactions, regular attendance, and

community involvement

Alcohol Brief Interventions

Health care providers, trained counselors,

Adolescents

Alcohol use

social workers or others provides

and adults

Excessive drinking

information and increases motivation to

Underage drinking

change or prevent problematic alcohol

Alcohol-related harms

consumption through screening, feedback

on clients’ behavior, and advice and decision-

making support

Case-managed Care for

Health professionals, often nurses, manage

Older adults

Nursing home use

Community-Dwelling

multiple aspects of patients’ long-term care,

with complex

Hospital utilization

Frail Elders

including status assessment, monitoring,

health needs

Day-to-day functioning

advocacy, care planning, and linkage

to services, as well as transmission of

information to and between care providers

Chronic Disease

Multi-component efforts that include

Adults with

Quality of life

Management Programs

planned health care visits to teach patients

chronic health Health outcomes

about their disease, coach them on healthy

conditions

Mental health

behavior change including medication

Hospital utilization

adherence, and skills for self-management

of chronic conditions in partnership with a

coordinated, multidisciplinary care team

Combined Diet and

Trained providers in clinical or community

People at

New-onset diabetes

Physical Activity Promotion settings work directly with program increased

Overweight

Programs to Prevent Type 2 participants for at least 3 months through risk of type 2

High blood glucose

Diabetes Among People at counseling, coaching, and extended support diabetes High blood pressure

Increased Risk

related to diet and physical activity

Abnormal lipid profile

Complete Streets &

Improvements to streetscape design,

Communities

Physical activity

Streetscape

including increased street lighting,

Pedestrian and cyclist

enhanced street landscaping and street

safety

furniture, increased sidewalk coverage

and connectivity of pedestrian walkways,

bicycling infrastructure, street crossing safety

features, and traffic calming measures

Creation of or Enhanced

Changing the local environment to create

Communities

Physical activity

Access to Places for

opportunities for physical activity, such as

Physical fitness

Physical Activity Combined creating walking trails, building exercise

with Informational

facilities, or providing access to existing

Outreach Activities and

nearby facilities

Places for Physical Activity

Health Insurance

Assistance in completing and submitting

Communities

Health insurance

Enrollment Outreach

insurance applications to individuals whose

coverage

and Support

employers do not offer affordable coverage,

who are self-employed, or unemployed with

health insurance needs

Page 9

Intervention and Link to

Intervention Type

Evaluated

Evaluation Outcomes

Evidence Summary

and Description

Population

Healthy Home Environment Home visitors, often community health workers Families Exposure to allergens

Assessments

(CHWs), similarly trained asthma outreach

affected by

Hospital utilization

workers, other professionals, paraprofessionals, asthma

Health outcomes

or volunteers assess and remediate

environmental health risks within the home

Home Visits to Increase

Home visitors assess clients’ vaccination

Adults and

Vaccination rates

Vaccination Rates

status, discuss the importance of

children

recommended vaccinations, and either

provide vaccinations to clients in their homes

or refer them to other services

Home-Based Depression

Trained depression care managers conduct

Older adults

Short-term depression

Care Management

active screening for depression, case

outcomes

management, and treatment supervised by a

psychiatrist

Housing Rehabilitation

Providing funding to repair, improve, or

Families

Housing conditions

Loan & Grant Programs

modernize dwellings, and remove health or

with low

Health outcomes

safety hazards from those dwellings

and medium

Mental health

incomes

Integrated Long-term Care A multidisciplinary team of professionals Older adults

Hospital utilization

for Community-dwelling

working collaboratively to meet the full range with complex

Day-to-day functioning

Frail Elders

of patient needs

health needs

Nursing home use

Caregiver satisfaction

Individually-Adapted

Programs that teach behavioral skills such as Adults and

Physical activity

Physical Activity Behavior

goal-setting and self-monitoring of progress, children

Physical fitness

Change Programs and

building social support for new behaviors,

Individually-Adapted

behavioral self-reinforcement, structured

Physical Activity Programs

problem solving to maintain behavior change

and prevention of relapse into sedentary

behavior

Interventions Engaging

Community health workers (including

Adults at

Blood pressure

Community Health

promotores de salud, community health

increased

Cholesterol levels

Workers*

representatives, community health advisors,

risk for

Physical activity,

and others) serve as a bridge between

cardiovascular Healthful eating habits

underserved communities and healthcare

disease, type

Smoking cessation

systems by providing culturally appropriate

2 diabetes;

Glycemic control

Lipid control

education, offering social support and

Adults

Healthcare use

informal counseling, connecting people

with type 2

Weight-related outcomes

with services, conducting blood pressure

diabetes

Colorectal screening

screening, and referring to healthcare for

Breast cancer screening

other screenings

Cervical cancer screening

Mixed-use Development

Mixed-use development supports a

Communities

Physical activity

combination of land uses, creating

communities with high densities that

incorporate places to work, shop, or play

within residential areas.

Multi-component Fall

Health care providers, such as primary care

Older adults

Falls

Prevention Interventions

physicians and physical therapists, deliver a

for Older Adults

fixed, multi-component set of fall prevention

interventions to older adults living in

community settings

Page 10 | Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community

Intervention and Link to

Intervention Type

Evaluated

Evaluation Outcomes

Evidence Summary

and Description

Population

Risk Assessments &

Health professionals such as registered

Older adults

Falls

Personalized Approaches

nurses or physicians conduct functional,

to Fall Prevention among

balance, gait, and/or exercise assessments

Older Adults

and provide multi-component interventions

designed to reduce their fall risk (e.g.,

balance, strength, and endurance training;

home or environmental modification;

medication management; education; and/or

vitamin D supplementation)

Team-based Care to

Multi-disciplinary care team provide

Adults with

Systolic and diastolic

Improve Blood Pressure

process support and share responsibilities

high blood

blood pressure

Control

of blood pressure control to complement

pressure

the activities of the primary care provider,

including medication management,

patient follow-up, and adherence and self-

management support

Table 1b. Interventions Relevant to Older Adult Health with Systematic Review Evidence Rated “Recommended (sufficient evidence)”

by Community Guide or “Some Evidence” by CHR&R

Intervention and Link to

Intervention Type

Evaluated

Evaluation Outcomes

Evidence Summary

and Description

Population

Community-based Digital

Websites, mobile apps, text messages,

Adults

Healthy eating

Health and Telephone

emails, or one-on-one telephone calls

Physical activity

Interventions to Increase

provide interventions such as coaching,

Healthy Eating and

counseling, self-monitoring, goal setting,

Physical Activity

social support, educational tools and

resources, motivation strategies, and

computer-generated feedback.

Home-delivered and

Home-delivered meal services or congregate Older

Malnutrition

Congregate Meal Services

meal services provided in group settings,

adults living

for Older Adults

such as senior centers, that give older adults independently

the opportunity to socialize

Intensive Lifestyle

Ongoing counseling, coaching, or

Adults

Glycemic control

Interventions for Patients

individualized guidance to patients to help

with type 2

Risk factors for

with Type 2 Diabetes

them change their diet, level of physical

diabetes

cardiovascular disease

activity, or both

Physical Activity: Digital

Web-based coaching, telephone sessions

Older adults

Physical activity

Health Interventions for

with intervention providers, automated

Adults 55 Years and Older

messages and reminders, print materials,

and/or apps deliver guidance and support

that is tailored to individuals’ activity level,

age, and health status

Service-enriched Housing

Permanent, basic rental housing in which

Families with

Homelessness

social services are available onsite or by

low incomes,

Housing stability

referral through a supportive services

older adults,

Hospital utilization

program or service coordinator

people with

disabilities,

veterans

*The Community Guide has reviewed different sets of Interventions Engaging Community Health Workers. Outcomes listed in the table are for Recommended (strong) and Recommended (sufficient evidence) reviews.

