Conducting a Needs and Assets Assessment for Older Adults Experiencing Homelessness

This toolkit is designed to guide stakeholders seeking a data-driven understanding of the needs of older adults experiencing homelessness in their community. The materials also provide a roadmap for conducting a scan of the existing resources and assets that can be leveraged to meet the health and housing needs of this population.

The content within this toolkit is the culmination of a process designed and led in partnership with the California Health Care Foundation, Community Solutions, Hc2 Strategies and Kerry Abbott to illuminate the needs of this population within Sacramento City and County, CA, as well as the extant assets and resource gaps to support older adults experiencing homelessness in getting their healthcare and housing needs met. 

This toolkit is designed for Continuums of Care, local governments, physical and behavioral healthcare providers, and housing and service providers seeking to collaborate to meet the needs of aging adults. We recognize that each community has its own nuances, unique policy landscape, levels of collaboration, and system(s) strengths. Still, there are tools enclosed that can be adapted for use in a project designed to understand the need, leverage current resources and advocate for additional resources to address the needs of older adults experiencing homelessness in any locale. 

This work is more timely and critical than ever before, as people aged 50 and older are the fastest growing segment of the population of people experiencing homelessness in the United States (cite Benioff). Additionally, the population of people experiencing homelessness in the United States is disproportionately comprised of Black, African American, and Indigenous people, making this work a critical component of healthcare and racial equity (HUD). To develop a comprehensive, strategic vision for meeting the needs of our older neighbors experiencing homelessness, a community should review this toolkit holistically to understand the work lanes and the steps within each. This toolkit does not need to be used linearly; rather, we invite communities to assess their current state and focus on the areas of the toolkit that are most useful in moving a community forward in this work. Please think of this toolkit as a menu of options your community can select from when working to develop a strategic plan for addressing the health and housing needs of older adults experiencing homelessness.

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Environmental Scan of Enabling Conditions

How to use this tool

Use this guide to map your local landscape before launching a collaborative effort. Complete each section to identify key stakeholders, assess current connections and gaps, and plan outreach. Refer to the linked templates to document your findings and build a shared understanding of your community’s readiness to address older adult homelessness.

Why this matters

When embarking on any collaborative process to address a complex problem in your community, the first important step is to have a concrete understanding of the current environment in which you will be operating. This environmental scan will lead to:

1. A stakeholder map of who is currently holding a “piece of the puzzle”, what work they are currently undertaking, and their level of connection to and collaboration with other stakeholders working on a similar topic area.
2. An understanding of the current strengths and areas of improvement for collaborating across the multiple systems and stakeholders that currently work or are well-positioned to work with this population. 

This environmental scan provides a foundation for assessing needs, resources, gaps, and opportunities to support older adults experiencing homelessness. 

What to complete

1. Identify the initial stakeholders you will engage in your effort. The ideal set of stakeholders will likely include:
   • The Continuum of Care (CoC) lead agency
   • The Homelessness Management Information System (HMIS) administrator [if not the same as the CoC lead agency]
   • Homelessness response community-based organizations (shelter, street outreach, housing providers)
   • Major health systems (specifically those with hospitals and Emergency Departments (EDs))
   • Major behavioral health providers (specifically those offering home and community-based services)
   • Other healthcare providers (Medical Respite/Recuperative Care programs, Federally Qualified Health Centers [FQHCs], street or mobile medicine teams)
   • Adult Residential Facilities [skilled nursing facilities, board and care facilities}
   • Local government (city and county behavioral health departments, older adult resources and services departments)

When creating your list of stakeholders, it is critical to consider an equity lens. The purpose of creating a collaborative approach is to build a coalition of stakeholders that can represent older adults experiencing homelessness and their needs across demographic categories like race, ethnicity, sexual orientation, and gender identity. 

2. Conduct a stakeholder analysis to understand different stakeholder perspectives and positions for working collaboratively to address the health and housing needs of older adults experiencing homelessness. These are the stakeholders identified in your system design map that you would like to include in this collaborative effort. The goal is to understand how each of these stakeholders enables or influences progress. 

