DISCLAIMER: The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.
This memorandum describes implementation challenges and early impacts of a program intended to improve health and decrease health care expenditures among elderly residents of affordable housing developments. In July 2011, the Support and Services at Home (SASH) program was officially launched with the opening of the Heineberg panel and expanded to include 36.5 panels by the end of 2013. The SASH program connects residents with community-based services and promotes coordination of health care. Using claims data for a sample of 549 Medicare fee-for-service (FFS) beneficiaries, the evaluation compares health care utilization and expenditures among SASH participants and two comparison groups (including Medicare beneficiaries in Vermont and New York). Relative to growth of total Medicare expenditures in two comparison groups, growth in annual total Medicare expenditures was lower by an estimated $1,756-$2,197 per beneficiary among beneficiaries enrolled in SASH panels established before April 2012 (i.e., well-established panels). However, SASH participants used more hospital services, a finding that warrants closer examination as the evaluation continues. Additionally, the analysis did not account for programmatic investments provided by the Medicare program to determine if the SASH program resulted in net savings for the Medicare program. Impact estimates in this memorandum are based on the first year of SASH implementation only and are thus preliminary.
Background
The U.S. Department of Housing and Urban Development (HUD) and the Office of the Assistant Secretary for Planning and Evaluation and the Administration on Aging at the U.S. Department of Health and Human Services (HHS) have a strong interest in affordable congregate housing models that provide long-term services and supports to low-income seniors who wish to age in an independent setting (Lewin Group, 2012). In 2008, the non-profit Cathedral Square Corporation (CSC) in South Burlington, Vermont, began developing the SASH program out of concern that frail residents in its properties were not able to access or receive adequate supports to remain safely in their homes. CSC focused on connecting residents with community-based support services and promoting greater coordination of health care. The SASH teams extend the work of the Blueprint for Health's Community Health Teams and primary care providers by providing targeted support and in-home services to Medicare FFS beneficiaries participating in the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration. In July 2011, the SASH program was officially launched with the opening of the Heineberg panel.
RTI International, and its subcontractor, the LeadingAge Center for Applied Research, were selected to evaluate the SASH program. The evaluation builds on the HHS Centers for Medicare and Medicaid Services-funded MAPCP Demonstration evaluation and assesses whether the SASH model of coordinated health and supportive services in affordable properties improves health and functional status of participants, and lowers medical expenditures and acute care utilization for seniors.
Implementation
The SASH program successfully launched 36½ panels as of December 2013 with further expansion continued in 2014. Each panel is staffed to provide services to 100 beneficiaries with one full-time SASH coordinator and one quarter-time SASH wellness nurse. A primary goal of the SASH program has been to create linkages with a diverse team of service, health care, and housing providers,enabling better coordination of care for SASH program participants. Property managers interviewed felt they were better able to perform their primary function because the SASH program focused on the health and wellness of participants. They also hypothesized that SASH activities helped to create a better community within the property and that by addressing unmet needs among aging residents (e.g., falls prevention), the financial risk to their portfolios, such as property legal liabilities, were reduced. Thus, they believed that the SASH program could reduce costs for housing properties.
Despite the successful roll-out of the SASH program broadly across supported housing properties in Vermont, there were a number of operational challenges. Vermont is largely rural and there are large geographic distances between properties or between participating properties and community residents; poor cellular service makes connection to the central data collection platform difficult; and there is limited public transportation for SASH staff and participants. A second challenge noted broadly across interviewees was that the perceived needed work hours exceeds actual budgeted hours for the SASH staff, in general, but, in particular, for the wellness nurse. Third, the SASH program monitors the progress of its participants through Vermont's central clinical registry, DocSite, and is heavily reliant on its functionality. Lack of widespread adoption of the registry by practices has reduced the potential for communication between SASH staff and providers, and a shut-down of DocSite for two months in 2013 negatively impacted program functioning. A fourth challenge was the freezing of program expansion in the fall of 2012. The SASH program relies heavily upon the Medicare program for financial support. Fewer than expected participating Medicare beneficiaries in the MAPCP Demonstration created a funding gap. The Medicare program subsequently increased the payment amount and expansion resumed in May 2013.
Characteristics of Properties and Participants in this Analysis
The SASH intervention group for the analysis reported here consists of Medicare FFS beneficiaries residing in SASH properties who have also been attributed to practices participating in the Blueprint for Health and the MAPCP Demonstration from July 1, 2011 through June 30, 2013. Only SASH participants that have signed a consent form to allow the SASH program staff to share their personal identification and health information with others participating in the MAPCP Demonstration are included in this analysis. Personal information (e.g., name, Medicare identification number, social security number) are used to link Medicare claims data and housing property data.