Page 11

SME INSIGHTS ABOUT THE

policies (Rammohan et al., 2011), and park, trail, and

INTERVENTIONS WITH SYSTEMATIC

greenway infrastructure interventions combined with

REVIEW EVIDENCE

additional interventions to increase physical activity

(Community Preventive Services Task Force, 2022).

SMEs also offered ideas for potential innovations that

Interviews with CDC SMEs (our third method of inquiry)

might improve the effectiveness of the evidence-

provided additional information about the set of 24

based interventions. The falls SME interview noted that

interventions with systematic review evidence. Key SME

Emergency Medical Services (EMS) are often called to

insights related to the findings above are summarized

respond to a fall that does not result in transport to the

here; a longer report of SME interview response themes

hospital. EMS staff might be able to conduct falls risk

is provided in Appendix D. In general, SME respondents

assessment and/or referral in those situations. Health-

agreed that the interventions with systematic review

related professions other than primary care and hospital

evidence do represent the interventions with strongest

providers were also suggested for engagement in

evidence for health outcomes in this population.

screening, assessing, referring, or caring for older adults

However, many cautioned that implementation fidelity

in HUD housing, including pharmacists, optometrists

and reach of those interventions can be a significant

and ophthalmologists, and public health departments.

challenge in real-world settings, and recommended

SMEs similarly noted that the systematic review evidence

against assuming that all programs within an intervention

base alone might not fully address health equity

category are equally well implemented or effective. They

considerations, the needs of caregivers of older adults,

noted the importance of having critical implementation

or the challenges specifically faced by those living

supports (e.g., training and technical assistance) for

in rural areas, tribal nations, or territories. They also

intervention success. The older adult falls prevention

recommended that, if possible, the voice of the affected

SMEs also noted that effective falls prevention

community be incorporated into these deliberations.

interventions assess an individual’s risk for falls (e.g.,

incorporating health factors such as strength, vision, and

A third key theme from SMEs involved the perspective

current medications and environmental factors such as

that other local, state, and federal agencies have a

accessibility within the home) and identifies the specific

role to play in supporting the health of older adults in

falls prevention activities indicated by the results of an

HUD housing. For example, Area Agencies on Aging,

assessment. They cautioned that although efforts to

existing senior centers, neighborhood associations,

build strength and balance in the whole population of

and faith-based organizations could be valuable

older adults might have a small effect on individual risk,

partners in local implementation and sustainability.

individualized interventions are critical in effective fall

National not-for-profit (e.g., Alzheimer’s Association)

prevention due to the wide range of potential causes

and professional organizations could offer expertise

of falls (e.g., medication, eyesight, strength, physical

and other partnership support. Specific federal agency

hazards, etc). SMEs in more than one area pointed out

programs mentioned included the Health Resources and

that although evidence is emerging for interventions

Services Administration’s (HRSA) Federally Qualified

provided virtually (e.g., via telehealth), older adults

Health Centers, the Substance Abuse and Mental

may have difficulty or reluctance in accessing the

Health Services Administration’s (SAMHSA) mental and

necessary modes of technology to enable full value

behavioral health treatment programs, CMS’s Medicare

of that intervention mode. Similarly, SMEs highlighted

annual wellness visits, and ACL’s resources to support

other potential challenges to participation of older

the needs of older adults and people with disabilities.

adults with low income in in-person services, including

transportation and walkability, affordability of services,

Finally, SME responses also offered suggestions for

and perceptions among some individuals that health

interventions that may impact more than one priority

issues (e.g., falls) are an “inevitable” part of the aging

health outcome, beyond the documented outcomes

process and thus prevention is not possible.

in the systematic reviews. For example, interventions

A second major theme across interviews was that the

that increase physical activity of older adults within a

interventions with systematic review evidence are

group setting (e.g., at senior centers) may also provide

not the only interventions they would recommend

participants with social interaction that could be

for consideration in this effort. Three SME interviews

protective against loneliness and depression. Similarly,

referred us to additional sources of evidence-based

some interventions to build strength and balance among

interventions, including CDC’s Compendium of Effective

older adults may also increase their physical activity

Fall Interventions (Burns et al., 2022), and Community

(and vice versa). Although SMEs tended to have deep

Guide’s recommendations on regulating alcohol sales

expertise in particular health areas, each interview also

outlet density in communities (Task Force on Community

indicated the importance of considering the whole

Preventive Services, 2009), commercial host liability

person and the whole community.

Page 12 | Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community

OLDER ADULT HEALTH DATA

Figure 2. Avenues for Potential Evidence-Based Action to

ANALYSIS: IDENTIFYING HEALTH

Support Aging in Place Among HUD-Assisted Older Adults

CONDITION PREDICTORS OF

HOUSING TRANSITIONS

From our fourth method of inquiry, analyses of the MCBS

data from 1558 dually eligible older adults provided

results to inform prioritization of health outcomes, to

further narrow down interventions. Of the 15 health

Healthcare System

conditions in the MCBS analysis, 6 health conditions

Physical Housing

Interventions

were deemed the highest priority health conditions

Standards or

and Partnership

for our considerations based on the potential value

Enhancements

Opportunities

of different evidence-based interventions. High blood

pressure and diabetes were considered higher risk

and higher prevalence (each reported by >40% of

the sample) conditions; stroke was considered higher

risk and moderate prevalence (reported by 16% of the

sample); and Alzheimer’s disease, psychiatric conditions,

and broken hip were considered higher risk and lower

prevalence (each reported by <5% of the sample). We

Programs and

Existing Community

used these potential outcome measures to further

Services HUD Could

Characteristics and

distinguish the potential value of interventions within the

Offer or Partner to

Services

groups defined by implementation strategy.

Provider

SYNTHESIS OF RESULTS FROM

THE FOUR METHODS: AVENUES

Table 2 displays the specific evidence-based

interventions and documented health outcomes within

FOR POTENTIAL EVIDENCE-BASED

the four avenues for potential action. These avenues

ACTION

are not necessarily mutually exclusive; for example,

Activity Programs for Older Adults (e.g., “senior

Examination of the 24 different interventions with

centers”) already exist in some communities and could

systematic review evidence revealed groups of

be implemented by HUD and community partners

interventions with similar approaches to how and where

where they do not already exist. The resulting four

the interventions are implemented. We identified four

avenues contained between 2 and 9 interventions in

potential groups of interventions with similarity of

each group, with a range of different health outcomes in

implementing agency/organization and location:

each (see Table 2), suggesting that further prioritization

1. One group of interventions focuses on the physical

of intervention options within each group could be

characteristics of housing units.

valuable for informing decision-making. Thus, we next

2. A second group of interventions requires

incorporated our learnings from the CDC SME interviews

implementation by credentialled healthcare

and the health condition predictor data analysis to aid

professionals and would typically only be provided

understanding of the potential relative value of different

in healthcare locations (or via telehealth by

approaches to supporting aging in place.

healthcare professionals).

3. A third group of interventions could be delivered

by HUD directly or in partnership with community

organizations for older adults who live in HUD-

assisted housing, either in project-based housing

(i.e., public housing or multi-family housing) or in

other nearby locations in the community.

4. The fourth group includes services or structures

that already exist in some communities that could

enhance the health of older adult HUD-assisted

residents in those communities

Figure 2 displays the four implementation strategy groups,

hereafter referred to as “avenues for potential evidence-based

action.”