3. Draft initial outreach to stakeholders to explain the project you are proposing. This initial outreach can be tailored to specific stakeholders based on their position within our community and your understanding of their strategic mission.

Defining Your Problem With Data

Why this matters

Data-driven approaches are powerful and compelling. When reviewing the current state of older adult homelessness in your community, including available resources and gaps, your community should aim to use both qualitative and quantitative data. Using data to define your problem grounds your engagement and advocacy efforts in the reality of older adult homelessness in your community. While there are national resources to draw from (see below), it is critical to supplement these findings with local data that helps further refine the scope of older adult homelessness, the resource landscape, and the gaps to fill through advocacy and resource creation. 

What to complete

1. Define your target population
   • We recommend defining the population of focus as older adults experiencing homelessness, specifically those aged 55 years and older.
   • This data set can and should be reviewed to understand the critical needs of this population within three key domains:
     • Housing Needs
     • Physical Health Conditions/Needs, including needs around activities of daily living and built environment needs
     • Behavioral Health Conditions/Needs
2. Plan your learning questions
   • Before considering the specific datasets you will review to understand the needs of the population, define a set of learning questions to guide your data collection and analysis efforts. Consider the following learning questions when beginning your work to request data from stakeholders:
     • What is the scale (total number) of people who are older adults experiencing homelessness in your community?
       • If your community has data that is collected more regularly than the Point in Time (PiT) Count, for example, a by-name dataset updated on a regular basis, use this. 
       • If your community does not have data that is regularly captured more frequently than the PiT Count, use your PiT data.
     • What specific physical health needs are represented within this population?
     • What insurance coverage do older adults experiencing homelessness have (Medicare, Medicaid, dual coverage, uninsured)?
     • What specific behavioral health (substance use and mental health) needs are represented within this population?
     • What are the insights, perceptions, and stories from people experiencing homelessness, frontline service providers, middle managers, and executives in working to meet the needs of this population?
     • What proportion of the older adult population is experiencing unsheltered, sheltered, or a combination in a given year? 
     • What proportion of the older adult population is experiencing chronic homelessness?
     • Where is this population engaging with services in the homelessness response, physical health, and/or behavioral health system?
3. Identify initial key datasets
   • When approaching a needs analysis, it is necessary to identify the types of data that can illuminate the needs of older adults experiencing homelessness. This data should be both qualitative and quantitative. In some instances, a dataset may currently exist to help answer learning questions. In other instances, your team will collect primary data. This is most commonly used for qualitative data. However, primary quantitative data collection can be conducted if there are gaps between the data that would help answer learning questions and the data that currently exist.
   • In addition to identifying datasets to be used in a needs analysis, it is important to explore the current data-sharing landscape, which can either enable or discourage data sharing. It is useful to leverage existing data-sharing pathways to obtain datasets. This data can be de-identified and/or aggregated, depending on privacy considerations and the comfort level of the stakeholders being asked to share data to answer learning questions.
   • Consider the following key datasets:
     • HMIS data for older adults experiencing homelessness.
     • Electronic Health Records (EHR) data on older adults experiencing homelessness.
       • EHR data can be analyzed by age and housing status if that information is regularly collected. 
       • In an EHR, for example, there may be a record of a Social Determinant of Health (SDOH) screening that denotes housing status. 
       • Some EHR records may contain the ICD-10-CM diagnostic code Z59.0 (unspecified homelessness), Z59.01 (sheltered homelessness), and/or Z59.02 (unsheltered homelessness)
       • In some instances, documentation of housing status may be captured in note form in a client’s medical record.
       • If the EHR data does not include information on someone’s housing status, this data can be cross-referenced with data from the homelessness response system to understand which older adults from an EHR data set are experiencing homelessness. Please see the documentation of existing data sharing pathways and the data sharing toolkit for more information on how to share data for this type of analysis.
     • Managed care organization (MCO) data on housing, physical, and behavioral health needs, as well as service utilization from billing data.
       • If a dataset from a managed care organization includes ICD-10-CM diagnostic codes for homelessness, filter your dataset to reflect individuals with these codes.
       • A dataset from an MCO may also include information about service utilization for things like housing and case management supports, which can also be used as a proxy measure to indicate if an individual in the dataset is experiencing homelessness or housing instability.
       • If it does not contain the ICD-10-CM codes for homelessness or utilization data that indicates services for housing stability, this data can be cross-referenced with data from the homelessness response system to understand which older adults from an MCO data set are experiencing homelessness. Please see the documentation of existing data sharing pathways and the data sharing toolkit for more information on how to share data for this type of analysis.
     • Qualitative information from frontline workers, middle managers, and executives in the healthcare, behavioral health, older adults, and homelessness systems. In the absence of a “system” for each of the listed domains, identify key organizations and governmental departments that work with older adults.
     • Qualitative information from older adults experiencing homelessness in your community.
4. Document Existing Data Sharing Pathways: Assess whether the organizations and stakeholders that hold relevant datasets can share information. First, determine whether publicly available data is available to review. Then inventory any existing data-sharing agreements and their scope. If you aren’t aware of data sharing agreements, include that question in early conversations with key potential collaborators in this effort.
5. Request Data: Requests can be made to various partners based on the information documented in the data-sharing matrix. 
   • Include discussions of data and data-sharing requests in partnership engagement conversations.
     • These discussions should outline:
       • The purpose of the data request 
       • How the data will be used
       • How sharing data will contribute to strengthening partnerships in the short and long term
         • Building shared accountability
         • Strengthening a shared understanding of needs in the population
         • Enabling collaborative advocacy for additional resources, policy changes, etc.
   • Document any next steps. 
   • Be sure your data request includes demographic information to enable assessment of over-representation based on race, ethnicity, gender, sexual orientation, or other identity categories.
6. Analyze Data: Return to your learning questions to guide your data analysis planning.
   • Ensure the datasets are representative of your target population by age and housing status. 
   • Examine the prevalence of specific physical and behavioral conditions and note which are most prevalent.
   • Identify which locations (emergency departments, shelters, housing providers, day centers, clinics, etc.) people within this population are accessing.
   • Look for themes in qualitative interviews that either affirm or depart from quantitative findings. 
   • Define common archetypes of need by looking for characteristics that illustrate profiles of typical clients.  

