SASH Continues to Slow Growth in Medicare Expenditures

Alisha's Blog | April 26, 2016

The Support and Services at Home (SASH) program continues to slow the growth of annual total Medicare expenditures for program participants, according to the second annual report from a 3-year evaluation conducted by the LeadingAge Center for Applied Research (CFAR) and RTI International.

The Support and Services at Home (SASH) program continues to slow the growth of annual total Medicare expenditures for program participants, according to the second annual report from a 3-year evaluation conducted by the LeadingAge Center for Applied Research (CFAR) and RTI International.

Based in affordable senior housing, the SASH program helps participants address and coordinate their health and social service needs. SASH teams consist of housing-based care coordinators and wellness nurses who work with community-based service agencies to support participating affordable housing residents.

Researchers used claims data for a sample of Medicare fee-for-service (FFS) beneficiaries to analyze health care utilization and expenditures among SASH participants. This data was compared with claims data for a comparison group of Medicare beneficiaries who were living in Vermont-based affordable housing properties that did not participate in SASH.

The results contained in the second annual report mirror those found in the first-year evaluation.

During the second year of the evaluation, researchers found that growth in annual Medicare expenditures was lowered by an estimated $1,536 per beneficiary among SASH participants in early panels, relative to members of a comparison group. However, slightly more than half of the participants in the sample -- those in late panels -- are not yet experiencing a lower rate of growth in Medicare expenditures, say researchers.
 

Participants in the SASH Evaluation

Established in July 2011, the SASH program included 49 panels and 3,485 participants by June 2014. Each SASH panel includes approximately 100 participants.

Researchers analyzed health care utilization and expenditures for 1,602 SASH participants and 1,458 members of the comparison group. The SASH sample was stratified into 4 cohorts:
 

  • An "early panel cohort" contained SASH participants in panels that started operating before April 1, 2012. About 45% of SASH participants in the sample belonged to the early panel cohort.
  • A "late panel cohort" contained SASH participants in panels that started operating on or after April 1, 2012.
  • A "site-based panel" cohort had a majority of participants living in affordable congregate housing.
  • A "mixed-panel cohort" had more than half of its participants living in the community.

Researchers decided to analyze the effect of SASH by early and late panel start dates because they theorized that panels need a certain amount of start-up time before their implementation of the SASH program becomes fully effective. Participants may also need exposure time to the program.

“We would expect to see a larger program impact among participants receiving services from earlier and therefore more experienced SASH panels,” says the report.
 

Findings on the Impact of SASH

The evaluation showed a positive impact on Medicare expenditures, especially for participants in early and site-based SASH panels.

  • Overall impact: Researchers observed that the rate of growth in total Medicare expenditures for beneficiaries in all SASH panels trended lower than the comparison group. However, this result does not reach statistical significance for data through June 2014, says the report.
  • Early panel participants: The SASH program reduced the rate of growth in total Medicare expenditures by $128 per beneficiary per month, or about $1,536 annually among participants in early panels. The early panel cohort also experienced statistically significant lower growth in expenditures for emergency room (ER) visits, hospital outpatient department visits, and primary care/specialist physician visits.
  • Site-based: The rate of growth in total Medicare expenditures trended lower among participants residing in the site-based SASH panels overall, but was only statistically significant in the third year of the program.

Since most of the early panels were also site-based panels, it is not clear whether success is due to longer experience or the environmental aspect of the panel.

“Despite the very positive findings with respect to reduced rates of growth in Medicare expenditures for SASH participants in the early panel cohort, we do not observe decreased rates of hospitalizations or ER visits among these SASH participants relative to the comparison group,” concluded the report. “Further exploration of the source of the reduced growth in Medicare expenditures is warranted.”

Maturing Relationships

The SASH program initially created apprehension about overlapping responsibilities among some community partners. But by early 2014, these relationships had improved considerably as community partners gained a better understanding of SASH and as roles and responsibilities were more clearly defined.

Some community-based providers still have concerns about duplication of services, according to the report. This is particularly true as the SASH program extends beyond affordable congregate housing sites and into the community.

The SASH program has implemented an extensive training program for staff working with the SASH program. Researchers found that balancing time with participants, particularly for wellness nurses who have more limited hours, with time in training is a primary challenge. Limited funding for training activities is also a challenge.

More About SASH

Developed by Cathedral Square Corporation, an affordable housing provider in South Burlington, VT, SASH operates in over 150 affordable housing sites, including public housing and various non-profit-owned properties. Individuals from the surrounding community may also participate in the program.

In 2011, SASH was integrated into Vermont’s Blueprint for Health, a statewide health reform effort that uses community health teams to support medical homes across the state by providing targeted prevention and disease management assistance to identified patients.

As a partner in the state’s Medicare Multipayer-Advanced Primary Care Practice (MAPCP) demonstration, SASH supports the community health teams by providing focused in-home support and services to Medicare beneficiaries in affordable senior housing properties and their surrounding communities. The MAPCP demonstration pays for the SASH onsite care coordinator and wellness nurse team.