Stage Four: Partnership Implementation

As your partnership between your Area Agency on Aging (AAA) and Continuum of Care (CoC) moves beyond its initial stages, you may have accomplished one or two small goals following the steps in Stage Three. This stage provides both steps and strategies you can follow to implement your partnership in a more substantial way. 

Steps

• Create a joint strategy for addressing homelessness among older adults in your community and embed relevant facets in each partner’s planning documents.   
  • Tip: Implementation Strategies (below) can provide inspiration from existing AAA-CoC partnerships. 
  • Ensure aging perspectives are included in CoC planning processes and workflows. Examples include funding applications and strategic documents. 
  • Include homelessness or housing partnerships directly in AAA area plans. 
  • Assign specific steps or actions to specific organizational staff or volunteer leaders for accountability and direction.

• Seek sources of funding to expand your partnership and enhance its mission. 
  • Collaborate on seeking funding or in-kind support to advance your shared goals. 
    • ​Introduce your partnership to potential funders or in-kind resource partners. 
    • Integrate your partnership into funding applications and emphasize the synergy created through a coordinated approach across networks. 
    • Establish sub-agreements for funding, as relevant. 
    • Support your partners’ funding applications, as relevant. 
  • Share funding opportunities with partners even when not pursuing joint applications. 
  • Use your organization's funding to support shared goals when appropriate. 
  • Adapt to funding changes and maintain core partnership work even when specific funding ends. 
     
• Promote broader community engagement to address homelessness among older adults that reaches beyond your direct partner(s).
  • Educate community members proactively about the issue and potential solutions to establish an informed population base.
  • Consider bringing in a new partner like a health system, affordable housing provider or large business that gives back to the community. 
  • ​Tip: The CoC-AAA partnership in Southeastern Virginia did this by creating a coalition around older adults’ homelessness comprised of stakeholders from many service networks (referenced in Stage Three’s Putting It Into Action: Partnership Progression). 
     
• Strengthen your partnership as your work progresses. 
  • Refine your collaboration by evaluating what is working and identifying areas for improvement, especially with challenges related to how your organizations interact. 
  • Look toward the future as you make progress on your joint strategy. 
    • Decide what comes next, if your current strategy should evolve or if you need to add a new one. 
  • Discuss changes in your macro environment. 
    • Evaluate if you want to work together on new opportunities or challenges as they arise.  
       
• Tell other AAAs and CoCs about the work you’re doing together and encourage them to follow your lead! 

Implementation Strategies 
Current CoC-AAA partnerships have developed various strategies to address homelessness among older adults. They are grouped into three categories: Internal Organization and External Interface, Community Capacity and Macro Environment. 

Internal Organization and External Interface 

• Develop efficient ways to share information between organizations. 
  • Refine any communication mechanisms you may have started at an earlier stage. 
  • For AAAs, become a member of the CoC, and include the CoC in your advisory boards or committees. 
  • Review potential data-sharing options and discuss their pros and cons. 
    • Evaluate related rules and regulations.  
    • AAAs that are members of CoCs may have access to the Homeless Management Information System. 
    • Other options may include community information exchanges, shared spreadsheets, databases or apps that comply with privacy protections. 
    • Case conferencing involving both CoC and AAA can be helpful with complex situations. 
  • Consider using a joint consent form that allows individuals to approve sharing their information with one or more other specific entities, supporting bi- or multi-directional information exchange. 
    • AAAs can consider allowing CoCs to access to their data systems. 
       
• Share screening, assessment and possibly case management tools with each other (see Stage Two). 
  • Review to better understand processes across networks. 
  • Identify opportunities to strengthen each other’s standardized tools to account for challenges related to age and/or homelessness. Better documentation supports more accurate identification of assets and needs, which helps connect the person to available assistance programs and resources. 
  • For CoCs, review—and update as needed—standardized screening tools to account for age-related difficulties and ensure coordinated entry processes are age-friendly and accessible. 
    • Documenting age-related difficulties at an early stage can help get the AAA involved sooner. 
  • For AAAs, enhance screening for possible housing insecurity or homelessness during needs assessment. 
    ​
• Refine bidirectional referral pathways between organizations. 
  • Cross-train staff in each other’s organizations to support coordination. 
  • Bring together staff to discuss ways to improve, especially in the initial months. 
  • Effective communication will help make sure services can transition with clients as their situation changes. 