Obtaining datasets and analyzing them requires flexibility. Datasets may be missing important information on housing status and/or physical and behavioral health needs. Data sharing may have to occur in an aggregate form, de-identified, or not at all. These are typical challenges a community may experience. And, learning about limitations around data completeness and data sharing opens up the opportunity to discuss data optimization, like working with health care partners to use SDOH screening and Z Codes, or building will and advocating for one-time or consistent data sharing to better serve this population of vulnerable older adults. 

Resources

Asset Mapping

Why this matters

Older adults experiencing homelessness (OAEH) may intersect with and need services from multiple systems that are not connected, such as homeless response, behavioral health, substance use disorder, palliative care, hospice, and older adult services. Understanding the existing continuum of services and what is available for the population can help providers quickly connect to potential supports to meet complex needs.

The System of Care asset mapping was developed by HC2 Strategies as a framework to support providers in building this cross-sector knowledge and identifying partners for delivery. System of Care asset mapping can also be a helpful step before designing new services, as existing resources are captured and gaps in services for the community are identified.

What to complete

Use the tools linked below to map existing resources across your community’s homeless response, older adult,  palliative care, and hospice systems. Identifying the organizations providing services in each category can assist in:

• Identifying partners for service delivery
• Identifying resources to meet client needs
• Identifying what gaps exist in the community to consider for strategic planning and new resource development

Who to engage

In the toolkit linked below, you will find internet and AI search suggestions for capturing resources. After initial research is captured, interviewing key organizations and individuals helps complete the map. In the toolkit, you will find suggested stakeholders to interview to garner the most comprehensive results. 

