To address key evaluation questions and complement our quantitative analyses, we used two methods of primary data collection: semi-structured, in-person interviews and quarterly conference calls with SASH staff and ASPE/HUD/AoA. The primary purpose of these two methods of data collection is to understand the details of program implementation and operation, monitor implementation progress and identify implementation and operational successes and challenges as the SASH program is expanded statewide and matures. More information on the qualitative data and methods is located in Appendix B. The analyses of these data have been designed to help the evaluation team understand the issues surrounding the SASH program start-up and operations, with a particular focus on understanding points that bear on program sustainability and replication. In this section, we use qualitative data to answer the following implementation research questions.
What are the operational challenges and successes of setting up the SASH program--that is, a coordinated system of housing, health services, and long-term services and supports?
What are the operational challenges to statewide expansion of the SASH program?
How were residents in assisted properties identified as potentially eligible for the SASH program? How were individuals in the community identified?
What were the processes for outreach, enrollment and assessment of SASH participants?
What, if any, impacts are there on participating properties, including in the following areas?
- Property maintenance and costs.
- Resident complaints and management's conflicts with residents.
- Property managers' workload, smooth running, or property administration.
RTI and CAR conducted a site visit of four SASH panels over a three-day period in February 2013. During the site visit, we interviewed SASH coordinators and wellness nurses, case managers and visiting nurses, CHT staff, and DRHO directors and property managers. In addition, the evaluation team conducts quarterly calls with SASH staff to receive ongoing feedback on the implementation of the program. Each call focuses on a specific aspect of the SASH program, giving the evaluation team a deeper understanding of the infrastructure and processes of the program. In the first year of the evaluation, we conducted four calls which focused on the structure and general components of the program, funding sources, the process for starting new panels, and the Blueprint for Health's clinical registry, DocSite, and its uses.
A main focus of the site visit and quarterly calls was the outreach, enrollment and assessment of SASH participants. SASH program participation is open to any resident living in a housing property included in the SASH program or any Medicare beneficiary living in the surrounding community. Residents in SASH properties and individuals living in the community are identified as potentially eligible for the SASH program through outreach conducted by the SASH team (described below). Additionally, referrals are made to the program by health care providers, community partners, hospitals, and CHTs.
Outreach for the SASH program is conducted in various ways. The SASH coordinators hold informational events in housing properties to educate residents about the program. Property managers inform residents about the program. One property manager always asks residents if she could give their name to the SASH coordinator to follow-up with them, believing residents would be less likely to follow-up if the onus was on the resident to contact the SASH coordinator. Another housing organization we spoke with promoted the program on the local community access channel. Some physicians and psychiatrists found out about the program through this method and contacted the SASH program to see if it could help their patients. One SASH coordinator hosts information sessions at the senior centers that are co-located in the panel's housing properties. Another SASH coordinator we spoke with wrote articles for the local paper about the SASH program.
After identifying residents, a formal enrollment and assessment is conducted. When enrolling in the SASH program, individuals first sign an Authorization for Use and Disclosure Agreement, which authorizes the SASH staff and team members to receive and share information about the participant's health. Next, participants receive a comprehensive assessment conducted by the SASH wellness nurse and SASH coordinator. The assessment collects information on health conditions, medications, care providers, history of falls, fall risk, emergency room (ER) visits, hospitalizations, nursing home stays, functional abilities, mental health, nutritional and cognitive status, and support services currently used or needed.
One SASH wellness nurse estimated that the assessment takes approximately 45-90 minutes to conduct. In the initial recruiting stage, the assessment appears to dominate the nurses' limited time. Some of the council on aging and home health agency representatives we spoke with believed the participant assessment is too invasive and/or too long and collects more information than necessary. Some also felt the assessment duplicates information that is also collected by their agency's assessment process. Currently, however, there is no mechanism for sharing assessment information that may have already been collected by a SASH team staff member with other community-based providers. Additionally, only a fraction of SASH participants are clients of the partner organizations. The goal of the Blueprint for Health and the SASH program is to create one integrated health record that can be accessed by all partner agencies.
SASH coordinators also complete an interview with each individual. The interview is designed to understand the participant in a more holistic manner and asks about the person's life milestones, personal interests and goals, significant events and relationships, daily routine, and existing social support network. From the assessment and interview, SASH staff develops a healthy living plan with the individual and the SASH team helps implement and monitor this plan. Results from the individual assessments are also aggregated across the SASH panel and a community healthy living plan is developed. Evidenced-based programming is then identified to help address common needs and issues.
