Older adults and people with disabilities in the U.S. often have to leave their home and move into a long-term care facility even though they would prefer to age in place. That’s because they may suffer from multiple chronic medical conditions and/or face difficulty in carrying out the activities of daily living. Many lack ready access to intensive primary care and non-medical support services. Research shows that people living in publicly supported housing have higher rates of chronic illness.
Back in the 2000s, Nancy Rockett Eldridge was working at Cathedral Square, a Vermont nonprofit that provides housing for older adults and people with disabilities. She grew increasingly frustrated that many residents were moving prematurely into nursing homes due to the lack of a system that connects people to primary care providers and other supportive services. Eldridge recognized that publicly supported housing sites assisted many of the state’s highest-need individuals and already had an infrastructure of buildings, meeting rooms, and staff, making it a viable locus for extending primary care to older adults and people with disabilities.
Program: Support and Services at Home (SASH)
Population: Older adults and people with disabilities, primarily those who are enrolled in Medicare or dually eligible for Medicare and Medicaid. Most program enrollees live in publicly supported housing.
Goal: Empower participants to drive their own health decisions by providing a range of support and in-home services to enable them to remain at home and live healthier lives while reducing health care costs, hospital and nursing home visits, and emergency department use.
Key Features: Community health workers and nurses work with groups of 70-100 program participants to maintain their health and gain access to needed health care, transportation, and support programs.
Under her leadership, Cathedral Square launched Support and Services at Home (SASH) in 2011 with $10.3 million in funding from the Centers for Medicare & Medicaid Services’ Multi-Payer Advanced Primary Care Practices demonstration. The program connected all 22 housing organizations in Vermont and established staffing teams to serve residents of publicly supported housing who wanted to participate. SASH later extended services to Medicare beneficiaries in the broader community.
Eldridge and the SASH team, led by Molly Dugan, worked with Vermont’s Blueprint for Health, a state-directed health care reform strategy, to establish a collaborative network with hospitals, home health, mental health agencies, and Area Agencies on Aging throughout the state. By 2014, SASH was fully rolled out at 140 publicly assisted housing sites.
“I was thinking how hard it is for physicians, particularly primary care physicians, to reach the patients who need the most support,” said Eldridge, who now is working to spread the SASH model nationally as CEO of the National Well Home Network. “If we could connect the primary care system with the housing network, we the 'housers' could be the extension of primary care.”
A team consisting of a full-time community health worker, known as the SASH coordinator, and a wellness nurse working 10 hours per week is assigned to serve a panel of 100 residents at each of the 140 publicly assisted housing sites in Vermont. Some sites have more than one team. All residents are invited to participate. People living in the community outside those sites can sign up for the free program through referral by a physician, senior center, or other service provider, or they self-refer.
“I was thinking how hard it is for physicians, particularly primary care physicians, to reach the patients who need the most support.”
Nancy Rockett Eldridge, CEO, National Well Home Network, and SASH founder
Participants initially take part in an interview to share what is important to them. Then they undergo a comprehensive assessment covering medical, social, family, nutrition, medication, transportation, and other needs. They develop a personalized healthy living plan. Every subsequent year, the wellness nurse leads an annual assessment SASH currently serves up to 5,000 Vermonters at any given time.
Participants choose how and how often they want to interact with the SASH coordinator and nurse. They may receive help with their medications, assistance in connecting with medical providers, or links to social or recreational programs. When they experience an acute medical episode such as a hospitalization or emergency department visit, the SASH coordinator and nurse provide support as needed to the participant and family and facilitate communications with and between medical providers.
Jason Kirchick, a SASH wellness nurse, shared that earlier this year, he sat with a hospitalized participant to provide emotional support and explain all the pain medications and upcoming tests. Then Kirchick participated in the discharge planning call with hospital staff, and helped the patient understand the diagnosis, discharge plan, and future steps.
“I try to be a navigator of the health care system for my participants if and when they need this,” he said. “It’s hard for people to imagine a situation where they may need us. But when something bad does eventually happen to a participant, we can be there to connect them with support and services so they can remain in their home.”
A key principle is for the SASH staff to identify participants’ goals and focus their efforts around those goals. “We need to respect people, listen to them, and give them true choice and control,” Eldridge said. “You ask them and go from there. That’s empowerment. If people aren’t empowered to determine their own health, you can call them every day to lose weight and it won’t happen because they don’t feel like they are part of the picture.”
Eldridge said she knew from the start that SASH needed to be a broad population health effort to have impact. So early on, in 2010, she approached the head of Vermont’s Blueprint for Health program to help connect all the state’s housing organizations, hospitals, nursing homes, mental health agencies, home health, and Area Agencies on Aging to create a collaborative effort.
When the state received the federal funds to launch SASH, she and Cathedral Square worked on establishing and training SASH teams at every affordable housing site in the state, including mobile home parks. Eldridge also made sure that all stakeholders were invited to participate and have input.
