Cathedral Square Assisted Living This community offers the benefits of assisted living at a choice location overlooking Lake Champlain in downtown Burlington. Conveniently located near the University of Vermont and Fletcher Allen Health Care, the community offers 28 assisted living units designed to be affordable to households wit... More Information.
Support And Services at Home (SASH) brings a caring partnership together to support aging at home. The partnership connects the health and long-term care systems to nonprofit affordable housing providers statewide. Together these systems can facilitate streamlined access to the services necessary to remain safely at home. SASH is part of Vermont’s health care reform model, Blueprint for Health. The Blueprint for Health is organized around a medical home model through which coordinated care is provided by an interdisciplinary community health team (CHT) that supports the patient’s primary care physician (PCP). The SASH teams will extend the work of the CHTs and PCPs by providing targeted support and services to SASH participants in their homes.
Core Components of the SASH Model
1. SASH staff creates an organized, person-centered presence in the community. The SASH staff embedded in the housing community includes a SASH Coordinator and Wellness Nurse. Staff utilizes person-centered approaches to build strong and trusting relationships with SASH participants. SASH staff focus their efforts around three areas of intervention that have proven most effective in reducing unnecessary Medicare expenditures:
a. Transitions support after a hospital or rehab facility stay;
b. Self-management education and coaching particularly relating to chronic health conditions such as diabetes, arthritis, etc.;
c. Care coordination.
2. Team-Based Care Management. The SASH Coordinator and Wellness are part of a larger SASH team comprised of designated staff members from community provider organizations including: Home Health Agencies, Area Agencies on Aging, mental health providers, PACE, and other local providers. The roles and responsibilities of the team members are formalized through a Memorandum of Understanding (MOU) between all partner organizations. The team meets twice a month to coordinate care and action plan solutions for high risk SASH participants as well as discuss general health and information needs for the SASH community. Importantly, the community provider staff on the team also provides direct care to SASH participants in the community and can bring direct knowledge about high-needs participants to the team meeting and personally follow up on team recommendations for additional health-related interventions.
3. Information Sharing through Technology. SASH participants agree to have their health related information shared on an as-needed basis with members of the SASH team. Communication between SASH team members and participants’ PCP, family members and other support persons or organizations is also available as directed by the SASH participant. Having accurate and up-to-date information allows the SASH team to respond quickly and effectively when a SASH participant is facing a challenging or unexpected health situation. The efficiency of information sharing will be maximized by each senior housing community being equipped with the health information technology necessary to access the state’s Health Information Exchange (HIE).
4. Individual and Population Based Approach to Care Management. The SASH model focuses on the individual participant through the relationships formed with SASH staff and the development of individual Healthy Aging Plans (HAP) for each participant. The health and wellness goals and actions to reach the goals and determined by the SASH participant. The SASH staff then provides encouragement, support and coaching to help the participant meet those goals. The overall SASH population in a community is served by the creation of a Community Healthy Aging Plan (CHAP). The CHAP is developed by aggregating the information found in all SASH participants’ assessments and identifying group programs that will meet the common needs. The CHAP includes specific interventions from a directory of evidence based programs organized around five key areas: falls, medication management, chronic conditions control, lifestyle barriers, and cognitive and mental health issues.
5. Maximize Volunteer Engagement. The SASH model relies on maximizing the volunteer capacity within a community to meet the support needs of SASH participants. Volunteers provide companionship through “buddy” programs, assistance with shopping, cooking, and other activities of daily living.
Presentations from the September 2, 2011 SASH Peer to Peer Exchange;
1. SASH Overview and Operational Tools - Molly Dugan, SASH Program Manager, Cathedral Square Corporation
2. SASH Funding and Roll-out Overview - Nancy Eldridge, Cathedral Square Corporation, Executive Director