The SASH program monitors the progress of its participants through the Blueprint for Health's clinical registry, DocSite, which records participant demographics, health status, and wellness goals. The coordinator and wellness nurse monitor SASH program activities and individual progress towards customized healthy living plans. At the state level, CSC runs reports through DocSite that track progress made by panels and highlight problem areas at the community level to help the SASH core staff identify possible group wellness activities. It is expected that, eventually, all Blueprint for Health patient-centered medical home electronic medical records (EMRs) will be connected with DocSite, allowing for a seamless exchange of information between health providers and SASH staff.
DocSite is credited for improving communication within panels, workflow tracking, and reporting. As a web-based platform, DocSite can be accessed from any location with an Internet connection which is helpful for SASH panels that are geographically dispersed. Also, because SASH staff members have the most experience working with DocSite, CSC has been able to take a leadership role in Vermont health information technology initiatives and talks.
The major SASH program implementation success has been the linkages the program has created among different community organizations. The SASH program formally links the SASH staff with dedicated staff from community service organizations, including the local home health agency, area agency on aging, and the mental health agency. The SASH team also creates linkages with CHTs, PCPs, and local hospital(s) serving their community. Establishing this diverse team of service, health care and housing providers enables better coordination of care for SASH program participants.
Despite the successful roll-out of the 36½ panels to date, operational challenges also exist. The large geographic distance between properties in rural areas of the state present challenges when it comes to the operation of the SASH program. In some cases, SASH staff must travel long distances between properties and to participants' homes. Transportation is a major problem for both SASH staff and participants. There is limited public transportation in most regions making it difficult for participants to get to appointments or activities. Communication can be difficult because of spotty cell service and Internet access. In particular, rural panel staff felt that Internet access hindered their ability to enter data directly during participant visits. This caused more work as they needed to enter data into the electronic data base, DocSite, on their own time after visits. To help address this issue, some SASH resources were used to open up Internet and cell phone "hot spots" at different hub locations.
Additionally, the perceived needed work hours exceeds actual budgeted hours for the SASH staff. The SASH coordinators with whom we spoke said it was difficult to judge the adequacy of staffing by panel size alone (i.e., ratio of 100 participants to a full-time SASH coordinator and quarter-time wellness nurse), because the complexity of participant needs varies across panels. One panel, for example, has a number of participants with mental health issues, which consumes a large percentage of the SASH coordinators' time, especially when they have co-occurring physical health issues. Inadequate funded hours for the SASH wellness nurses was also highlighted as a challenge. Wellness nurses work quarter-time for each panel, which limits the amount of time they can spend with SASH participants, especially conducting one-on-one in home visits with the community participants.
Though SASH staff understands it is critically important to enter data into a central registry, and SASH staff members are the biggest users of DocSite, there have been operational challenges with the technology. As its sole data platform, the SASH program relies heavily on DocSite's functionality. Vermont has experienced delays connecting practice EMRs with DocSite, but continues to make progress towards statewide adoption of the registry. Over the summer of 2013, Vermont was forced to shut-down DocSite for two months while connecting the registry with the state's multi-payer claims data base and health information exchange. While DocSite was down over the summer of 2013, SASH staff had to record data in a paper format, creating a backlog of data-entry needs. This hiccup resulted in an estimated 300 additional hours of work. Also, the number of practices feeding data into DocSite was found to be lower than the Blueprint for Health had expected. DocSite will not reach its full potential until it is widely adopted across providers and is interoperable with Vermont's multi-payer claims data base and health information exchange.
There is also concern around the sustainability of the SASH program's data capture and reporting. As mentioned in the site visit findings, SASH staff enters substantial amounts of data manually. This creates a serious time burden, especially for the wellness nurses. Discussions also arose around whether or not the SASH program was trying to collect too much data. Furthermore, SASH coordinators and wellness nurses are not currently able to run reports for their panels on their own--almost all reports are created by a central person at CSC. Though Covisint, the company which hosts DocSite, is working on one click reporting capabilities, this current workflow seems challenging.
