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Service Delivery Innovation Profile

Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health

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The Cathedral Square Support and Services at Home program provides onsite assistance to help senior citizens (and other Medicare beneficiaries) remain in their homes as they age. Using evidence-based practices, key services include an initial assessment by a multidisciplinary onsite health team, creation of an individualized care plan, onsite nursing and care coordination with team members and other local partners, and community activities to support health and wellness. In a year-long pilot test with 65 residents, the program reduced hospital admissions and readmissions, had no bounce backs to nursing homes, decreased falls, improved nutritional status, and increased levels of physical activity.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of inpatient admissions, readmissions, falls, nutritional status, and physical activity levels among 65 residents participating in a year-long pilot test of the program.
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Developing Organizations

Cathedral Square Corporation
Burlington, VTend do

Date First Implemented

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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Insurance Status > Medicare; Age > Senior adult (65-79 years)end pp

Problem Addressed

A large, growing number of older adults have physical and mental limitations and hence require assistance with activities of daily living. To age successfully at home, these individuals need a range of support services, but state funding cuts often make these services difficult to access for low-income seniors.
  • Large, increasing number of older adults who need assistance: By 2030, more than 70 million Americans will be age 65 or older, twice the number in 2000.1 Currently, about 42 percent of those over age 65 have physical limitations or need assistance with activities of daily living, such as eating, bathing, or dressing.2 Many also have cognitive limitations and hence need assistance with activities such as medication management. Cathedral Square conducted resident assessments in several of its 20 independent housing buildings, finding that only 47 percent of residents could pass a cognitive screening test, 37 percent had fallen in the past year, and 50 percent took six or more medications.
  • Need for medical and social services to remain at home: To age successfully at home, these older adults often require a range of supportive services, such as home health care, homemaker services, transportation, respite care, and home-delivered meals.3
  • Limited access for low-income seniors: Drastic reductions and in some cases elimination of state-funded programs have significantly reduced access to needed support services for low-income adults and their caregivers.3 Historically, these state programs have provided critical services not covered by Federal support programs.

What They Did

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Description of the Innovative Activity

The Cathedral Square Support and Services at Home program provides onsite assistance to help senior citizens (and other Medicare beneficiaries) remain in their homes as they age. Implemented in one of its affordable housing communities, the nonprofit employs a full-time coordinator and part-time wellness nurse who work with a multidisciplinary onsite health team to implement the program. Together, they provide care coordination, wellness education and coaching, and transitions support after a stay at a hospital or rehabilitation facility. Using evidence-based practices, key services include an initial assessment by the health team, creation of an individualized care plan, monitoring by the onsite care coordinator and wellness nurse who link residents to services offered by team members and other local partners, and community activities to support health and wellness. Key elements of the program include the following:
  • Enrollment and initial interview: As part of the enrollment process, the program coordinator interviews each resident to explain the program. The coordinator asks residents if they would like family members to participate in any aspect of the planning process. When family members do participate, residents sign a consent form in compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations, as with other situations when information is shared with partner agencies.
  • Assessment by master’s-level wellness nurse: Using a modified version of the state’s Independent Living Assessment Tool used by Medicaid, the nurse conducts a 2-hour functional and cognitive assessment in the resident’s home. The assessment tool includes a complete list of medications taken, along with a nutrition screen, depression screen, and cognitive screen.
  • Customized healthy aging plan: A multidisciplinary team (including an acute care nurse, case manager, intake nurse, mental health provider, and representatives of other home- and community-based service providers in the area) develops the plan. Using the individual’s assessment data, the care coordinator helps the resident refine the plan by identifying specific health-improvement goals that he or she wants to pursue, such as losing weight, getting more exercise, or eating a more nutritional diet. As part of the program, the team provides specific guidance and coaching to help the resident meet those goals.
  • Ongoing care/service coordination: The onsite care coordinator monitors residents' well-being and helps them adhere to their aging plans. Other employees within the housing community (e.g., property managers, custodians, resident services coordinators, activity directors) support the program by alerting the care coordinator if they notice changes in the health or functional status of a resident. Examples of specific tasks undertaken by the care coordinator include the following:
    • Scheduling appointments with wellness nurse: A part-time wellness nurse visits ill residents in their homes to monitor vital signs, support adherence to their medication regimen, and address specific health needs. The nurse works in collaboration with the senior's local providers in the community.
    • Arranging for needed services, especially after an acute stay: The care coordinator works with local partners to arrange for any services a resident might need, such as transportation to a medical appointment, an appointment with a mental health provider, intensive care management from an area agency on aging case manager, or home visits from a visiting nurse. As part of this effort, the coordinator pays particularly close attention to those residents transitioning home after an inpatient or rehabilitation facility stay, especially those living on their own. The coordinator generally has access to the resident's discharge plan from the facility, and knows what type of support the resident may need during those critical days after returning home (a period when many readmissions occur).
  • Monthly team meetings focused on high-risk residents: The program team meets for 2 hours twice a month to discuss residents' general health and information needs, as well as the specific needs of high-risk residents. As the team members who often care for these high-risk residents, the visiting nurse and area agency on aging case manager typically follow up on any recommendations for needed interventions and services.
  • Community education and wellness activities: The program team aggregates information from all resident assessments to create a healthy aging plan for the entire community, with a focus on general wellness education and coaching. Programs typically cover five key areas: preventing falls, managing medications, controlling chronic conditions, improving health-related lifestyle behaviors, and managing cognitive and mental health issues. For example, the team introduced a building-wide program called “Eat Less, Move More” after assessment data showed that many residents ate poorly (thus putting them at risk of inadequate nutritional status) and did not get regular exercise. The care coordinator oversees these wellness programs, which are often implemented with help from community volunteers.
  • Information technology support: Program participants agree to have their health-related information shared on an as-needed basis with members of the onsite health team, along with designated family members and service providers. To share information efficiently, team members currently enter and retrieve data through a database that can create a variety of reports. Information provided in May 2012 indicates the health assessment data is currently being entered into Vermont's Central Clinical Registry. A wellness nurse conducts the assessment at a participant's home, and the data is immediately stored in the Central Registry, making it easier to evaluate results across sites.