Once a month, representatives from all relevant agencies meet to coordinate their services. For instance, the representative from an Area Agency on Aging may say she is backlogged with cases and ask a SASH coordinator to handle a Medicaid application for a SASH participant, or vice versa, Eldridge said.
After the demonstration funding ended, the state of Vermont sought and received approval from the Centers for Medicare & Medicaid Services for an all-payer model that has funded SASH for the past four years.
During the COVID-19 pandemic, SASH coordinators and wellness nurses have been able to maintain their regular contacts with and programs for participants through telehealth visits, helped by donations of computer tablets and other technology.
Kirchick said he regularly connects with his panel members and reviews how they are doing with their chronic conditions and medications. He also links them to programs such as Tai Chi and jazzercise classes.
“Their medical provider may only spend 15 minutes with them, but we have the advantage of getting to know the person and understanding their goals,” he said. “Most medical providers like knowing they have a nurse in the community serving as additional eyes and ears.”
SASH enters the medical data it gathers into a database to monitor patients’ chronic conditions both individually and collectively. That helps physicians keep tabs on their patients and enables public health planners to watch trends.
Kirchick, who now works exclusively with SASH participants enrolled in the Blue Cross and Blue Shield of Vermont Medicare Advantage plan, gave an example of how he supplements the efforts of medical providers. He helped a terminally ill participant who was having lots of hospital visits and his family come up with a plan for him to stay at home until he died.
“Their medical provider may only spend 15 minutes with them, but we have the advantage of getting to know the person and understanding their goals. Most medical providers like knowing they have a nurse in the community serving as additional eyes and ears.”
Jason Kirchick, SASH wellness nurse
“I would bring a milkshake to him, and we’d sit and laugh and have good conversations,” he said about the man, who died in March. “It was better for the participant and the family.”
A multi-year evaluation of SASH published by the Assistant Secretary for Planning and Evaluation in 2019 found statistically significant reductions in both Medicare and Medicaid costs for low-income SASH participants living in publicly supported housing. Participants in urban areas experienced slower growth in Medicare expenditures compared to non-participants, at approximately $1,450 per beneficiary per year due to slower growth for hospital, emergency department and specialty physician costs. Medicaid long-term care costs for low-income SASH participants living in publicly supported housing sites averaged about $400 a year less than for non-participants.
Additionally, SASH had a favorable impact on the incidence of injuries leading to emergency department visits or hospitalizations among SASH participants over age 65, noting that these injuries are often associated with falls. The evaluation also found that SASH participants reported higher overall health and functional status and less difficulty with common medication management tasks than non-participants. Property managers and SASH staff reported that the program was successful in helping participants remain in their homes.
While approximately one-quarter of the program’s total participants live outside of the publicly supported housing, the study was not able to identify a control group to study the impact of SASH on this group.
SASH has been replicated in Rhode Island and is currently expanding. Eldridge is in the early planning stages of launching a SASH demonstration in Los Angeles in cooperation with LeadingAge California.
Scale and density boost the chances of a SASH program succeeding. That is why Eldridge said she’s enthusiastic about establishing SASH in large publicly supported housing sites in Los Angeles where thousands of residents live near hospitals, community health centers, and other services.
It can be difficult to get people to sign up. This is because they do not necessarily understand what SASH is. Kirchick said SASH leaders need to improve outreach at physician offices, senior centers, and other agencies to reach older adults and people with disabilities who could benefit. Once people understand the program, he added, many are happy to sign up, particularly after being so isolated during the past two and a half years of the pandemic.
"You have people going from a wonderful program to nothing, or not knowing about programs they’re eligible for. We need a horizontal net that connects people with all those great programs.”
Nancy Rockett Eldridge, CEO, National Well Home Network, and SASH founder
Residents of publicly supported housing sites may benefit more from SASH than participants in the community. According to the 2019 evaluation, this may be because it’s easier for SASH staff to meet with residents of the housing sites.
A broad population health model like SASH can help connect people to more narrowly focused programs. Eldridge noted that many good programs discharge participants when they meet a health target, even though they continue to have the underlying chronic conditions. “You have people going from a wonderful program to nothing, or not knowing about programs they’re eligible for,” she said. “We need a horizontal net that connects people with all those great programs.”
Thanks to Nancy Rockett Eldridge, Molly Dugan, and Jason Kirchick for helping inform this blog post.
*Author Harris Meyer is a freelance journalist who has been writing about health care policy and delivery since 1986
In the Field: Spotlight on Complex Care Interventions
This Better Care Playbook blog post series spotlights how organizations are implementing evidence-based and promising innovations to improve care for people with complex health and social needs. For organizations seeking to develop or enhance complex care programs, it is valuable to see how peers in the field are rethinking approaches to care. VIEW SERIES