Supportive Services that Make Community Living Possible (2024)

Many older adults and people with disabilities need help with the daily tasks of life. For some people this is physical help such as help with dressing and eating. For others, it is help with making decisions and planning. Still others require a blend of supports. Each person is unique, and the help they may need is unique, as well. The services they receive, therefore, also should be unique — they should be planned in accordance with the preferences and priorities of the person receiving them, and provided in a way that fits that person's life.

Supportive services provide assistance with everyday activities and help make it possible for many people with disabilities and older adults to live in their chosen housing environments and participate in their communities. Meals, transportation, personal care assistance, housekeeping, case management, wellness checks, tenancy support, and care coordination some examples of services that help people thrive in their communities.

Access to needed services is a key component of making a person's home, and their community, accessible, so there is clear benefit to improving coordination and collaboration between the housing, aging and disability, home and community-based services, homelessness services, and health sectors. Such partnerships can bring community living and health services to rental properties, remove barriers so services are easier to obtain, make homes more accessible, fill vacancies with renters who have housing vouchers, and more.

Emerging Partnerships and Opportunities

The links below provide information about some new or recently modified programs available that support community living with access to voluntary services. By learning about these programs, you can begin to identify opportunities to collaborate with other sectors to help people access services that support housing stability, health, and independence.

• ADvancing States Analysis of State American Rescue Plan Act (ARPA) Plans: analysis of state plans for using the increased Federal Medial Assistance Percentage (FMAP) for Medicaid home and community-based services
• American Rescue Plan Act of 2021 (ARP) Section 9817: data and descriptions in these presentation slides reflect details on State Spending Plans for the first quarter of Federal Fiscal Year 2023
• Community Mental Health Services Block Grants (MHBG): website about this program, for community-based mental health services to assist adults with serious mental illness and children with serious emotional disturbance
• COVID-19 Resources for the Aging and Disability Networks: website with programs, promising practices, guidance, and funding for the aging and disability networks related to services offered as part of the COVID-19 response
• COVID-19 Stimulates New Housing and Services Partnerships for People with Disabilities and Older Adults: brief with an overview of housing-related challenges during the pandemic, new opportunities with federal resources, and partnerships that are making a difference
• Implementation of American Rescue Plan Act of 2021 Section 9817: Additional Support for Medicaid Home and Community-Based Services during the COVID-19 Emergency: letter to state Medicaid directors with guidance on how states can receive enhanced funding to increase access to home and community-based services (HCBS) for Medicaid beneficiaries
• Money Follows the Person: website about this program in which, states can provide Medicaid beneficiaries who choose to move from nursing homes to housing in the community with the services they need for independent living
• Opportunities in Medicaid and CHIP to Address Social Determinants of Health: letter to state health officials on opportunities under Medicaid to better address social determinants of health in programs design, benefits, and services
• Substance Abuse Prevention and Treatment Block Grants (SABG): website about this program to support and expand the full continuum of substance use disorder services, including prevention, treatment, and recovery
• Summary of Key Provisions of the Home and Community-Based Services (HCBS) Settings Final Rule: fact sheet with summary of regulatory requirements that HCBS settings must meet for reimbursem*nt so that individuals in HCBS programs have access to the benefits of community living and receive services in the most integrated setting
• Unwinding of Policy Changes due to the COVID-19 Pandemic: guidance and resources for programs as they move from operations during the Public Health Emergency (PHE) back to normal operations

The Transitions Out of Institutions section has related information on housing choice vouchers, recent changes to the Money Follows the Person (MFP) program, and the enhanced federal funding available to states under the American Rescue Plan Act.

Solutions for Access to Services that Support Community Living

The links below provide information about evidence-based programs and practices to enhance access to voluntary services that support community living and health. You can use this information to identify opportunities to collaborate with other sectors to help people stay in or return to housing in the community.