Context of the Innovation

Founded as a ministry of the Cathedral Church of St. Paul in 1977, Cathedral Square Corporation is a nonprofit organization that owns and manages properties for seniors and individuals with special needs. In 2005, Cathedral Square leaders began working with other Vermont housing providers, state legislators, and LeadingAge (formerly the American Association of Homes and Services for the Aging) to develop a model to allow employees of nonprofit housing organizations and public housing authorities to help residents access needed medical and social services without becoming trained medical providers. To that end, the nonprofit's leaders obtained funding to design, test, and refine a "housing with services" model program. (See the Planning and Development Section below for more details.)

Did It Work?

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In a pilot test with 65 residents, the program reduced hospital admissions and readmissions, decreased falls, improved nutritional status, and increased levels of physical activity among residents.
  • Fewer admissions and readmissions: During the first year after implementation, inpatient admissions among the 65 residents fell by 19 percent (21 admissions the year before implementation, 17 admissions a year later). In addition, no resident discharged from the hospital during the year after implementation was readmitted and there were no bounce backs to nursing homes.
  • Fewer falls: The number of residents experiencing falls declined by 22 percent in the first year after implementation (30 resident falls the year before implementation, 16 resident falls a year later).
  • Better nutritional status, more physical activity: The number of residents at moderate nutritional risk fell by 19 percentage points (46 at-risk residents the year before implementation, 34 a year later) while the number of physically inactive residents fell by 10 percentage points during the first year after implementation.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of inpatient admissions, readmissions, falls, nutritional status, and physical activity levels among 65 residents participating in a year-long pilot test of the program.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Identifying problem: As noted in the Problem Addressed section, Cathedral Square conducted resident assessments in several buildings that identified many residents with cognitive issues, complex medication regimens, and other issues that put them at risk of falls, inpatient admissions, and other acute problems.
  • Networking with partner organizations: Cathedral Square leaders networked with other housing providers and stakeholders to identify ways that providers of affordable housing could support the health and safety of residents. Partner organizations included those providing acute care, long-term care, affordable housing, and mental health services. Additional partners from academic institutions also contributed to the model design.
  • Obtaining funds and designing model: In addition to its own contributions to program development, Cathedral Square applied for funding to design and pilot test a housing-with-services model program. They obtained funds from the Vermont legislature, the Vermont Health Foundation, and the MacArthur Foundation to work with partner organizations to design and test a model that would reduce avoidable costs to Medicaid and Medicare, provide essential services to housing residents who wanted to age in place, and be replicable elsewhere. Partners included five nonprofit and public housing providers representing all regions of the state.
  • Selecting test site and enrolling participants: Cathedral Square leaders decided to test the program in the company's Heineberg Senior Housing facility, which provides affordable housing for seniors in an apartment building setting. To obtain participation, Cathedral Square leaders posted and distributed flyers and held meetings with residents. In July 2009, 65 residents agreed to participate in a pilot program for 1 year to help refine the housing-with-services model. Information provided in May 2012 indicates that as of April 2012, programs have begun in 10 of Vermont's 14 counties. Currently, Support and Services at Home (SASH) is offered at 57 nonprofit affordable housing communities and is scheduled to expand to 150 sites in all counties in 2013.
  • Creating local program team: Cathedral Square hired a program coordinator and wellness nurse and, along with its partners, identified local service providers to participate on the program team (onsite health team).
  • Informing and educating housing facility employees: As part of program planning, the care coordinator introduced the program to housing facility employees at an all-staff meeting, providing an opportunity for them to ask questions and raise topics of concern. To give the message that every employee has a role to play, the program is on the agenda of every all-staff meeting and open for discussion at all times. For example, at a recent training on conflict resolution, maintenance staff raised the issue of not knowing whether to share information with the care coordinator when they observe questionable behavior of a resident. This enabled program staff to explain how staff can and should communicate concerns respectfully and on a “need to know basis.”
  • Establishing goals for measuring success: As part of the planning process, program leaders identified the need for future implementers to measure the program's impact on four areas: process, health status, resident satisfaction, and cost.
  • Securing funding for statewide expansion: Based on the success of the pilot study and the projected savings that could be achieved from wide-scale replication, the program was included as part of an application from the Vermont Blueprint for Health to the Center for Medicare and Medicaid Services' (CMS) Multi-Payer Advanced Primary Care Practice Medicare Demonstration program. (The Blueprint for Health is Vermont's health care reform initiative to increase access to affordable health care for all residents.) CMS approved the application, thus giving Vermont funding to expand the program to over 100 subsidized housing sites over a 3-year period.
  • Meetings with advisory group: Program developers created an advisory group called the Local Table to provide support and track program progress. The group, which meets periodically throughout the year, includes representatives of regional organizations, such as the hospital, home health, Area Agency on Aging, United Way agencies, mental health agencies, religious groups, colleges, and nursing homes.

