As an occupational therapist working in medical respite care, Caitlin Synovec saw people in their 50s or 60s at a moment when their lives had forever shifted. Perhaps a stroke or other serious medical event sent them to the hospital. But too often, during their extended treatment, they lost their jobs and then their housing. Newly homeless, they might manage to snag a spot in a respite care program designed for people without stable housing who need a place to continue their recovery. But then, a question would loom over their future: Where would they go next?
Many patients in that situation wind up living on the streets or in shelters, despite efforts to find them permanent housing. A surprising number of older adults, however, find themselves in a nursing home—even if they don’t need or want that level of care.
According to research from the United Health Foundation, one in 11 people in nursing homes have “low-care needs,” meaning they do not require physical assistance for bed mobility, transferring, using the toilet, or eating. The ratios vary by state, from a low of 2.5% in Hawaii to nearly 23% in Oklahoma.
It’s an expensive housing solution: One year in a nursing home costs $119,340 on average, compared to around $16,000 per person per year for subsidized permanent supportive housing that includes some services.
Synovec recalls one client in her 50s who lost her housing while she was in the hospital getting treatment for a stroke. Although a family member was willing to take her in, she couldn’t navigate their second-floor apartment. The stroke left her without the use of one arm and with mild cognitive problems, but she still was able to manage most daily activities, including taking the bus to visit family, friends, and her church. She needed some help—for example, with getting dressed—but she valued her independence.
“She didn’t want to be institutionalized,” says Synovec, who is now assistant director of medical respite at the National Health Care for the Homeless Council. “She wanted to be in the community.”
The woman went to a homeless shelter, but then she fell and ended up in the emergency room. The hospital discharged her to a nursing home. Many emergency shelters aren’t equipped for the elderly, even though older adults are the fastest-growing segment of the homeless population.
Shelters often house people in bunk beds. Their bathrooms typically aren’t designed for people with disabilities. And shelter residents must leave early each morning and fend for themselves until the shelter reopens in the evening.
The better option—permanent supportive housing—has an average wait list of over two years, and even that housing may lack accessibility for elderly people with mobility issues. Under the Trump Administration’s shift away from permanent supportive housing toward time-limited transitional housing, wait lists are expected to grow, and some formerly homeless older adults could be displaced.
“They get to a point essentially where there’s not a place in the community for them to go,” says Synovec. “The option is long-term care—nursing home care—or they die on the street.”
Gaps in the social safety net are widening as Baby Boomers age, says Dennis P. Culhane, a University of Pennsylvania social science researcher with a focus on housing policy and homelessness. In 2025, one out of every five people living in emergency shelters or on the streets was 55 or older. “We’re failing in every direction in terms of not providing shelter—exposing people to greater harm and health risk and disability,” Culhane says.
As a social worker and researcher, Ian Johnson interviewed dozens of social workers, nurses, and other professionals in Seattle who were helping unhoused older adults cope with serious medical conditions. Many of the older adults feared being in a more restrictive environment if they went to a nursing home, and nurses and social workers told of patients who chose to return to the streets from a hospital or rehab unit rather than enter long-term nursing home care.
That’s a common sentiment. Three out of four older adults want to age in their current home and community, according to surveys by AARP, an advocacy organization for older Americans. “Early institutionalization” often separates people from their family, friends, and neighborhood. “That is not different for people living in supportive housing or sometimes living in a tent in the woods or at a homeless shelter,” says Johnson, who is now at Boston University School of Social Work. “People want to spend their end of life still having a sense of self and a sense of autonomy.”
At the same time, stories also abound of nursing homes discharging vulnerable older adults to homeless shelters—or to no destination at all. The triggering event could be a violation of rules, such as smoking or substance use, or depletion of insurance.
Those opposing trends don’t make much sense, except in the context of cost pressures and sparse options. When short-term rehabilitation care ends, patients are expected to pay on their own or leave. Medicaid covers long-term nursing home care, but state eligibility rules vary. Some people who just need parttime help with personal care and medication may end up lingering in a nursing home, covered by Medicaid. In other cases, despite federal rules about safe discharges, nursing homes have dropped off residents at shelters.
One answer to this predicament is to build subsidized housing that meets the mobility and care needs of older adults with very low incomes but preserves their sense of independence. In other words, age-friendly, low-income housing would give people who are aging and homeless the “4 Ms” framework that seeks to address mobility, medication, mentation, and what matters most to older adults.
Finding the right care for older adults facing homelessness could be part of a broader rethinking of long-term care. Dr. Jeffrey Farber, a geriatrician who is president and CEO of The New Jewish Home in New York City, has written that “nursing homes serve three distinct populations of older adults—and only one of those actually belongs in what we think of as a nursing home.”
Hospitals tend to discharge patients as soon as they’re medically stable, so nursing homes, also known as skilled nursing facilities, became providers of short-term rehabilitation. When they leave rehab, most patients rely on family caregivers or paid aides for any ongoing help.
“Some of those patients, when the system breaks down and there’s no place for them to go that’s safe and affordable, they just end up staying” in the nursing home, Farber told me. “They’re benefiting from some services that we provide, but they certainly could be cared for in a lower-acuity setting or a lower-cost setting.”
Farber envisions a remake: Hospitals would provide the sub-acute care and only discharge patients when they are ready to go home. People who are homeless and aging with manageable medical conditions would have access to subsidized housing and special programs tailored to their needs.
The rest would receive long-term monitoring and care for their complex medical needs at a transformed version of nursing homes that he would rebrand as Compassionate Care Homes, “always non-profit, mission-driven.” He added that these homes must be funded adequately, with investment in workforce training.
The oldest Baby Boomers turn 80 in 2026. By 2030, every Baby Boomer will be 65 or older. Just as they have impacted so many aspects of society, they will overwhelm the capacity for senior housing, long-term care, and emergency shelter.
It never made sense to house people with low-care needs in nursing homes, but this wave will make doing so unsustainable. Farber wants to spark a conversation about transforming long-term care and the way it’s funded.
“The system is fundamentally broken,” he says, “and we’re not going to fix it with band-aids.”
