2. What is SASH? A caring partnership brought together to help people remain in their homes. The partnership connects the health and long-term care systems to nonprofit affordable housing providers.

3. Profile of Heineberg Residents 85% over 70; 40% over 85 49% used ER in past year 54% take 6 or more prescription meds 71% have high blood pressure, 59% arthritis, 39% chronic pain. 61% fallen in past year 32% self-reported mental health concerns 59% use a cane or walker 49% failed 2-3 components of a cognitive screen

4. Story of Two Residents “Polly”- 67 years old; obese, heart condition, high blood pressure, Type 2 diabetes, arthritis, chronic pain, takes 13 prescription medications. Leg infection led to hospital-nursing home stay. “Betsy”- 87 years old, asthma, high blood pressure, arthritis, cancer, macular degeneration, anxiety, chronic back pain, 7 prescription medications. Fell and broke pelvis- hospital to nursing home.

5. Results at Heineberg 19% reduction in hospitalizations No bounce backs from Nursing Homes Reduced falls- 22% Increased physical activity Reduced nutritional risk- 26% reduction Better health, better care & lower costs

6. Implementing SASH in your state Build partnerships Written Agreements (not “lip service”) Need Leadership from the State Tell the Story!

7. The SASH Alliance Government Entities Division of Health Care Reform Department of Aging Department of Public Health Medicaid Division Legislature Non Profit Business Sector Housing: Non Profit and PHAs Hospitals Medical Homes Home Health PACE AAA’s Community Mental Health Agencies Philanthropic Leaders Vermont Health Foundation McArthur Foundation Enterprise Community Partners People’s United Bank Foundation United Way Academic Experts University of Vermont, Center on Aging – Geriatric Fellows Albany College of Pharmacy Castleton School of Nursing Other AARP

8. Regional Collaborative Agreements

9. SUCCESS FACTORS  Connecting HOME to the Medical Home  An MOU with all the partners  Breaking the Information Barrier  Population based and targeted  Ability to measure outcomes  Outcomes: Cost savings, health, satisfaction  The Team: non duplication and mutual aid  Person Centered  Care Management  Prevention and Wellness  Workforce: highest and best use

10. Lessons Learned Ask for input- again and again Fear of Change Anticipating Cross Sector Opportunities Patience Pays Off Leadership- state and local

11. What are the Essential Elements? Person-centered – Population based SASH Staff Team Based Care Management Information Sharing through Technology Prevention and Wellness through Healthy Living Planning Volunteers

12. Participants

13. SASH Staff = Trusted Guides

14. SASH Coordinator- Duties at a Glance

15. Wellness Nurse- Duties at a Glance

16. Team Based Care Management Nonprofit Housing Visiting Nurse Assoc. Area Agency on Aging PACE

17. Information Sharing Housing Staff Community Providers (VNA, AAA, Mental Health) Community Health Team Hospital Family Support Persons Primary Care Provider Nursing Homes/Rehab Facilities

18. Healthy Living Planning and Support

19. Eat Better Move More Program

20. Volunteers

21. What Does SASH Provide? Comprehensive Assessment Person Centered Healthy Aging Planning Informed Team to Help in a Crisis Transitions Support back Home Proven Practices through the CHAP Regular Check Ins Coaching Wellness Nurse Supports Link with CHT and Medical Home

22. What is the Blueprint for Health? A program for: integrating a system of health care for patients; improving the health of the overall population; controlling health care costs by promoting health maintenance, prevention and care coordination and mgmt.

23. Connecting the Medical Home to Home Housing Based SASH Team Housing - Mental Health – PACE – VNA - AAA Community Health Team Medical Home Vermonter

24. Statewide Rollout $700 per enrollee per year  Supports SASH Coordinators and Wellness Nurses 6,120 enrollees over 3 years 112 SASH hubs

25. How will SASH Expansion be Managed? Organizational Infrastructure includes  Cathedral Square as Statewide Administrator  Six Designated Regional Housing Organizations (DRHOs)  CSC, CVCLT, BHA, RHA, RAHC, GHT