Support and Services at Home (SASH), Vermont Conducted March 2011

Transcription

1 Affordable Senior Housing Plus Services Case Study Support and Services at Home (SASH), Vermont Conducted March 2011 This case study describes the Support and Services at Home (SASH) program. The study details how the strategy evolved, the available services and supports and how they are delivered, and the strategy s perceived successes and challenges. Any noted challenges are not intended as criticisms of the entities involved in the program, but merely highlight issues faced when programs and organizations are working together in new and different ways. The intention is to inform providers of concerns they may face when creating and operating housing plus service programs and/or to highlight needed policy and regulatory changes. The study was conducted via a site visit and interviews with staff from the housing property, service partners and local and/or state officials. Any errors in the case study are the responsibility of the authors. This case study was conducted after the SASH program had been piloted in one site and before it was rolled out to other sites across the state. It is current only to that stage and does not reflect additions and refinements to the program or operational experiences and identified success and challenges after that point in time. LeadingAge is partnering in an evaluation of the SASH program that will examine the program and its impact after it has rolled out statewide. Updated information and results will be posted on the LeadingAge website as they are available. Overview/Background Support and Services at Home (SASH) is a care coordination program that links health and supportive services to the home to support older adults ability to manage their care needs and age in place. SASH is anchored in affordable senior housing properties, serving residents in the property and seniors living in the surrounding communities. SASH has been developed and piloted in one site, Heineberg Senior Housing, and is being rolled out through a statewide demonstration. This case study will profile the program as piloted at Heineberg and will then describe the planned roll out, which is scheduled to begin in October Cathedral Square Corporation began developing the SASH program in 2008 out of concern that frail residents in their properties were not able to access and/or receive adequate supports to remain safely in their homes. In 2005, Vermont adopted a Medicaid 1115 waiver, called Choices for Care, which equalized participants choices of where they received care. Participants could choose to receive

2 services in their home, an assisted living facility or a nursing home. According to Cathedral Square, housing providers in the state strongly supported the waiver because it promised significant savings and that those savings would be funneled into the home and community-based services (HCBS) system to support aging in place for individuals with high acuity levels. After the waiver was adopted, the state created a tiered priority system for receiving services and only the frailest (termed Highest Need ) were able to access a waiver slot. Some believed savings were not funneled back into the HCBS system, and people were being waitlisted for Choices for Care slots. Cathedral Square perceived the Highest Need residents had insufficient supports to live independently even with the resources of Choices for Care and the program did not provide housing organizations any additional resources. Cathedral Square believed they need to address the problem for residents of their affordable senior housing properties and others because: 1) new money is unlikely to flow into the HCBS system given the state and national fiscal situation; 2) consumers will desire to stay in their home; and 3) even if a person got a Choices for Care waiver slot, the average participant received 27 hours a week of care, which may not adequately support their needs. A high need person not receiving care was not only a risk to themselves, they perceived, but also to their neighbors and the housing stock. Cathedral Square also believed affordable housing providers were an underutilized asset in the health and long-term care systems, believing they offered three advantages: 1) they provide congregate housing to the lowest-income individuals who because of age and poverty have a high incidence of chronic conditions and health care usage; 2) because a number of housing properties are scattered throughout the state they offer services hubs embedded in the community; and 3) they have significant assets to be leveraged in the form of staff, information and infrastructure. For these reasons, Cathedral Square believed housing providers can increase efficiency, increase the reach of the healthcare system into the community and assist in achieving health care reform goals. Cathedral Square decided to seek a supportive services solution that could be funded with the savings that could be derived within the current delivery structure. The goal was to create true system change, not a program for one housing site. They were striving to build a model that could be replicated across housing properties and communities and that would have a sustainable funding mechanism. In 2008, Cathedral Square asked the Vermont legislature for funding to support the development of a housing with services model. The legislature agreed to give them $100,000 a year for three years, if they could match it. The Vermont Health Foundation put up the match, and also decided that this would be one of the foundation s two multi-year focal areas. The foundation felt it was important to have all stakeholders involved in the design process, and facilitated the creation of the local table to oversee and advise on the model design. The group included players such as the VNA, AAA, Fletcher Allen Health Care, AARP, University of Vermont Center on Aging, and was chaired by a well regarded physician and professor in Vermont. Cathedral Square believes it was key to have a person who was trusted and respected by all the participants lead the group, as some organizations had concerns about the potential model. Cathedral Square also received funding from the MacArthur Foundation to assist with the model design process. The funding was part of a larger grant awarded to the state to support the preservation of affordable housing. Initially, the foundation did not see the connection between supportive service programs and housing preservation. Cathedral Square described for them how energy gets wasted because a resident is not mobile enough to turn off their lights or heat, the maintenance costs associated with health issues such as incontinence and the potential of lawsuits. (Cathedral Square saw

