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Nancy Rockett Eldridge Cathedral Square Corporation August 10, 2011

Nancy Rockett Eldridge Cathedral Square Corporation August 10, 2011. WHY SASH?. Medicaid and Medicare Spending. Determinants of health Source: New England Journal of Medicine. Resident Snapshot. 85% 70+ 40% 85+ 49% ER visits 54% 6+ meds 61% fell 32% mental health issues

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Nancy Rockett Eldridge Cathedral Square Corporation August 10, 2011

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  1. Nancy Rockett Eldridge Cathedral Square Corporation August 10, 2011

  2. WHY SASH? Medicaid and Medicare Spending Determinants of health Source: New England Journal of Medicine

  3. Resident Snapshot 85% 70+ 40% 85+ 49% ER visits 54% 6+ meds 61% fell 32% mental health issues 59% use a cane or walker 49% failed cognitive screen

  4. THE SASH MODEL Nonprofit Housing Visiting Nurse Assoc. PACE Area Agency on Aging • ASSESSMENTS • PERSON CENTERED PLANS • TEAM REVIEWS • INDIVIDUALIZED SUPPORTS • TRANSITIONS SUPPORT • CARE COORDINATION • EVIDENCE BASED PRACTICES • HARD WIRED TO HEALTH INFORMATION EXCHANGE • WRAP AROUND EXISTING PROGRAMS AND POPULATION

  5. Connecting the Medical Home to Home Vermonter Medical Home Community Health Team Housing Based SASH Team

  6. Community Building Among residents In the neighborhoods Across not for profit housers With home and community based providers In alliance with hospitals and medical homes

  7. SASH Designated Regional Housing Organizations #6 Gilman Housing Trust #1 Cathedral Square Corporation #5 Central Vermont Community Land Trust Finalized #2 Rutland Public Housing Authority DRHO Designation in Process #4 Brattleboro Public Housing Authority #3 Regional Affordable Housing Corporation

  8. Results • 19% reduction in hospitalizations • No bounce backs • Reduced falls • Increased physical activity • Reduced nutritional risk Better health, better care & lower costs

  9. Statewide Rollout • NeighborWorks members • Public Housing Authorities • CHDOs • Other housing nonprofits = 112 SASH HUBS

  10. FUNDING SASH • Now: • Medicare MAPCP • Medicaid Global Commitment • State/Federal HIT Grant • Vermont Health Foundation • Enterprise Foundation • Peoples United Bank Foundation • HUD/Housing Assistance Council • Next: • Dually Eligible Medicaid and Medicare • Private Pay and more Foundation involvement

  11. SASH: REPLICABLE AND SUSTAINABLE SYSTEMS CHANGE • Consumer Needs • Neighborhood based • Statewide infrastructure • Federal Programs • Lower costs • A network of states with housing as the platform

  12. Contact Information:Nancy Rockett EldridgeExecutive DirectorCathedral Square Corporation412 Farrell Street, Suite 100South Burlington, Vermont 05403 www.cathedralsquare.org eldridge@cathedralsquare.org 1 802 863 2224 HEALTHY HOMES CARING COMMUNITIES POSITIVE AGING

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