Comments on Green Mountain Care Board Act 167 Public Input Process

The Green Mountain Care Board (GMCB) is currently soliciting comments and questions on its Act 167 report regarding the future of healthcare in Vermont, in particularly its ongoing cost challenges and opportunities for transformation. This process is happening as Vermont's "All Payer" waiver is ending and a new model called AHEAD is being considered.

On Tuesday evening July 30, GMCB and Porter Hospital held an open public session to present findings from the Act 167 study and gather feedback. The presentation focused heavily on housing as a key driver of health care costs and outcomes, both due to the workforce housing shortage driving up labor costs and the lack of access to quality affordable housing causing worse health outcomes especially among low-income and vulnerable Vermonters.

AHW provided the following public comments online to encourage that healthcare transformation include housing-based health services for low-income residents of affordable housing and the surrounding neighborhoods:

Addison Housing Works serves over 750 families and individuals in Addison County, including some of our most vulnerable neighbors. Nearly half of our residents subsist on poverty-level incomes, and many have multiple mental and physical health challenges. 32% have a self-identified disability and 37% are elderly. Seniors who live in our housing and the surrounding communities have access to a wonderful program called SASH, which stands for Support and Services at home. Run by Addison Housing Works in Vergennes, Bristol, and Shoreham/Orwell and in Middlebury by Vermont State Housing Authority, SASH provides a full-time service coordinator and a quarter-time wellness nurse through Addison County Home Health and Hospice. SASH focuses on prevention and helps seniors age safely in place, so they stay healthier and don't have to move to higher levels of care for as long as possible. SASH is a capitated model that has been funded by the All-Payer Waiver and now must continue to be funded through AHEAD.

In 2021, based on the success of the SASH program, AHW launched the Family Support Program, which strives to offer some of the same services and benefits of SASH to all of our residents regardless of their age. Family Support is funded almost entirely by charitable donations as no state funding sources exist to support this critical prevention and support work.

Tonight I want to stress the importance of investing in community-based prevention models that address the social determinants of health, especially housing. In particular, the SASH Program is critically important to the health of seniors in our region and must continue to be funded. Moreover, similar funding should be allocated to support non-seniors on a capitated basis and embedded in affordable housing. Funding for supportive services on-site at affordable housing developments works on two levels: 1) it directly supports healthy housing as a social determinant of health; and 2) it capitalizes on housing as a platform for other health interventions from health food initiatives to direct health care access on-site where people live.

Home-based care models like the VNA are vitally important but not enough. Enrollment processes, sporadic appointment availability, and lack of coordination with other parts of the health care system all act as barriers to effective uptake of these services among the most vulnerable (and often highest cost) Vermonters. The SASH Program offers a proven model to address these issues where people live. SASH works with existing providers like the VNA but is a person-centered approach to ensuring that a participants' care is holistically integrated across the parts of the healthcare system with which they may interact. For example, full-time SASH Coordinators convene monthly meetings of area service providers to review health needs of panel participants, and monitor hospitalizations and discharges to make sure participants are doing well at home if they do experience a medical event.

Not only does SASH act as a bridge across existing care providers, it also offers preventive services where people live to reduce demand on the healthcare system. For example, SASH sites have a full-time SASH Coordinator who can organize bone builders classes, blood pressure clinics, and simply spot someone who may not be doing well early enough to intervene before they require an ED visit.

Let me tell you a story about one of our residents who participated in our Family Support Program. This person had a disability and several chronic health issues that made leaving their apartment difficult and also jeopardized their housing because they could not complete their recertification paperwork without assistance. This person may have been eligible for services but did not know who to call for help. Their story might have ended there, with the loss of their rental assistance and safe stable housing, likely worsening their health. However, AHW was able to refer this person to our Family Support Coordinator, who not only helped them maintain their housing assistance, she also noticed that this person was out of food and got them signed up for food shelf deliveries. When this person needed medical care, they reached out to our Family Support Coordinator for help making an appointment because they had built a trusting relationship with someone who was there five days a week. In this case, housing was literally health care because of AHW's residential support program.

AHW would like to expand the Family Support Program along the lines of "SASH for All" which is being piloted in other places around the state, but can't for lack of funding. Demand for these services far outstrips supply. Yet SASH has proven to be a cost-effective intervention, leading to reduced Medicare billing in one Gold Standard Evaluation of the program. The same SASH principles should be applied to a preventative housing-based care coordination system for all residents of affordable housing and the surrounding communities, regardless of their age and Medicare eligibility. Investments should be flexible and not require complicated medical billing or enrollment to access. With homelessness at unprecedented levels, housing and services must work together to keep people happy, healthy, and housed.