A movement that began in Vermont to provide services and care coordination to older adults in their homes has spread to Rhode Island and Minnesota, with California planning to pilot the Support and Services at Home (SASH) model in 2023.
SASH is a model of care created more than a decade ago by Cathedral Square Corp. of South Burlington, Vt., which operates 24 independent-living communities. SASH is now based in 140 affordable-housing communities in Vermont and serves up to 5,000 participants statewide at any given time. Its mission is to help older Vermonters age in place by fostering connections and coordinating care to help reduce the impact of chronic health conditions. SASH has been shown to improve population health, reduce costs, and enable people to age in place safely and healthily. In addition to helping improving the health of participants, SASH has been independently documented to reduce Medicare and Medicaid expenditures for participants.
Beyond Vermont, SASH is the inspiration for a seven-state demonstration by the U.S. Department of Housing & Urban Development, and it has been replicated by affordable-housing providers in Rhode Island and Minnesota, with California in the planning stages. Providers in additional states are working with the National Well Home Network to bring SASH to their region.
During a May 11 webinar sponsored by the National Center for Complex Health & Social Needs, two leaders of the effort in Vermont described its origins and impact.
April Mentzer, M.S.W., statewide remote SASH coordinator, first gave some background: Cathedral Square saw that the residents living in independent housing were living longer and had functional changes that didn't require a move to a facility, although they needed some more support and help with problem-solving and accessing services, she said. “They knew that assisted living was not the answer. People wanted to stay home. Unfortunately, assisted living is not financially workable with the current payment system for healthcare. What the residents needed was a real system of support and partnership where they lived so they didn't have to move somewhere new.”
Cathedral Square officials piloted their idea at one of their properties starting in 2009. SASH was able to spread across Vermont easily because there was already an established affordable housing network in Vermont, Mentzer said. “SASH built off this existing system by weaving care support and formalized partnerships with existing community providers.”
Mentzer explained that each participant in SASH is supported by a SASH coordinator — a community health worker who helps the participant identify their needs and facilitate access to health maintenance and prevention programs. The offices of these coordinators are located at SASH housing sites, which provides accessibility to programming and resources and support for the participants. Sash participants are also connected to a wellness nurse, who provides assessments health coaching, medication management and support around chronic conditions. “Wellness nurses are present on site from between five and 20 hours per week depending on the program,” she said. “SASH participants also benefit from a collaboration of community partners who work together with the SASH coordinator and wellness nurse to provide additional support to the participants and to help SASH achieve comprehensive, coordinated community health in their region.”
One of the tenets of SASH is that it is very focused on the individual’s goals, starting with the initial assessment and interview with the SASH coordinator around medications, chronic conditions, social isolation and substance use, but also around relationships, routines, life milestones, preferences and social network. “One of the tools that we use to help our participants reach their goals is a healthy living plan,” Mentzer said. SASH participants are encouraged to create a plan with their SASH coordinator and/or a wellness nurse to reach their personal health-related goals. SASH staff provide the support and resources to help make their goals a reality.”
Casey Doerner, B.S.N., R.N., wellness nurse lead and assistant director of the SASH program, noted that the initial SASH pilot was able to demonstrate a 19 percent reduction in hospitalizations in its participants. In 2010, SASH expanded with funding from a Medicare demonstration grant, and by 2013, had expanded to every county in Vermont.
RTI evaluations in 2014 and 2016 demonstrated that SASH saves Medicare dollars, which paved the way in 2017 to replicating the model in Rhode Island. “In addition, we received further funding to be able to pilot having an embedded mental health practitioner in two of our housing sites, which added a mental health person to the team of the wellness nurse and the SASH coordinator to support participants. In 2019 we replicated in the state of Minnesota,” Doerner said.
She noted that SASH was greatly challenged by the COVID pandemic in 2020. “One of the basic tenets of our program is to meet people in their homes and to visit with them at home, so the program had to really shift to a lot of phone and virtual support for participants to keep them safe and still keep them connected.”
She provided more detail about funding and how the model works: SASH is free to all participants. The only requirement to join the program is having Medicare insurance or living in a housing site that hosts the SASH program, which was initially funded through a Medicare demonstration project. In 2017 SASH became part of OneCare, which is Vermont’s accountable care organization all-payer model, and SASH continues to be funded by Medicare dollars through OneCare, Doerner said. It also is funded through several other grants, including through the Department of Aging and Independent Living, and the Vermont Department of Health, as well as several local and private funders.
In 2021 SASH served about 5,000 people in Vermont. Seventy percent are female, and the average age is 73. The top three chronic conditions of participants are hypertension, arthritis and chronic pain, with the fourth one being diabetes. She noted that 75 percent of participants have three or more chronic conditions with the mean number being six. About 80 percent of the 5,000 people lived in congregate housing sites, with the other 20 percent dispersed throughout the community.
SASH has a significantly higher percentage of adults with controlled hypertension compared to the average in the United States, Doerner said. It also helps participants keep up on vaccinations, including COVID vaccinations. It has an initiative around a reduction of falls by exercise classes, assessments, and tai chi. It has a 26 percent fall rate compared to the national average of 29 percent. Another initiative is to support participants in having advanced directives in place.
SASH is continuing to grow and is currently seeking funding to expand the embedded mental health pilot. Nancy Eldridge, SASH’s original founder, has created the National Well Home Network. She has made it her mission to replicate SASH around the country, and there are housing and healthcare organizations in multiple states with an interest in replicating SASH, but they've not progressed for lack of sustainable funding sources, Doerner said.
Congressional leaders are considering including housing-based management models such as SASH in the fiscal year 2023 federal budget. If they do, then the Center of Medicare and Medicaid Innovation would have approximately $30 million to award to models that support healthcare in housing. Doerner said California is the furthest along of other states seeking to replicate the model, and is expected to adopt SASH in the Los Angeles area with a target date in 2023.