3 housing providers were in a catch-22 in that they retain residents consistent with Fair Housing protections, yet do not have the resources to support residents with significant health issues to age safely at home). Ultimately, the foundation was convinced. The working design team included Cathedral Square staff, led by a consultant hired by the Vermont Health Foundation. The consultant was a well-known and respected nurse in Vermont s aging and longterm care communities, which, in addition to her expertise, proved beneficial in helping to bring along skeptical partners. The University of Vermont s Center on Aging also recruited a geriatric fellow (a medical student deferring their education for one year) to work with the design team. Finally, the design team worked with residents in the pilot site, asking for their input and review. The design team researched evidence-based practices to inform the development of the model. In the course of their exploration, they realized that care management was a key component. They believed that if they could set up a system that provided care coordination, helped residents manage their health conditions and supported transitions from the hospital and/or rehab facility, they could both improve resident outcomes and save money to the public payer systems. The design team also looked at ways they could better coordinate with community service providers who were serving residents, such as the Visiting Nurse Association (VNA), the Area Agency on Aging (AAA), and the Program for all Inclusive Care for the Elderly (PACE). Staff believed there were many inefficiencies in the way these providers worked with residents and the housing properties. They felt there were redundancies with some residents while others faced gaps in care. They also knew that service providers were prohibited from communicating with the housing property due to HIPAA restrictions, although the housing staff often had a wealth of knowledge about residents. Service partners had concerns that housing providers might duplicate their services and/or take away their funding. Cathedral Square believes they have built a model that firewalls these areas. Resident Services and Supports The SASH model is centered on an interdisciplinary team of providers that includes a SASH coordinator, wellness nurse and representatives from a network of community service providers. The description below will detail the team developed at Heineberg Senior Housing in Burlington, VT. As SASH expands in housing properties across the state, the community service providers may vary slightly based on the needs and resources available in a particular community. Cathedral Square hopes to include community Mental Health agencies on the team as the program rolls out statewide. Each team, however, will follow a similar structure and set of processes. Heineberg s SASH team includes the SASH coordinator and wellness nurse, both employed by the housing property, a geriatric fellow from the University of Vermont College of Medicine 1, a Visiting Nurse Association of Chittenden and Grand Isle Counties (VNA) nurse, a Champlain Valley Agency on Aging (CVAA) case manager and a PACE Vermont intake coordinator. 2 Each community service organization dedicates an individual to the property to provide care for all of the agency s clients in the 1 The University of Vermont s Center on Aging dedicated a geriatric fellow position to work with the SASH design and pilot teams. The fellow and the wellness nurse currently conduct the resident assessments. However, the fellow may not always be available to Heineberg and will not be available to other SASH sites around the state. 2 At the time of our site visit, the pilot was not yet enrolling individuals from the surrounding community. A community liaison position will be part of the team in the future.

4 property and participate in the interdisciplinary team. For example, all residents receiving services from the VNA are cared for by a nurse and aid assigned to the property. All agencies represented on the SASH team enter into a Memorandum of Understanding (MOU) that details the rights and responsibilities of each party. Additional parties to the MOU include the hospital to ensure compliance with the SASH discharge protocols, the Vermont Health Foundation who guarantees the funding for team member participation at twice monthly team meetings and the UVM Center on Aging as the funding source for the geriatric fellow. The MOU is for one year and will be revised and extended as new parties join the collaboration. Each community agency serves Heineberg residents in the same manner as any other individual in the community. Residents go through each agency s application and assessment process, services are arranged directly between the individual and the agency, and the agency bills either the individual or an appropriate insurance or publicly-funded program. There is no central funding source for services. What is different is that all of the agency representatives participate in an interdisciplinary team where they share information about clients, help develop solutions to identified needs and coordinate care across common clients. The Heineberg SASH team meets twice a month for approximately two hours. The team begins by reviewing selected residents. Participants identified for discussion include new participants and those who have had a hospital or nursing home stay, a change in health status or a fall. Generally, about six to 12 participants are reviewed at each team meeting. The team follows a discussion template for each resident, which includes why the team is discussing the individual, action planning to address issues and needs and any needed changes to the individual s healthy aging plan (described below). Following the individual resident reviews, the team covers more global issues, concerns and issues including the Community Healthy Aging Plan or CHAP, a population wide plan to promote wellness. A range of services and supports are provided through the SASH program Available onsite Service/Support Delivery Mechanism Provider Care coordination Property staff Heineberg Senior Housing Wellness and health promotion Property staff Heineberg Senior Housing Homemaker Limited contract Visiting Nurse Association of Chittenden and Grand Isle Counties Available through SASH team partner* Home and personal care, skilled nursing Services offered by Area Agency on Aging Partner Partner PACE Partner PACE Vermont Visiting Nurse Association of Chittenden and Grand Isle Counties Champlain Valley Area Agency on Aging *While these services would be available to individuals in any housing property and residents are served just as any other individual in the community would be, in the SASH program these community agencies are purposeful partners and participate in bi-monthly interdisciplinary meetings. Care Coordination