See Also

Social Support Services - European Centre for Social Welfare Policy and ResearchGlossary: Ecosystem servicesWhat are the Three Levels of Servitization?HP Layoffs to Impact Up to 6,000 Workers Through 2025

• AAA Housing and Homelessness Programs and Partnerships: fact sheet on services, supports, and partnerships that area agencies on aging (AAAs) have created to address housing instability and homelessness
• ADvancing Equity for Older Adults Resource Guide: curated list of resources to address equity and systemic discrimination for older adults for for older adults and with examples of state and local-level resources
• Age-Friendly Inclusive Services: A Practical Guide to Creating Welcoming LGBTQ Organizations: profile of LGBTQ challenges for older adults and best practices for including LGTB older adults in programing
• Best Practices in the HCBS Settings Rule: Bringing HCBS to the 21st Century: webinar recording with an overview of the HCBS settings Rule promising practices and outcomes-focused tools
• Chronic Disease Self-Management Education Programs: website about evidence-based programs that provide people with disabilities and older adults with education and tools to help them manage chronic conditions
• Community Care Hubs: A Promising Model for Health and Social Care Coordination: report on existing community care hubs that contract with health care entities to provide services to address social needs related to health outcomes
• Comparing New Flexibilities in Medicare Advantage with Medicaid Long-Term Services and Support: Final Report: report with an overview of early implementation of the expanded supplemental benefits
• Evidence-Based Practices Resource Center: website with information and tools for communities, clinicians, policymakers, and others to incorporate evidence-based practices for prevention, treatment, and recovery support services for mental and substance use disorders in community or clinical settings
• Evidence-Based Programs: searchable database to promote health and prevent disease among older adults that are approved for funding through Older Americans Act Title III-D
• Falls Prevention: website about evidence-based community programs and services to reduce falls
• Health-Related Social Needs (HRSN) 1115 Framework: guidance clarifying an option states may consider employing in Medicaid managed care programs to reduce health disparities and address unmet HRSNs
• Healthy Aging with a Disability: website about healthy aging with a disability
• Innovations from the Field: Area Agencies on Aging (AAA) Housing and Homelessness Programs: report with case studies of AAAs and their partnerships to address housing stability
• Report to Congress Innovative State Initiatives and Strategies for Providing Housing-Related Services and Supports under a State Medicaid Program to Individuals with Substance Use Disorder (SUD) Who are Experiencing or at Risk of Experiencing Homelessness: report on the impact of SUD on Medicaid beneficiaries and the relationship between SUD and homelessness, along with profiles of five state Medicaid program and highlights of several local programs
• Service Coordination Partnerships Toolkit: HSRC toolkit for community and state leaders on forming cross-sector partnerships to expand access to service coordination
• Strategic Framework for Action: State Opportunities to Integrate Services and Improve Outcomes for Older Adults and People with Disabilities: report to support state efforts to 1) address the holistic needs of older adults and people with disabilities through program coordination and integration with health care financing and service delivery; and 2) support partnerships across health care and social service organizations to improve health care outcomes and lower costs by effectively addressing social determinants of health
• Strengthening Social Connection in Housing Communities: Innovative Approaches -- Webinar Recording: Commit to Connect hosted a webinar on social connection and housing among older adults and people with disabilities. View the slides or watch the recording.
• 30 Years of Community Living for Individuals with Intellectual and/or Developmental Disabilities (I/DD): digital book and video on the evolution of integration and inclusion of people I/DD in American society from 1987-2017, including supportive services that enable them to live in the community

Core Knowledge

The links below can build core knowledge about this topic or help you find networks of service providers who may be potential partners. To support action on enhancing access to services, also visit our collections of toolsandmodel practices and partnerships.