The SASH program sites included in this year's analysis are those that implemented the SASH program prior to July 1, 2013. Designated SASH sites include a range of non-profit affordable housing properties funded through a variety of sources, including HUD, the Low Income Housing Tax Credit (LIHTC), the U.S. Department of Agriculture Rural Development, and other sources available through the State of Vermont. Sites also include a few mobile home parks. This current analysis includes only properties that receive funding assistance from HUD. This includes properties receiving assistance through HUD's multi-family programs, such as Section 202 and Section 8, and the public housing program.
Important CSC properties are excluded from this analysis because we do not yet have resident-level data available for LIHTC properties. In future analyses, we will be able to expand our analyses to include LIHTC-funded properties and residents participating in SASH. For the current memorandum, we limited the analysis to HUD-assisted properties.
As of June 30, 2013, 1,502 Medicare FFS beneficiaries were participating in the SASH program. After applying a number of beneficiary and property exclusion filters as noted above, the SASH program sample for this analysis is 549 Medicare beneficiaries. The two primary reasons for exclusion include: (1) not being attributed to a Blueprint for Health practice participating in the MAPCP Demonstration as of June 30, 2013; and (2) residing in non-HUD housing. We also experienced challenges linking residents with HUD data that requires further exploration prior to the next analysis. Thus, we may not have a representative sample of SASH participants in our current analysis; however, a comparison of health status and demographic characteristics of SASH participants with Medicare beneficiaries not included in the analysis found them to be similar (see Appendix A). Further, the small sample size of SASH participants and the large variation in the observed outcomes produced large standard errors and confidence intervals limiting the outcomes that we could study for this report and reducing the precision of the regression estimates.
The comparison group comprises Medicare FFS beneficiaries residing in non-SASH, HUD properties. Comparison beneficiaries are separated into two distinct groups. The first comparison group was drawn from residents of non-SASH properties in Vermont and consists of 1,143 Medicare FFS beneficiaries participating in the MAPCP Demonstration. The second group of beneficiaries was drawn from residents of similar supported housing properties in a rural geographic area in upstate New York State that does not have a MAPCP Demonstration program. A total of 1,903 Medicare FFS beneficiaries comprise the second comparison group.
We use these two comparison groups to evaluate two SASH program effects:
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SASH/MAPCP Demonstration beneficiaries versus non-SASH/MAPCP Demonstration beneficiaries: this comparison yields estimates of the SASH program effect (among MAPCP Demonstration beneficiaries).
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SASH/MAPCP Demonstration beneficiaries versus non-SASH/non-MAPCP Demonstration beneficiaries: this comparison yields estimates of the combined SASH/MAPCP Demonstration effect.
Quantitative Findings
We estimated the impact of the SASH program relative to the non-SASH/MAPCP Demonstration comparison group and the non-SASH/non-MAPCP Demonstration comparison group. Moreover, we estimated the impact for both the group of SASH program participants as a whole and for two subgroups of participants: an "early panel" cohort and a "late panel" cohort. The early panel cohort comprises SASH participants who received SASH services from a panel that started operating before April 1, 2012. The late panel cohort comprises SASH participants who received SASH services from a panel that started operating on or after April 1, 2012. When analyzing the SASH program effects stratified by early versus late panel start dates, under the hypothesis that panels need a certain amount of start-up time before their implementation of the SASH program becomes fully effective, we would expect to see a larger program effect for participants receiving services from earlier and therefore more experienced SASH panels.
The SASH program was associated with a lower rate of growth in total Medicare expenditures1 and expenditures for post-acute care among SASH participants residing in SASH properties that implemented their program before April 2012 relative to both comparison groups. The SASH program was also associated with a lower rate of growth in acute care payments among participants residing in the early SASH panels, but relative only to beneficiaries in the non-SASH/non-MAPCP Demonstration group; this suggests a possible synergistic effect of the MAPCP Demonstration and the SASH program. Medicare expenditures for hospital outpatient department services increased at a faster rate among SASH participants residing in the early SASH panels, but only relative to beneficiaries in the non-SASH/non-MAPCP Demonstration group; this may reflect identification of previously unmet need by both the SASH program and MAPCP Demonstration providers. Interestingly, while we see reduced rates of growth in Medicare expenditures, we observe higher rates of hospitalizations and emergency room (ER) visits among SASH participants relative to non-SASH/MAPCP Demonstration beneficiaries. Finally, the analysis did not account for programmatic investments provided by the Medicare program to determine if the SASH program resulted in net savings for the Medicare program.
Conclusion
The findings of the SASH evaluation thus far raise further questions. Impact estimates are based on the first year of SASH implementation only and are thus preliminary. Furthermore, although SASH participants had higher rates of hospitalizations and ER visits relative to non-SASH/MAPCP Demonstration beneficiaries, the early SASH panels were associated with lower rates of growth in Medicare expenditures relative to a comparison group. Future analyses will examine the costs of administering the SASH program relative to benefits that accrue to participants in the SASH program and the impact on Medicare and Medicaid expenditures.