Community Capacity 

• Connect organizations in your networks with other providers who can collaboratively address needs or close gaps. 
  • Example: Matching aging service navigators to shelters, or housing navigators to nutrition providers. 
  • Communication with your partner will help identify organizations that could benefit each other. 
• Explore using a joint mobile team that provides specialized assistance to older adults experiencing homelessness. 
  • Tip: Find two different approaches for these mobile teams in USAging’s case studies on Multnomah County and Western Piedmont Council of Governments. 
  • Bring assessment-and-intake or information-and-referral services directly to older adults in a variety of community settings. 
• Establish links with other service networks to create a community infrastructure to serve shared populations. For example, connect with Adult Protective Services, veterans services, behavioral health providers and reentry programs.  
• Develop a pilot program to meet a need in your community. 
  • Tip: Great places to start include engaging older adults with lived experience of homelessness in program design, reviewing data on community assets and needs, revisiting earlier goals or building on  early partnership efforts (see earlier stages). 
  • Use innovative approaches to serve older adults experiencing homelessness who may not fit traditional programs or funders’ criteria. 

• Embed staff on the frontlines of both partners’ service providers, like aging resource specialists at a shelter or a homelessness resource specialist at an older adult congregate meal site, to serve as onsite experts and coordinators. 
• Work together to develop, establish or advocate for permanent supportive housing for older adults. 
• Offer legal services for older adults who are at risk of losing their housing or experiencing homelessness. 
• Coordinate nutrition services for older adults in transitional housing. 
• Launch a rapid rehousing program for older adults experiencing homelessness. 
• Collaborate on an education project to teach health care providers how to effectively screen older adults for housing instability. 
• Provide housekeeping services to older adults at risk of becoming homeless to help secure their housing. 

• Assemble a joint task force or committee to bring multiple stakeholders together.  
  • Engage other community partners including health care systems, foundations, affordable housing providers and service providers. 
    • Create a coalition that extends beyond just AAA-CoC partnership to open a path to real solutions for systemic issues. 

Macro Environment 

• Educate your community about resources that are available from both networks, as well as solutions that the broader community can support. 
  • Inform community members about the landscape of homelessness among older adults: the scope of the problem and impact on people’s lives, community capacity challenges in preventing and addressing homelessness and potential solutions. 
• Advocate for increased funding for services or crucial policy changes from decision-makers. 
  • Use your positions as keystones in your networks; advocating for change together on shared goals will make your “asks” more compelling (as mentioned in Stage Three). 
  • Encourage state-level bodies to consider homelessness and aging populations in your service area when determining and distributing funding. 
• Consider specialized training for Aging Network case managers and benefits enrollment teams to strengthen how they support older adults who are experiencing homelessness in accessing eligible benefits. 

Putting It Into Action: Leveraging Connections! 


Columbus, OH 
In 2020, the City of Columbus received federal funding to test pilot programs providing emergency rental assistance. Partnering with the regional CoC lead, the Community Shelter Board (CSB) started the Homelessness Prevention Network (HPN) to develop housing solutions and prevent homelessness. The HPN established  25 access point partners and integrated housing resource specialists into each as part of its network. During intake at those partners’ locations, the specialists screen for housing risk. If the client is deemed above a certain risk level, the specialist connects that individual with the network for needs assessment and service triage. With a housing assistance program already in place and frequent collaborations with the City of Columbus and CSB, the Central Ohio Area Agency on Aging (COAAA) was a natural choice as an access point partner. 

The COAAA also contributes its own funding to housing support services for older adults. 

In summer 2023, HPN merged with other CSB initiatives and evolved into the Central Ohio Stable Housing Network, a coordinated regional program providing a range of coordinated community services and holistic solutions to address homelessness. 

Western Piedmont, NC
Across a four-county region in rural North Carolina, the partnership between the regional CoC leadership and the AAA is strengthened by being housed together within the Western Piedmont Regional Council of Governments. The CoC leadership team, including the Coordinated Entry Lead and Unsheltered Access Coordinator, work side by side with the AAA under the same roof, making collaboration and coordination across services easier and more effective. 

They used this institutional connectivity to bridge silos and form strong intra-agency relationships, developing mutual knowledge to provide joint support to people served. This integrated, strategic service delivery is especially important for individuals with complex situations. The agencies also work collaboratively to find consensus on how to leverage each other’s strengths and capabilities, extending even comingling funding when appropriate.