Holding a community meeting with key stakeholders to validate and add to the map can be helpful. Organizations change frequently across sectors, and some with active websites may no longer provide services. The final step in capturing community wisdom is important for an accurate, comprehensive map.

Key stakeholders to consider in the interview process include:

• Experienced Homeless Continuum of Care partners
• Experienced Emergency Department and Hospital Inpatient Case Managers
• City and County experts focused on Older Adult services and homelessness
• Healthcare for the homeless providers (FQHC case managers, Mobile Healthcare providers)
• Area Agency on Aging providers
• Partners focused on the local Master Plan on Aging Services
• Managed Care Plan partners focused on Older Adult Services

Assets to Leverage

Once the map is complete, review it to identify what services are strong in the community. It is common for community members to have an “a-ha” experience when viewing the completed map, as there are resources they were unaware of, even as experienced providers. Use the map to identify what resources could be accessed for clients in the community. 

Assets to strengthen

The map can also be used to identify areas with low service density or limited service provision. Consider what additional investment or technical assistance is needed for existing resources before building new services.

System gaps

In the final step, use the map to identify clear gaps in the system of care services to determine the focus for development of new resources. The categories in the map are based on national best practices in delivery and can spark conversation about assets the community has not yet developed to meet client needs.

How to do it

1. This guide provides detailed guidance on conducting an asset map in your community. 
2. This folder contains resources to support building your own asset map, including a how-to document and resources that can be used to document assets and summarize information in a slide presentation. Please read the ‘how-to guide’ first.

Relationship Building and Engagement

Why this matters

This cross-sector work requires healthcare and community-based providers to build and sustain partnerships with one another and with people with lived experience of homelessness. 

Forging meaningful collaborations between healthcare institutions and community-based organizations helps build a comprehensive ecosystem of care, enabling coordinated access to housing, mental health, substance use treatment, and other essential social services. Working in partnership builds care pathways that promote a more holistic system of care and foster a better understanding of the health outcomes of people experiencing homelessness at the population level. These partnerships can also identify and begin to fill gaps at the community level to support a more equitable system of care.

What to complete

Please see the “Environmental Scan of Enabling Conditions” Section for guidance on selecting partners and stakeholders to invite to this project. Once you have completed a system map and  stakeholder analysis with identified next steps for initial engagement, you should begin to communicate with your partners. See the resources for sending an initial email and a project one-pager to guide your process.

If one or more of the identified partners collect data that would be useful for analyzing the needs of older adults experiencing homelessness in your community, review the section “Defining your Problem with Data” to ensure you have completed the steps to plan for communications around obtaining and analyzing this data.

Once you have identified your ideal set of stakeholders to participate in this project and begin to communicate with them, be prepared to share how you will convene partners involved in this project.

1. Create a project management plan that includes regular touchpoints for the key stakeholders you have invited to participate.
   • This project management plan can include:
     • Key project milestones with target completion dates
       • Stakeholders Engaged and Committed
       • Needs Data Collection Complete
       • Needs Data Analysis Complete
       • Assets Mapping Data Collection Complete
       • Assets Mapping Data Analysis Complete
       • Final Presentation with Findings and Recommendations Complete
       • Final Presentation with Findings and Recommendations Delivered to Stakeholders 
       • Convene Stakeholders for Strategic Planning around Implementation of Recommendations
     • Tasks that must be completed to achieve key milestones with target completion dates
2. Develop a plan for regular meetings with key stakeholders to check in on progress, problem-solve around task completion, and maintain regular communication across partners.
   • Propose meeting on a biweekly basis for 60 minutes
   • Use a scheduling tool like a Doodle Poll, Calendly, or other tool to offer times to key stakeholders to identify a regular meeting time
   • Send a calendar invitation for recurring meetings with dial-in details for virtual meetings or with location information for in-person meetings
3. Plan for initial partner meeting
   • Prepare a short presentation or other materials to offer a high-level overview of the project
   • Create an agenda that includes:
     • Intentional space for connection amongst partners to build a foundation of trust and collaboration
     • Review the draft project plan with a request for partners to offer feedback and revisions before the next biweekly meeting
     • Request that partners share ideas of stakeholders that need to be kept informed of the project’s progress, who are not part of the key stakeholder group
4. Develop Key Talking Points and Plan for Ongoing Communication with Partners or Leaders outside of Key Stakeholder Group
   • Develop a one-pager or short slide deck that includes shared messaging:
     • Motivation for the project
     • Goal of the project
     • Current Status
     • Timing of Regular Updates
   • Share this plan with key stakeholders for review and approval
     

