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Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health

June 12, 2020
Last Updated Date: January 11, 2021
This innovation was identified by the AHRQ PSNet Editorial Team from the AHRQ Health Care Innovations Exchange. That resource, established by AHRQ in 2008, was retired in March 2021; AHRQ now offers select content from the Innovations Exchange, including its downloadable databases, through a microsite. This particular innovation was identified by the Editorial Team as one of continued interest and importance to AHRQ PSNet users and therefore was selected to be updated and included in this new section of the AHRQ PSNet website. To prepare this updated summary, the Editorial Team worked closely with representatives associated with the innovation. Updates include increased use by other organizations, slight modifications to the description of the innovative activity, additional results that include Medicare and Medicaid expenditures and additional outcomes findings, changes to the staffing model, changes to the funding sources, additional publications, and ensuring accurate contact information.

The Support and Services at Home (SASH®) program provides onsite assistance to help senior citizens (and other Medicare beneficiaries) remain in their homes as they age. Using evidence-based practices, a multidisciplinary, onsite team conducts an initial health assessment, creates an individualized care plan based on each participant’s self-identified goals, provides onsite nursing and care coordination with local partners, and schedules community activities to support health and wellness. A multi-year evaluation of the program found that total Medicare expenditures per SASH participant were $1,100-$1,450 lower per year compared to their non-SASH peers. It also found that participants were less likely to report issues with medication self-management compared to non-participants, and that Medicaid expenditures for long-term care for a subset of SASH participants were $400 less per person per year.

Innovation Patient Safety Focus

The SASH program personalized care coordination services successfully helped elder adults avoid medication management issues, particularly associated with adherence. Appropriate adherence has helped to control chronic conditions and avoid hospital admissions and readmissions. Additionally, the program saw residences experience a decrease in the number of falls.

Resources Used and Skills Needed
  • Staffing: For every 70-100 person panel of program participants, each site receives funds for a full-time coordinator and 10 hours a week for a wellness nurse. In addition, oversight of the program at the state level includes a statewide administrative team at Cathedral Square providing oversight in training, data management, analytics, quality assurance and grants management.
  • Costs: Staff funding through the multi-payer program is based on a general ratio of 100 participants x $734/year = $73,400 to cover the full-time coordinator and a 0.25 FTE wellness nurse. This budget was originally based on $24/hour salary/benefits for a coordinator and $35/hour salary/benefits for a wellness nurse.
Use By Other Organizations

SASH has been replicated in Rhode Island and parts of Minnesota. A third state is working to implement the program in 2020. In addition, SASH was the inspiration for a multi-year, seven-state demonstration of a SASH-like program funded by the U.S. Department of Housing & Urban Development and currently underway.

Date First Implemented
Problem Addressed

A large, growing number of older adults have physical and mental limitations and hence require assistance with activities of daily living. To age successfully at home, these individuals need a range of support services, but state funding cuts often make these services difficult to access for low-income seniors.

  • Large, increasing number of older adults who need assistance: By 2030, more than 70 million Americans will be age 65 or older, twice the number as in 2000. Currently, about 42 percent of those over age 65 have physical limitations or need assistance with activities of daily living, such as eating, bathing, or dressing. Many also have cognitive limitations and hence need assistance with activities such as medication management. Cathedral Square conducted resident assessments in several of its 20 independent housing buildings, finding that only 47 percent of residents could pass a cognitive screening test, 37 percent had fallen in the past year, and 50 percent took six or more medications.
  • Need for medical and social services to remain at home: To age successfully at home, these older adults often require a range of supportive services, such as home health care, homemaker services, transportation, respite care, and home-delivered meals.
  • Limited access for low-income seniors: Drastic reductions and in some cases elimination of state-funded programs have significantly reduced access to needed support services for low-income adults and their caregivers. Historically, these state programs have provided critical services not covered by Federal support programs.
Description of the Innovative Activity

The Support and Services at Home (SASH) program, administered at the Vermont state level by the nonprofit Cathedral Square Corporation, provides onsite assistance to help senior citizens (and other Medicare beneficiaries) remain in their homes as they age. Currently, over 5,000 people in Vermont benefit from SASH in one of 140 affordable housing communities across the state. Residents are grouped into panels of 70-100 residents, and supported by a full-time coordinator and part-time wellness nurse, who work with a multidisciplinary team of community providers to implement the program. Together, they provide care coordination, wellness education and coaching, and transitions support after a stay at a hospital or rehabilitation facility. Using evidence-based practices, key services include an initial assessment by the SASH staff team, creation of an individualized care plan, monitoring by the onsite care coordinator and wellness nurse who link residents to services offered by team members and other local partners, and on-site evidence based programs and activities to match the needs identified by the assessments. Key elements of the program include the following:

