OneCare Vermont, a Vermont accountable-care organization, has invested in an innovative pilot program to enhance mental health and substance-use treatment services for residents at two Cathedral Square affordable-housing communities in the Burlington area.

Working in collaboration with the Howard Center and SASH® (Supports and Services at Home) at Cathedral Square, the program will deliver an improved health-care experience by providing a full-time Howard Center clinician who will split their time between the two housing sites.

“The embedded clinical care that Howard Center will provide at two Cathedral Square communities will ensure residents are receiving timely care, with a goal of fewer avoidable emergency room visits,” said Catherine Simonson, chief client services officer at the Howard Center.

The role of the SASH-based clinician at the two sites will be to promote emotional wellness to all participants and residents while having the flexibility to provide more intensive individual therapeutic supports to individuals in need. The clinician will enhance already-existing services provided by SASH in the form of both individual and group therapeutic support as well as participation in care-coordination and treatment planning.

“The pilot program will provide easy access to flexible team-based supports, including direct one-on-one support and group-based programming,” said Molly Dugan, director of SASH.

The program is part of OneCare’s campaign to improve how health care is delivered to Vermonters by using value-based service models instead of fee for service, also known as the all-payer model.

“This is a natural next step for OneCare and for Vermont,” said Sara Barry, director of clinical and quality improvement at OneCare Vermont. “We know that one way to achieve population health is to focus on people in their homes and communities. We are meeting people who need our help where they are. We know this is where people are spending their time, so what we are now addressing is, how do we increase the knowledge of staff on site, and the quality of counseling and mental health services?”

The pilot, for older adults who experience mental health and substance-use challenges, will test the effectiveness of locating mental health practitioners and prevention resources on site, bringing care to the patients.

“This pilot will enhance the existing community-partner-based SASH model,” said Deb Bouton, director of outreach and marketing at Cathedral Square. “The existing SASH model already provides comprehensive, team-based care and prevention programs to help participants stay healthy in their homes. We are looking to build on this program and make it even better.”

Nearly 5,000 people in Vermont rely on the acclaimed SASH program, which uses the state’s affordable-housing network as a platform to support healthy aging at home through services coordinated with nonprofit housing organizations, area agencies on aging, home health organizations, community mental health and developmental services organizations, and primary care health providers.

With an initial investment from OneCare of $97,000, the Cathedral Square-Howard Center pilot is expected to serve up to 200 residents and realize shortened time frames to access mental-health services, reduce avoidable emergency room visits, improve the patient experience, and enhance inter-agency team coordination. The pilot began Nov. 1 and will continue through Dec. 31, 2018.


About the Organizations

  • OneCare Vermont supports initiatives designed to improve patient health in the Vermont provider network and partners with Vermont communities to support activities meeting the needs of their specific patient populations.The statewide accountable-care organization (ACO) works with Medicare, Vermont Medicaid and commercial exchange programs to improve the health of Vermonters. OneCare Vermont comprises an extensive network of providers, including hospitals in Vermont and New Hampshire, and coordinates the health care for more than 100,000 combined Medicare, Medicaid and commercial-exchange Vermont members.
  • The Howard Center serves more than 16,000 people from 60 locations in six counties, offering services and treatment for mental health, substance-use and developmental disabilities. It also operates First Call for Chittenden County, a round-the-clock mobile crisis service.
  • Cathedral Square Corporation, founded in Burlington in 1977, is a national leader in the development of affordable, service-enriched housing for seniors and individuals with special needs, with nearly 30 affordable housing communities in Chittenden and Franklin counties. It also is state administrator of the nationally recognized SASH® (Support and Services at Home) program, which it created and piloted in 2009.
  • SASH® (Support and Services at Home) uses housing as a platform to provide group and one-on-one supports to older adults and people with disabilities so they can stay healthy and “age in place” at home. Based in affordable-housing communities throughout Vermont, SASH connects participants with providers in home health, aging services, mental health and addiction services, community health and primary care as needed, with the goal of avoiding unnecessary hospitalizations and nursing care. SASH has been documented to improve health outcomes while saving Medicare expenses.