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SASH: Health Equity Begins at Home

Nancy Rockett Eldridge, MA, Chief Executive Officer, National Well Home Network
Lisa Dulsky Watkins, MD, Director, Primary Care Networks, Milbank Memorial Fund

A decade ago, primary care practices and housing nonprofits in Vermont partnered to reduce chronic conditions among older adults and younger adults with a disability in collaboration with the state’s Blueprint for Health. Today, as an extender of the Blueprint, Support and Services at Home (SASH), which supports healthy aging in place, is helping to advance health equity in the state.

The SASH model theory of change is that by empowering the lowest-income Vermonters to define and achieve their life goals, they can become a primary determinant of their own health. SASH differs from traditional housing-based care models because it integrates three critical components into a single program: individualized health plans and activation, clinical care coordination during care transitions, and a set of hyper-local structured relationships between the housing organizations and specific health care and community-based aging organizations. SASH currently offers services to residents in 140 publicly assisted housing sites and their surrounding neighborhoods. The results have been impressive, as studies have shown that SASH has helped to:

  • reduce health disparities,
  • improve diabetes and hypertension management and prevention,
  • reduce Medicare and Medicaid spending, and
  • increase access to mental health services.

SASH has been so successful that Blue Cross Blue Shield of Vermont is piloting the model with a cohort of its Medicare Advantage population.

SASH in Other States

Rhode Island. In 2017, Saint Elizabeth Community (SEC), a nonprofit housing organization, piloted the SASH model at a 149-unit HUD property in Providence. SEC is now expanding SASH to three additional housing nonprofits, including Pawtucket Public Housing Authority. Eighty-two percent of the Pawtucket residents have incomes below 30 percent of area median income. Most residents, whose top needs are access to mental health services and reducing isolation driven by COVID-19, are Hispanic, Portuguese, and Cape Verdean.

The SASH expansion in Rhode Island has been made possible with federal Money Follows the Person funding provided by the state. The state and federal government are testing SASH as a diversion strategy to prevent nursing facility admissions.

California. LeadingAge California is working with housing organizations in Los Angeles to bring SASH to some of the lowest-income, most diverse populations in the city. They are in the planning phase of the new California Integrated Care at Home (CICH) model, based on SASH.

LeadingAge California is partnering with UCLA’s Ziman Center for Real Estate, the National Well Home Network, Valon Consulting, and Health Management Associates to tailor the SASH model to California’s unique regulatory structure, Medicaid reforms, and the California Master Plan for Aging. The residents of the initial housing nonprofits seeking to participate in CICH have extremely low incomes, are racially diverse, and have a high need for language translation services.

LeadingAge California is seeking public and private funding to launch a CICH pilot in late 2023 to include up to 3,000 participants. In the meantime, the state has provided $12.5 million to fund Healthier Homes – Age in Place Nurse Pilot Program in eight counties. Healthier Homes has similar staffing as the SASH model and is well positioned to serve as a precursor to a statewide CICH model.

Housing to Health

The Vermont, Rhode Island, and California SASH and SASH-based initiatives demonstrate:

  • the value proposition of housing to health,
  • many nonprofit housing champions have fully committed to a population health model,
  • the need for health and housing partners to leverage public funds to scale and expand, and
  • the importance of prioritizing the empowerment of people facing health inequities.

This expansion of SASH models represents a national opportunity to advance CMS’ goals of equity and affordability in health care. Supporting primary care practices and the mission of affordable housing, partnering organizations can improve the quality of life for vulnerable populations through this scalable and replicable population health system.

Keys to Success, Scalability, and Sustainability

  • Targeted leveraging of public funds. The five-year CMS Multi-Payer Advanced Primary Care Practice (MAPCP) demonstration funded the expansion of SASH statewide in Vermont using Medicare funds. When the MAPCP ended as planned, SASH was included in Vermont’s All-Payer Model waiver, and does so to this day.
  • Congregate housing as an effective locus of support. The number of low-income individuals living under one roof creates an opportunity to embed community health workers and wellness nurses where health begins—at home—meeting the unique needs of each participant.
  • Simple and flexible capitated payments. SASH receives a fixed amount of funding to support each panel of approximately 100 participants, providing a value-based payment for population health management.
  • Together, the Blueprint for Health and SASH are a patient-centered population health system. Each participant is asked what matters to them and what motivates them to be healthy. Their goals inform their unique Healthy Living Plan, co-developed by the participant and SASH team. Coaching empowers participants to make truly informed decisions. By agreeing on how multiple disciplines and organizations together can better serve vulnerable populations, the patient is squarely at the center of their care.
  • Efficient training and workforce development. Cathedral Square, the nonprofit founder of SASH, developed training and technical support to promote staff retention and quality services that are cost-efficient and scalable. The SASH team includes a Health Systems Educator who trains SASH staff and participants on chronic disease management. Regular technical assistance calls and SASH annual conferences ensure that the model is updated and implemented consistently.
  • Rigorous data collection and analysis. Annual assessments, validated screening tools, and consistent documentation are part of an efficient SASH electronic health record (Preferred Population Health Management), which guides services delivered and provides an evaluation structure. While interoperability remains a goal for many Electronic Health Records (EHR), the SASH EHR allows patients to bring accurate medication lists, blood pressure tracking and other important information to primary care and hospital visits.

Funding for California Integrated Care at Home (CICH)

A special thanks to RRF Foundation for Aging and Archstone Foundation for their generous support funding the CICH 2-year planning period.

Read the article on Grantmakers in Health

Learn More About Cathedral Square
Cathedral Square improves the lives of older adults and people with diverse needs by creating and maintaining quality, affordable housing with services tailored to their unique circumstances. Learn more at: