Last summer, after graduating from the University of Vermont College of Medicine, Eric Chang, M.D.’15, saw first-hand how an elderly man struggling to care for his sick wife could get so tired and distracted that he would forgot to take his blood-pressure medication.
A geriatric fellowship through the University of Vermont Center on Aging gave Chang important insight into the social dynamics that influence a person’s health.
“When you go into people’s homes, you begin to understand why certain disease processes are more chronic,” says Chang, now an internal medicine resident at Morehouse School of Medicine in Atlanta, Ga.
He was one of two 2015 fellows working for Support and Services at Home (SASH), a federal and state-funded program intended to further Vermont’s health care reform efforts by employing community-based care coordinators and wellness nurses at low-income, nonprofit housing facilities. Coordinators and nurses work out of the buildings or residential communities (known as “housing hubs”) and coordinate care, health education and activities for the Medicare-eligible participants who live there and in the surrounding community.
SASH recently won the 2016 Excellence in Program Innovation Award from the American Public Health Association (APHA) and the charitable Archstone Foundation. The award recognizes top initiatives in health and aging and includes an invitation for the winners to make a presentation at the APHA’s annual meeting, which takes place October 29 to November 2, 2016 in Denver, Colo.
The idea for SASH came from Nancy Eldridge, former executive director of the Cathedral Square, a non-profit housing and services organization serving primarily Chittenden and Franklin counties for over 40 years.Ms. Eldridgeobserved ambulances coming and going for residents and saw the need for an alternative to give them care at home.
Prior to the SASH program, housing based staff, had no clearance to discuss patients’ health needs with doctors, hospitals or community providers such as Home Health agencies and Area Agencies on Aging. SASH participants provide consent to allow their housing based coordinator and wellness nurse to communicate as needed with a team of professionals, known as the “SASH Team” to help participants stay healthy at home, says Jeanne Hutchins, executive director of the UVM Center on Aging.
Each SASH site covers a “panel” of typically 100 residents, registered through Medicare. If a building has only 75 residents that qualify, the panel can expand to Medicare-eligible adults living elsewhere in the community.
SASH launched with a pilot program at Heineberg Senior Housing in Burlington in 2009 and, once funded as part of the state’s Blueprint for Health initiative, went statewide two years later. It now includes 54 panels; serving over 5,000 Vermonters statewide
The uniqueness of SASH is its arrangement through the housing system, rather than the health care system, Hutchins says. “This was unheard of before, putting services in housing by housers.”
SASH coordinators form close relationships with participants, getting to know the details of their lives and health issues. They check to make sure they’re eating right, taking their medication or getting flu shots – the kind of attention that a primary physician, pressed for time and seeing patients under duress, often can’t provide. This at-home coordinated care ideally leads to the improved health outcomes and less costly medical care that the Vermont Blueprint for Health envisions.
A report released in June by research agency RTI International, which examined Medicare claims information, found that health care costs for SASH participants increased $1,536 less per year than they did for seniors living in affordable housing who were not involved in SASH.
Since its start, SASH has collected reams of health care data, showing the areas of greatest need for participants with issues such as diabetes or depression. Chang led presentations on those topics and others for SASH groups.
“There’s a limit to how much can be done from the medical side of things,” says Chang. “Medicine has to address the social side of things, too. I didn’t really appreciate that before I did the fellowship.”