5 The core of the SASH team is the SASH coordinator. The SASH coordinator role is designed to go beyond the traditional service coordinator role and engage with residents at a deeper level. While the service coordinator role can vary, the focus is generally on helping residents identify and access needed resources, but does not go so far as helping residents manage their services. Through a comprehensive assessment, the SASH coordinator becomes knowledgeable about a resident s needs and interests and helps them coordinate their care. Heineberg has two SASH coordinators who cover a total of 50 hours, allowing for some coverage in the evenings and weekends. Participation in the SASH program is entirely voluntary. Sixty-three out of 80 residents in Heineberg elected to participate in the program. Residents who do not formally enroll the SASH program may still receive assistance from the SASH coordinator and may participate in the community activities. However, they generally do not receive the benefit of the coordination and communication between the property staff and program partners because they have not consented to allowing them to discuss and share information about them. Once a resident expresses interest in enrolling, the SASH coordinator spends about an hour reviewing the program with them and completing the following documents: 1) A participation document describing what it means to enroll and what a participant can expect to receive; 2) A disclosure agreement defining who SASH team members can communicate with; 3) A notice of privacy practices and confidentiality; and 4) A liability waiver, which states that Cathedral Square Corporation is not a healthcare provider. After the resident enrolls in the program, the SASH coordinator schedules an assessment for the individual. The assessment takes one to two hours to complete and is conducted by the wellness nurse or the geriatric fellow. The fellow believes it is helpful to have some degree of a medical background to conduct the assessment, although it is not necessary. The SASH design team is reviewing the current assessment form and may revise it so that a medical background is not needed. Currently the assessment is done in paper form, but the ultimate goal is complete it electronically so that the information can be shared with the community health teams (to be discussed later). The comprehensive assessment looks at medical conditions, functional limitations, emotional health, nutrition, cognition, medications, ER and hospital use, falls, physical activity, support network and services currently utilized. The tool was developed by the nurse consultant who worked with the SASH design team and is based on the state s independent living assessment to allow for potential sharing and comparing of data. The design team felt the state s assessment was not broad enough, however, and added additional questions looking at areas such as cognition. After the assessment is completed, the SASH coordinator conducts a person-centered interview with the individual utilizing a tool developed by the University of New Hampshire s Institute on Disability. The interview lasts about one hour and is designed to help understand the participant s values, what motivates them and ways the SASH team will be successful in working with the individual. At the next SASH team meeting the team debriefs on the assessment and interview and begins exploring the components of the individual s Healthy Aging Plan (HAP). The SASH coordinator drafts the HAP and then discusses it with the resident. The coordinator reviews what they learned in the assessment and interview, areas in which the SASH team could assist them and potential interventions, and then asks the resident for their feedback and input. They find that residents say no to some intervention areas (often around nutrition), but are accepting of many others (such as falls prevention and chronic disease

6 self management education). Cathedral Square believes the resident ultimately needs to be in control of the plan. The SASH team is developing a protocol for monitoring residents HAPs. The protocol will likely be based around the individual s level of need. For example, the SASH coordinator would check in with someone with a high level of need every three months, someone with moderate needs every six months, and low needs annually. The coordinator would engage with anyone, regardless of their need level, if they have an incident or change in condition. The SASH coordinator aggregates the results from the individual resident assessments to develop a community healthy aging plan (CHAP). The coordinator looks for issues that may be affecting a number of residents in the community and then identifies opportunities to help address those concerns. For example, the assessments at Heineberg revealed that 23% of residents in the property had diabetes. In response, the coordinator brought in a diabetes management course. The SASH team focuses on bringing in evidence-based interventions, and has developed a catalogue of evidenced-based programs that address a range of issues that might affect residents of affordable senior housing. While any programming at the property is open to all residents, the SASH coordinator is also able to target marketing to individuals whose assessment identified the activities may be particularly relevant. SASH has developed a protocol for assisting residents transitioning home from a hospital or nursing home stay. SASH has established an agreement with Fletcher Allen, the one hospital in Burlington, that the discharge planners will communicate with the SASH coordinator. 3 When the SASH coordinator finds out a resident has been hospitalized, they send an to the discharge planner. Currently, there is no system in place for the hospital to notify the SASH coordinator that a participant has been admitted, but the goal is to establish one. Once the resident comes home, the SASH coordinator or wellness nurse follows-up immediately with the resident. Based on the Coleman transition model, they makes contact with the resident within 24 hours, talk to the family and ensure that any home health services set up are activated. Because the VNA nurse is part of the SASH team, they can have immediate contact with her. The geriatric fellow notes that part of what they are hoping to do with SASH participants is to change their patterns of how they interact with the healthcare system. Instead of going to the ER, they hope participants might come to SASH staff and they could help them call their doctor and the doctor could say come see me today. SASH staff also state they are trying to build participants self-management capacities. Many, they believe, just go to the doctor and think that takes care of everything. After completing the first round of Healthier Living (the Chronic Disease Self Management Program) residents said they needed motivation to help keep them going. The property started a healthier living support group that meets every other week, and is trying to transition the group to be a peer led one. Wellness and Health Promotion Together with the SASH coordinator, the wellness nurse is the anchor of the SASH team. The nurse, employed by the housing property, is at Heineberg two days per week. As the program rolls out around the state, SASH sites will have the choice of employing the wellness nurse directly or contracting them from an outside organization such as the VNA. 3 The head of Fletcher Allen s discharge department was a member of the SASH design team, now called the local table.

