Craig Jones, MD

Molly Dugan

Kevin Loso

Nancy Eldridge

Aging in Place

We All Want to Stay Home

• Home centric• Consumer driven• Unlicensed

WE BUILT AN EDUCATION SYSTEM

FOR THE BABY BOOMERS IN 1953

NOW THEY NEED A LONG TERM CARE SYSTEM!

150 + HUBS All Incomes, Ages and Settings Medicare Dual Eligibles Others??

A Network of Care Management HUBS

Housers at Health Reform Table with the State

Mental Health

UniversityFunder

AAA

PACEHospital

Housing

Home Health

The Technology Embedded Home

Central Clinical

Registry

iPads

Tele-Tai Chi

Broadband for all!

Cyber Seniors

THANK YOUENTERPRISECOMMUNITYPARTNERS!!

THE SAVI!!

HEALTHY HOMESCARING COMMUNITIES

POSITIVE AGING!

How Will Our Residents Benefit?

Land TrustsCCRC’s

Non-Profit Housers

Public Housing Authorities

AssistedLiving

ResidentialCare

Facilities

Housers Working Together

04/18/23 10

Department of Vermont Health Access

Vermont Blueprint for HealthCommunity Systems of Health

Housing Assistance Council

June 5, 2012

04/18/23 11

Department of Vermont Health Access

Building A Foundation For The Future

Advanced Primary Care Practices (PCMHs)

Community Health Teams (core)

Community Health Teams extended(MCAID CCs, SASH Teams)

Multi-insurer payment reforms

Health Information Infrastructure

Evaluation & Reporting Systems

Learning Health System Activities

04/18/23 12

Health IT Framework

Evaluation Framework

Advanced Primary

Care

Hospitals

Public Health Programs & Services

Community Health TeamNurse Coordinator

Social WorkersNutrition Specialists

Community Health WorkersPublic Health Specialist

Extended Community Health TeamMedicaid Care Coordinators

SASH Teams

Specialty Care & Disease Management Programs

Mental Health & Substance Abuse

Programs

Social, Economic, & Community Services

Healthier Living Workshops

12

Advanced Primary

Care

Advanced Primary

Care

Advanced Primary

Care

Department of Vermont Health Access

Multi-Insurer Payment Reform Framework

04/18/23 13

Department of Vermont Health Access

MedicaidMedicareBlueCrossMVPCignaSelf Insured

Advanced Primary Care

NCQA StandardsPatient Centered CareAccessCommunicationGuideline Based CareUse of Health IT

Community Support

Community Health TeamsMCAID CCsSASH Teams

Fee for Service - Volume

$ PPPM (NCQA) - Quality

Specialized Services

HospitalsSpecialty CareMental Health ServicesSubstance Use ServicesFamily ServicesSocial ServicesEconomic ServicesLong Term CareNursing Homes

Payment Reform Delivery System ReformFinancing

Shared Costs - Utility

Data warehouse

Vermont

Health InformationExchange

(VHIE)

Central Clinical Registry

(Covisint-DocSite)

Core data elements

Core data elements Core data elements

Hospital -hosted EMR

FQHC -hosted EMR

Web

Acc

ess

Web

Acc

es

s

CommunityHealth Team

Central Registry•Visit planners•Care coordination•ReportingFQHC-owned

Primary Care Practices

Independent Primary Care

Practices

Primary Care PracticeNo EMR

Hospital-owned Primary Care

Practices

Core dataelements

Unique Patient identificationinformation

Core data elements

Blueprint Information Technology Architecture

EMR

04/18/23 15

Blueprint ExpansionJanuary 2012

16

Department of Vermont Health Access

Gifford CME 3-2-201204/18/23 17

Department of Vermont Health Access

Care Management Begins at Home

Multi-payer Advanced Primary Care Practices (MAPCP) Medicare Demonstration States

Maine

Michigan

Minnesota

New York

North Carolina

Pennsylvania

Rhode Island

Vermont

Integrated Care for the Dually Eligible

California Connecticut Colorado Massachusetts Michigan Minnesota New York North Carolina

Oklahoma Oregon South Carolina Tennessee Vermont Washington Wisconsin

Department of Vermont Health Access

Data Sources & Evaluation

Central Clinical Registry

Multi-payer Claims Database

Chart Reviews

NCQA Scoring

Public Health Registries

Patient Provider Qualitative Assessment

Patient Experience

Department of Vermont Health Access

Early Trends – Inpatient Discharges

Department of Vermont Health Access

Early Trends – Inpatient Discharges (Rate / 1000)

04/18/23 25

Department of Vermont Health Access

Craig Jones, MDLisa Dulsky Watkins, MDJenney SamuelsonTerri PriceDiane HawkinsBeth TanzmanPat JonesJulie Trottier (Milbank Fellow)

Blueprint Team

SASH is a System, Not a Type of Housing

All settings – all ages – all incomes Access to information for housing based staff Population based – plus targeting SASH as an extender to the Blueprint for Health- VT’s Medical Home Model.

