LTSS Choices

Coordinating Housing, Health and LTSS Through Home-Based Care Management

Published September 30, 2022

Housing infrastructure can be used to address some of the most intractable challenges in the long term services and supports (LTSS) system, and many health care and LTSS providers alike are working to strengthen their relationships with housing programs and systems. Housing-based care management (HBCM) programs use the housing system to extend primary care and human services practices into the homes of people with needs for LTSS.

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This report describes and evaluates the SASH (Support and Services at Home) program in Vermont as one model of HBCM programs. Founded in 2009, SASH now partners with 70 organizations, including hospitals, community-based organizations, and academic institutions in sites across the state.

Essential Components of SASH’s HBCM Model

The participant panel. Every SASH participant is a member of a group of approximately 100 people who are all focused on staying healthy and living independently in their own homes. Each works with an interdisciplinary staff team to develop a “Healthy Living Plan," a person-centered plan developed through shared decision making based on data gathered in a health and social needs assessment.

Housing partners. SASH works with existing housing organizations and creates infrastructure. A network of community partners centered on one’s home help enable consistent relationships and reliable, timely services.

Formalized partnerships with community agencies. Agencies on Aging, community mental health agencies, home health agencies or other critical community-based assets agree to send one, consistent staff person to monthly SASH meetings at the housing site to coordinate on action plans for high-need participants.

Care coordinators. These members of the care team work one-on-one with participants to develop their wellness plans and to connect with essential services, following the community health worker model in which coordinators are meant to be representative of the community they serve.

Wellness nurses. Serving each SASH panel is a part-time registered nurse who regularly checks in with participants, coordinates with primary care providers and, when needed, helps manage chronic conditions, oversees self-management of medications, and  facilitates transitions with health care facilities.   

Value-Based Care and HBCM Models

SASH provides an excellent example of how value-based care systems function. Initial funding in 2011 through a CMS Medicare Demonstration provided $70,000 per panel to support the SASH care coordinator and wellness nurse. The idea is that this investment will save the state and federal governments money through preventing more serious health care expenses down the road. Some of these savings have already been demonstrated.

How to Evaluate HBCM Models

Since SASH was launched in 2009, its advocates have explored many ways to capture its impact. This report includes a thorough discussion of the program’s demonstrably positive impacts on costs, clinical outcomes, health care utilization and subjective well-being reported by participants, for example:

  • A 2010 external evaluation found participants in SASH’s urban panels saw slower growth in Medicare expenditures, reducing growth by over $1,450 per beneficiary per year. Growth in Medicaid expenditures for institutional long-term care was also significantly slower for participants in site-based and rural panels, with an average impact of $400 per participant per year.
  • 70 percent of SASH participants in a Vermont Department of Health-funded study reduced their blood pressure and 50 percent even moved into a lower risk category for serious illness.
  • Studies from the Vermont Department of Health showed decreases in hospitalizations from falls at several SASH sites in the state, particularly among participants who frequently visit the emergency room.
  • In several different surveys aimed at measuring SASH participants’ sense of empowerment and subjective well-being, participants said that they felt that they had easier access to mental health services and reduced social isolation.

Questions to be Addressed as the HBCM Model Spreads

The report concludes with a discussion of the scalability and applicability of the SASH model in other settings and populations, and offers some promising preliminary evidence that addresses the following questions:

  • How can HBCMs be adapted to states and localities with a variety of payment systems and policy priorities?
  • How might the administration and impact of HBCMs look different in a more urban environment?
  • How can a national body of knowledge and evidence be developed for HBCM models?
  • Can the HBCM model help to address health equity?
  • Could similar partnerships between LTSS and housing impact other vulnerable populations?

This Spotlight is part of the AARP Public Policy Institute’s LTSS Choices initiative. This initiative includes a series of reports, blogs, videos, podcasts, and virtual convenings that seeks to spark ideas for immediate, intermediate, and long-term options for transforming long-term services and supports (LTSS). We will explore a growing list of innovative models and evidence-based solutions—at both the national and international levels—to achieve system-wide LTSS reform.


Coordinating Housing, Health and LTSS Through Home-Based Care Management

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Suggested Citation

Benedict-Nelson, Andrew, Ana Hervada, Patricia Polansky, and Carrie Blakeway Amero. LTSS Choices: Coordinating Housing, Health and LTSS through Home-Based Care Management. Washington, DC: AARP Public Policy Institute, September 30, 2022.


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