7 The wellness nurse provides assistance in a range of areas, including monitoring vital signs (blood pressure, oxygen, glucose (does not draw blood, but will review glucose level trends)), assistance with making appointments and communicating with doctors, self-care counseling and education, and answering health-related questions. The nurse will also provide coaching on proper medication management and will assist residents with filling their medication boxes. Heineberg nurse notes this is a time consuming service; pre pouring meds for a full month can easily take an hour. She currently assists six residents with their medications. The property also has a medication dispensing machine that residents and families can test out and determine if they would like to purchase their own. The nurse also provides foot care. There is a fee of $10 for this service; all other areas of assistance are free to residents. The nurse does not provide any sort of skilled nursing care, such as wound management. The nurse believes it reduces the anxiety of many residents to have someone around who can check their blood pressure and answer their health-related questions. The nurse and other members of the SASH team believe this may have prevented some residents from unnecessarily calling 911. The SASH program also brings in health and wellness promotion programs, which are selected based on the resident needs identified in the community healthy aging plan. Where possible, SASH looks first to evidenced-based programs and practices. For example, they brought the Healthier Living program to the property, a six-week education program that teaches individuals how to manage their chronic diseases. Homemaker(onsite) Heineberg contracts a licensed nursing assistant (LNA) from the VNA for nine hours per week to float flexibly around the property to help residents who need homemaker or personal care assistance. The position is funded by a grant from the Vermont Health Foundation. The concern was that residents who needed this type of assistance, but did not meet the high acuity level required to be eligible for the Choices for Care program, were struggling with unmet needs. The LNA is at the property three hours/day, three days/week and is able to assist residents. The LNA position was funded at Heineberg to test whether this position would be beneficial to help address unmet needs in a property. It is not currently a funded position and will not be included in the role out of the SASH teams in housing properties and communities around the state. Home and Personal Care Home health agencies provide care to residents in Heineberg Senior Housing who may be receiving home care services following a hospital or nursing facility care or through the Choices for Care (Medicaid waiver) program or may be receiving hospice care. These services are provided just as they were prior to the creation of the SASH program and as they would be to anyone else in the community. The resident chooses which agency they would like to use. The distinction is that VNA staff, including an RN, LNA and personal care attendant, is now dedicated to the property and cares for all residents receiving VNA services. The nurse also serves as a member of the SASH interdisciplinary team. Additionally, the VNA provides training for the SASH team members in areas such as body mechanics, dementia, performance improvement measures, etc. The VNA staff coordinates, as necessary, with the onsite wellness nurse. According to the VNA s CEO, the staff dedicated to Heineberg have been very pleased with the assignment. They talk about their people and feel a sense of ownership. They also enjoy participating in the interdisciplinary team meetings and being able to give advice about all residents in the building.