Page 13

Table 2. Avenues for Potential Evidence-Based Actions to Support Aging in Place

Evidence-Based Interventions, by Avenue for Potential Action

Health Outcomes

Exposure to allergens

A. Physical Housing Healthy Home Environment Assessments

Hospital utilization

Health outcomes

Standards and/or

Enhancements

Housing conditions

Housing Rehabilitation Loan & Grant Programs

Health outcomes

Mental health

Case-managed Care for Community-Dwelling Frail Elders

Nursing home use

or Integrated Long-term Care for Community-dwelling

Hospital utilization

Day-to-day functioning

Frail Elders [such as CMS’s Program of All-Inclusive Care

Caregiver satisfaction

for the Elderly]

B. Healthcare

Quality of life

System

Health outcomes

Interventions

Chronic Disease Management Programs

Mental health

and Partnership

Hospital utilization

Opportunities

Medicare-covered Risk Assessments & Personalized

Falls

Approaches to Fall Prevention among Older Adults or Multi-

component Fall Prevention Interventions for Older Adults

Systolic and diastolic

Team-based Care to Improve Blood Pressure Control

blood pressure

Home-Based Depression Care Management

Short-term depression

outcomes

Homelessness

Service-enriched Housing

Housing stability

Hospital utilization

Blood pressure

Cholesterol levels

Physical activity

Healthful eating habits

Interventions Engaging Community Health Workers or

Smoking cessation

Glycemic control

C. Programs and

Combined Diet and Physical Activity Promotion Programs

Lipid control

Services HUD Could to Prevent Type 2 Diabetes Among People at Increased Risk

Healthcare use

Offer or Partner to

Weight-related outcomes

Colorectal screening

Provide

Breast cancer screening

Cervical cancer screening

Health outcomes

Activity Programs for Older Adults

Mental health

Isolation

Quality of life

Home-delivered and Congregate Meal Services for

Malnutrition

Older Adults

Physical Activity: Digital Health Interventions for Adults

Physical activity

55 Years and Older

Home Visits to Increase Vaccination Rates

Vaccination rates

Page 14 | Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community

Evidence-Based Interventions, by Avenue for Potential Action

Health Outcomes

Case-managed Care for Community-Dwelling Frail

Nursing home use

Hospitl utilization

Elders or Integrated Long-term Care for Community-

Day-to-day functioning

dwelling Frail Elders [such as CMS’s Program of All-

Caregiver satisfaction

Inclusive Care for the Elderly]

Blood pressure

Cholesterol levels

Physical activity

Interventions Engaging Community Health Workers

Healthful eating habits

Smoking cessation

or Combined Diet and Physical Activity Promotion

Glycemic control

Programs to Prevent Type 2 Diabetes Among People at

Lipid control

Increased Risk

Healthcare use

D. Existing

Weight-related outcomes

Community

Colorectal screening

Breast cancer screening

Characteristics

Cervical cancer screening

and Services

Health outcomes

Activity Programs for Older Adults

Mental health

Isolation

Quality of life

Home-delivered and Congregate Meal Services for

Malnutrition

Older Adults

Environments/spaces that facilitate physical

Physical activity

activity: Complete Streets & Streetscape, Mixed-use

Pedestrian and cyclist safety

Physical fitness

Development, Creation of or Enhanced Access to Places

for Physical Activity Combined with Informational

Outreach Activities and Places for Physical Activity

Avenue A: Physical Housing Standards

People at Increased Risk, and Activity Programs for

and/or Enhancements are in HUD’s

Older Adults) have systematic review evidence for

purview. However, evidence for the pair

priority health outcomes. The other three interventions

of interventions that relate to the physical

in this group (Home-delivered and Congregate Meal

characteristics of housing units (Healthy

Services for Older Adults, Physical Activity Digital

Home Assessments and Home Modification Loans and

Health Interventions for Adults 55 Years and Older,

Grants) is strongest for specific populations and health

and Home Visits to Increase Vaccination Rates) only

outcomes (e.g., hospitalizations for pediatric asthma)

have systematic review evidence on health-related

that are less central to older adults’ ability to age in

outcomes (malnutrition) and behaviors (physical

place.

activity, vaccinations) rather than the health conditions

suggested by our MCBS analysis.

The second group of interventions falls

more clearly in the healthcare system.

The final group of interventions (Avenue

Each of the interventions listed as Avenue

D) is the set of potentially Existing

B: Healthcare System Interventions and

Community Characteristics and Services

Partnership Opportunities has systematic

with systematic review evidence. Six

review evidence for one or more priority health

interventions, each of which were also

conditions. The intervention approaches and outcomes

included in either the healthcare system

focus on clinical management of diagnosed chronic

intervention avenue or the HUD or partner intervention

conditions (e.g., high blood pressure, depression) or falls

avenue, have evidence on identified priority health

risk assessment and prevention.

outcomes. Three other interventions focus on community

approaches to providing environments or spaces that

The third group of interventions is

facilitate physical activity (i.e., Complete Streets &

comprised of Programs and Services

Streetscape, Mixed-Use Development, and Creation

HUD Could Offer or Partner to Provide

of or Enhanced Access to Places for Physical Activity

for HUD Residents (Avenue C). Within

Combined with Informational Outreach Activities) and

this group, four interventions (Service-

have evidence on health-related outcomes rather than

enriched Housing, Interventions Engaging Community

the prioritized health outcomes suggested by our

Health Workers, Combined Diet and Physical Activity

MCBS analysis.

Promotion Programs to Prevent Type 2 Diabetes among

Page 15

DISCUSSION

Figure 3. Avenues with the Strongest Evidence to Improve Health

of HUD-Assisted Older Adults

Our results reflect a stepped approach to investigation

in which each method of inquiry led to and informed

the next. The literature review and environmental scan

indicated that aging in place is a complex, multifaceted

outcome, that also likely has many causes and influences.

The individual intervention literature is thus difficult

Healthcare System

Programs and

to summarize in a new primary review. Capitalizing

Interventions

Services HUD Could

on published systematic reviews narrowed the field

and Partnership

Offer or Partner to

of intervention approaches to consider, by relying on

Opportunities

Provider

the established methods to identify broad intervention

approaches with high levels of evidence. That smaller

Of the identified Programs and Services HUD Could

pool of intervention approaches could be stratified

Offer or Partner to Provide for HUD residents (Avenue

by implementation method, to offer concrete options

C), four specific interventions had systematic review

for HUD and partners to pursue. Data from the MCBS

evidence on key health outcomes to support older adults’

allowed us to understand the relative risks for transition

aging in place: Service-enriched Housing, Interventions

conveyed by different health conditions, and prioritize

Engaging Community Health Workers or Combined Diet

interventions within implementation method types. SME

and Physical Activity Promotion Programs to Prevent

interviews confirmed that those interventions should be

Type 2 Diabetes Among People at Increased Risk, and

given due consideration, along with other interventions

Activity Programs for Older Adults. These interventions

not included in the systematic reviews. SMEs also offered

are preventive in nature, intended to reduce the risk

suggestions for innovation, for engaging traditional

of chronic physical and mental health conditions that

and non-traditional partners, and for what contextual

contribute to transitions out of independent living.

information that will influence effectiveness is not

reflected in the published evidence alone.

Among the identified Healthcare System Interventions

and Partnership Opportunities (Avenue B), those with

Taken together, the information and evidence gathered

systematic review evidence on key health outcomes

via these methods indicates that no single intervention

were: Case-managed Care for Community-Dwelling Frail

or implementation strategy is likely to fully support

Elders or Integrated Long-term Care for Community-

aging in place of HUD’s older adult population,

dwelling Frail Elders, Chronic Disease Management

given the range of potential health needs of the

Programs, Risk Assessments & Personalized Approaches

population and the range of documented health

to Fall Prevention among Older Adults or Multi-

outcomes of interventions. Considerations of avoiding

component Fall Prevention Interventions for Older

potential redundancy of interventions, and of potential

Adults, Team-based Care to Improve Blood Pressure

“multisolving” interventions (i.e., interventions that can

Control, and Home-Based Depression Care Management.

simultaneously address multiple health outcomes),

With the exception of the fall prevention interventions

could be used to inform combinations of approaches

(for which healthcare provider screening is an important

to pursue first.

component), these healthcare interventions focus on

management of diagnosed chronic conditions.

