Care That Works: SASH

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Innovations in how to best care for people with complex health and social needs are happening across the country. Our “Care That Works” series seeks to examine and elevate these successful programs and share the stories of the people they serve.

The third brief in this series, “Care That Works: SASH,” profiles the Support and Services at Home (SASH) program based in South Burlington, Vermont. Founded in 2009, SASH coordinates the resources of social service agencies, community health providers and nonprofit housing organizations to support Vermonters who choose to live independently at home. Individualized, on-site support is provided by a Wellness Nurse and a SASH Care Coordinator with offices based in participating housing facilities. SASH serves older adults, as well as people with disabilities who are enrolled in Medicare. SASH touches the lives of approximately 5,000 people throughout Vermont. The brief shares the story of Ms. Regina Fournier, a SASH participant since 2015.

SASH participants range in age and level of need from age 20 to 101 and from active and healthy to having multiple, complex chronic conditions, including dementia. Participants are assigned to “panels” of approximately 70 to 100 participants served by a full-time care coordinator and a part-time wellness nurse. In working with SASH participants, the SASH care coordinator and wellness nurse focus on wellness and prevention; information sharing; person-centered goal setting and shared responsibility. A core tool of the SASH program is the healthy living plan developed with each participant. The plan development process begins with a person-centered interview conducted by the SASH care coordinator, which aims to learn about the individual beyond solely medical needs and identify the person’s broader life goals.

Read the Brief