National Church Residences illustrates the value of investing in high-quality service coordination and partnering with the community to support prevention.
National Church Residences, a national nonprofit organization, has one of the largest portfolios of U.S. Department of Housing and Urban Development (HUD) Section 202 affordable housing for older adults in the United States (along with other types of housing). The nonprofit serves more than 70,000 older adults in 360 communities in 23 states as of October 2025. Much of their portfolio consists of independent-living settings (apartments and detached homes), but they also operate assisted living, memory care, skilled nursing care, and permanent supportive housing.
National Church Residences believes that embedding a dedicated service coordinator within their residences offers the most effective opportunity for older adults to thrive as they age in place. By proactively coordinating services and addressing whole-person health needs, their service coordinators help reduce the risk of transitions to higher levels of care. The coordinators also engage community organizations in bringing comprehensive preventive care programming to campuses.
Over time, National Church Residences has scaled its service coordination program so it is available in over half of the buildings that they operate and manage. They also invested in program quality (see Quality Assurance and Training [LINK to that section on page 3 below]). As a result of these actions, more than 35,000 older adults have on-site service coordination from carefully vetted professionals with expertise in timely referrals and access to appropriate services. Further, the nonprofit has both housing and health care contracts to deliver service coordination at other affordable housing sites and to health plan beneficiaries, such as individuals transitioning home after a hospitalization.
According to National Church Residences’ internal review of health assessments conducted by their service coordinators in 2024, people living in their communities had these three top health concerns:
- 63% reported a diagnosis of high blood pressure.
- 33% reported experiencing chronic pain.
- 28% reported having diabetes.
During the same reporting year, less than 1% of older adults’ assessments indicated an unplanned hospitalization or emergency room-only visit. (For comparison, in the 2020 University of Michigan National Poll on Healthy Aging, 32% of adults age 65-80 reported an emergency department visit in the prior two years.) These data are an indicator that service coordination directly contributes to older adults’ improved health outcomes and stability.
Keys to Success
- Invest in high-quality service coordination with dedicated professionals and comprehensive training.
- Develop strategic community partnerships to access specialized expertise for complex situations and bring preventive care supports on campus.
- Leverage benefits enrollment coordinators to provide specialized assistance to older adults who may be eligible.
- Implement systematic quality assurance to ensure compliance and optimize resource accessibility.
Service Coordination Model
Service coordination is integral to National Church Residences’ goal to advance independence and well-being for all older adults as their needs change. The nonprofit has developed strict standards for the provision of service coordination and invests in both tools and its workforce. Its core service coordination practices are as follows:
- Build trusting relationships.
- Adhere to person-centered principles, including being responsive to each individual's priorities.
- Promote self-care and management.
- Analyze available data to address broad-based needs at a group level.
- Help navigate complex health care systems and provide educational and emotional support.
- Assist with coordination of public benefits, such as Medicaid and Medicare.
- Connect with local organizations to address older adults' needs.
- Collaborate, when individuals request, with other care managers who may be assisting those individuals.
Strategic Community Partnerships for Wellness
Service coordinators maintain comprehensive resource directories that prioritize community-based organizations. They actively research and build relationships with area agencies on aging (AAAs), neighborhood institutions, faith-based ministries, and grassroots organizations, which is considered a best practice for service coordination. This systematic approach creates responsive support networks that evolve as residential community needs change. When working with individuals, service coordinators use directories to generate a list of potential supports and providers and then discuss available options. Ultimately, each person chooses their provider based on their individual preferences and circumstances.
Given the complex care needs of many older adults, service coordinators also create opportunities for trusted community service partners to deliver care and programming directly within residential settings. Community members can then readily access comprehensive preventive care programs that support aging in place. Examples include free or low-cost health fairs, wellness clinics in which health care providers offer on-site health screenings and educational programming (such as for diabetes and hypertension), fitness classes, and other preventive care initiatives that provide medical and nutritional instruction or counseling. Other local partnerships may engage local food pantries to address food insecurity and community organizations to provide social engagement and recreational activities, financial literacy, and digital skills training.