  • Enrollment and initial interview: As part of the enrollment process, the program coordinator interviews each resident to explain the program. The coordinator asks residents if they would like family members to participate in any aspect of the planning process. Residents sign a consent form in compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations, as with other situations when information is shared with partner agencies.
  • Assessment by wellness nurse: Using a modified version of the state's Independent Living Assessment Tool used by Medicaid, the nurse conducts a functional and cognitive assessment in the resident's home. The assessment tool includes a complete list of medications taken, along with many validated risk screens, including nutrition, depression and cognitive screens.
  • Customized "Healthy Living Plan":  SASH participants in partnership with a multidisciplinary team (including an acute care nurse, case manager, intake nurse, mental health provider, and representatives of other home- and community-based service providers in the area) develop a plan with goals and action steps. Using the individual's assessment data, the care coordinator helps the resident refine the plan by identifying specific health-improvement goals that the participant wants to pursue, such as weight management, getting more exercise, increasing social activities or eating a more nutritional diet. As part of the program, the team provides guidance, opportunities and coaching to help the resident meet those goals.
  • Ongoing care/service coordination: The onsite care coordinator monitors residents' well-being and helps them adhere to their healthy living plans. Other employees within the housing community (e.g., property managers, custodians, resident services coordinators, activity directors) support the program by alerting the care coordinator if they notice changes in the health or functional status of a resident. Examples of specific tasks undertaken by the care coordinator include the following:
    • Scheduling appointments with wellness nurse: A part-time wellness nurse visits high-risk residents in their homes to monitor vital signs, support adherence to their medication regimen, and address specific health needs. The nurse works in collaboration with the senior's local providers in the community.
    • Arranging for needed services, especially after an acute stay: The care coordinator works with local partners to arrange for any services a resident might need, such as transportation to a medical appointment, an appointment with a mental health provider, intensive care management from an area agency on aging case manager, or home visits from a visiting nurse. As part of this effort, the coordinator pays particularly close attention to those residents transitioning home after an inpatient or rehabilitation facility stay, especially those living on their own. The coordinator generally has access to the resident's discharge plan from the facility, and knows what type of support the resident may need during those critical days after returning home (a period when many readmissions occur).
    • Monthly team meetings focused on high-risk and nearing risk residents: The program team meets monthly to discuss residents' general health and information needs, as well as the specific needs of high-risk residents. As the team members who often care for these high-risk residents, the visiting nurse and area agency on aging case manager typically follow up on any recommendations for needed interventions and services. The team also focuses on those residents who have had a recent change in health or functional status and brainstorm ways to support them and restore them to baseline.
    • Community education and wellness activities: The program team aggregates information from all resident assessments to create a Community Healthy Living plan for the entire community, with a focus on evidence based prevention and management programs  and health coaching. Programs typically cover five key areas: preventing falls, managing medications, controlling chronic conditions, improving health-related lifestyle behaviors, and managing cognitive and mental health issues. For example, the team introduced a building-wide program called “Eat Less, Move More” after assessment data showed that many residents ate poorly (thus putting them at risk of inadequate nutritional status) and did not get regular exercise. The care coordinator oversees these wellness programs, which are often implemented with help from community volunteers.
    • Information technology support: Program participants agree to have their health-related information shared among SASH partners and on an as-needed basis with members of the onsite health team, along with designated family members and service providers. To share information efficiently, team members currently enter and retrieve data through a database that can create a variety of reports. SASH uses a HIPAA compliant on-line data management system, Population Health Logistics. The wellness nurse and care coordinator conduct the assessment at a participant's home, and the data is quickly entered into the centralized data system, making it easier to evaluate results across sites.
Context of the Innovation

Founded as a ministry of the Cathedral Church of St. Paul in 1977, Cathedral Square Corporation is a nonprofit organization that owns and manages properties for seniors and individuals with special needs. In 2005, Cathedral Square leaders began working with other Vermont housing providers, state legislators, and LeadingAge (formerly the American Association of Homes and Services for the Aging) to develop a model to allow employees of nonprofit housing organizations and public housing authorities to help residents access needed medical and social services without becoming trained medical providers. To that end, the nonprofit's leaders obtained funding to design, test, and refine a “housing with services” model program. (See the Planning and Development Section below for more details.)


Since statewide expansion in 2011, SASH has undergone three rigorous, independent evaluations. The latest study, released in July 2019, showed that the program created significant savings to Medicare, as well as improvements in participant-reported medication management and modest savings in Medicaid expenditures.