Avenues for Potential Action to

The two other avenues for potential action (Avenue

Improve the Health of Older Adults

A: Physical Housing Standards and/or Enhancements

Served by HUD Programs

and Avenue D: Existing Community Characteristics

Of the four avenues for potential action, Figure 3 displays

and Services) appear to have less potential for

the two avenues that currently offer stronger published

effectiveness based on current evidence. Among the

and contextual evidence to support their consideration

interventions that address Physical Housing Standards

for possible action by HUD and partners from the health

and/or Enhancements, the evidence is most clear for

system, communities, and other federal agencies:

health outcomes and populations that are less directly

Programs and Services HUD Could Offer or Partner

relevant to health risk for transitions out of independent

to Provide and Healthcare System Interventions and

living among older adults (e.g., pediatric asthma

Partnership Opportunities.

hospitalizations).

Page 16 | Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community

However, additional research or evidence review could

be valuable to identify specific housing requirements

or modifications that would be supportive of priority

health outcomes among older adults, to inform future

HUD support for that type of intervention. The avenue

of Existing Community Characteristics and Services was

initially considered as having potential for use in HUD

prioritization of future housing locations and vouchers,

to place HUD residents in neighborhoods with available

services to support their health. However, that kind of

prioritization raises health equity questions, as such

a decision would also result in further concentration

of services in certain areas, potentially at the cost of

providing housing to those most in need. Given that

several SMEs emphasized the potential value of built

environment approaches that could serve as “upstream”

and multisolving preventive interventions by creating

spaces to facilitate older adult physical activity and

socialization (i.e., Complete Streets & Streetscape,

Mixed-use Development, Creation of or Enhanced

Access to Places for Physical Activity Combined

with Informational Outreach Activities and Places for

Physical Activity), this avenue of Existing Community Characteristics and Services may also benefit from

further investigation and consideration.

Page 17

CONCLUSIONS

We sought to identify evidence-informed policies and

practices related to aging in place, and offer guidance

about what is most needed, relevant, and immediate for

HUD-assisted older adult tenants at this time. We used

four methods of inquiry to characterize and understand

the evidence from published intervention literature,

systematic reviews, health data on older adults, and

CDC subject matter experts. Given the diversity of

health factors that likely contribute to aging in place,

multiple interventions or avenues may be needed to

support HUD’s priority for this population. We found

the strongest support for two groups of interventions:

Healthcare System Interventions and Partnership

Opportunities for management of existing chronic

health conditions among older adults and reduce

risk for falls, and Programs and Services HUD Could

Offer or Partner to Provide to promote health and

prevent impairment among all older adults in HUD

housing. Further research or exploration might be

valuable to identify which specific physical standards,

enhancements, or characteristics of housing and

communities support aging in place among older

adults. SMEs identified important considerations for

selection and implementation of interventions, including

the potential for “multisolving” interventions that could

address multiple health issues, future research to address

systematic review evidence gaps (e.g., built environment

approaches), potential innovations in identification and

amelioration of risk (e.g., for falls), potential barriers to

program participation, critical implementation supports

to promote intervention fidelity to evidence-based

models, and other local, state, and federal agency

partnerships to support implementation

and sustainability.

Page 18 | Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community

REFERENCES

Administration for Community Living. (2021). 2020 Profile of Older Americans. US Department of Health and Human Services, Washington, DC. https://acl.gov/sites/default/files/aging%20and%20Disability%20In%20

America/2020Profileolderamericans.final_.pdf

Burns, E. R., Kakara, R., Moreland, B. A. (2022). CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults. 4th ed. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA. https://www.cdc.gov/falls/programs/compendium.html

Centers for Medicare & Medicaid Services, Office of Enterprise Data and Analytics. (2021). Medicare Current Beneficiary Survey 2019 Methodology Report. Centers for Medicare & Medicaid Services, Washington, D.C. Available at

https://www.cms.gov/files/document/2019-mcbs-methodology-report.pdf

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Cubanski J., Koma W., Damico A., Neuman T. (2018). How Many Seniors Live in Poverty? Kaiser Family Foundation Issue Brief. Henry J Kaiser Family Foundation. https://files.kff.org/attachment/Issue-Brief-How-Many-Seniors-Live-in-Poverty

DeCuir-Gunby, J. T., Marshall, P. L., & McCulloch, A. W. (2011). Developing and Using a Codebook for the Analysis of Interview Data: An Example from a Professional Development Research Project Field Methods, 23(2), 136–155.

https://doi.org/10.1177/1525822x10388468

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MacQueen, K. M., McLellan, E., Kay, K., & Milstein, B. (1998). Codebook Development for Team-Based Qualitative Analysis.

Cultural Anthropology Methods, 10(2), 31–36. https://doi.org/10.1177/1525822x980100020301

Minkler, M., Fuller-Thomson, E., & Guralnik, J. M. (2006). Gradient of Disability across the Socioeconomic Spectrum in the United States. The New England Journal of Medicine, 355(7), 695–703. https://doi.org/10.1056/NEJMsa044316

Rammohan V., Hahn R. A., Elder R., Brewer R., Fielding J., Naimi T. S., Toomey T. L., Chattopadhyay S. K., Zometa C., & The Task Force on Community Preventive Services. (2011). Effects of Dram Shop Liability and Enhanced Overservice Law Enforcement Initiatives on Excessive Alcohol Consumption and Related Harms: Two Community Guide Systematic Reviews. American Journal of Preventive Medicine, 41(3), 334-343. https://doi.org/10.1016/j.amepre.2011.06.027

Ryan, G. W., & Bernard, H. R. (2003). Techniques to Identify Themes. Field Methods, 15(1), 85–109.

https://doi.org/10.1177/1525822x02239569

The Task Force on Community Preventive Services (2009). Recommendations for Reducing Excessive Alcohol Consumption and Alcohol-Related Harms by Limiting Alcohol Outlet Density. American Journal of Preventive Medicine, 37(6), 570-571. https://doi.org/10.1016/j.amepre.2009.09.021

The Task Force on Community Preventive Services (2022). Physical activity: Park, Trail, and Greenway Infrastructure Interventions when Combined with Additional Interventions. Available at:

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Taylor, L. A. (2018). Housing and health: An Overview Of The Literature. Health Affairs, Health Policy Brief.

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U.S. Census Bureau (n.d.) 2021 American Community Survey 1-Year Estimates. [Data tables]. U.S. Department of Commerce. Retrieved February 22, 2023, from https://data.census.gov/table?g=0100000US&tid=ACSST1Y2021.S0101

Waidmann T, Thomas S. (2003). Estimates of the Risk of Long-Term Care: Assisted Living and Nursing Home Facilities.

Washington, DC: Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.

https://aspe.hhs.gov/reports/estimates-risk-long-term-care-assisted-living-nursing-home-facilities-0

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APPENDIX A. STATEMENT OF WORK:

AGING IN PLACE JOINT STUDY WITH HHS

APPENDICES

APPENDIX A. STATEMENT OF WORK:

AGING IN PLACE JOINT STUDY WITH HHS

Interagency Agreement# 86614621E00002

PURPOSE

The Department of Housing and Urban Development (HUD) and the Centers for Disease Control and Prevention (CDC) plan to establish a collaborative relationship to leverage opportunities and resources in support of shared agency goals and priorities related to aging in place. The first shared priority is to provide evidence informed approaches for affordable senior housing programs that coordinate health, wellness, and supportive services to help older adults remain healthy, age in their community, and reduce their use of costly health care services. The broad purpose of this interagency agreement is to build a sustainable, collaborative partnership between HUD and CDC to intentionally advance shared priorities related to health and housing.

