Back in the 2000s, Nancy Rockett Eldridge was working at Cathedral Square, a Vermont nonprofit that provides housing for older adults and people with disabilities. She grew increasingly frustrated that many residents were moving prematurely into nursing homes due to the lack of a system that connects people to primary care providers and other supportive services. Eldridge recognized that publicly supported housing assisted many of the state’s highest-need individuals and already had an infrastructure of buildings, meeting rooms, and staff, making it a viable locus for extending primary care to older adults and people with disabilities.

Under her leadership, Cathedral Square launched Support and Services at Home (SASH) in 2011 with funding from the Centers for Medicare & Medicaid Services’ Multi-Payer Advanced Primary Care Practices demonstration. The program connected all 22 housing organizations in Vermont and established staffing teams to serve residents of publicly supported housing who wanted to participate. By 2014, SASH was rolled out at 140 publicly assisted housing sites.

This profile of the SASH model is part of an ongoing series, In the Field: Spotlight on Complex Care Interventions, that is highlighting how organizations are implementing evidence-based and promising innovations to improve care for people with complex health and social needs.

*Author Harris Meyer is a freelance journalist who has been writing about health care policy and delivery since 1986