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

SASH Keeps “Katie” in the Driver’s Seat

SASH Staff = Trusted Guides

Multi-Agency Team Based Care Management

Nonprofit Housing

Visiting Nurse Assoc.

Area Agency on

Aging

PACE

Comm. Mental Health Agency

The SASH Teams

Care Manager

Wellness Nurse

Acute Care Nurse

Case Manager

Mental Health Expert

PACE Intake

Assessments

Person Centered Plans

Individualized Supports

Transitions Support

Self-Management of

Chronic Conditions

Care Coordination

Prevention and Wellness

Volunteers!

Where are we now?

Started rolling out in October 2011

Currently have 19.5 panels up and running!

1,950 people have access to SASH supports.

57 affordable housing sites are SASH sites

DocSite- Statewide Repository of Data is on-line.

Vermont’s SASH Goes Statewide

• An Extension of the Community Health Team

• Support for Goals of the Medical Homes

• CHT Case Manager Representation on Functional Team

• SASH Representation on CHT Planning Committee

• SASH Representation on CHT Referral Committee

SASH and the Blueprint for Health

• Rutland Regional Medical Center (RRMC): Social Work Department• RRMC: Case Management Department (Discharge Planners)• RRMC: Community Wellness Programs• Rutland Area VNA & Hospice – Nursing and Wellness Services• Southwestern VT COA– Case Management and Programming• PACE Vermont – Intake Coordination• Rutland Mental Health Services – Elder Care Clinician & Case

Management• Southern VT Area Health Education Center – Interns • Vermont Department of Health – Programming• Castleton State College, School of Nursing – Interns

Rutland County SASH Community Partners

The Pines of Rutland (SNF) – Discharge Planning Vermont Division of Disability & Aging Services – Choices

For Care Community Health Center of the Rutland Region (FQHC) –

Medical Homes Albany School of Pharmacology – Interns The BUS – Transportation Local Farmers – Nutrition Programs Castleton Community Center – Programming Retired Senior Volunteer Program – Volunteers Lions Club – Vision Program LensCrafters – Vision Program

SASH and the Blueprint for Health

Engages key community leaders in SASH

Provides support, guidance and general oversight

Represents interests of the SASH population

Members include leaders representing community

partners, other providers, and other community

stakeholders

SASH Local Table

General promotion of SASH to the community

Reviews strategic direction and priorities

Reviews protocols and services

Support in seeking funding sources

Reviews reports

Provides specialized experience

Reviews processes, data and outcomes

Supports overall development and sustainability

SASH Local Table Roles & Responsibilities

Templewood Court 49 residents enrolled

39 females 10 males

Average age: 72 years old Average # of prescription

medications taken: 7 Have 3 or more medical

conditions: 90% Have 5 or more medical

conditions: 55%

Sheldon Towers 40 residents enrolled

17 female 23 male

Average age: 58 years old Average # of prescription

medications taken: 6 Have 3 or more medical

conditions: 80% Have 5 or more medical

conditions: 55%

SASH Local Table Roles & ResponsibilitiesProfile of Residents

Templewood Court

Failed cognitive screening: 39%

Used ER: 43% Have self-reported mental

health concern: 33% Have moderate to high

nutritional risk: 83%

Sheldon Towers

Failed cognitive screening: 12%

Used ER: 48% Have self-reported

mental health concern: 45%

Have moderate to high nutritional risk: 75%

Profile of Residents

Templewood Court

Top 5 Medical Conditions– Vision– Arthritis– High Blood Pressure– Heart or Circulatory Problems– Chronic Pain

33% have fallen in last year

Sheldon Towers

Top 5 Medical Conditions– Vision– High Blood Pressure– Arthritis– Depression– Chronic Pain

33% have fallen in last year

Profile of Residents

Castleton State College Nursing Programs - Internship Program

Vermont Center for Independent Living - Hunger Free Vermont Nutritional Program

Council on Aging; AmeriCorps Members – Tai Chi, Walking Program

Beauchamp & O’Rourke Pharmacy – Brown Bag Medication Review, Diabetes Education

Castleton Community Center – A Matter of Balance

RRMC – Eat Well Feel Great

Community Program Support

Housing Staff

Community Providers

(VNA, AAA, Mental Health)

Community Health Team

Hospital

Family Support Persons

Primary Care Provider

Nursing Homes/Rehab

Facilities

Information Sharing

Enhanced quality of life

Decreased isolation

Increased physical activity

Improved nutritional status

Increase in primary care

Vision issues addressed

Reduction in ER and SNF utilization

Earlier treatment of health issues

• Enhanced aging in place

Benefits to Residents

1. Added supports for a changing resident population2. Liability exposure reduced3. Increase in on-site support staff4. Operate without a blindfold5. Application of evidence-based practices 6. Integral part of home & community-based services

aging network7. Part of linking non-profit assets8. Sustainable funding for services9. Place at the health care table10. Benefit from a collaborative network

SASH Benefits To Housers