Vermont's population is aging, and that demographic trend has put new pressure on Medicare spending. It's also highlighted the need to improve care for older Vermonters. A unique program that links health care and other services to affordable housing complexes in Vermont may be part of the solution.
Because the program is sustainable and uses services and infrastructure already in place in many communities, federal health officials believe it may become a model for other states.
But before we get into the specifics of the program, let's throw out some numbers.
In Rutland, A typical trip to the emergency room costs about $1,500. Meanwhile, a one-month stay in a Vermont nursing home will run about $9,000.
Older adults frequent both ERs and nursing homes more than they need to, say health experts, often because of issues that could be taken care of at home or in a doctor’s office.
Just ask Karyn Crossman. She’s a coordinator for a nonprofit called SASH, which stands for Support And Services At Home. “I worked before as a registered nurse,” she says. “But I choose to do this.”
"This" is making house calls on 100 clients who live in Templewood Court, an affordable housing complex in Rutland.
On this particular day, she knocks on Lloyd Piggrem’s door. “Hi Lloyd! Oh, you got a new carpet. It looks great,” says Crossman as she bustles in.
Piggrem, an 88-year-old who lives alone, greets her warmly. Last year, she says the former long-distance trucker visited the ER 19 times.
Sitting at his kitchen table, he shakes his head remembering how expensive it got. “I said, well, I gotta stop this," he says.
The hospital agreed, which is when SASH got involved. The program provides personalized coordinated care to help Vermonters such as Piggrem stay in their homes safely.
Crossman makes herself at home in Piggrem’s tidy kitchen. “So, how are you doing?” she asks. She chats and laughs while recording his weight, checking a scab on his arm, taking his blood pressure and going over his upcoming medical appointments.
Over the past year, Crossman has gotten Piggrem set up with a local primary care doctor, a dermatologist and a cardiologist.
She’s taught him to read food labels and watch out for sodium, which was playing havoc with his high blood pressure. “So, no more beef broth and no more tomato juice still, right?” she gently teases.
Crossman says getting clients to be more aware of their eating habits is challenging. But it’s so important, she says, considering how many chronic conditions many of them have.
Another critical part of her job is helping clients like Piggrem stay on top of their meds. “One day last summer I came over and he was having a hard time putting his pills together,” says Crossman. “And I looked at them and checked and I noticed that there were two Losartan in there. And I’m like, ‘Oh my goodness, you’re not supposed to be having two of these.’ So that’s when I figured, uh oh, there’s issues here.”
Crossman called the pharmacy and it now organizes and seals the dozen or so pills Piggrem takes into daily doses.
“It’s a lot easier,” he admits. “If I forget something, they don’t forget. She doesn’t forget,” he adds with a nod toward Crossman.
Since having visits from Crossman and other social workers, and using the blister pack medicines prepared by the pharmacy, Piggrem says he’s rarely had to go back to the hospital.
“Not very often, no. If I go back at all it’s because of an emergency,” says Piggrem. “But it shows things have got better.”
Better and less costly, according to an independent analysis by the U.S. Department of Health and Human Services and H.U.D., the Department of Housing and Urban Development.
Molly Dugan, the Burlington-based director of SASH, says, “We are extremely excited by the results from our independent evaluator, which is showing a reduction in Medicare expenditures for our SASH participants of more than $1,500 per person per year. That's compared to a similar group in the northeastern United States who were not participating in SASH."
SASH originated in Burlington in 2009 and has grown rapidly. About 4,300 Vermonters are now enrolled in all 14 counties. Medicare pays most of the cost, which is between $700 and $1,000 a year per person.
Dugan says SASH has grown quickly because it utilizes affordable housing agencies and services, such as visiting nurses, and councils on aging and mental health agencies that already exist statewide. “So the infrastructure is there,” she says, "and services are provided where people live which makes it easier."
Many of their elderly and disabled clients are very isolated, Dugan says, so staff members can become like family. "The personal relationships SASH creates are invaluable," she adds.
Emily Rosenoff, a senior policy analyst with the U.S. Department of Health and Human Services, says the idea of providing health services and other supports where people live isn’t new. But she says what makes Vermont’s SASH program unique is it’s been able to do it on a statewide level in a sustainable way.
“We’re excited about this,” says Rosenoff. “HUD and HHS, we really see SASH as a promising practice. That’s why we’ve been evaluating it.” She says more data is needed to ensure the program can be sustained long term, but so far, she says the results they do have are encouraging.
In January, $15 million in federal funding was made available to affordable housing providers nationwide to study ways to develop a model like SASH.
Molly Dugan smiles and says their phone has been ringing. “The interest is there, so now this is the next step in getting it replicated throughout the nation," she says. "There’s nothing in this model that can’t happen in another state.”