Coordinating housing, healthcare and LTSS through home care management


Residential infrastructure can be used to address some of the most intractable challenges in the long-term services and supports system (LTSS), and many health care providers and LTSS are working to strengthen their links with residential programs and systems. Home-based care management (HBCM) programs use the housing system to extend primary care and human service practices into the homes of people with LTSS needs.

This report describes and evaluates Vermont’s SASH (Support and Services at Home) program as one model of HBCM programs. Founded in 2009, SASH now partners with 70 organizations, including hospitals, community organizations and academic institutions at sites across the state.

Key components of SASH’s HBCM model

The panel of participants. Each SASH participant is a member of a group of approximately 100 people who are all focused on staying healthy and living independently in their own homes. Each works with an interdisciplinary team of staff to develop a ‘Healthy Living Plan’, a person-centred plan developed through shared decision-making based on data gathered through health and social needs assessments.

Housing partners. SASH works with existing housing organizations and creates infrastructure. A network of community partners focused on home help enables consistent relationships and reliable, timely services.

Formalized partnerships with community agencies. Agencies on aging, community mental health agencies, home health agencies, or other critical community assets agree to send one resident staff member to monthly SASH meetings at the residential site to coordinate action plans for high-need participants.

Care Coordinators. These care team members work individually with participants to develop their wellness plans and connect with essential services, following the community health worker model in which coordinators must be representative of the community they serve.

Wellness nurses. Manning each SASH panel is a part-time registered nurse who regularly screens participants, coordinates with primary care providers and, when needed, helps manage chronic conditions, monitors medication self-monitoring, and facilitates transitions with healthcare facilities.

Value-based care and HBCM models

SASH provides an excellent example of how value-based care systems work. Initial funding in 2011 through a CMS Medicare demonstration provided $70,000 per panel to support the SASH care coordinator and nurse. The idea is that this investment will save the state and federal governments money by preventing more serious health care costs in the future. Some of these savings have already been demonstrated.

How to evaluate HBCM models

Since SASH launched in 2009, its advocates have explored many ways to capture its impact. This report includes an in-depth discussion of the apparently positive impact of the program on costs, clinical outcomes, health care utilization and subjective well-being reported by participants, for example:

  • A 2010 external evaluation found that SASH urban panelists saw slower growth in Medicare spending, reducing growth by more than $1,450 per beneficiary per year. Medicaid spending growth for institutional long-term care was also significantly slower for participants in the place-based and rural panels, with an average impact of $400 per participant per year.
  • 70 percent of SASH participants in a study funded by the Vermont Department of Health reduced their blood pressure, and 50 percent even moved into a lower risk category for serious disease.
  • Studies from the Vermont Department of Health have shown a reduction in hospitalizations from falls at several SASH sites in the state, particularly among participants who frequently visit the emergency department.
  • In several different studies aimed at measuring SASH participants’ sense of empowerment and subjective well-being, participants said they felt they had easier access to mental health services and reduced social isolation.

Issues to be considered in the dissemination of the HBCM model

The paper concludes by discussing the scalability and applicability of the SASH model in other settings and populations and offers some promising preliminary evidence that addresses the following questions:

  • How can HBCMs be adapted to countries and localities with different payment systems and policy priorities?
  • How might the administration and impact of HBCM look different in a more urban setting?
  • How can a national body of knowledge and evidence for HBCM models be developed?
  • Can the HBCM model help address health equity?
  • Could similar partnerships between LTSS and housing impact other vulnerable populations?

This focus is part of the AARP Public Policy Institute’s LTSS Choices initiative. This initiative includes a series of papers, blogs, videos, podcasts, and virtual meetings that seek to spark ideas for immediate, mid-term, and long-term options for transforming Long-Term Services and Support (LTSS). We will explore a growing list of innovative models and evidence-based solutions – both nationally and internationally – to achieve systemic LTSS reform.

Suggested quote:
Benedict-Nelson, Andrew, Anna Hervada, Patricia Polanski, and Carrie Blakeway Amero. Choosing LTSS: Coordinating housing, health and LTSS through home care Management. Washington, DC: AARP Public Policy Institute, 30 September 2022. https://doi.org/10.26419/ppi.00170.001

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