What is SASH?

A caring partnership brought together to help people remain in their homes.

The partnership connects the health and long-term care systems to nonprofit affordable housing providers.

Profile of Heineberg Residents

85% over 70; 40% over 8549% used ER in past year54% take 6 or more prescription meds71% have high blood pressure, 59% arthritis,

39% chronic pain.61% fallen in past year32% self-reported mental health concerns59% use a cane or walker49% failed 2-3 components of a cognitive

screen

Results at Heineberg

• 19% reduction in hospitalizations

• No bounce backs from Nursing Homes

• Reduced falls- 22%• Increased physical activity• Reduced nutritional risk-

26% reduction

Better health, better care & lower costs

Implementing SASH in your state

Build partnerships

Written Agreements (not “lip service”)

Need Leadership from the State

Tell the Story!

The SASH Alliance

Government Entities• Division of Health Care Reform• Department of Aging• Department of Public Health• Medicaid Division• Legislature

Non Profit Business Sector• Housing: Non Profit and PHAs• Hospitals• Medical Homes• Home Health• PACE• AAA’s• Community Mental Health

Agencies

Philanthropic Leaders• Vermont Health Foundation• McArthur Foundation• Enterprise Community Partners• People’s United Bank

Foundation• United Way

Academic Experts• University of Vermont, Center

on Aging – Geriatric Fellows• Albany College of Pharmacy• Castleton School of Nursing

Other• AARP

Regional Collaborative Agreements

Mental Health

University

Funder

AAAPACE

Hospital

Housing

Home Health

SUCCESS FACTORS

Connecting HOME to the Medical Home An MOU with all the partners Breaking the Information Barrier Population based and targeted Ability to measure outcomes Outcomes: Cost savings, health, satisfaction The Team: non duplication and mutual aid Person Centered Care Management Prevention and Wellness Workforce: highest and best use

•

Lessons Learned • Ask for input- again and again

• Fear of Change

• Anticipating Cross Sector Opportunities

• Patience Pays Off

• Leadership- state and local

What are the Essential Elements?

Person-centered – Population based

SASH Staff Team Based Care ManagementInformation Sharing through Technology

Prevention and Wellness through Healthy Living Planning

Volunteers

Participants

SASH Staff = Trusted Guides

SASH Coordinator- Duties at a Glance

Wellness Nurse- Duties at a Glance

Team Based Care Management

Nonprofit Housing

Visiting Nurse

Assoc.Area

Agency on Aging

PACE

Information Sharing

Housing Staff

Community Providers

(VNA, AAA, Mental Health)

Community Health Team

Hospital

Family Support Persons

Primary Care Provider

Nursing Homes/Rehab

Facilities

Healthy Living Planning and Support

Eat Better Move More Program

Volunteers

What Does SASH Provide?

Comprehensive AssessmentPerson Centered Healthy Aging PlanningInformed Team to Help in a CrisisTransitions Support back HomeProven Practices through the CHAPRegular Check InsCoachingWellness Nurse SupportsLink with CHT and Medical Home

Statewide Rollout$700 per enrollee per

year Supports SASH

Coordinators and Wellness Nurses

6,120 enrollees over 3 years

112 SASH hubs

How will SASH Expansion be Managed?

Organizational Infrastructure includes Cathedral Square as Statewide Administrator

Six Designated Regional Housing Organizations (DRHOs) CSC, CVCLT, BHA, RHA, RAHC, GHT