Service Coordination Partnership Toolkit: Housing Providers

Many older adults and people with disabilities living in federally-subsidized housing and other homes have unmet needs and require services and assistance that property owners or housing managers cannot identify or effectively coordinate. Service coordinators help with this challenge. They coordinate the provision of supportive services to help individuals age in place and delay or avoid the need for higher levels of care, such as assisted living or skilled nursing. 

To learn more about service coordinator programs that housing providers can implement, the HSRC interviewed housing partners from four cross-sector partnerships developed to increase community access to robust service coordination programs. 

The case studies demonstrate how on-site service coordination is an effective and efficient way to reach older adults and people with disabilities and connect them to the supportive services they need. They illustrate how service coordination can help prevent crises, hospitalizations, and transitions to higher levels of care through prevention and early intervention.  

When offering service coordination, housing providers should consider the following themes and lessons learned from these case studies. 

Keys to Service Coordination Program Implementation Success  

• Emphasize person-centered planning and coordination. All the housing case study organizations use comprehensive assessments to understand each individual's priorities, needs, and goals. Then, develop customized support plans that respect personal preferences and promote self-management.  
• Build trusting relationships with individuals residing on-site. Conduct regular, proactive outreach to all older adults and people with disabilities on campus, not just those formally enrolled in programs. 
• Coordinate with the local housing team. Regular meetings between the service coordinator and other on-campus staff will help to identify and address problems early.  
• Invest in the workforce. Positive outcomes are tied to the quality of the service coordination. Hire staff with strong interpersonal skills, problem-solving abilities, and a commitment to person-centered approaches. Then, invest in ongoing training, supervision, standardized procedures, and tools.  
• Focus on prevention and whole-person health. Provide nutrition assistance (congregate meals, home-delivered meals, food pantries, and produce distribution), fitness classes, falls prevention, chronic disease self-management, and social connections services. These will help older adults and people with disabilities remain safely at home. 

Critical Community Partnerships 

• Develop extensive community partnerships. Each housing case study organization cultivates relationships with many community organizations to bring additional services and programming. Examples include food banks, aging and disability resource centers, benefit enrollment centers, health care providers, assistive technology programs, disability network organizations (e.g. centers for independent living, university centers for excellence in developmental disabilities, and state councils on developmental disabilities), aging network organizations (e.g. area agencies on aging, senior centers, and councils on aging), and transportation.  
• Leverage partnerships with community organizations to bring programs and services to the campus, such as nutrition assistance, assistive technology, social engagement, technology use classes, and transportation services. The complexity of serving older adults with behavioral health issues, chronic conditions, and multiple service needs require service coordinators to develop strategic partnerships and interdisciplinary approaches.  
• Create pathways for health care providers to bring services to campus. All  four housing case study organizations connect service coordination with health care through partnerships with health plans, primary care providers, hospitals, and specialty care clinicians. These partnerships improved older adults’ access to health screenings, vaccination clinics, and chronic disease management classes, and some enabled a nurse or wellness coordinator to be routinely on site. Care coordination contracts with health partners can be another way to provide more intensive assistance to eligible individuals. 

Funding Flexibility and Sustainability 

• Do not leave service coordinator-specific funding on the table. Take advantage of program-specific service coordinator funding including the U.S. Department of Housing and Urban Development’s (HUD) Service Coordinator in Multifamily Program grants. Make sure to include service coordinator funding in each property’s operating budget as allowed by the funding authority. 
• Maximize other funding options. Expect to braid funding from multiple sources to supplement the program, especially at start up. Each case study organization uses multiple funding sources including HUD’s Service Coordinator, operating budgets, health plan contracts, philanthropic support, and state and local programs to sustain and expand service coordination.