Another topic the evaluation team has focused on during site visit interviews and quarterly calls is the SASH program's statewide expansion. This topic was highlighted by CSC as one of the major successes of the program. In July 2011, the SASH program was officially launched with the opening of the Heineberg panel. In October 2011, the program expanded by 4½ panels. Over the course of 2012, 21 panels joined the initiative. Expansion of the program was then frozen at 26½ panels in the fall of 2012 due to a funding gap, which occurred because fewer than anticipated Medicare FFS beneficiaries were attributed to PCPs participating in the MAPCP Demonstration. With a $1.89 increase in the Blueprint for Health's PBPM payment from CMS, expansion resumed and the SASH program added 5½ more panels in May 2013 giving a total of 32 panels. Though they were able to overcome this hurdle, CSC felt that the freeze in expansion greatly hindered the program's momentum and reduced the amount of time CSC could plan with the housing hosts for the May roll-out. As of December 2013, the SASH program had 36½ panels with further expansion expected in 2014.
One of our quarterly calls was framed around learning more about the process of identifying and setting up new SASH panels. SASH program expansions occur by either starting brand new panels or expanding existing panels. The foundational cornerstone of the SASH program is the relationship it maintains with community partners. For this reason, CSC worries that, by adding panel capacity to established areas, the number of team meetings partner agencies attend may strain their staff resources. CSC will examine ways to utilize partner time as efficiently as possible.
As the state-level entity, CSC identifies opportunities for new SASH sites and facilitates the launch of new panels. To determine new sites, CSC takes into consideration:
Areas in need; Vermont's Blueprint for Health medical homes that do not have SASH supports nearby.
The non-profit housing presence in the area whose mission is to serve both the community and its residents.
Community provider partnerships already established in the area, such as Area Agencies on Aging, CHTs, and nursing associations.
When selecting housing organizations, CSC ensures that the potential site is fully aware of the program's mission and the changes that must be made in order to join the SASH program. Once the housing organization agrees to become a SASH property, CSC and the DRHO walks them through the legal agreements and sets clear expectations of the organization.
After the contracts are signed, the housing host is responsible for hiring the core SASH staff (coordinator and wellness nurse). CSC echoed concerns uncovered during the site visit that the wellness nurse position was severely underfunded. With the core staff in place, CSC conducts initial and ongoing training for the staff. As soon as the core staff are trained, the housing host is responsible for marketing and launching the program. In the first year of the program, there was some confusion surrounding the roles between the DHROs and CSC. CSC has since learned the importance of clearly dividing responsibilities between the two groups.
One organization decided not to join the SASH program out of concern over the lack of permanency of the funding; a concern shared by CSC. CMS payments, which make up the bulk of the SASH program's funding, are only guaranteed through the end of the MAPCP Demonstration. The SASH program would need to find another large funding source if CMS funds expire on December 31, 2014. CSC mentioned approaching state officials in charge of the Vermont State Innovation Model (SIM) initiative (another CMS-funded project) and the ACOs that are supported through that grant. However, they feel it is important that they receive guidance from CMS as to what criteria must be met under the MAPCP Demonstration in order for the SASH program to receive continued support under the SIM initiative. Although 16 housing authorities and non-profit housing providers are participating in the SASH program, some housing organizations decided not to adopt the SASH model due to the additional costs they may incur as a result of becoming a SASH program property.
During the site visit and quarterly calls, the evaluation team was able to glean some information about the impacts of the SASH program on participating properties' maintenance and costs, tenant conflicts, and property managers' workload. The DHRO and housing organization staff mentioned perceived general successes with the SASH program. Property managers that had not formerly had support services in place before the SASH program felt that they are better able to perform their primary function because the SASH coordinator and wellness nurse are able to focus on the health and wellness of participants. One property manager felt that aging residents with unmet needs present financial risk to their portfolios such as physical property damages and property legal liabilities. For this reason, they felt the SASH program could reduce costs for the housing properties. Furthermore, SASH staff and property managers felt that SASH activities help create a better community within the property. In addition to providing opportunities for social engagement, the program helps address resident conflicts and complaints which can be disruptive to the community.
In future site visits, the evaluation team will investigate the SASH program's impacts on participating properties in more depth. In addition to learning more about the property maintenance and costs, resident conflicts, and property managers' workload, we will also inquire about turnover rates and vacancy reductions and property improvements for accessibility.