Long-standing systemic health and social inequities have put many racial and ethnic minority groups at increased risk of getting sick and dying from COVID-19. Therefore, this collaboration takes on special importance as the nation responds to the COVID-19 pandemic. CDC is the Nation’s leading science-based, data-driven, service organization that protects the public’s health. HUD administers programs that provide housing and community development assistance, and in this role houses millions of the nation’s most vulnerable populations. This collaboration provides a unique opportunity to pilot evidence-informed policies and practices supported by CDC subject-matter experts in HUD-assisted housing.

The goals for this collaboration are to:

y

Identify evidence-informed policies and practices related to aging in place.

y

Narrow the scope to what is needed, relevant and immediate for HUD-assisted tenants at this time.

APPENDICES

y

Convene HHS and HUD partners to explore opportunities to align the array of existing HHS collaborations and investments to increase access to community and clinical services for wellness and care coordination for low income older adult populations.

y

Convene HHS and HUD to jointly assess learnings from environmental scans, convening, and interim findings from the IWISH demonstration to inform future directions for scaling aging in place models in HUD assisted housing.

y

Inform the design, research questions and evaluation for HUD to develop, implement, and evaluate pilot tests based on research design in HUD sites; and

y

Identify appropriate ways to scale-up evidence-informed policies and practices to improve the health of the nation’s low-income population.

The focus of this collaboration will begin with, but will not be limited to, the nation’s older adult population.

TASKS/DELIVERABLES

Specific detailed descriptions for tasks and deliverables will be contained in 7600 Part B forms submitted for each year of this IAA. Funding obligated to CDC will be used to fund cooperative agreements to complete project deliverables and will not support salaried CDC employees.

Four overarching deliverables have been agreed upon by CDC and HUD. These may be modified as needs arise, upon the agencies’ mutual agreement and modification to the IAA. The overarching topics are:

V. Conduct environmental scans, scoping reviews, and host key critical discussions to identify what CDC has learned from research and program activities that is useful to HUD-assisted housing and its efforts to support aging in place among low income households; identify needs, barriers, challenges, policies, guidance, best practices, practice-based evidence, opportunities, lessons learned and available cost or finance models for supportive services that specifically apply to low income older adult populations served by HUD.

a.

The low-income older adult population that is aging in place in multifamily private market and public

supported housing, and the owners, investors, lenders, builders, (the producers) of such housing.

b. The low-income population that is aging in place in single family owner and renter occupied private market and federally subsidized housing, and the producers, owners, and investors in such housing.

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VI. Convene Federal Interagency Summit on Aging in Place with HUD, CDC, and HHS partners including CMS, ACL, NIH, HRSA (others) stakeholders to fill gaps and document the array of existing HHS and HUD investments, select learnings from grantees, and emerging practice models, to increase access to community and clinical services for wellness and care coordination for low income older adult populations. Topics for discussion and learnings from the Federal Interagency Summit on Aging in Place could include:

a.

Defining existing barriers and challenges associated with coordinating federal supportive services programs b. Opportunities for interagency collaboration or alignment

c.

Summary of findings for cost-sharing options

d. Future directions including, research questions, and research design concepts or pilots

VII. Develop, in collaboration with HUD and federal partners, a synthesis of learnings from environmental scans and sense making with federal partners into a report on future directions including: research questions, research design concepts or pilots, and collaborations for aging in place in federally assisted housing. The report will summarize the scale and scope of research pilots or demonstrations and build on interim IWISH findings and knowledge gained through environmental scans and Federal Summit on Aging in Place. The sense making

endeavor will inform research questions for HUD to consider and the design of pilots that identify opportunities for HUD stakeholders to support older adults aging in place. CDC may propose pilots or demonstrations to HUD

to test promising financial, technological, and organizational models to produce better outcomes for aging in place in assisted housing, and which reflect the collaboration needed between federal, state, and local agencies to accomplish this goal.

VIII. Provide technical consultation and assistance to HUD and partners on the implementation, monitoring, and evaluation of demonstrations or pilots. CDC will provide strategic leadership and scientific oversight, in close collaboration with HUD and other key stakeholders. As part of determining lessons learned, CDC will have access to the active learning phase of IWISH projects and early stages of the pilots. Findings and conclusions will be shared for scaling promising approaches.

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APPENDIX B. CDC SUBJECT MATTER EXPERTS

SEMI-STRUCTURED INTERVIEW GUIDE

Background and objective:

y

As indicated in the email, CDC’s Office of Policy Analytics and Population Health (OPAPH) and HUD have entered a 5-year IAA to leverage opportunities and resources in support of shared agency goals and priorities related to aging in place.

y

NNPHI and GHPC have been engaged this year to support the building of relationships across agencies, share priorities and existing efforts, and work in partnership with the team on an environmental scan.

y

As part of this year’s efforts, GHPC and the Office of Policy Analytics and Population Health (OPAPH) have done a rapid review of published recommendations, to identify broad approaches with strong evidence of health impacts related to aging in place.

Through SME interviews like this one, we want to elicit contextual and implementation expertise about the evidence base to help us prioritize among the array of different avenues HUD could pursue.

Here is some information regarding what we’ve learned from the evidence:

y

To arrive at an initial set of broad-based approaches with strong evidence, we compiled and condensed

recommendations from the Community Preventive Services Task Force Community Guide and the County Health Rankings & Roadmaps What Works for Health resource that have relevance to health aspects of aging in place.

y

We also categorized lists of specific evidence-based interventions from sources like the National Council on Aging and the Administration from Community Living whose interventions often are encompassed by the more general recommendations.

y

One of the first challenges we encountered was that there are few studies measuring transition into assisted living or nursing facilities as an intervention outcome.

y

Thus, we must consider interventions with evidence for outcomes on a broader set of precursors of individuals not being able to care for themselves.

y

Those precursors include cognitive or mental limitations (such as dementia), physical limitations (such as from injuries resulting from falls), and special health needs (including chronic diseases or acute illnesses) y

Given your expertise in [insert area(s) of expertise] we are seeking more in-depth about the intervention evidence, potential transferability and implementation of different evidence-based interventions in HUD

housing like Section 202 housing, and any other relevant insights you might have regarding this topic and/or intervention(s).

Attached to this email is a spreadsheet that includes high-evidence recommendations we identified [insert brief description].

Questions Specific to the Spreadsheet:

1. Can you share with us the evidence and relevance of interventions addressing [insert area(s) of expertise] that you think are important to the partnership between CDC and HUD?

2. Do you have any questions about the spreadsheet?

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Discussion Questions:

1. What are the critical funding and implementation supports and challenges that we need to consider with these kinds of interventions? Where does funding primarily come from? What role does insurance coverage and

reimbursement policies play?

2. Who are the critical partners, implementers, or funders of these kinds of interventions? Do partners differ at the national, state, and local levels?

3. If we were only looking at these evidence-based recommendations and interventions, what key information about [insert area(s) of expertise] would be missing? In other words, what is not captured by the published recommendations that we need to know about?

Are there innovative approaches or emerging evidence that we need to consider that haven’t risen to the level of strong evidence yet? What can you share regarding studies that might be recent or currently underway and relevant to the topic?

4. Do you know of any large-scale implementations or pilots – especially in similar populations or in conjunction with housing – that are models for what HUD could do in this area? Do you have any implementation ideas or suggestions for HUD?

5. Are there any potential “multisolver” interventions in [insert area(s) of expertise] that are being used to achieve other health objectives?

6. Sometimes in a health area there are known interventions with harmful effects or a contentious history. Are there any intervention areas in [insert area(s) of expertise] that you would caution us against considering for any reason?

7. Is there anything else you feel we need to know as we consider [insert area(s) of expertise] in relation to the IAA with HUD, that we did not ask about?

8. Are there any additional resources or contacts that you can share with us that may further assist our efforts?

Resources could include reports, papers, briefs, etc. Contacts could be internal and external to CDC.