8 He notes it has created a bit of assignment envy for other VNA staff. As the first VNA to participate in the SASH program, the Chittenden and Grand Isle Counties VNA has been a sort of ambassador to other VNAs around the state. The CEO has told them to be prepared for the enthusiasm they will see from their staff. The VNA CEO believes developing the SASH program has helped community providers learn a lot more about each other. He believes the VNA is known as intermittent care providers, but when they started working together through SASH, Cathedral Square learned that they also have other major programs that provide regular care. Similarly, the VNA CEO says he thought of housing as an apartment building where someone puts the mail in the boxes, takes out the trash and calls the home office when the heater does not work. SASH is requiring them to learn more about each other than they presently know. In order for SASH to be successful, the VNA CEO says community service and housing providers are going to have to become more informed and trusting of each other. They are also going to have to make some adjustments to the boundaries between them. Some of his colleagues have expressed concerns that Cathedral Square is trying to become a home health provider. When the VNA CEO says the organization only has wellness nurses and is not trying to move into that end of the spectrum, some are still concerned of what that might lead to. He also notes that all community service providers will need to get along well and collaborate at the level required by the SASH model.. The VNA CEO believes it helped to have an independent entity, the Vermont Health Foundation, bring the services providers together to create SASH. Even more beneficial, was the fact that Cathedral Square hired a widely admired individual as a consultant to help design the program. Everyone trusted this person and believed she would not sell them down the river. The VNA notes two primary motivations for participating in the SASH development process and program. The first was the fact that the Vermont Health Foundation declared they were only going to work on two areas this year and SASH would be one of them. The second was that Cathedral Square hired a respected consultant to guide the process. Like Cathedral Square, the VNA CEO was also concerned about the train wreck coming down the pike when the current residents in affordable housing property have aged and the needs have increased. Both believe that affordable assisted living is not a scalable model due to inadequate Medicaid funding and is not a viable solution for the number of lower-income seniors who need support. The VNA CEO realizes that his small agency will not be able to take care of everyone. In fact, he believes, none of the community agencies will be able to do it alone. The CEO did wonder if the SASH program might increase acute care admissions, but so far they have not seen that. Area Agency on Aging Services Like the VNA, Champlain Valley Agency on Aging (CVAA) has a case manager dedicated to Heineberg Senior Housing to work with all residents in the property who may be receiving services through the organization. Residents may be receiving assistance through any of the programs CVAA offers including case management, assistance with applying for benefits, Meals on Wheels, HICAP, etc. The case manager also participates in the bi-weekly team meetings. The CVAA case manager appreciates having a SASH coordinator because they are able to assist residents with many things. Because of the SASH coordinator, she does not consider Heineberg a high need property. In comparison, she is at another Cathedral Square property daily that does not have a SASH

9 coordinator and has a higher number of Choices for Care clients. The difference she sees for her clients participating in SASH is that they have a support system and someone to go to ask questions. Having a source of information is half the battle she believes; many people do not even know CVAA exists. Although the SASH coordinator is working with residents more intensely, finding out their needs and interests and setting up programs, CVAA s executive director does not get the sense that the SASH coordinator and CVAA case manager are stepping on each other s toes. He also believes the agency has probably gained some new clients through the SASH program that might not have been identified otherwise. The CVAA executive director does have concerns about individuals landlords also being their case manager and feels there should be a separation of roles. Some people move into an apartment only wanting a safe, clean place to live, he believes, and there should be no pressure to participate in programs or services. He does not think this has been a problem in the SASH pilot site. Some residents have chosen not to enroll, although it is unclear to him what happens if a resident does not participate in the program. The executive director does not believe there have generally been strong relationships between housing properties and AAAs around the country. He does not think there has been an interest on behalf of housing providers. However, he also believes that AAAs have an advocacy function for residents getting evicted from properties, and a relationship with housing providers creates a hypothetical barrier to that role. Cathedral Square may have felt they were out of the loop with all of the service providers who were going into their building. But the question, in his mind, is do they need to know what is going on? He does appreciate the fact that residents voluntarily enroll in SASH and give permission for providers to share information. The executive director believes the wellness nursing aspect of SASH (checking blood pressures, talking to people about their situation, etc.) has been valuable for residents. He would be concerned if a resident called the SASH coordinator (a non-medical person) instead of calling 911 when having an acute episode. Despite some misgivings, the CVAA director does think SASH will have a positive impact. PACE PACE Vermont s intake coordinator participated in the SASH design team. At first, she had a difficult time seeing how you could have this type of program in an independent living situation because lines would be crossed. She worried that the involvement of multiple service providers would breach the concept of independent living. As the program has rolled out at Heineberg, however, she has found that is not the case. PACE Vermont has not had too many clients in independent housing properties, and before SASH began only had one client in Heineberg. The service coordinators, they believe, do not generally have enough information to know if an individual could be eligible for PACE (health, financial, support network). They have tried to do presentations to housing staff and residents, but find that the individuals who might be eligible for PACE generally do not make it to the presentations. The SASH program could help because the SASH coordinators now have a lot of information about the participants. PACE Vermont does not currently have any clients at Heineberg as they have found residents are not eligible. PACE is an option under Choices for Care and few people at Heineberg are clinically eligible for