Since 2019 in Ohio, National Church Residences has augmented service coordination through their Benefits Enrollment Center using Administration for Community Living funding. This program has a team of highly trained benefits enrollment coordinators who go to various community settings to help individuals connect with benefits that pay for health care, food, transportation, home weatherization, and more. These specialists can work more in-depth with older adults on benefits than service coordinators. In 2026, the nonprofit plans to incorporate the BenefitsCheckUp® tool into all service coordinator programs.
Preferred Provider Network
"Preferred providers" represents a distinct aspect of National Church Residences' approach that involves strategic partnerships with local organizations committed to delivering supportive services to older adults. Service coordinators carefully vet these organizations and designate select partners that demonstrate a commitment to meeting the comprehensive needs of older adults within the nonprofit’s properties as preferred providers.
To ensure the quality and safety of these partnerships, National Church Residences had its quality assurance team establish comprehensive vetting guidelines that verify provider credentials through resources such as Medicare.gov, the Better Business Bureau, and state attorney general offices. The due diligence process requires providers to obtain certificates of liability insurance, participate in collaborative meetings to review service expectations and confidentiality protocols, and execute formal preferred provider agreements that establish clear partnership parameters. This approach ensures that all on-site services are delivered by reputable, qualified partners who align with the organization's mission.
Quality Assurance and Training
National Church Residences has established a quality management framework that strives to support consistent, high-quality service delivery across all communities through both technology tools and systematic oversight. The framework has a set of 30 core standard operating procedures that address essential areas, including care planning, confidentiality protocols, community engagement, documentation standards, and volunteer utilization.
Service coordinators utilize the organization's internally developed Care Guide platform, which integrates evidence-based assessment tools that have been evaluated for non-clinicians (including Mini Cog© (cognition); Lubben Social Network (social engagement); STEADI (fall risk); and Short Michigan Alcoholism Test Geriatric Version. The platform generates risk scores based on internal algorithms and recommends appropriate next steps and services, while also producing the documentation required for HUD compliance and internal quality assurance processes.
The quality assurance team provides comprehensive training, ongoing support, and regular evaluation to maintain program fidelity and meet HUD standards. For oversight, each service coordinator receives a minimum of four comprehensive reviews annually, supplemented by monthly calls focusing on quality benchmarks and key performance metrics. This process ensures accountability and identifies both areas of strength and opportunities for improvement.
National Church Residences has also maintained Certified Organization for Community Resident Engagement and Services (CORES) certification since 2018, demonstrating adherence to the national framework developed by Stewards of Affordable Housing for the Future (SAHF). CORES Certification recognizes National Church Residences’ systematic approach to community member services through clear policies, data tracking systems, and person-centered quality measures. This external validation ensures consistency and accountability across National Church Residences’ 360 communities while providing a replicable model for other housing providers seeking to implement comprehensive service coordination programs.
Scaling and Sustaining Effective Service Coordination
National Church Residences uses a variety of HUD Section 202-related funding sources for service coordination at those types of housing sites. In its Low-Income Housing Tax Credit properties, the nonprofit funds service coordination through its operating budget. Even in buildings with modest service coordination coverage (e.g., a part-time position), National Church Residences ensures everyone can obtain a basic level of support.
National Church Residences has successfully expanded service coordination to more than half of the housing in its network. Three of its scaling strategies include delivering high-quality service coordination and documenting outcomes, cultivating top-level organizational support for service coordination, and using some funding from operational budgets.
In recent years, National Church Residences has also integrated digital skills navigation programming into some of its properties so that older adults can learn how to use technology to access health care, social activities, employment opportunities, and to pay rent. At some sites, the benefits enrollment team supports digital skills navigation, and at other sites, service coordinators take the lead. In post-program surveys, older adults report improved confidence and new ways to navigate health care, socialization, and even employment.
Learn More
- National Church Residences
- Benefits Enrollment Center, National Church Residences
- Bringing Service Coordination Home in Rural Ohio, LeadingAge LTSS Center @UMass Boston