Page 24 | Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community

APPENDIX C. CDC SUBJECT MATTER

EXPERTs INTERVIEWED

BY AREA OF EXPERTISE, CENTER AND DIVISION

Table 3: Potential Evidence-Based Actions to Support Aging in Place

Areas of Expertise

CDC Center and Division

SME Name(s)

Aging, Dementia and Alzheimer’s National Center for Chronic Disease Prevention and Janelle Gore

Disease, Care and Service

Health Promotion, Division of Population Health,

Eva Jeffers, MPH

Provision

Healthy Aging Branch

Lisa McGuire, PhD

Behavioral Health

National Center for Chronic Disease Prevention and Marissa Esser, PhD, MPH

Health Promotion, Division of Population Health,

Epidemiology and Surveillance Branch, Alcohol and

Public Health

Diabetes

National Center for Chronic Disease Prevention and Christopher Holliday, PhD,

Health Promotion, Division of Diabetes Translation

MPH

Patricia Schumacher, MS

Holly Williams

Disability and Health Equity

National Center on Birth Defects and

Shannon Griffin-Blake, PhD

Developmental Disabilities, Office of Policy,

Partnerships and Strategy

Fall Prevention

National Center for Injury Prevention and Control,

Gwen Bergen, PhD, MPH

Division of Injury Prevention

Christopher Earl, MPH

Robin Lee, PhD, MPH

Heart Disease and Stroke

National Center for Chronic Disease Prevention and Written comments provided

Health Promotion, Division of Heart Disease and

in lieu of SME interview

Stroke Prevention

Minority Health and Health Equity Office of the Director, Office of Minority Health &

Jeff Hall, PhD, MSPH

Health Equity

Physical Activity

National Center for Chronic Disease Prevention and David Brown, PhD

Health Promotion, Division of Nutrition, Physical

Heather Devlin, MA

Activity, and Obesity

Katherine Irani, MPH, MSW

Ken Rose, MPA

Ayla Schermer, MURP

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APPENDIX D. CDC SUBJECT MATTER EXPERT

INTERVIEW SUMMARY

The main body of the report contains the insights from the SME interviews that are most relevant to the report’s main findings and conclusions; this appendix provides a lengthier summary of the themes mentioned in the interviews.

Prior to the interviews, CDC SMEs were provided with background information regarding the IAA and a spreadsheet of information regarding the interventions with a high level of systematic review evidence pertaining to their areas of expertise. At the beginning of each interview, the background for the IAA and the methods used to identify the list of interventions were reiterated. The SMEs were given the opportunity to ask clarifying questions about the objectives and methods of the project before the structured interview began (see Appendix B for the Interview Guide and Appendix C

for the list of SMEs and areas of expertise).

INITIAL REACTIONS TO THE LIST OF INTERVENTIONS

SMEs indicated that they were familiar with the included interventions and offered positive, affirming reactions to those interventions. They expressed a general understanding and approval of the inclusion of the categories of interventions that were recommended by the Community Guide and County Health Rankings and Roadmaps with the highest levels of evidence. The SMEs suggested that specific program examples be drawn from those same sources of information, or from CDC-developed resources such as CDC’s Compendium of Effective Fall Interventions: What Works for Community-

Dwelling Older Adults. The SMEs noted the importance of standardized interventions with appropriate implementation supports to ensure fidelity to the evidence-based models, as well as the potential value in intentional adaptations to standardized programs to tailor for the context, culture, language, or other characteristics of a population. Resources

for Enhancing All Caregivers’ Health (REACH), implemented by the Department of Veterans Affairs and Indian Health Services, was shared as a program example that was adapted for veterans and tribal communities.

SMEs recognized the value of population-level approaches, although for some content areas they emphasized screening and assessment of an individual’s specific risks, health status, and/or functional abilities (e.g., via health care provider or community health worker) and matching them with the appropriate intervention strategy. For example, SMEs noted that although efforts to build strength and balance in the whole population of older adults might have a small effect on risk, individualized interventions are critical in effective fall prevention due to the wide range of potential causes of falls (e.g., medication, eyesight, strength, physical hazards, etc). A related theme that arose during several interviews was the awareness of community members’ needs, desires, and wishes. One SME suggested reviewing the literature regarding community engagement theories and guiding principles as interventions are considered. Another SME further emphasized this point, saying, “Are there older adults that we could ask? Because…when we’ve had panels of older adults, they’ll quickly go, ‘Ah, that that’s not going to work.’ And they’ll immediately tell you why it’s not going to work.”

Several SMEs recommended that the voice of members of the affected community be incorporated into

decision-making.

ADDITIONAL EVIDENCE-BASED INTERVENTIONS, EMERGING EVIDENCE,

AND GAPS

SMEs suggested several additional evidence-based recommendations and interventions for consideration, beyond the list they were provided. Some of the suggestions were from the reviewed evidence-based recommendation sources while others were from different sources:

y

Community Guide recommendations related to alcohol sales outlet density and commercial host liability, or dram shop liability, for preventing and reducing alcohol-related harms at the community-level

y

Interventions included in CDC’s Compendium of Effective Fall Interventions: What Works for Community-

Dwelling Older Adults

y

A new recommendation from the Community Guide about the importance of interventions that increase

awareness, engagement, programming, and access to the outdoor environment

During some of the interviews, the SMEs identified the opportunity to include more general strategies or approaches, in addition to the programmatic interventions from the spreadsheet we provided. For example, the Still Going Strong campaign aims to raise awareness among older adults regarding preventable injuries. The SME described the campaign Page 26 | Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community

this way: “it cuts across all injuries and tries to give a very positive kind of empowered vision of being an older adult and saying, you can still do things you used to do, and you just need to do these things to prevent injury.” They reflected that efforts to increase knowledge and decrease stigma might increase participation in available interventions, even if such efforts alone have not been shown to impact key health outcomes of this IAA.

Similarly, some of the SMEs reflected on the opportunity to incorporate additional organization- and community-level approaches or initiatives into the project that are broader and not limited to individual-level health outcomes. An example identified during two of the interviews was AARP’s Network of Age-Friendly States and Communities, which SMEs reported offers elected officials and partner organizations assistance with assessing how age-friendly a geographic area is and working to plan, implement, and evaluate activities to increase quality of life for all individuals in the community. SMEs also highlighted USAging’s Dementia Friendly America, which they reported is focused on engaging a variety of sectors and organizations in raising awareness and building capacity to support people living with dementia and their caregivers, thereby elongating community living.

Some SMEs noted that interventions to support caregivers of older adults were absent from the list of identified interventions and suggested their consideration, especially regarding effective interventions for supporting aging in place for individuals with dementia or other cognitive or physical impairments. One SME described the importance of caregivers this way, “We do a lot of work looking at caregivers in the health and wellbeing of caregivers, because we know how crucial they are to not only maintaining their health, wellbeing, and independence, but also the person they provide care for.” To that end, the SMEs also suggested groups such as ACL’s RAISE Family Caregiving Council, a federal advisory council that recently delivered a report to Congress about strategies to support family caregivers.

IDENTIFYING POTENTIAL MULTISOLVERS

We asked SMEs to suggest known or potential “multisolving” interventions, that might impact more than one health condition or reduce the risk factors for more than one disease or condition. SMEs discussed how addressing characteristics of the neighborhood, including ensuring safe and high-quality housing, decreasing community density of alcohol sales, increasing safety, reducing crime, and increasing accessibility and walkability could support older adults to make healthier choices, have more social interaction, and provide a healthier community in which they live –

each of which might contribute to prevention of conditions that lead to transitions out of independent living. Specific potential multisolving interventions highlighted include CDC’s National Diabetes Prevention Program, telehealth, and interventions that engage Community Health Workers, which have potential to positively impact multiple health outcomes relevant for reducing transitions and improving quality of life. Stopping Elderly Accidents, Deaths, and Injuries

(STEADI), for example, was mentioned as a possible multisolving approach for addressing falls and chronic conditions, but could potentially address depression, loneliness, social isolation, and concerns related to self-harm and suicide, according to SMEs.

