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, poses significant challenges for those who want 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 have been documented to have better health outcomes, including fewer falls, lower rates of hospitalizations, fewer emergency room visits, and lower Medicare and Medicaid expenditures.
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 program 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
- State of Vermont
- MacArthur Foundation
- Multi-Payer Advanced Primary Care Practice (MAPCP)
- OneCare Vermont
- 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 are grouped into "panels" of approximately 70 to 100 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.
Participants start by signing disclosure forms that allow their medical information to be shared among SASH partners. Participants then meet 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" based on what participants set as their own goals.
SASH staff then make regular home visits to review each participant's goals and progress, identify any risks, and alert community partners and primary care providers to issues such as prescriptions that need to be refilled. They 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
- Initiatives to reduce isolation and support mental health, which have been stepped up significantly during the COVID-19 pandemic
Participation in SASH is voluntary and completely free. Costs are covered by partner housing agencies; OneCare Vermont, which oversees the state's CMS-approved demonstration of the all-payer model of healthcare delivery and payment; the state of Vermont; and grants.
In addition, a three-year pilot that ended in December 2020 added mental health counseling to the list of services provided to participants at two SASH housing sites in Burlington, Vermont. The program embedded a mental health clinician into the SASH staff at both locations. The clinician conducted workshops, one-on-one and group counseling sessions, and informal "emotional check-ins" as needed. The program succeeded in meeting the goals of improved and faster access to care, improved patient experience, and a reduction in ER visits due to a mental health crisis. Based on this success, funding was secured to continue the program through 2021.
To learn more about the SASH program, please watch this two-minute video:
Piloted in 2009 and expanded statewide in 2011, SASH serves up to 5,000 Vermonters at any given time. Compared to national averages, participants have been shown to have:
- Fewer falls
- Lower rates of hospitalizations and emergency room visits
- 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
- Lower Medicare expenditures
- Higher rates of immunization
SASH has undergone three independent evaluations by RTI International and LeadingAge Center for Applied Research. While previous evaluations cited savings in Medicare expenses for SASH participants, the latest study, released in July 2019, also documented savings in Medicaid. Among the findings:
- Very low-income SASH participants in most areas of Vermont saw a significantly slower growth in long-term institutional care costs compared to non-participants. For participants who are 65 or older, receive Medicaid, and live at SASH affordable-housing sites, Medicaid long-term care costs were about $400 less per beneficiary per year.
- Overall, SASH participants reported that they had less difficulty than a comparison group with medication management.
Recognition of SASH includes the following:
- SASH has been replicated in Rhode Island and in five affordable-housing communities in Minnesota. A third state is working to incorporate SASH in 2021.
- 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 have provided assistance and training in this national demonstration, which may be extended.
- SASH has been featured in several academic journals and publications, including the 2017 National Academies of Sciences, Engineering, and Medicine publication Developing Affordable and Accessible Community-Based Housing for Vulnerable Adults.
To learn more about SASH, please read the following:
U.S. Department of Health & Human Services; Assistant Secretary for Planning and Evaluation; Office of Disability, Aging and Long-Term Care Policy (2019). SASH Evaluation Findings, 2010-2016.
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)
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 the resources of housing-based staff 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
Minnesota, Rhode Island, Vermont
November 14, 2016
Date updated or reviewed
February 2, 2021
Suggested citation: Rural Health Information Hub, 2021. SASH® (Support and Services at Home) [online]. Rural Health Information Hub. Available at: https://www.ruralhealthinfo.org/project-examples/932 [Accessed 21 September 2021]
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.