Housing as a Vaccine: How A Stable Affordable Home is a Prescription for Good Health

1. Housing as a Vaccine: How A Stable Affordable Home is a Prescription for Good Health Megan Sandel MD MPH October 2018

2. Roadmap • Dimensions how Homes affect Health • Quality, Stability, Affordability, Location • How a Home can it be like a Vaccine • Homes and People (Population Health) • How Can Healthcare and Housing Exchange Value • Homes as a route to Health Equity

3. Evidence on HomeQuality • Accidents/Injuries – exposed wiring, needed repairs • Development and worsening asthma, allergies tied to home • Pests (cockroaches and mice) • Molds/Chronic Dampness • Tobacco smoke • Lead exposure tied to long term effects • Developmental delay, Attention deficit • Heat or eat Skinner et al,2014

4. Home Quality and Mental Health • Poor housing quality strongest predictor of emotional and behavioral problems in low-income children • Much of association between poor housing quality and children’s wellbeing operates through parental stress, parenting behaviors and mental health

5. Stability: The Home Iceberg HOMELESS HIDDEN HOMELESS: HOUSING INSECURE • Multiple moves • Overcrowded • Doubled Up UNAFFORDABLE HOUSING

6. Exploring three forms of unstable housing with caregiver and child health • Among 22,234 families, 34% had at least one adverse housing circumstance: • 27% behind on rent • 8% multiple moves • 12% history of homelessness • Each circumstance individually associated with adverse health and material hardship compared to stable housing Pediatrics Feb 2018

7. Little overlap among three adverse housing conditions Most families were renters and behind on rent and impacted health Pediatrics Feb 2018

8. Outcomes of unstable housing with health and material hardship outcomes Sandel et al Pediatrics Feb 2018

9. Location: Poverty and Zip code remain linked

10. Place, Opportunity, and Health Mapping elevations in the blood pressure of 3 years olds by Child Opportunity Index from diversitydatakids.org Vital Village Network at Boston Medical Center maps relationship between opportunity and life course (elevated BP at age 3)

11. Public Health 101 – Vaccine Review Why vaccinate? • Personal protection • “Herd immunity” • Community and economic benefit

12. Kids in Food Insecure Families were TWO FOLD less likely to be underweight if they had a housing subsidy than similar kids who were eligible but did not receive a subsidized home

13. For Healthcare costs alone, it did not save money, but cost $2 per chicken pox case prevented. But by societal costs, every $1 invested in vaccines saved $5 including work-loss costs

14. How Should Population Health be Defined? Population by Housing Risk How Healthcare Alone Looks at Risk Trade high-cost services for low-cost management Homelessness Addressed Avoid unnecessary, higher-acuity, higher-cost spending Housing Instability Addressed Keep patient healthy, loyal to the system No Need Addressed

18. A pilot program for high risk patients is an example of new care models to improve health outcomes but social determinants remain key Of 50 patients enrolled in Care Management between Dec 2016 and May 2017: Inpatient stays 3 months pre/post intervention, n=20 Recent or current homelessness: 47% Heart Failure: 49% Substance use disorder: 38% Average age: 57 Mental health condition: 79% Pre Post

19. We have identified the Roxbury and North Dorchester areas of Boston where community investments may have the most impact to our patients given the concentration of high cost high need patients there Among the top 3% of patients with the highest hospital charges, the top 5 zip codes are in our neighborhoods of interest: Roxbury/South End 02119, 02118 Dorchester 02124, 02121, 02125

20. Our Housing Intervention is tied to Boston neighborhoods to maximize Community Health Improvement Pine St Inn Boston Medical Center Dudley Square Madison & NuestraComunidad Franklin Field The Community Builders Fields Corner Codman Sq NDC

21. We are investing $6.5M in housing initiatives in Boston’s most underserved neighborhoods. Our first venture into housing is a key opportunity to partner with our community and impact population health Funding Partners • This fall, we innovatively guided Determination of Need obligated funding towards housing. • We aim to support housing and wrap-around services our patients and use Community Investment Tax Credits to stretch dollars. • We plan to test multiple approaches and have devoted $0.65M to evaluation and oversight to determine the best approach. • We look forward to working with other Boston hospitals to make similar investments and work collaboratively to improve community health. • Housing Project Investments $2.2M • Housing Support Service $0.9M • Hybrid Housing Project Investment $1.3M • Community Engagement & Housing Stability $1.7M • Social Impact Fund $0.5M

22. Market that Values Homes for Health* *Acknowledging David Erickson “Marketplace that Values Health” • Healthcare Sector Pain Point • Unstably housed patients cost $ • What is the Housing Sector’s Pain Point • Can we find a cure?

23. What is the Housing Sector’s Pain Point? • Capital • To Build New Units • Renovate existing housing stock • Capital to assist retail on the first floor • Money to cover resident services • Operating subsidies

24. What Value Does the Housing Sector have? Cutts et al. MCH, 2014. • Units • New construction • Renovation • Turnover • Proven Method of Addressing Chronic Homelessness • Onsite residential services • Monitoring • Link with medical case management • Wellness (Health, Financial)

25. What Value does the Healthcare Sector have? Cutts et al. MCH, 2014. • Money • Provider (ACO)/Insurance • Community Benefit • Investment portfolio • Political capital • Services dollars • Case management • Community Health Workers • Health/wellness

26. How Could the Two Sectors Exchange Value? Cutts et al. MCH, 2014. • Set aside units for investment (new units/preservation/upgrades) • Fair Housing Waiver • Units for High Utilizers • Investment portfolio invests capitol • Set aside units for services dollars • Fair Housing Waiver • Units for High Utilizers • On site resident services paid for

27. How Could the Two Sectors Exchange Value? • Set aside units for investment in broader development • Fair Housing Waiver • Units for High Utilizers • Patient capitol for healthy retail on first floors • Flex funds for rent with landlords • Pool of funds for rent • Units for High Risk populations • Resident services paid for by Healthcare

28. What Could This Look Like in Action • Healthy Start in Housing • Housing insecure, high risk pregnant/ parenting families, child <5 with complex condition requiring specialty care • Secure and retain housing to • improve birth outcomes • improve the health and well-being of women and families • Provision of housing by public housing • Intensive case management: housing retention, engagement in services, family development plan paid for by health sector Boston Public Health Commission & Boston HousingAuthority

29. Neudorf C, Kryzanowski J, Turner H, et al. (2014). Better Health for All Series 3: Advancing Health Equity in Health Care. Saskatoon: Saskatoon Health Region. Available from: https://www.saskatoonhealthregion.ca/locations_services/Services/Health- Observatory/Pages/ReportsPublicatlions.aspx