INTERVENTIONS TO AVOID

Overall, SMEs did not warn against any interventions due to known harmful effects or contentious history. However, they expressed concern about potential unintended consequences of interventions. SMEs discussed that it is important to consider where unintended consequences occur, how often, and how they can be prevented from happening. For example, one interview discussion noted that if building more housing in a community increases demand and housing costs, that could lead to the displacement of lower-income people and renters. One SME suggested that HUD may be especially well positioned to address these questions in relation to the impact of housing supply, housing costs, and inequitable displacement. Several SMEs also expressed concern about the wide variation in program quality and fidelity in the field, even within evidence-based intervention models. The SMEs noted again the tension between standardization and intentional tailoring, i.e., although fidelity to the key components of an evidence-based model is typically the goal, careful tailoring to local needs and resources could remove barriers to participation and effectiveness.

IMPLEMENTATION CONTEXT, REACH, AND POTENTIAL IMPACT

As described below, the SMEs discussed a diverse range of issues related to the implementation context and reach and identified several potential considerations they advised to be assessed during the IAA. Further, SMEs felt that it is still unclear how best to adapt, scale up, and disseminate the interventions to decrease health disparities and improve health outcomes, and avoid unintended consequences of implementation.

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Population variation. Several SMEs emphasized the diversity of populations that need to be taken into consideration when making decisions about interventions to support aging in place. For example, one SME described the variation in the populations reached by HUD-supported housing and the variation in the individuals’ needs when they stated,

“…as you’re talking about your interventions and HUD, that whole range from frailty to healthy older adults I think is something to consider.” Several other SMEs shared similar thoughts, cautioning against thinking that all older adults have similar needs as they age. One SME went further to note the variability within individuals over time: “You’ve got people who are fully independent, you’ve got people who might have a certain low level of needs for certain types of supports, with specific instrumental activities of daily living. You have other people who are beginning to reach a threshold where they may need to be shifted to a place, such as an assisted living facility. And then depending on their health conditions, people cycle in between the different circumstances.” SMEs thus felt that no single solution or intervention would likely be adequate.

Efforts to improve the community’s provision of supportive environment for individual needs related to aging in place was also noted as important for existing housing. Reflecting on this opportunity, one SME stated, “you can’t age in place well without having an environment that is supportive of the individual…we talk about a person with a disability, it’s really not the disability that causes the impairment, it’s the environments that create a lack of access or accessibility and be able to have full independence and functioning.” Other characteristics identified by SMEs as relevant to the appropriateness and success of interventions included marital status, age, availability of care partners, social support, health status, and receipt of other community-based and health care services. SMEs cautioned that ignoring population variation could result in lower effectiveness of interventions.

Barriers to participation. Related to individuals and to the population as a whole, SMEs raised several issues regarding potential barriers to participation of older adults in interventions. One SME said, “you can have the best program in the world, but if people can’t do it or won’t do it or don’t feel like they’re able to do it, then it’s not worth much.”

SMEs recommended working to better understand the barriers to participation and which wraparound supports and incentives are most effective to maximize the benefit of the interventions. SMEs noted that older adults typically have more available time post-retirement to engage in health-promoting activities and an inclination to take advice from their doctor or health care provider. However, one SME said, “It’s not enough to just have a doctor recommend an intervention to a patient. They of course have to adopt it, to do it, and follow through on it.” For example, one SME noted that many people believe that falls are an inevitable part of aging and there is nothing that can be done to prevent them.

Thus, a doctor or health care provider’s recommendation may not be enough; signing up for the program, adopting the recommendations, and changing attitudes and beliefs may also be necessary. Other barriers to participation in interventions mentioned by SMEs included transportation, cost, and perceived value of the intervention.

Telehealth and other digital interventions were mentioned by SMEs as both a potential barrier and facilitator of participation by older adults. Telehealth and digital interventions were suggested as potential solutions to barriers such as transportation and service availability outside urban or suburban areas. According to one SME, “we think the digital space is really an opportunity for more innovation and thinking more about how people, particularly through learning through the pandemic, get their medical information… our biggest opportunity here to really dig deep and figure out what are some of the opportunities [are] going forward, whether it is thinking of what we’ve learned over the last two years through telehealth and how to build that infrastructure.” However, SMEs also noted that older adults may not have as much cognitive ability, motivation, or interest in telehealth and digital interventions as younger populations, and such innovations cannot serve those who cannot access high-speed broadband. Thus, while telehealth and digital interventions may offer some promise, SMEs cautioned against assuming that those approaches would solve all participation and access barriers.

Insurance coverage. Costs of participating in interventions was identified as a potential barrier in several SME interviews, which often led to SME discussion of insurance coverage and reimbursement. Medicare and Medicaid were specifically mentioned, given the magnitude of the coverage the public programs provide for older adults with low-income. It was noted that the availability and scope of home- and community-based services, particularly those provided by Medicaid, vary by state. Specific examples included lacking or inconsistent coverage of health and wellness programs, home modifications, assistive technology, and vision coverage. Those services were highlighted by SMEs as potentially critical supports for aging in place among individuals receiving supportive housing who require assistance with activities of daily living or instrumental activities of daily living. The Medicare annual wellness visit, established as a benefit under the Affordable Care Act, was pointed to by a few SMEs as an opportunity to identify, screen, and refer patients to programs or other follow-up care.

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Payment mechanisms and insurance coverage were also referenced by SMEs in relation to the sustainability of programmatic interventions. The 2020 Reauthorization of the Older Americans Act (P.L. 116-131), administered by the Administration for Community Living, was identified by several SMEs as a critical statute for supporting aging in place.

The infrastructure of the Area Agencies on Aging and funding that stems from the Older Americans Act were highlighted by SMEs as providing a sustainable source of health and wellness, caregiver, and home and community-based services.

Many of the interventions have standards, requirements, and monitoring related to their implementation including explicit expectations regarding how it is delivered, and by whom. In most cases there are accrediting bodies, or another type of organization that provides oversight. These factors were mentioned as relevant in considering the steps and organizations involved in delivering some of the interventions included in the list.

Community around the housing. Community features and characteristics were described as facilitators of healthy behaviors and aging in place, and thus as appropriate intervention opportunities, according to SMEs. Communities that are accessible, safe, walkable, and have amenities like pharmacies were described as supportive for all populations, including older adults. One of the SMEs discussed the importance of the community context saying, “Upstream things…

around housing, around transportation, around adequate green space to be able to walk, a safe environment, safe from violence, all have to be complimentary so they can make these changes and sustain them over time.” It was noted that there are opportunities to prioritize housing development in places that have these features, as one SME stated,

“But as we think about housing, whether it’s section 202 or other types of residencies, we need to be more intentional again about what is around the housing that we’re developing.” Most of the SME interviews touched on aspects of the surrounding community in some way, urging the project team not to neglect those opportunities in favor of only including traditional health system interventions.

Local and state policy context. Relatedly, several SMEs noted the local and state policy context as influencing the communities in which HUD residents live. As mentioned above, they noted that state and local zoning, land use, and licensing policies (e.g., the density of alcohol sales outlets, improving accessibility and walkability, and access to transportation and green space) could affect the feasibility and implementation of interventions as well as the health of older adults. A complicating factor that SMEs noted with respect to the policy context is that implementation of interventions to support aging in place often cross sectors, authorities, contexts, and geographic boundaries. As an illustration of this awareness, an SME said, “We have a specific lane we tend to work in. Think about it, when you bring in your partners, they’ll say, ‘Oh, no, we can’t do that. Policy such and such will prohibit.’…it’s like looking for the lines in the matrix, if you will.” One SME presented a different picture of the challenge some states face: “Another question to ask is, is there an aging focus within the infrastructure somewhere? Because there are some states where, with meager resources, you might have one person focused on aging.” A recurring theme across interviews was the recommendation of needing to build relationships and strengthen cross-sector partnerships to address those challenges to implementing interventions to support aging in place.