• ADvancing States - Person-Centered Approaches: Connecting Individuals to Services and Benefits: this brief describes person-centered approaches to gain understanding of an individual’s long-term services and supports needs and preferences to live the life they desire and value
• Aging and Disability Networks: website on local, state, and national organizations and committed advocates that support older adults and people with disabilities in living independently in the community
• Behavioral Health Treatment Services Locator: online services locator offering confidential and anonymous source of information for persons seeking treatment facilities for substance use/addiction and/or mental health problems
• Centers for Independent Living (CILs): fact sheet with an overview of CILs, including philosophy, core functions, and real-life examples of their impact
• Centers for Independent Living (CILs) Data Briefs and Maps: data briefs on youth with disabilities across counties in the United States to assist CILs and their partners in more effectively serving out-of-school youth with disabilities from minority backgrounds
• Community Health Workers: website on these frontline public health workers who help link health and social services to the community and improve the quality and cultural competence of service delivery
• Disability RAPP (Research Advocacy Policy & Practice), Disability and Housing: magazine issue discussing universal design, housing rights, the impacts of housing insecurity and more
• Finding Accessible Housing: tip sheet that shows how to find accessible housing to rent or buy with information about what to say to landlords or property owners, laws, housing definitions, and more
• Housing and Transportation: website with publications and training on housing and transportation services
• In-Home and Residential Long Term Supports and Services for Persons with Intellectual or Developmental Disabilities Status and Trends for 2017:report on residential service setting types, setting sizes, funding authorities, and expenditures for persons with I/DD
• Medicaid Housing-Related Services and Partnerships: website for technical assistance, information, and a toolkit from the Medicaid Innovation Accelerator Program
• Minority Aging: Statistical Profiles: set of reports with critical statistics on people aged 65 years and older: African Americans, American Indians and Alaska Natives, Asian Americans, and Hispanic Americans; reports include information about disability, household, income, residence, and participation in Older Americans Act programs
• New Opportunities to Expand Services Through Aligning Health and Social Care: Administration for Community Living (ACL) blog on new U.S. Department of Health and Human Services (HHS) policies and efforts to address health-related social needs
  • Call to Action: Addressing Health-Related Social Needs in Communities Across the Nation (HHS)
  • Coverage of Health-Related Social Needs (HRSN) Services in Medicaid and Children’s Health Insurance Program (Centers for Medicare & Medicaid Services (CMS)
  • The U.S. Playbook to Address the Social Determinants of Health (Domestic Policy Council)
  • Calendar Year (CY) 2024 Medicare Physician Fee Schedule Final Rule | CMS (CMS)
• No Wrong Door (NWD) Systems: A Guide to Fundamentals and Engagement for Community Organizations: issue brief that describes the fundamentals of the NWD System initiative in developing a resource hub and access point for long-term services and supports and benefits for states and territories
• Older Veteran Behavioral Health Resource Inventory: provides information on resources to help health and social service professionals support older veterans and other older adults who have or are at risk for behavioral health conditions
• Overview of Older Americans Act Title III Programs: 2018 Summary of Highlights and Accomplishments: report with information and insight on Older Americans Act (OAA) services, milestones, and impact
• A Place to Call Your Own: Housing for People with Intellectual or Developmental Disabilities (I/DD): article highlighting key findings from The University of Minnesota's most recent Residential Information Systems Project (RISP) report about the places that people with I/DD live
• Resources on Personal Assistance Services: website with links to guidebooks, toolkits, publications, and websites related to personal assistance services
• Service Coordinator Program: program information on social service staff that support HUD assisted housing as a platform for financial security, physical security, social connections, and the delivery of long-term community based supportive services
• State Strategies to Leverage Medicaid Managed Care Contracting for Investments in Health and Housing Alignment Report: this HRSA-funded toolkit provides examples of state Medicaid programs' innovative strategies with managed care contracts and policies to deliver housing supports and services.

Transportation

• ADA-PARC: website with a collection of public data sets on the status of people with disabilities at the national, state, county, and city levels in three main areas: community living, community participation, and work & economics
• Coordinating Council on Access and Mobility (CCAM): federal interagency council that works to coordinate funding and provide expertise on human services transportation for three priority populations: people with disabilities, older adults, and individuals of low income
• National Aging and Disability Transportation Center (NADTC): national technical assistance program that promotes the availability and accessibility of transportation service options for older adults, people with disabilities and caregivers
• National Center for Applied Transit Technology (N-CATT): a technical assistance center to provide small-urban, rural, and tribal transit agencies with practical, replicable resources that help them apply technological solutions and innovations
• National Center for Mobility Management (NCMM): a national technical assistance center to promote customer-centered mobility strategies that advance good health, economic vitality, self-sufficiency, and community
• National Rural Transit Assistance Program (RTAP): a program to address the training and technical assistance needs of rural and tribal transit operators across the nation, and support state RTAP programs. Technical assistance programs and resources including webinars, newsletters and technical briefs, research, and more are available
• Shared-Use Mobility Center: an organization dedicated to achieving equitable, affordable, and environmentally sound mobility across the U.S. through the efficient sharing of transportation assets
• Transportation Technical Assistance Coordination Library (TACL): a platform for access and findability of rural and tribal transit coordination resources across a diverse range of transportation technical assistance centers and the Federal Transit Administration (FTA)