10 the program because of the high threshold to qualify for nursing home care in Vermont. 4 As the SASH program roles out into other communities it may help identify potential clients. In the future, as resident needs increase, the SASH program may also be a potential referral source for them. PACE Vermont staff believe one of the biggest benefits of SASH is that it touches people who might otherwise fall through the crack. The state is not building any more nursing homes and it is very difficult to get into affordable assisted living, so SASH provides an option. As a model whose philosophy is about keeping people in their homes, PACE Vermont is an absolute supporter of the SASH program s goals. PACE does have multiple participants in two of the Burlington Housing Authorities properties. They believe there are also additional residents who receive services from the VNA through the Choices for Care program. They find their clients in the public housing properties have very poor support networks compared to residents in Heineberg or higher income buildings. Challenges The SASH team has identified some challenges thus far. The biggest challenge is record keeping. The core of the model is shared information. Currently, records are kept in paper form. The SASH coordinator is focused on spending time with residents, so documentation gets pushed to the side. Partner agencies have their own documentation system, so getting them to stop off in the wellness office and duplicate their notes in the SASH record is difficult. The SASH team is in the process of developing an access database, which will be used as a stop gap measure until the state s information exchange is operational. Team building was also a challenge. When putting a team together for the first time, it takes time for relationships to build. Initially, all the team members did not understand why they were working together. They started bringing the team members together on a weekly basis before launching the program in the property to do training (confidentiality, memory loss, evidenced-based practices, personcentered planning, etc.). In the end, they believe the SASH team at Heineberg gelled well, but this is something that will have to be nurtured and monitored in future teams. What SASH coordinators and wellness nurses do is very hands on and specific (daily check ins) and it has raised expectations of residents and family. This has raised the need to bring some sort of back up when the SASH coordinator is not available. However, it must still be kept in mind that this is independent living, not assisted living. Vermont Health Reform The state of Vermont has been working on healthcare reform for the past decade, formally launching the Blueprint for Health in The goal at the time was to address the increasing costs of caring for people with chronic illnesses, with an early emphasis on diabetes management. In 2006, the Vermont Legislature expanded the scope and scale of the Blueprint to a broad health reform effort intended to increase access, improve quality and contain the cost of health care for state residents. In 2007, the state established a pilot project in three communities to test a care delivery system based on a patient centered medical home model supported by community health teams (CHTs) and an 4 Choices for Care participants can choose to receive care through either the VNA or PACE. PACE is a relatively new program in Vermont, while the VNA is a long-established organization.

11 integrated information technology infrastructure. The state also introduced payment reforms to support the delivery innovations. In 2010, legislation expanded the advanced primary care practice infrastructure (medical homes and CHTs) statewide. Also in 2010, Vermont was selected to participate in the Centers for Medicare & Medicaid Services Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Project. 5 Through the demonstration, Medicare will come on board as a participating insurer with the Blueprint joining private insurers and Medicaid to provide financial support for the advanced primary care practices. A goal of the Blueprint model is seamless coordination across the broad range of health and human services (medical and non-medical) to optimize patient experience and engagement and improve the long-term health status of the population. The CHTs partner with the primary care practices to help achieve this goal. Each CHT is staffed by five full-time equivalent employees and serves a population of 20,000. The composition of each team is determined locally, but teams typically include nurse coordinators, behavioral health counselors, social workers, community health workers, public health specialists and dieticians. The teams offer individual care coordination, health and wellness coaching and behavioral health counseling, and connect patients to social and economic supportive services. Statewide Expansion of SASH As the state began preparing its MAPCP demonstration application, Cathedral Square approached the state about incorporating the SASH program into the demonstration. Cathedral Square s argument was that many of the state s high-cost health care users resided in affordable senior housing properties, and through the SASH program the SASH team would have extensive knowledge of the residents and the elements in place to help residents better manage their health and supportive services needs. Cathedral Square worked with the state to show the impact the SASH program could have on the ten cost centers the state was evaluating through an economic impact model. The model found there would be increases in some cost areas (home health, labs, mental health care) and decreases in others (hospital stays, ER visits, nursing home care, medications), with a net savings of $1.2 billion over the three year demonstration. This economic impact analysis helped convince the state to include the SASH program in its application. Initially, CMS was not convinced about the inclusion of SASH. According to Vermont officials, while CMS thought the concept was good, they viewed it as a long-term care model and felt it needed to be funded elsewhere. Ultimately, the state was able to help CMS understand the broader approach of the SASH program and how it fit into health care reform. Through the MAPCP demonstration, SASH teams will function as extenders of the CHTs. SASH will be rolled out to 112 housing communities across the state over three years, ultimately enrolling up to 6,120 participants. The SASH teams will serve both residents in affordable housing settings as well as nonprofit residential settings such as Continuing Care Retirement Communities and Residential Care Facilities. SASH will also be offered to seniors in the surrounding communities. 6 Each panel of 100 SASH 5 Under this demonstration, CMS will participate in multi-payer reform initiatives currently being conducted by states to make advanced primary care practices more broadly available. The demonstration will evaluate whether the advanced primary care practice will reduce unjustified utilization and expenditures; improve the safety, effectiveness, timeliness, and efficiency of health care; increase patient decision-making and increase the availability and delivery of care in underserved areas. 6 Although the SASH program was initially intended to serve residents in the communities surrounding the housing properties, Medicare explicitly restricts discrimination based on where people live. As the SASH sites roll out across

