How One Visionary Is Pioneering Change in Care Management

By Cloud, Deborah | Aging Today, May/June 2012 | Go to article overview

How One Visionary Is Pioneering Change in Care Management


Cloud, Deborah, Aging Today


There's no doubt that America is failing a percentage of its elders, and sometimes it becomes a citizen's job to step in and advocate. Nancy Rockett Eldridge is one of those advocates.

Eldridge's leadership and tenacity are legend, especially when it comes to raising awareness of the vital role senior housing communities can play in helping residents remain independent as they age in place.

A Model of Advocacy

Eldridge is executive director of Cathedral Square Corporation, a nonprofit organization in Burlington, Vt., that owns and manages 24 affordable housing communities for elders and others with special needs. She is also the visionary behind the Support and Services at Home (SASH)

program, through which interdisciplinary teams of health professionals and service providers help residents at housing sites meet health and wellness goals.

The SASH program, an outgrowth of collaboration among many partners- from housing and healthcare providers to social service agencies-seeks to reduce costs while improving elders' health and quality of life. Using funds from the Vermont legislature, the Vermont Health Foundation, the MacArthur Foundation and its own funds, Cathedral Square developed and piloted SASH in an 82-unit affordable housing site in Burlington in 2009-2010.

After the one-year trial, SASH's success led to the model's integration in July 2011 into Vermont's new Blueprint for Health plan. As part of that initiative, a Medicare-funded SASH is on track to extend its team-based model statewide in a phased rollout. By 2014, all 112 nonprofit affordable housing communities for elders in Vermont are slated to be SASH service hubs. The program also will serve other Medicare beneficiaries, regardless of age, income or location.

"We know that problems such as avoidable falls and nursing home stays, unmanaged chronic health conditions, excessive use of emergency room services and medication misuse can be aproached in a better way," Eldridge says. "SASH tackles these issues head on."

During the pilot, SASH helped reduce hospital admissions by 19 percent and falls by 22 percent among housing residents at the test site. The number of residents who were physically inactive dropped 10 percent. The number at moderate nutritional risk fell 19 percent.

As the program expands, so should the savings. "We believe we will show significant savings on the hospital and nursing home sides," Eldridge says. "We'll show that by redirecting some of those savings back to prevention and on-the-ground, person-centered care management, you just keep on saving. …

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