Resources Used and Skills Needed

  • Staffing: During the pilot year, Cathedral Square had the equivalent of 2 full-time equivalents (FTEs) working on the program. They included a full-time coordinator, a part-time wellness nurse at 16 hours per week, an administrative assistant who provided administrative and information technology support at 8 hours per week, and the executive director of Cathedral Square who spent 50 to 75 percent of her time on program-related activities. When the program is implemented through the Multi-Payer Advanced Primary Care Practice Medicare Demonstration program, each site will receive funds for a full-time coordinator and 10 hours a week for a wellness nurse for every 100 person panel of program participants.
  • Costs: The administrative costs for each housing facility to implement the program average roughly $20,000. Staff funding through the multi-payer program will be based on a general ratio of 100 participants x $700/year = $70,000 to cover the full-time coordinator and a 0.25 FTE wellness nurse. This budget is based on $24/hour salary/benefits for a coordinator and $35/hour salary/benefits for a wellness nurse.
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Funding Sources

MacArthur Foundation; Vermont General Assembly; Vermont Health Foundation; Vermont Community Foundation; United Way of Chittenden County; J. Warren and Lois McClure Foundation; Amy E. Tarrant Foundation; Cathedral Square Corporation
In addition to these major funders, Cathedral Square obtained small grants from local foundations to support program design and testing. While the care coordinator and nurse are paid by Cathedral Square, the CMS' approval of the Multi-Payer Advanced Primary Care Practice Medicare Demonstration program application means that CMS will reimburse for their services going forward.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Conduct needs assessment: Would-be adopters should assess the number of seniors living in affordable housing communities who could benefit from this type of program. Factors to consider include not only the size of the population, but also their level of physical and cognitive functioning and in-home service needs, along with the availability of local service providers to provide in-home care.
  • Gauge stakeholder support: Would-be adopters should assess the level of support among key stakeholders, including the state legislature, to integrate this model into elder care initiatives. As previously discussed, Cathedral Square worked closely with members of Vermont’s legislature and other stakeholders to develop and test the program.
  • Investigate legal and licensing issues: State law and licensing issues may have an impact on the ability of housing facility employees to provide certain services to senior residents. Would-be adopters should investigate these laws and regulations and work with appropriate authorities to ensure that the proposed program complies with all relevant statutes.
  • Consider small-scale pilot test: A small-scale pilot test can be used to prove to key stakeholders that the program can improve health outcomes and reduce costs.
  • Develop business case, approach funders: Results from the pilot test can be used to create a broader business case for the program. For example, after completing the successful pilot, Cathedral Square estimated potential cumulative savings to Medicare, net of program costs. Armed with this information, Cathedral Square leaders were able to convince Vermont Blueprint for Health leaders to include the program in its application to CMS, which ultimately led to the securing of funds that will allow for widespread replication of the program.

Sustaining This Innovation

  • Continue monitoring, reporting on program impact: To sustain support, implementers need to monitor and document the program's impact on key health outcomes over time, such as admissions, readmissions, falls, nutritional status, levels of physical activity, and the ability of residents to self-manage their health conditions and adhere to their medication regimen.
  • Plan for expansion: Expanding the program requires careful planning and documentation. During the year-long pilot test, Cathedral Square worked closely with five nonprofit and public housing providers throughout the state to make sure the program could be replicated on a larger scale. This work resulted in the development of planning and procedures documents that will be used to guide program expansion and implementation.

More Information

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Contact the Innovator

Nancy Rockett Eldridge
Executive Director
Cathedral Square Corporation
412 Farrell Street
South Burlington, VT 05403
Phone: (802) 863-6566
Fax: (802) 863-6661

References/Related Articles

More information about the program is available at:

A case study of the program is available at:
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

To learn more about aging in place and other aging issues, see:


1 U.S. Census Bureau. National Population Projections, 2008. Available at:
2 Older Americans 2010: Key indicators of Well-Being. Federal Interagency Forum on Aging-Related Statistics. December 2010. Available at:
3 Policy Priorities 2011. Promote the Health, Security and Well-Being of Older Adults. National Association of Area Agencies on Aging. March 2011. Available at:
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 07, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 16, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 15, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.