Feb 052012

Earlier this year (2012), the Agency for Health Care Research and Quality (AHRQ) released an innovation profile about Vermont’s  Support and Services at Home (SASH – https://sashvt.org/) program, which provides onsite assistance to older adults and other Medicare beneficiaries so that they can age in place. As AHRQ describes it, SASH offers key evidence-based services, such as “an initial assessment by a multidisciplinary onsite health team, creation of an individualized care plan, onsite nursing and care coordination with team members and other local partners, and community activities to support health and wellness.” Basically, SASH combines supportive housing with critical medical and nursing services on-site. In a year long pilot study with 65 residents, the program reduced hospital admissions and readmissions, had decreased falls, improved nutritional status, increased levels of physical activity, and no bounce backs to nursing homes.

Cathedral Square Corporation (CSC) Executive Director Nancy Eldridge spent an hour talking with MediCaring to offer more insights into the successful program. Conceived in 2006, she says the program came in reaction to a realization that the community faced a “backlog of people in need in our communities, people who had significant complex physical needs, cognitive impairment, depression, and medication management issues.”

“We were involved in looking at models that would be scalable, replicable, and sustainable,” says Eldridge. “We need a system in this country of making sure that people can stay in their homes, a system that is as comprehensive and robust as our public education system, which was developed in response to the needs of the same population, the Boomers. We needed a system then to make sure Boomers were educated, and we need an equally comprehensive and sustainable system for the long term care they will need.”

Cathedral Square owns or manages 24 sites throughout four Vermont counties. Originally funded through a combination of state funds and philanthropic donations, SASH is currently funded through Medicare’s Multi-Payer Advanced Primary Care Practice Medicare Demonstration program, one of 8 states in the country funded for this 3 –year endeavor.  As part of the demonstration, SASH will expand to 112 sites throughout Vermont.

Building on its successful SASH pilot, leaders at Cathedral Square approached leaders at other affordable housing organizations, going “organization by organization until we had covered all corners of the state,” says Eldridge. SASH is now operating in 7 counties, and will be statewide by the end of 2012.  The program’s partners include all five state Area Agencies on Aging, Visiting Nurse Associations, and PACE Vermont, as well as every hospital in the seven counties currently participating.  Each participating housing organization commits one person to the SASH site. For example, the community’s Area Agency on Aging would commit one case manager to one SASH hub site; she is the point person for all AAA clients at the hub site.

When SASH rolls out to the planned 112 sites and their neighborhoods, the new projects will include public and non-profit housing programs and their catchment areas, with the aim of reaching out to the entire community. Affordable housing sites are widely dispersed throughout Vermont, and bringing the core SASH services to very rural areas is a key element of the program. Eldridge says they are “using that core as a platform to integrate with other work. For example, we are helping with the use of CDC tobacco cessation funds as a way to convert all of these properties to smoke-free facilities.”

In another collaborative program, Cathedral Square is working with the housing collaborative and other stakeholders to support a broadband initiative, one that would get connectivity into affordable housing sites, making them anchor sites for free fiber optic networks. This helps to advance goals around health information exchange. “If we start looking at the system, and we approach problems in long-term care, we find we can raise many boats. We don’t benefit only the elderly, but families and the housing network as well.”

To read the full innovation report, go to http://www.innovations.ahrq.gov

To learn more about Cathedral Square, and to see a video about the SASH program, visit http://cathedralsquare.org/

Key words: care transitions, supportive services, SASH, AHRQ, innovation