As the organization or department that acts as a backbone entity for this project, you can anticipate needing to perform the following functions:

1. Convene regular key stakeholder calls
2. Develop agendas, facilitate meetings, document notes, and next steps
3. Plan for and convene regular communications about the project with Partners and Leaders outside of the key stakeholder group
4. Provide ‘in between’ or ‘just in time’ support for requests from key stakeholders and other partners, including one-off meeting requests and answering questions

It is a best practice to identify staff within your organization or department who will be assigned to perform these functions. 

1. Data obtained  [Engagement plans and shared messaging tools.]

Tips and strategies for engaging new partners or strengthening existing ones:

• Add to the community-wide mechanism for multi-stakeholder flexible funding, to incentivize achieving and sustaining an end to homelessness 
• Develop internal policies and practices to align the allocation of Community Benefit, foundation, and/or Corporate Social Responsibility funds with the strategic goal of eliminating chronic homelessness.
• Conduct regular partner meetings 
• Use storytelling and co-created visuals
• Design liaison roles focused on the intersection of homelessness and healthcare within each system. 
• Start looking at cross-referenced data across systems to explore commonalities, such as populations known to both systems and outcome metrics.
• Select one project that engages both systems and grow from there. 
  • Cross-Sector Case Conferencing is a project that clearly defines the roles of homeless response systems and healthcare partners, facilitating partnership, shared goals, and exchange of information.

How to do it

Pilot sites expressed that sustaining these partnerships to boost capacity into the future would be easy, as they had successfully built commitment and knowledge that no one sector can do it alone. However, health systems representatives from a couple of sites raised questions about the sustainability and scalability of staffing arrangements and whether policy changes would be necessary to continue system-level work.

Some of the enabling conditions for partnering in cross-sector coordination: 

• Having a common vocabulary — “get rid of acronyms so we know what we’re saying to each other!”
• Trust and open communication to build commitment and alignment on priorities from both sides.
• A strong gaps analysis, preliminary data, and vision from the CoC lead agency help shift the focus to system-level strategy, investments, and sustainability instead of programmatic work.
• Precedence of joint funding among health systems.

Resources

Capacity Building

Why this matters

Building cross-sector competency to meet the needs of OAEH requires a 360-degree approach to build skills in each sector that speed resolution of challenges experienced by OAEH..

Some common areas by sector are included below:

How to do it

Training & Technical Assistance

Implementation Guidance: Articulating the Need and Solutions

Why this matters

The work your community has done to complete a needs assessment and asset mapping activity is meant to influence a second phase of work focused on implementation, advocacy, and improvement. 

Resource Library

Templates & Checklists

Ready-to-use tools for asset mapping, stakeholder engagement, data collection, etc

Reference materials

Reports, case studies, policy briefs, or successful models from other places.

• Dashboard – My courses – Start course | Center for Learning – National Alliance to End Homelessness
• Center for Learning – National Alliance to End Homelessness – Store
• Supporting Older Adults Experiencing Homelessness | HHRC
• Training – Homeless Training
• Older adults – National Health Care for the Homeless Council