SASH® (Support and Services at Home)
- Need: In Vermont, the growing population of older adults, coupled with a lack of a decentralized, home-based system of care management, posed significant challenges for those who wanted to remain living independently at home.
- Intervention: SASH® (Support and Services at Home), based in affordable-housing communities throughout the state, works with community partners to help older adults and people with disabilities receive the care they need so they can continue living safely at home.
- Results: Compared to their non-SASH peers, SASH participants report better health outcomes, including fewer falls, lower rates of hospitalizations, fewer emergency room visits, and the completion of more advance directives – all of which has the potential of saving millions of dollars.
Evidence-levelPromising (About evidence-level criteria)
The ability to live safely, independently, and in good health is particularly important in a rural state like Vermont, where roughly 625,000 residents are spread across more than 9,000 square miles, with 2/3 of people living outside the state's sole metropolitan area. An innovative initiative uses housing as a platform to provide care and services to older adults and individuals with disabilities so they can remain living independently.
SASH® (Support and Services at Home) uses the state's existing network of affordable housing organizations to connect participants with community-based support services and provide evidence-based coaching and programs on site. These 22 affordable-housing organizations encompass more than 140 housing sites that serve as SASH hubs and provide a comprehensive and consistent platform for the delivery of care and support where people live.
Organizations across the state sign on to a "SASH Collaboration Agreement" to work together to help participants address their challenges to remaining healthy at home. The nonprofit Cathedral Square Corporation manages SASH at the state level, while six Designated Regional Housing Organizations (DRHOs) oversee the program at the regional level.
Funding for SASH has been provided by the following:
- Cathedral Square Corporation
- Centers for Medicare and Medicaid Services (CMS)
- Champlain Investment Partners
- Department of Vermont Health Access (DVHA)
- Enterprise Community Partners
- Housing Assistance Council
- Legislature of the State of Vermont
- MacArthur Foundation
- Multi-Payer Advanced Primary Care Practice (MAPCP)
- People's United Community Foundation
- University of Vermont Medical Center Foundation
- University of Vermont Center on Aging
- Vermont Blueprint for Health
- Vermont Community Foundation
- Vermont Department of Disabilities, Aging and Independent Living (DAIL)
- Vermont Department of Health
- Vermont Housing & Conservation Board (VHCB)
SASH staff are based at affordable-housing properties in every county and serve residents there as well as Medicare beneficiaries in the surrounding area. Vermonters can sign up by clicking on their county in the SASH Statewide Location Map and completing the referral form.
Participants start by meeting with their local SASH coordinator (also called a care coordinator or community health worker) and SASH wellness nurse to complete a health assessment, identify their goals, and develop a personalized "Healthy Living Plan." (Participants set their own goals. SASH staff provide information and support, but they do not tell participants what to do.)
SASH staff then make regular home visits to discuss participants' goals and progress, identify any risks, and alert community partners and primary care providers to issues such as prescriptions that need to be refilled. Participants are grouped into "panels" of approximately 70 members, with each panel served by a SASH coordinator and wellness nurse. The coordinator and wellness nurse meet at least monthly with community partners to create action plans and develop group programs based on the majority health needs of their panel members.
SASH staff also typically provide the following services for each participant:
- Wellness check-ins and health coaching on chronic conditions
- Help in developing systems to manage medications
- Planning for successful transitions to and from hospitals or nursing homes
- Help in scheduling medical appointments and completing advance directives
Participation in SASH is voluntary and completely free. Costs are covered by partner housing agencies, Vermont's "All Payer Model" (a healthcare payment and delivery reform program through CMS), the state of Vermont, and grants.
To learn more about the SASH program, please watch this 2-minute video:
SASH serves roughly 5,000 Vermonters. Since its pilot program in 2009 and its statewide expansion in 2011, some participants have experienced:
- Fewer falls
- Lower rates of hospitalizations, including emergency department costs
- Increased access to evidence-based programs related to chronic disease management
- Lower rates for specialty medical visits and higher rates for primary care
- Less or better-managed hypertension
- Slowed growth in Medicare expenditures (a savings of $1,227 per beneficiary per year from July 2011 to April 2015)
- Higher rates of immunization
- Greater completion of advance directives, compared to the national average
In addition, recognition of SASH includes the following:
- SASH has been replicated in Rhode Island and is slated to be replicated in five affordable-housing communities in Minnesota in 2019.
- In January 2017, the U.S. Department of Housing and Urban Development awarded $15 million to 40 nonprofit housing sites in 7 states so they could test SASH-like models in their communities over three years. SASH staff are providing assistance and training in this national demonstration.
- SASH has been featured in several academic journals and publications, including a 2017 National Academies of Sciences, Engineering, and Medicine publication called Developing Affordable and Accessible Community-Based Housing for Vulnerable Adults.
- The latest third-party evaluation of SASH, released earlier this year, assesses the program's first four years and documents positive outcomes for participants as well as Medicare savings for participants living at the affordable housing sites serving as SASH hubs. A summary of this evaluation includes links to the full 2017 report and to earlier third-party evaluations.
- In 2016, SASH received the national Archstone Award for Excellence & Innovation from the American Public Health Association, which recognizes best-practice models in gerontology and geriatrics.
To learn more about SASH, please read the following:
Kandilov, A., Keyes, V., van Hasselt, M., Sanders, A., Siegfried, N., Stone, R., ... & Brophy, J. (2018). The Impact of the Vermont Support and Services at Home Program on Healthcare Expenditures. Cityscape, 20(2), ePub. Article abstract
Center for Consumer Engagement in Health Innovation brief (August 2018): Care That Works: Support and Services at Home (SASH)
U.S. News Report (August 2018): Aging into a Better Life
Initially, some were concerned that SASH would overlap or duplicate the work of its community partners in home health, aging services, and related organizations. These concerns diminished as roles and responsibilities were more clearly defined and more regularly scheduled interagency team meetings took place.
Access to mental health supports is a major barrier due to the lack of adequate funding for local community behavioral health agencies. This is especially challenging in rural areas, where the number of licensed mental health clinicians is vastly inadequate to meet the needs of isolated older adults.
One of the most pressing barriers to maintaining good health and well-being for SASH participants in rural areas is the lack of public transportation. SASH staff work tirelessly to connect participants in isolated communities with ride-share opportunities and encourage special-service transit providers to establish weekly routes.
SASH works because it capitalizes on Vermont's strong affordable-housing foundation to connect a vulnerable population with the existing statewide infrastructure of aging, home health, primary care, and behavioral health services. While there are fewer service providers in rural areas, the addition of affordable housing in this infrastructure extends the reach of these services and inspires the development of new ones to support more people as they age in place.
Working early and often with existing community-provider agencies to identify gaps in services and supports and to determine how housing-based staff’s resources can add value to the existing system of support is key to successful replication.
Aging and aging-related services
Community health workers
Home and community-based services
People with disabilities
Rhode Island, Vermont
November 14, 2016
Date updated or reviewed
December 5, 2018
Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.