Several years ago, Jeanne Daley was hit with three back-to-back challenges: Her husband died, she fell and fractured a knee and an elbow, and her son was transferred to Colorado for work, not long after she'd moved to Pennsylvania to live near him.

"I was just about ready to give up on everything," she says.

But then, another son in Vermont set her up in an income-restricted apartment complex designed for older adults in Burlington. "I came up to Vermont and thought maybe I'd last six months if I was lucky – and that was five years ago," Daley says.

Daley's building isn't standard low-income housing. It's part of the state's Support and Services at Home program, a housing-based initiative that addresses many health and social needs of low-income seniors and some disabled adults in the settings where they spend the most time: their homes and their communities.

One of roughly 5,000 SASH participants across Vermont , Daley participates in meditation and art classes offered through the program, and has her blood pressure checked weekly by a wellness nurse who works in the apartment complex.

"I'm really starting to feel younger – it's taken me back 10 years. I no longer feel my age since I've been up here," says Daley, who will turn 92 in October and has ditched her walking cane for dancing shoes since moving to the apartment.

By integrating housing, health care and social services, SASH program coordinators seek to help older adults age healthily and independently, reducing their medical costs and delaying or preventing institutional care while in turn easing the burden on the nation's health care system.

Piloted in 2009 by the affordable housing nonprofit Cathedral Square, the SASH program has become a model for home-based health approaches as an aging America yields more complex and costly health conditions and payers and providers increasingly consider prevention as well as treatment to curb those costs.

"This is a hard thing to do – I see this as changing the paradigm of how health care and supportive services are delivered," says SASH Director Molly Dugan. "We know things about them that their doctors don't know, that other community providers don't know, because we see them day in and day out."

Through the program, wellness nurses spend 10 hours per week with patients, while full-time care coordinators embedded in the housing sites synchronize the services provided by various home-health groups, area aging agencies, primary care providers and hospitals, and behavioral and mental health agencies often involved in caring for an aging or disabled adult.

Emphasizing independence, the coordinators tailor participants' care plans to their individual needs, which differ based on health conditions and lifestyle goals. They also assess participants' homes for potential health risks – such as areas where they might be likely to fall – as well as facilitate transitional care from the hospital and serve as a patient advocate with primary care doctors.

"It works because we don't have a uniform program for all of them," Dugan says. "We have a system where all of our staff who are embedded in the housing come up with a very specific person-directed plan that they have to work on."

High blood pressure – a major cause of heart disease and stroke – is the most common chronic condition reported by SASH participants, according to the organization's most recent annual report . Among the program's interventions, participants like Daley receive help managing their diet, regularly tracking their blood pressure and reporting their results to their primary care doctors.

The model appears to be making a difference: Blood pressure readings were considered in control for nearly 90 percent of SASH patients with hypertension, compared with about half of patients nationwide, and 70 percent of SASH participants reduced their blood pressure within six months of beginning the program, the report said.

"It's all about purpose," says Nancy Eldridge, who developed the SASH initiative in her previous role as Cathedral Square's CEO. "Nobody wants to reduce their salt intake – they want to do what motivates them and what means something to them."

Another key: deploying the program within existing affordable and public housing units, where Dugan says many residents may live with similar health conditions and care team members can see more patients in any given day.

"We have these housing sites where you have this efficiency of scale – you can get to a whole bunch of people with some similar challenges and needs and connect them with the services," Dugan says. "It's really about capitalizing on infrastructure that has already been invested in by the government."

Most SASH participants live in 138 affordable housing sites across the state, though Dugan says 10 percent to 20 percent live in mobile homes, single-family homes or other apartments.

Older adults in all types of housing have reported stronger overall functioning and less difficulty managing their medication. And though an independent review of the program's early years found that Medicare savings were insignificant in rural housing sites and compared with beneficiaries in other publicly assisted housing, it also found that Medicare cost growth was significantly slower in SASH panels run by Cathedral Square and those in Chittenden County , which is the state's most urban and populated area and encompasses Burlington.

The savings also were greater in connection with participants who were dually eligible for both Medicare and Medicaid.

Eldridge says the sample size for rural participants was too small to show statistically significant savings, and argues the review "doesn't mean (SASH is) not achieving its goals – it just means it's not saving money in Medicare."

Indeed, the review says SASH "has other potential benefits," noting improved physical functioning among participants and past research showing fewer hospitalizations among older residents in housing with "onsite service coordinators." And with about 162,000 residents in 2017, Eldridge says Chittenden County might be considered rural in other states where the model could be expanded.

"I'm working to get this to scale in urban areas with the hopes that we can achieve so much savings there," Eldridge says. "Most urban areas in this country have a higher volume of low-income seniors, and more density, which is so (different than) staff driving around the Northeast Kingdom in Vermont. It just saves time."

To help fund the SASH program, the Centers for Medicare and Medicaid Services – through the state's all-payer accountable care organization model – pays $68,600 for each of the 54 "panels" of about 100 participants. That accounts for care coordinators and part-time wellness nurses, but not the administrative work to oversee the program or track outcomes, Dugan says.

"You don't keep having good outcomes if you're not constantly monitoring quality," Dugan says.

Cathedral Square – which owns the housing sites that initially hosted SASH and now oversees its implementation by local housing authorities throughout Vermont – also receives support from the state and charitable organizations, but program leaders say securing sustainable funding poses an ongoing challenge for SASH and programs like it.

Still, advocates say they are moving in the right direction. In June 2017, Eldridge launched the National Well Home Network to expand the model at the state level, beginning with Rhode Island and Minnesota .

"The truth with all of these models is the devil is in the details in how they get implemented," says Robyn Stone, senior vice president of research at LeadingAge, a coalition of about 6,000 aging-services providers that has consulted for the SASH program.