  • Medicare Expenditures:  Overall Medicare expenditures are lower for SASH participants than non-participants, especially those in urban areas ($1,450 less per beneficiary per year). This is driven by “statistically significant slower growth in Medicare expenditures for hospital stays, emergency room visits, and specialist physicians, which is consistent with the SASH program goal of preventing unnecessary high-cost care.”
  • Medication Management: A survey of SASH participants and non-participants found that SASH participants had significantly fewer difficulties with common medication management tasks, such as remembering to take all the pills and getting refills on time.
  • Medicaid Expenditures: Growth in Medicaid expenditures for SASH participants over 65 in institutional long-term care was about $400 slower per year compared to non-participants. There was, however, no statistically significant effect on total Medicaid expenditures between participants and non-participants.

Other outcomes:

  • Hypertension control: Seventy-six percent of SASH participants with hypertension have it under control, compared with the U.S. average among older adults of 30 percent.
  • Advanced Directives: Sixty-six percent of SASH participants have documented advance directives, compared to the national average of 26 percent.
  • Fewer admissions and readmissions: During the first year after implementation, inpatient admissions among the 65 residents fell by 19 percent (21 admissions the year before implementation, 17 admissions a year later). In addition, no resident discharged from the hospital during the year after implementation was readmitted and there were no bounce backs to nursing homes.
  • Fewer falls: The number of residents experiencing falls declined by 22 percent in the first year after implementation (30 resident falls the year before implementation, 16 resident falls a year later).
  • Better nutritional status, more physical activity: The number of residents at moderate nutritional risk fell by 19 percentage points (46 at-risk residents the year before implementation, 34 a year later) while the number of physically inactive residents fell by 10 percentage points during the first year after implementation.
Planning and Development Process

Key steps included the following:

  • Identifying problem: As noted in the Problem Addressed section, Cathedral Square conducted resident assessments in several buildings that identified many residents with cognitive issues, multiple chronic conditions, complex medication regimens, and other issues that put them at risk of falls, inpatient admissions, and other acute problems.
  • Networking with partner organizations: Cathedral Square leaders networked with other housing providers and stakeholders to identify ways that providers of affordable housing could support the health and safety of residents. Partner organizations included those providing acute care, long-term care, affordable housing, and mental health services. Additional partners from academic institutions also contributed to the model design.
  • Obtaining funds and designing model: In addition to its own contributions to program development, Cathedral Square applied for funding to design and pilot test a housing-with-services model program. They obtained funds from the Vermont legislature, the Vermont Health Foundation, and the MacArthur Foundation to work with partner organizations to design and test a model that would reduce avoidable costs to Medicaid and Medicare, provide essential services to housing residents who wanted to age in place, and be replicable elsewhere. Partners included five nonprofit and public housing providers representing all regions of the state.
  • Selecting test site and enrolling participants: Cathedral Square leaders decided to test the program at the organization's Heineberg Senior Housing community, which provides affordable housing for seniors in an apartment building setting. To recruit participants, Cathedral Square posted and distributed flyers and held meetings with residents. In July 2009, 65 residents agreed to participate in a pilot program for 1 year to help refine the housing-with-services model. As of 2020, SASH is being implemented in 140 affordable-housing communities across Vermont and includes over 5,000 participants.
  • Creating local program team: Cathedral Square hired a program coordinator and wellness nurse and, along with its partners, identified local service providers to participate in the program team (onsite health team).
  • Informing and educating housing facility employees: As part of program planning, the care coordinator introduced the program to housing facility employees at an all-staff meeting, providing an opportunity for them to ask questions and raise topics of concern. To give the message that every employee has a role to play, the program is on the agenda of every all-staff meeting and open for discussion at all times. For example, at a recent training on conflict resolution, maintenance staff raised the issue of not knowing whether to share information with the care coordinator when they observe questionable behavior of a resident. This enabled program staff to explain how staff can and should communicate concerns respectfully and on a “need to know basis.”
  • Establishing goals for measuring success: As part of the planning process, program leaders identified the need for future implementers to measure the program's impact on four areas: process, health status, resident satisfaction, and cost.
  • Securing funding for statewide expansion: Based on the success of the pilot study and the projected savings that could be achieved from wide-scale replication, the program was included as part of an application from the Vermont Blueprint for Health to the Center for Medicare and Medicaid Services' (CMS) Multi-Payer Advanced Primary Care Practice Medicare Demonstration program. (The Blueprint for Health is Vermont's health care reform initiative to increase access to affordable health care for all residents.) CMS approved the application, thus giving Vermont funding to expand the program to over 100 subsidized housing sites over a 3-year period.
  • Meetings with advisory group: Program developers created an advisory group called the Local Table to provide support and track program progress. Local Tables exist in multiple regions of the state ensuring local needs and conditions are addressed. The groups, which meet periodically throughout the year, include representatives of regional organizations, such as the hospital, home health, Area Agency on Aging, United Way agencies, mental health agencies, religious groups, colleges, and nursing homes.
Resources Used and Skills Needed
  • Staffing: For every 70-100 person panel of program participants, each site receives funds for a full-time coordinator and 10 hours a week for a wellness nurse. In addition, oversight of the program at the state level includes a statewide administrative team at Cathedral Square providing oversight in training, data management, analytics, quality assurance and grants management.
  • Costs: Staff funding through the multi-payer program is based on a general ratio of 100 participants x $734/year = $73,400 to cover the full-time coordinator and a 0.25 FTE wellness nurse. This budget was originally based on $24/hour salary/benefits for a coordinator and $35/hour salary/benefits for a wellness nurse.
Funding Sources
  • Development funding: Major funders included the state of Vermont, the Vermont Health Foundation, and the MacArthur Foundation, as well as small grants from local foundations to support program design and testing.
  • Ongoing Funding: SASH funding is included in the state of Vermont’s All-Payer Model agreement with the Center for Medicare and Medicaid Services.  This agreement was finalized in 2017 and goes through 2022 with the ability for extension. Statewide administrative funding is provided primary by the State of Vermont general fund and matched with federal Medicaid innovation funding.
Getting Started with This Innovation
  • Conduct needs assessment: Would-be adopters should assess the number of seniors living in affordable housing communities who could benefit from this type of program. Factors to consider include not only the size of the population, but also their level of physical and cognitive functioning and in-home service needs, along with the availability of local service providers to provide in-home care.
  • Gauge stakeholder support: Would-be adopters should assess the level of support among key stakeholders, including the state legislature, to integrate this model into elder care initiatives. As previously discussed, Cathedral Square worked closely with members of Vermont's legislature and other stakeholders to develop and test the program.
  • Investigate legal and licensing issues: State law and licensing issues may have an impact on the ability of housing facility employees to provide certain services to senior residents. Would-be adopters should investigate these laws and regulations and work with appropriate authorities to ensure that the proposed program complies with all relevant statutes.
  • Consider small-scale pilot test: A small-scale pilot test can be used to prove to key stakeholders that the program can improve health outcomes and reduce costs.
  • Develop business case, approach funders: Results from the pilot test can be used to create a broader business case for the program. For example, after completing the successful pilot, Cathedral Square estimated potential cumulative savings to Medicare, net of program costs. Armed with this information, Cathedral Square leaders were able to convince Vermont Blueprint for Health leaders to include the program in its application to CMS, which ultimately led to the securing of funds that will allow for widespread replication of the program.
Sustaining This Innovation
  • Continue monitoring, reporting on program impact: To sustain support, implementers need to monitor and document the program's impact on key health outcomes over time, such as expenditures, admissions/readmissions, falls, nutritional status, chronic conditions self-management, levels of physical activity, and the ability of residents to adhere to their medication regimen.
  • Plan for expansion: Expanding the program requires careful planning and documentation. During the year-long pilot test, Cathedral Square worked closely with five nonprofit and public housing providers throughout the state to make sure the program could be replicated on a larger scale. This work resulted in the development of planning and procedures documents that will be used to guide program expansion and implementation.
References/Related Articles