12 participants will be staffed by one full-time SASH coordinator and a quarter-time wellness nurse. Medicare will pay $700/participant/year, which covers only the salary of the SASH coordinator and wellness nurse. 7 The payment does not cover any administrative/overhead or programming expenses. 8 The state has been broken into six regions and each assigned a Designated Regional Housing Organization (DRHO), which provides leadership and technical assistance to the SASH sites within the region. The DHROs are charged with: Building partnerships with SASH team member organizations (i.e., AAAs, home health agencies, PACE, community mental health agencies) and planning the SASH roll-out within the region. Negotiate and execute MOUs with SASH team partners. Building relationships with the CHTs in the region to determine structure for referrals and support to SASH participants. Create and staff the Local SASH Table (regional Advisory Committee) made up of regional public and private partners such as hospitals, universities, nursing homes, community provider organizations, the Blueprint, etc. Support CSC in conducting regional SASH team trainings. As part of the MAPCP demonstration, the SASH sites will be incorporated into the state s health information exchange (HIE), called DocSite. DocSite will not be operational as the SASH rollout begins and the SASH sites will initially begin collecting data in an Access database. 9 The state does not perceive there are any issues (privacy, confidentiality) with SASH sites having access to personal data through the HIE as long as a resident consents. SASH sites are extenders of CHTs, which are extensions of the physician practices. The HIPPA consent an individual signs at their doctor s office will cover the SASH site exchanging information with the CHT and physician practice. However, the state also recognizes that once the SASH sites are hooked up to DocSite they might discover wrinkles they have not considered. As the SASH design team prepared for a statewide rollout, the design consultant and representatives from Burlington s local table began meeting with service providers around the state to educate them about the program and engage their input. For example, the six AAA directors around the state meet monthly and the design consultant meets with them. SASH will face several challenges as it expands around the state. One will be that the development of the CHTs and the rollout of the SASH teams may not be on the same time frame. The SASH teams cannot draw the funding from the MAPCP demo until the CHT that they are tied to is functioning. Another challenge is planning and start-up funding to help get all the SASH teams and regional entities in place and running as they expand around the state. The MAPCP funding only funds the salary of the SASH coordinator and the wellness nurse and is provided on a reimbursement basis. Cathedral Square is the state, however, the enrollment selection system will focus initially on enrolling participants in the housing properties and then will recruit individuals from the surrounding community. 7 This payment is not intended to substitute for existing funding for these positions, but to augment the existing resources. 8 Initially SASH requested $1100/per participant, but this amount was reduced by the state during the Business Case Model development process. 9 Health Information Technology has been in embedded in Vermont s health reform effort since the beginning, and the state has made substantial investments in this area. The state has also helped primary care practices purchase electronic health record systems allowing them to share information with the HIE. All hospitals in the state are required to be connected to the HIE. Physician practices are not required to do so, but the state believes most will.

13 working with the state to identify potential sources to help fund the start-up and implementation costs of expanding the SASH sites around the state. Cathedral Square has applied for a HUD housing assistance peer-to-peer grant to reach out to the housing providers around the state to get them on board and ready to roll out the program. About six housing entities have been involved in the SASH design stages, and together they will help outreach to other housing providers. Cathedral Squares has found mixed interest from housing providers; some are eager to get started and others are opposed to the model. Cathedral Square has not had formal communications with all housing providers yet, because they have not had answers to the key questions of how and when the funding is going to flow. Some of the service partners in the Heineberg SASH pilot site anticipate potential challenges as the program expands both within their catchment areas and around the state. The VNA, CVAA and PACE Vermont are all concerned about the time required for their SASH-designated staff to attend bi-weekly, two-hour team meetings. When aggregated across multiple sites, this is both a potential loss of revenue and time available for client care. While the VNA believes the model is manageable for them at one housing site, they have concerns about staffing multiple sites. Under the statewide roll out plan, they will be responsible for 30 housing sites. They attempt to guarantee all their clients consistent scheduling and currently have a full caseload for all their nurses. If they have to dedicate nurses to all the SASH sites within their jurisdiction, they are not sure how they will be able to staff their non-sash clients. They also worry about their ability to pick enough nurses who have the best skills and personality for this type of role. Finally, they are concerned about the lost revenue when a nurse is attending a team meeting. In the pilot SASH site, the VNA nurse is being paid $50/hr to attend the interdisciplinary meeting. If the nurse were seeing patients she would receive approximately double that. This is also two hours during which nurses, who already have a full caseload, will not be available to see clients. CVAA is also concerned about staffing when the SASH program is expanded to other properties. They are apprehensive of a case manager spending hours at multiple team meeting each week. Case managers currently spend a lot of time at meetings with family members and other providers, so this type of activity is not out of the ordinary for them. However, multiple meetings every week can take too much time away from clients. Similarly, PACE Vermont is concerned about their capacity to participate in team meetings as SASH expands. The Burlington local table s concern is that as SASH rolls out the expansion sites will not be able to have the depth that the pilot site has had. Burlington has the medical and nursing schools, the college of pharmacy and Fletcher Allen Hospital in addition to a variety of community organizations. Many areas around the state will not have this level of resources. The VNA also notes that many rural areas have difficulty recruiting nurses and have to pay higher wages to get them to locate there; this may be a challenge for securing wellness nurses. Perspective of State Officials Vermont s Deputy Secretary for Human Services and Commissioner on Aging are both supportive of the SASH program and its potential contribution to the state s health care reform and long-term care efforts. The Deputy Secretary believes stable housing is fundamental to any area in which the agency works, and that linking services with the housing setting can potentially help avoid institutionalization.

14 According to the Commissioner, the state made a commitment ten years ago to change the face of longterm care and not be wed to an institutional model. The notion of being able to get services in housing fits nicely with what the state has been trying to do, she says, but congregate housing settings have often been overlooked. The human services agency has good relationships with housing developers and funders, says the deputy secretary, and meets regularly with them to discuss populations ranging from the homeless to the elderly. He believes housing entities will generally be amenable to adopting SASH, but service providers may possibly be more skeptical. The Deputy Secretary believes the biggest challenge to SASH s success will be keeping assistance in the building 24 hours a day. Through CMS s Innovative Demonstration Project for Dual Medicaid/Medicare Members grant program, for which the state will apply, they may be able to craft a solution to this. The grant will provide the state flexibility in utilizing Medicaid and Medicare funds. For example, they could provide funding to hire after hour care in some SASH sites on the belief that that presence could help prevent some 911 calls and ER visits. The Deputy Secretary prefers the idea of supporting individuals in a regular housing setting with a mix of persons that does not target populations. However, he also recognizes there often tends to be a concentration of certain kinds of people and that may be a way to better manage a population and control costs. For example, the state participated in the development of a Cathedral Square community that provides 10 housing units for extremely disabled people with the funding for VNA 24/7 onsite caregivers to assist the residents. The model works well, and although expensive, the cost is less than supporting the nine individuals in a nursing home. The Deputy Secretary believes a housing with services model does not necessarily need to be licensed. He believes you need licensing in closed systems where there is no outside view into the system. A housing with services model, however, has checks and balances by virtue of the multiple providers involved, some of which are licensed and regulated. He also believes the concept of housing with services can work everywhere; you just may have to make adaptations depending on the circumstances. For example, you might not be able to have an onsite 24/7 presence in a small rural property, but you can do it through shared services and technology. The Commissioner recognizes some have concerns over housing providers having information about their residents situations. Some of the AAAs in Vermont, she says, are opposed to the idea that a landlord should know anything about the resident. While she appreciates these concerns, she feels she has become less worried over time about this blurring of roles so long as people who live in the housing properties know they have the choice to avail themselves of services or not. The AAAs in Vermont do case management for the state s waiver program, and some had initial concerns that SASH would be a competitor. The Commissioner believes that SASH can help fill a gap in providing services to people who do not need the state s long-term care services. It can provide a sort of pre long-term care service, perhaps slowing down the need for long-term care services. She recognizes it may be difficult, though, to measure outcomes such as delaying entry to the waiver. She does think that through health promotion activities, SASH may help decrease ER and hospital use and hospital length of stays. Through building healthier communities and support systems, SASH may help lessen participants reliance on the state s farther

15 end services. The Deputy Secretary also appreciates that the SASH pilot has shown better outcomes for participants, not just savings. Some are concerned about medicalizing housing, especially when the funding for services comes from the medical side (i.e. Medicare). However, SASH, she feels, broadens the conversation to quality of life and living in a healthy community. In this regard, the Commissioner sees SASH as a conceptual model that will allow the state and service providers to partner in new ways and target different populations. The program may help meet the state s public health goals. Thus far, the state has primarily only looked at public health in terms of mothers and children. The state may be facing possible budget cuts to IADL services in the waiver. Congregate settings can possibly build communities that can help supplement that; this is one possible way where SASH could enhance waiver services. The Commissioner believes there can be an illusory concept of independence. SASH can help make a step to understanding interdependence and community. Postscript: Since this case study was completed, the SASH program began rolling out statewide. As of December 2012, the SASH program has been implemented in 80 residential sites across the state. LeadingAge is partnering in an evaluation of the SASH program that will examine the program s implementation and impact after it has rolled out statewide. Updated information and results will be posted on the LeadingAge website as they are available. This research was funded by the U.S. Department of Health and Human Services and the Department of Housing and Urban Development under contract HHSP WC. The views expressed are those of the authors and are not those of the U.S. Department of Health and Human Services or the U.S. Department of Housing and Urban Development. The LeadingAge Center for Applied Research, bridges practice, policy and research to advance highquality health, housing and supportive services for America s aging population. The Center s three signature objectives are to advance quality of aging services, develop a high-performing workforce and enhance resident options through services and supports. Through applied research, the Center creates an evidence-base to improve policy and practice. LeadingAge is an association of 6,000 notfor-profit organizations dedicated to expanding the world of possibilities for aging. Visit to learn more about the Center s work.