Local, state, national, and federal partners. An emphasis was placed in many interviews, particularly those focused on chronic disease or injury, on clinical health care partners. Partnership with health care partners was frequently centered around the screening, assessing, referring, or caring for patients. As discussed previously, understanding the relevant risks at an individual- or population-level was key to connecting people to the appropriate clinical health programs and services for some health conditions. Health care partner sites that were mentioned include primary care, hospital-based providers, Federally Qualified Health Centers (FQHCs), and public health departments. SMEs also mentioned a ranges of specific health care providers who might be engaged in this effort, including doctors, nurses, optometrists, ophthalmologists, pharmacists, and emergency medical services (EMS). One SME said, “another emerging area that we’re trying to look at and evaluate is EMS and community paramedicine in the community…EMS a lot of time gets called to a house to pick somebody up after a fall, and the person never gets transported, but a huge number of calls are for this. So they’re in a good position to identify people who need medical assessment for falls risk reduction and treatment.” Thus, although clinical health care was a frequent topic of discussion for SMEs, none recommended relying exclusively on traditional primary health care providers. Several SMEs mentioned the potential for valuable data linkages within the health care system and between health care and non-health care settings, to better identify individuals who need specific interventions or services.

Another theme regarding partnering with health care was the suggestion of the variety of ways to help people access the health care system, including community health workers, social workers, community paramedicine, and online screening tools. Relying on community health workers and community paramedicine for assistance within their scope of practice might also help address the workforce shortage in health care fields, according to the SMEs. Non-health care Page 29

partners were also suggested for the potential to maximize reach, tailoring, uptake, retention, and overall sustainability and success of interventions. As one SME explained, “We recognize delivery organizations of all types to offer this program in all kinds of settings. It can be taken to settings in the community. It can be taken to senior centers. It can be taken to assisted living or active senior communities. All those kinds of settings are absolutely appropriate and possible.”

Other organizations, such as local and state government, tribal, and nonprofit organizations were also highlighted by several SMEs in facilitating increased capacity for aging in place and avoiding or delaying transitions to institutional settings. Government and nonprofit organizations were identified often, and included the Area Agencies on Aging, groups focused on caregiving, faith-based organizations, the Alzheimer’s Association, senior centers, neighborhood and professional associations, and transportation and land use planning departments. Drawing on the capacity and expertise of those and other on-the-ground organizations was suggested as an enabling factor for HUD and others to be positioned to accomplish desired goals. Partnering with community organizations and service providers to offer onsite services in HUD-supported housing sites was shared by SMEs as an approach to increase awareness, and access to supports for older adults and their caregivers.

Finally, as SMEs considered HUD’s role, they also thought about other federal partners that should be included in the project, in addition to CDC. Specifically, SMEs identified the Environmental Protection Agency, Department of Transportation, and several agencies within the Department of Health and Human Services, including the Administration for Community Living, the Housing and Resources Service Administration, the Substance Abuse and Mental Health Services Administration, and the National Institutes of Health.

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GLOSSARY OF ACRONYMS

ACL: Administration on Community Living

ADBI: Aging and Disability Business Institute

CDC: Centers for Disease Control and Prevention

CHR&R: County Health Rankings and Roadmaps

CMS: Centers for Medicare & Medicaid Services

EMS: Emergency Medical Services

GHPC: Georgia Health Policy Center

HHS: Department of Health and Human Services

HRSA: Human Resources and Services Administration

HUD: Department of Housing and Urban Development

IAA: Interagency Agreement

IWISH: Integrated Wellness in Supportive Housing

MME: Medicare/Medicaid (“dually eligible”) Enrollees

MCBS: Medicare Current Beneficiary Survey

NCOA: National Council on Aging

NNPHI: National Network of Public Health Institutes

OADPS: Office of the Associate Director for Policy and Strategy (now Office of Policy, Performance and Evaluation: OPPE) OPAPH: Office of Policy Analytics and Population Health (now Policy Analysis and Engagement Office; PAEO) OPPE: Office of Policy, Performance, and Evaluation

PIC: Public and Indian Housing Information Center

PIH: Public and Indian Housing

SAMHSA: Substance Abuse and Mental Health Services Administration

SME: Subject matter expert

STEADI: Stopping Elderly Accidents, Deaths, and Injuries

TRACS Tenant Rental Assistance certification System

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Document Outline

Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community, April 2023

TABLE OF CONTENTS

EXECUTIVE SUMMARY

Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community

Context for the Evidence Review

Older Adults, Poverty, & Health

HUD-Assisted Older Adult Population and Services

Project-based programs

Tenant-based program

Multifamily Housing Programs

Office of Healthy Homes and Lead Hazard Control

METHODS

Literature Review and Environmental Scan

Review of Systematic Evidence Reviews

Interviews with CDC Subject Matter Experts

Older Adult Health Data Analysis: Identifying Health Condition Predictors of Housing Transitions

RESULTS

Literature Review and Environmental Scan

Review of SystematicEvidence Reviews

SME Insights about the Interventions with Systematic Review Evidence

Older Adult Health Data Analysis: Identifying Health Condition Predictors of Housing Transitions

Synthesis of Results from the Four Methods: Avenues for Potential Evidence-Based Action

DISCUSSION

Avenues for Potential Action to Improve the Health of Older Adults Served by HUD Programs

CONCLUSIONS

REFERENCES

APPENDICES

APPENDIX A. STATEMENT OF WORK: AGING IN PLACE JOINT STUDY WITH HHS

APPENDIX B. CDC SUBJECT MATTER EXPERTS SEMI-STRUCTURED INTERVIEW GUIDE

APPENDIX C. :CDC SUBJECT MATTER EXPERTs (SMEs) INTERVIEWED

APPENDIX D. CDC SUBJECT MATTER EXPERT (SME) INTERVIEW SUMMARY

GLOSSARY OF ACRONYMS

Table of Contents

Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community, April 2023

TABLE OF CONTENTS

EXECUTIVE SUMMARY

Evidence-Based Actions to Help HUD-Assisted Older Adults Remain Healthy and Age in Their Community

Context for the Evidence Review

Older Adults, Poverty, & Health

HUD-Assisted Older Adult Population and Services

Project-based programs

Tenant-based program

Multifamily Housing Programs

Office of Healthy Homes and Lead Hazard Control

METHODS

Literature Review and Environmental Scan

Review of Systematic Evidence Reviews

Interviews with CDC Subject Matter Experts

Older Adult Health Data Analysis: Identifying Health Condition Predictors of Housing Transitions

RESULTS

Literature Review and Environmental Scan

Review of SystematicEvidence Reviews

SME Insights about the Interventions with Systematic Review Evidence

Older Adult Health Data Analysis: Identifying Health Condition Predictors of Housing Transitions

Synthesis of Results from the Four Methods: Avenues for Potential Evidence-Based Action

DISCUSSION

Avenues for Potential Action to Improve the Health of Older Adults Served by HUD Programs

CONCLUSIONS

REFERENCES

APPENDICES

APPENDIX A. STATEMENT OF WORK: AGING IN PLACE JOINT STUDY WITH HHS

APPENDIX B. CDC SUBJECT MATTER EXPERTS SEMI-STRUCTURED INTERVIEW GUIDE

APPENDIX C. :CDC SUBJECT MATTER EXPERTs (SMEs) INTERVIEWED

APPENDIX D. CDC SUBJECT MATTER EXPERT (SME) INTERVIEW SUMMARY

GLOSSARY OF ACRONYMS