More information about the program is available at:

U.S. Department of Health & Human Services Assistant Secretary for Planning and Evaluation; Office of Disability, Aging and Long-Term Care Policy. SASH Evaluation Findings, 2010-2016. 2019.

Kandilov A, Keyes V, van Hasselt M, Sanders, et al. The Impact of the Vermont Support and Services at Home Program on Healthcare Expenditures. Cityscape. 2018;20(2):ePub.

The National Academies of Sciences, Engineering, and Medicine. Developing Affordable and Accessible Community-Based Housing for Vulnerable Adults. 2017.

A case study of the program is available at:

To learn more about aging in place and other aging issues, see:


U.S. Census Bureau. National Population Projections, 2008. U.S. Census Bureau website. Available at:

Federal Interagency Forum on Aging-Related Statistics. Older Americans 2010: Key indicators of Well-Being. December 2010. Available at:

Policy Priorities 2011. Promote the Health, Security and Well-Being of Older Adults. National Association of Area Agencies on Aging. March 2011.

U.S. Department of Health & Human Services Assistant Secretary for Planning and Evaluation; Office of Disability, Aging and Long-Term Care Policy. SASH Evaluation Findings, 2010-2016. 2019.

Original Publication
Original Publication indicates the date the innovation profile was first posted to the AHRQ Health Care Innovations Exchange website.
July 16, 2014
Date Verified by Innovator
Date Verified by Innovator indicates the most recent date the innovator provided feedback during the review process.
June 12, 2020
The inclusion of an innovation in PSNet does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter or developer of the innovation.
Contact the Innovator

Molly Dugan, Director

SASH® (Support and Services at Home)


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