A Better Coordinated, More Participatory System That Links Healthcare to Where People Live Is Needed to Stave Off Disparities

Ethel (neither names are real), an older Black woman living in a high-rise affordable housing site is having an anxiety attack in its lobby during the COVID-19 shut down.

Amenda, a 72-year-old woman who speaks no English, is discharged from a nursing home to her HUD apartment. But her medications are confusing and look different than those on her discharge paperwork.

These situations are all too familiar to those in aging advocacy. Fortunately, both women participate in Saint Elizabeth Community’s Support And Services at Home (SASH) model in Providence, R.I. SASH embeds a Community Health Worker and Wellness Nurse in affordable housing sites to serve residents and the surrounding community, and links those teams to all the healthcare providers and services that could interact with their residents.

The SASH care team chats with Ethel, validating her feelings of isolation and depression, and provides her with some breathing exercises to be practiced at home. They walk her back to her apartment and encourage her to call staff when she starts feeling fearful or anxious. A behavioral health crisis is averted and Ethel feels back in control.

The SASH Wellness Nurse sorts out Amenda’s medications and discusses with her and her family how to more easily organize the medications, thus avoiding a medication error and emergency department visit. Amenda now knows she has the support needed to stay home.

SASH is a system solution.

The SASH system was created to connect the dots between where people live and primary care, hospitals, behavioral health, public health, nursing homes and community-based services. Cathedral Square Corporation in South Burlington, Vt., founded SASH, driven by the belief that housing nonprofits cannot continue to operate as a silo when their residents are often high-need patients trying to navigate a complex healthcare system. If nonprofit housing organizations are to advocate for residents’ health, they must become extenders to the healthcare system. But such organizations do not have the clinical resources to help. SASH is a system solution.

For the past decade, SASH participants have benefited from reduced admissions to hospitals and nursing homes, managed their hypertension and diabetes, and determined their health futures via Healthy Living Plans and Advanced Directives that put their wishes first.

By operating as one system, SASH has reduced the rate of growth in Medicare expenditures by more than $1,450 per person, per year among urban participants, and reduced Medicaid spending by $400 per person, per year. The SASH scale and infrastructure ensures the accountability and quality expected of all partners in the healthcare system.

SASH Expanding in More Urban Locations to Reduce Racial Disparities in Healthcare

West Baltimore Housing Partners
  • Bon Secours Community Works
  • Housing Authority of Baltimore City
  • The Community Builders, Inc.
  • Enterprise Community Development, Inc.
  • Homes for America

Leaders in Baltimore and Los Angeles have recognized they need a bold new approach and are tailoring SASH to their cities.

Baltimore’s Integrated Complex Care at Home—Powered by SASH

Maryland is home to high-capacity housing nonprofits and one of the most advanced healthcare delivery systems and payment models in the country. Through tight collaboration, partners in the proposed Integrated Complex Care at Home (ICCH) model will help reduce chronic condition exacerbations, while empowering people to determine their own health.

Initial partners include the Maryland Primary Care Program, LifeBridge Health, public health agencies and affordable housing providers. Non-profit housing organizations stepped up to participate in Baltimore’s Integrated Complex Care at Home after participating in Healthy Aging in Affordable Housing, an Enterprise Community Partners project funded by the Harry and Jeanette Weinberg Foundation.

‘Baltimore’s population density creates an opportunity to significantly increase the savings achieved by SASH Vermont.’

Baltimore’s population density creates an opportunity to significantly increase the savings achieved by SASH Vermont, while reducing racial health disparities through this empowerment model. With the support of planning grants from The SCAN Foundation and the Milbank Memorial Fund, the partners in Baltimore are seeking funding to bring SASH to more urban locations with a pilot starting in 2022 in West Baltimore.

California Integrated Care At Home (CICH), Los Angeles, Calif.

LeadingAge California is tailoring SASH to Los Angeles, which is not only the second largest city in the country, but has a diverse population that speaks many languages. Rather than creating an alternative to the robust and diverse array of long-term services and supports (LTSS) that already exist there, California Integrated Care At Home (CICH) will be an aggregation of L.A.’s strengths. This population health system aims to serve the mix of older adults living in Los Angeles, including those dually eligible for Medi-Cal and Medicare, as well as “The Forgotten Middle” whose incomes are above Medicaid limits but can’t afford healthcare or housing.

The State’s recently released Master Plan for Aging prioritizes “housing for all ages and stages” and “health reimagined.” CICH suits the Master Plan perfectly as a bold approach that links healthcare to where people live.

LeadingAge California and its partners, the National Well Home Network, Valon Consulting and the UCLA Ziman Center for Real Estate will bring together nonprofit housing organizations, traditional health providers, behavioral health, public health, Aging and Disabilities Resource Centers (ADRCs), long-term care and community-based organizations as a hub to support many participants. By focusing in an area with a concentration of multiunit senior residential buildings, CICH can achieve care management in a flexible and cost-efficient manner. The outreach also creates a CareHub for the surrounding community, further linking the entire system of care.

LeadingAge California is proposing a three-year CICH demonstration in Los Angeles embedding care teams in affordable senior housing communities. With nearly half a million affordable rental units across California, this system can be scaled statewide. LeadingAge California is in the early planning stages seeking partners that share the State’s goal to “improve quality outcomes, reduce health disparities and drive delivery system transformation and innovation through value-based initiatives, modernization of systems and payment reform.”

SASH has modeled how housing and community-based services can fully integrate into a health system to make healthcare work for all. SASH is ready-made to tailor to any state.

Nancy Eldridge is the CEO at the National Well Home Network in Burlington, Vermont. For more information on SASH contact Nancy.eldridge@wellhome.org.