Transcript Designing a Model for Replication

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 85
 49% used ER in past year
 54% take 6 or more prescription meds
 71% have high blood pressure, 59% arthritis, 39%
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chronic pain.
61% fallen in past year
32% self-reported mental health concerns
59% use a cane or walker
49% failed 2-3 components of a cognitive screen
Results at Heineberg
• 19% reduction in
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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
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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
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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
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Other
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AARP
Regional Collaborative Agreements
Home
Health
Housing
Mental
Health
University
Hospital
Funder
PACE
AAA
SUCCESS FACTORS
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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 Management
 Information 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
PACE
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Assoc
Area
Agency on
Aging
Information Sharing
Nursing
Homes/Rehab
Facilities
Housing Staff
Community
Providers
(VNA, AAA,
Mental Health)
Primary Care
Provider
Community
Health Team
Family Support
Persons
Hospital
Healthy Living Planning and Support
Eat Better Move More Program
Volunteers
What Does SASH Provide?
 Comprehensive Assessment
 Person Centered Healthy Aging Planning
 Informed Team to Help in a Crisis
 Transitions Support back Home
 Proven Practices through the CHAP
 Regular Check Ins
 Coaching
 Wellness Nurse Supports
 Link with CHT and Medical Home
Statewide Rollout
 $700 per enrollee per year
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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