A new free cross-sector toolkit helps community partners align on shared planning and action.

Across the country, a growing number of older adults are experiencing homelessness, many of whom are aging without stable housing after years, or even decades, of instability. Others lose housing later in life, often after a disruption such as the loss of income, the rising cost of housing, or the natural decline of support systems. Together, these older adults—including grandparents, retirees, and military veterans—are increasingly aging in shelters, tents, or cars, while facing complex health, behavioral health, and mobility needs that intensify over time.

Adults 50 years and older are the fastest-growing group of people experiencing homelessness. Recent reports cite growth from 20% to almost 50% of the unhoused population, and the numbers are predicted to double by the year 2030.

Despite the best efforts of health care, housing, aging services, public health, and community-based organizations, older adults experiencing homelessness are often forced to navigate systems that were never designed to work together. Without shared planning across sectors and a clear picture of local needs and assets, even these best efforts can feel fragmented.

HC2 Strategies and its partner Community Solutions were honored to collaborate with communities across the United States in developing a new free resource for the field, funded by the California Health Care Foundation: Conducting a Needs and Assets Assessment for Older Adults Experiencing Homelessness.

“As a provider, I’ve cared for older adults living outside or dying on the street, and designed systems to meet their complex needs,” says Lauran Hardin, MSN, CNL, FNAP, FAAN, HC2’s Chief Integration Officer and leader in the development of the toolkit. “When we come together across sectors with a deep understanding of our population and where we can better serve them, we can meaningfully change that experience for the elders in our community.”

A Practical Toolkit for Communities Doing the Work

The toolkit—hosted by Community Solutions, the lead organization on the project—was created for communities that want to plan their service delivery and coordination more intentionally. It offers guidance, practical tools, templates, and resources to:

• Understand the specific needs of older adults experiencing homelessness in your community
• Identify and build on existing assets and partnerships
• Bring health care, housing, aging services, and community organizations to the same table
• Turn assessment findings into shared priorities and next steps

It’s about helping communities ask the right questions—and use the answers to move forward together.

You can access the full toolkit here:
https://community.solutions/research-posts/conducting-a-needs-and-assets-assessment-for-older-adults-experiencing-homelessness/ 

Who This Toolkit Is For

This toolkit was designed to be specifically useful to those actively delivering and coordinating services for older adults experiencing homelessness, including:

• Continuums of Care and homeless service providers
• County agencies and regional collaboratives
• Health systems and managed care plans
• Aging adult service providers
• Community-based organizations and coalitions
• Funders and planners supporting population-level strategies

If your work touches aging, homelessness, health, or community well-being, this toolkit can help create a shared foundation for planning and implementation.

Turning Insight into Action

Good tools matter—but they’re only a starting point. What really makes a difference is how communities use them to build alignment, make decisions, and follow through.

HC2 Strategies partners with communities to move from assessment to action—supporting cross-sector planning, implementation, and long-term systems change.

If you’re thinking about how to apply this toolkit locally or want support strengthening collaboration across systems, we’d be glad to connect. Send us an email at info@hc2strategies.com, and we’ll partner with you.

Toolkit  Highlights

The toolkit provides a wealth of resources for community partners to assess needs and resources. Examples include:

System of Care Asset Mapping Guide: This guide in the toolkit provides guidance, content sources, and templates for mapping the system of care delivery for specific populations. It includes a dedicated section for older adults experiencing homelessness as well as sections for other populations with complex needs that many communities are coming together to serve:

• People experiencing homelessness
• People with serious illness and those at end of life
• People experiencing mental health conditions
• People experiencing substance use disorders
• People who are justice-involved
• Those experiencing inequities in maternal and infant health

Asset Mapping Instructions and Templates with Archetypes: Organizations and communities can use these tools to document resources, identify gaps, and think through the pathways of older adults experiencing homelessness.

Triage Pathway: This tool helps homeless response and health system partners quickly assess people experiencing homelessness for end-of-life, cognitive impairment, and other challenges and direct them to the right resources.

Related HC2 Strategies Publications

• Davis, V., Sandor, B., Arsenault, M., Chimowitz, H., and Hardin, L. (May 2024).  Health Care’s Role in Ending Homelessness. Health Affairs Forefront.  Health Care’s Role In Ending Homelessness | Health Affairs 1377/forefront.20240523.243875 https://www.healthaffairs.org/content/forefront/health-care-s-role-ending-homelessness
• Domlyn A.M., Scaccia J., Lewis N., Ebony Coleman S., Parry G., Saha S., Wandersman A., Ramaswamy R. The community transformation map: A maturity tool for planning change in community health improvement for equity and well-being. Am J Orthopsychiatry. 2021;91(3):322-331. doi: 10.1037/ort0000526. PMID: 34138626. https://pubmed.ncbi.nlm.nih.gov/34138626/
• Howard P., Lewis N., McPherson M., Reid A., Torres T. “Deep Dive: Basic Needs: Health Care.” In: Milstein B, Roulier M, Kelleher C, Hartig E, Wegley S (editors). Thriving Together: A Springboard for Equitable Recovery and Resilience in Communities across America. CDC Foundation and Well Being Trust; July 2020. https://www.ihi.org/library/publications/thriving-together-springboard-equitable-recovery-and-resilience-communities
• Kennedy, W., Hardin, L., Kinderman, A., Meier, D., Loughnane, J., Volandes, A. (February 2020). Five Strategies to Expand Palliative Care in Safety-Net Populations. New England Journal of Medicine Catalyst. https://www.insted.us/wp-content/uploads/2021/04/Article-1_NEJM-Catalyst-CAT.20.0004.pdf
• Mather, C., Hardin, L., and Arsenault, M. (November/December 2023). Improving Care for People Experiencing Homelessness. Healthcare Executive. 48-51. https://bit.ly/4rBfPxw