In 2008, the non-profit Cathedral Square Corporation (CSC) in South Burlington, Vermont, began developing the Support and Services at Home (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 (CHTs) and primary care providers (PCPs) by providing targeted support and in-home services to Medicare fee-for-service (FFS) beneficiaries participating in the Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration. Though closely associated with the MAPCP Demonstration, the SASH program is offered to all Medicare beneficiaries residing in or near SASH properties with active programs including beneficiaries not assigned to Blueprint for Health PCPs participating in the MAPCP Demonstration. In July 2011, the SASH program was officially launched with the opening of the Heineberg panel.
The SASH program is a Vermont-wide initiative coordinated at the state, regional, and local level. CSC oversees the program at the state level and is responsible for defining and implementing the programmatic elements along with coordinating program expansion and training. At the regional level, six Designated Regional Housing Organizations (DRHOs) are responsible for planning the roll-out of the SASH program across their geographic regions. The program is delivered at the community level through SASH panels, which are operated by the housing host organizations.
Each panel has the ability to serve roughly 100 beneficiaries and has a core staff made up of a dedicated full-time SASH coordinator and a quarter-time SASH wellness nurse. The SASH program launched in July 2011 and began expansion of panels immediately, though this growth was paused in the fall of 2012 due to a funding gap. After receiving an enhanced payment from the U.S. Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS), the program was able to add more panels and as of December 2013, the SASH program had 36½ panels with 2,010 full benefit participants. Of that total, 1,555 participants resided in SASH properties and 455 lived in surrounding communities. Panels partner with local service provider organizations, such as home health agencies and councils on aging, which create the SASH Team. Using evidence-based practices, key services provided by core SASH staff (coordinator and wellness nurse) include a comprehensive health and wellness assessment, creation of an individualized care plan, on-site one-on-one nurse coaching, care coordination, and health and wellness group programs. Local service providers build on these core tenets by offering additional community activities, health and wellness workshops, and direct services.
When individuals choose to participate in the SASH program, they consent to allowing the SASH staff and community partners to share information about them with each other and their health care providers. With this consent, SASH staff work with the participants' health care providers when necessary to ensure proper medication usage, successful hospital discharges, and overall coordination and continuity of care. Importantly, the SASH program does not "discharge" participants. Rather, the SASH program provides a continuum of support and services that meet participants' needs whether they are extremely healthy and looking for minimal supports or very frail participants in need of more robust support from the full SASH Team. This ensures that the SASH program is ready to provide the help that is needed when circumstances change unexpectedly for participants. Individuals who do not consent, but live in SASH properties can still receive assistance from the SASH coordinator and wellness nurse and participate in SASH programming. However, without consent to share their information, staff cannot serve these individuals as intensively. SASH coordinators and wellness nurses are expected to communicate and meet with participating service providers on the SASH Team regularly (at least once a month) to discuss participant specific cases and group wellness approaches.
The SASH program receives financial support from a variety of sources. As the state coordinator, CSC is responsible for overseeing and securing funds for the program as a whole. At the regional level, DRHOs are encouraged to solicit additional funds from local organizations for ongoing support for their panels. CMS is the largest funding source and makes a per-beneficiary per-month (PBPM) payment to the SASH program through the MAPCP Demonstration. The MAPCP Demonstration provides $70,000 in funding annually for each panel, which covers the cost of the SASH coordinator and the wellness nurse. Other program costs are covered through a variety of sources. Medicaid is the second largest contributor, sourcing funds at both the federal and state level. Other sources include the Department of Aging and Independent Living, the Department of Vermont Health Access, the Department of Health, and various foundations and grants. These sources represent the funding for the SASH program and not the actual health or long-term care services coordinated and arrange for as part of the SASH program.
The U.S. Department of Housing and Urban Development (HUD) and the Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the Administration on Aging (AoA) at 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. The SASH program offers an important opportunity to evaluate the impact of these services on program participants and, in particular, to determine the impact of the program on health outcomes and Medicare and Medicaid expenditures.
RTI International, and its subcontractor, the LeadingAge Center for Applied Research (CAR), were selected by ASPE/HUD/AoA to evaluate the SASH program. Through a mix of qualitative and quantitative methods, we are conducting a comprehensive evaluation of the first phase of the SASH program. The evaluation builds on the CMS-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 Medicare and Medicaid expenditures and acute care utilization for seniors.