Service helps seniors stay at home

MIDDLEBURY — When Larry Carlson moved into the 25-unit Vergennes Senior Housing project on Armory Lane earlier this year, he was immediately impressed with the accommodations. But as a 71-year-old diabetic, Carlson was concerned about his ability to stay in his new apartment as his medical needs escalate to the point of sending him into the hospital.
His worries have lessened greatly with the arrival in Vergennes of Support And Services at Home (SASH), a new experimental program through which Medicare recipients will receive help in accessing services and wellness programs designed to keep them living independently and therefore out of more costly nursing home and hospital settings. SASH is being piloted in Vermont over a three-year period thanks to a $10 million federal grant through the Center for Medicare and Medicaid Services. Vermont is one of eight states to get such a grant to study innovative ways of delivering primary care.
The grant will pay for a full-time SASH coordinator and a part-time wellness nurse per “panel” of 100 Medicare patients signed up in Vermont communities. Vergennes Senior Housing is now the home base for a Vergennes-area SASH panel, though participants don’t have to be residents of the project.
Vergennes is only the beginning. SASH organizers announced plans to introduce the program in Middlebury on Oct. 1; in Orwell and Shoreham on Jan. 1, 2013; and in Bristol and New Haven on March 1, 2013.
“I’m getting assessed by a (SASH) nurse this week,” a gratified Carlson said on Monday. “It makes you feel good, knowing that someone will be there to guide you to the right spot.”
Helping to import SASH to this region is the Addison County Community Trust (ACCT), which spearheaded Vergennes Senior Housing and has developed and overseen more than 600 affordable units throughout the area since its inception in 1989. Cathedral Square Corp. — a South Burlington-based nonprofit organization that owns and manages properties for seniors and individuals with special needs — pioneered SASH in concert with several other community providers.
It all began with a test SASH program in Burlington’s New North End, financed by Cathedral Square, foundation grants and some state dollars. Receipt of the grant money has allowed another 27 SASH programs to get up and running statewide since October of 2011, according Molly Dugan, SASH program director for Cathedral Square. By the end of the three-year pilot project in 2014, plans call for SASH to be in more than 150 housing communities in all 14 counties, according to organizers.
“It will create a blanket of services and supports that are not only available to residents in congregate housing, but are also available to people living in surrounding areas in single family homes or mobile homes,” Cathedral Square Executive Director Nancy Eldridge announced at a July 25 regional housing forum in Bar Harbor, Maine.
The payback on the SASH investment is looking good in the early going, according to Eldridge. She reported that SASH has already reduced Medicare and Medicaid costs by an estimated $100,000, through reduced hospital admissions and nursing home readmissions. The program has also prevented falls, increased physical activity and reduced nutritional risk among those enrolled, she said. Resulting savings have “more than covered the cost to Medicare of $70,000 per year per 100 participants, or $700 per person per year,” she said.
ACCT Executive Director Terry McKnight believed that the SASH program would be a good match for his organization’s housing that caters to Medicare-eligible citizens. So he pitched the idea to like-minded organizations and forged a “memo of understanding” with them to bring in SASH. Signing the document on June 20 were representatives of Cathedral Square, the Champlain Valley Agency on Aging, Addison County Home Health & Hospice, Porter Medical Center and the Counseling Service of Addison County.
“I think it’s a very exciting program,” McKnight said of SASH, which has already been making its mark at Vergennes Senior Housing.
Nina Welch is the new Vergennes SASH coordinator. She has been a caregiver, activities organizer and advocate for seniors for the past 25 years. In her job, Welch will provide her clients with services such as comprehensive health and wellness assessments; help in navigating the long-term care system; planning for healthy aging; help in health crisis situations; aid in transitioning from the hospital back home; periodic check-ins to make sure the patient is doing well; coaching; and a link to the SASH wellness nurse.
“My job is to coordinate with the different agencies and make sure people can stay at home,” said Welch, who has been signing up local Medicare patients to reach the 100-client threshold for a SASH panel. She envisions multiple offerings for SASH participants, including walking groups, seminars on flu and diabetes, blood pressure and foot care clinics, exercise sessions and perhaps a “healthy aging” education series.
McKnight said Vergennes Senior Housing is providing a good platform from which to stage SASH programs. Around 60 seniors have been showing up at each of two weekly lunches at the facility, where participants are given pointers on nutrition, wellness and other helpful advice.
Pauline Rheaume, 76, is a resident of Vergennes Senior Housing. She is now recovering from a heart-related operation and is pleased to have SASH officials available to check up on her.
“I think it will be a good thing,” she said.
ACCT officials are now sizing up sites to host the planned SASH programs in Middlebury, Orwell/Shoreham and Bristol/New Haven communities.
“That’s the challenge,” said Steve Sak, director of property management for ACCT. “We want to try to piggyback on any existing spaces, such as (venues for) senior meals programs or senior centers.”
Dugan acknowledged that SASH faces an uncertain future once the three-year grant expires in 2014. But she is confident it will prove enough of a Medicare money saver to earn an extension or even permanent funding from the feds.
“Obviously, our data has to prove it has made a difference,” Dugan said. “But you don’t change a system without taking risks.”
Reporter John Flowers is at [email protected].

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