Housing and Health

1. Housing and Health David Fukuzawa Laurie Stillman James Krieger Rishi Manchanda GIH March 8, 2012

2. Questions • What are effective strategies for improving housing that link clinical and community approaches? • How can funders support and sustain efforts to address upstream factors like housing?

3. At the Intersection of Health Care and Social Determinants of Health, The Current Standard of Care Isn’t Good Enough

4. Current Standard of Care Photo taken with permission SocHx: Damp, Moldy Home Dx: Migraines/ Sinus Headaches + Allergic Rhinitis Tx: Symptom relief + Housing Case Management • 33 year old uninsured woman presents with 4 week history of severe throbbing frontal headaches. • 3 visits to emergency room at 2 different hospitals in last 3 wks • 2 Head CTs • 1 Lumbar Puncture • Blood tests… “all normal” You have 10 minutes

5. The Problem: Unhealthy social conditions drive disease and health disparities, costing Americans over $400 billion/year. People who bear the burden of these unhealthy conditions often interact with the health care system. But 4 out of 5 physicians don’t feel equipped to address their patients’ social needs. Challenge: Can we treat people while changing the conditions that make them sick?

6. Towards a Higher Standard of Care Photo taken with permission Redesign Care to Change the Conditions that make People Sick Earn and Redeem Rewards Learn ways to support healthier communities

7. Housing and Health Housing is linked to: Asthma Allergies Lung Cancer Injuries Mental Health Brain Development Respiratory Infections

8. Housing Hazards • Biological agents • allergens, mold • Toxics • lead, secondhand smoke, carbon monoxide, radon, asbestos, VOCs, etc. • Temperature extremes • Injury hazards • Crowding

9. Housing Conditions • Ventilation • Energy efficiency • Structural integrity • Sanitation and plumbing • Siting • Building materials

10. Asthma Triggers • Dust Mites • Mold • Secondhand Smoke • Rodents • Cockroaches • Irritant Chemicals • Pets

11. Significant Exposure to AllergensUS Homes Natl Survey of Lead and Allergens in Housing

12. Health Impact Pyramid What does this mean in terms of our work to make homes and people healthier? by Thomas Frieden

13. Healthy Homes:Home visits for asthma

14. Home Visits Community Health Workers make 3-5 visits over one year Asthma self-management skills Home environment assessment and trigger reduction Provide asthma trigger control resources Provider-patient communication

15. Healthy Homes Outcomes Urgent Care Use • Symptoms decease by 21 days per year • Urgent health care use decreases 40-70% • Caretaker knowledge and actions increase • Exposure to triggers decreases • Return on Investment:5.3 – 14.0

16. CDC Community GuideMeta-Analysis The Task Force recommends: The use of home-based multi-component, multi-trigger environmental interventions In children with asthma On the basis of strong evidence of effectiveness in Reducing symptom days, Improving quality of life or symptom scores, Reducing the number of school days missed. Return on investment: 5.3-14.0

17. The Limits of Home Visits

18. Breathe Easy Homes Old Housing New Breathe Easy Home

19. 60 Breathe Easy units for children with asthma at High Point Public Housing site

20. Breaths Easy Homes Outcomes • Symptoms decrease by 0.8 days/2 wks more in BEH group • Urgent health care use decreases more • Quality of Life measure improvement no better • No statistically significant differences across groups

21. Moving Clinicians Towards Higher Standard of Care Photo taken with permission Redesign Care to Address Slum Housing Earn and Redeem Rewards Learn ways to support healthier communities www.healthbegins.org

22. Equip Clinics to Change the Conditions that make Patients sick Identify Local Social Determinants & Population Identify Local Resources Adapt Clinic Screening & Linkage Systems Care Team Training and Intervention Evaluation Activities Community Health Detailing -EMR 2.0 -Geomapping -Mobile apps/ Social Network Perf.Impr CME/Webinar In-Service Data Analytics Geomapping CBPR Tools CME /CEUs/ Career Development Cash Time-credit and cashless incentives Discounts Recognition Incentives Outcomes Higher Quality Care, Satisfied Team-Based Workforce, Lower Costs, Improved Health

23. Courtesy: Andrew Curtis, Dept of American Studies & Ethnicity, USC Geomapping Tailored Social Screening in EMR

24. Tiers of Health Care Setting Interventions on the Social Determinants of Health • III. Hospital/Clinic influences policy and programming interventions outside hospital • Lobby for increased cigarette taxes • Promote healthier benefits food packages • Advocate for local street re-design III. General Population-Level • II. Hospital/Clinic promotes interventions directed towards hospital population • Provide on-site Farmer’s Markets (Kaiser) • Offer physical activity subsidies or programs for members (eg on-site gym) II. Clinic Population-Level • I. Hospital/Clinic incorporates interventions directed towards individuals • CHWs do home safety/health assessments • Medical Assistants refer food insecure patients to county benefits programs • Clinic provides free legal services • to patients with legal needs I. Patient-Level Source: L.Gottlieb, HealthBegins

25. Improve Public Health Healthy Homes Strategic Planning Mission Goal Objectives Goal Objectives Goal Objectives Strategies

26. Pre-planningBuilding Relationships and Common Understanding

28. Can the Patient-Centered Medical Home Improve Health Where it Begins? • May improve biomedical care, but may not be enough to improve population health or bend cost curve • 2014: 32 million newly insured Americans with disproportionately higher social needs may not get the care they need • Limited Data, funding and reimbursement mechanisms to support clinic-integrated ‘evidence-based health’ interventions (vs ‘evidence-based medicine’ interventions) • Enabling Services are inadequately evaluated, funded, and costs are rising • Few structural incentives to integrate and coordinate public health interventions and medical care

29. Questions • What are effective strategies for improving housing that link clinical and community approaches? • How can funders support and sustain efforts to address upstream factors like housing?