What if real estate developers worked with on-site nurses and social workers to help frail older adults and younger people with disabilities stay in their apartments? Could they deliver–in a cost-effective way–social supports and care coordination that would improve the well-being of residents, reduce their health care costs, and benefit property managers?
The answer is: They can, especially for older adults. A new study of a Vermont program called Support and Services at Home (SASH) finds that delivering care management and wellness nursing to an apartment building with large numbers of low-income seniors can produce a win-win for residents and developers.
The study, by the consulting firm RTI International and the LeadingAge Center for Applied Research, was published by the federal Department of Health and Human Services It found some SASH locations reduced Medicare costs by as much as $1,450 annually, largely by reducing costs for hospital care. It also found that the program may help older adults stay at home and delay or even prevent their move to a nursing home or other institutional care facility.
The model may not work for everyone. There appear to be important differences among rural and urban sites, among older adults and younger people with disabilities, and even among property managers. But for some, the SASH model is one that other states and developers should consider.
SASH works like this: real estate developers work with the state to locate a full-time service coordinator and a part-time wellness nurse in their buildings with a significant number of low-income older adults and younger people with disabilities. Residents choose whether or not to participate. The nurse identifies emerging health care issues and works with participating residents to address them. The coordinator links those participants with community social services.
At some sites, services are available only to tenants in the designated building. At others, people living in the neighborhood may participate.
Vermont started SASH in 2011 and expanded it in 2016. Currently, more than 20 affordable housing organizations are offering SASH at 116 properties, each with an average of 79 units. About 6,100 people, with an average household income of roughly $16,000, participate.
Cathedral Square Corp (CSC), a non-profit housing provider, created the program, oversees it, and serves as one of six regional housing organizations that manage SASH in their geographical areas. The operators all are non-profits and receive some form of federal low-income housing subsidy.
The study identified important successes at some sites but also found a great deal of variation across the state. The CSC’s own locations, especially those in the Burlington area (Chittenden County), saved the most money. Compared to non-SASH participants, total annual Medicare costs were $1,100 lower for the CSC enrollees, and $1,400 lower for those living at CSC’s urban sites. Medicare spent an average of about $7,700 for a SAS participant, so the cost saving is substantial. More than half of the Medicare saving was due to lower acute hospital costs. Other savings came from lower costs for emergency department visits and specialist care.
Despite those successes, rural sites showed little Medicare savings. The authors speculate this may have been for two reasons: Because the nurses had to spend so much time traveling among sites, they had less time with residents; and rural areas had fewer social service providers than Burlington. Thus, the SASH team might have identified a tenant’s need for additional services but there was no one to provide that support.
The study also found fewer benefits for sites with larger numbers of younger people with disabilities or for those that expended services beyond the building and into the neighboring community.
SASH also reduced Medicaid nursing home costs– by about $400 annually. This suggests that SASH may have at least delayed nursing home stays for participants. Interestingly, participants in rural areas did benefit from this feature of the program.
The study found other benefits besides direct cost savings. For example, participants reported that it was easier for them to manage medications. And many property managers said the program made their work easier by helping improve relationships with tenants.
SASH may not work for everyone, or everywhere. And we don’t know if the model works for for-profit developers or would benefit more moderate income tenants.
But it is an important example of the potential advantages of pairing senior housing with services. It can help older adults stay at home longer, and may keep them out of the hospital and reduce Medicare costs. I hope others will try it.