Healthy Homes = Healthy Kids: Housing Advocacy Strategies for Medical Providers

1. Healthy Homes = Healthy Kids:Housing Advocacy Strategies for Medical Providers Dawn Bolyard, APN, Mercy Children’s Hospital Children’s Pulmonary Center Robert Cohn, MD, Mercy Children’s Hospital Children’s Pulmonary Center Robert Cole, Esq., Advocates for Basic Legal Equality, Inc. Date: June 20, 2012

2. Objectives • Recognize links between housing conditions and child health; • Screen patients for common housing issues: housing affordability, conditions of disrepair and utilities access; • Understand housing conditions issues as a public health problem; • Develop advocacy strategies to help families with housing related issues; • Understand the impact of engaging in systemic advocacy on the lives of patients.

3. Common Housing Conditions and their Health Impacts: Overcrowding Behavioral consequences Mold, Pests, Carpeting, High-Dry Heat Asthma Stairs Mobility Disabilities Insufficient Heat Sickle Cell, Asthma, Injury Lead Poisoning, Developmental Delays, Behavior Problems Lead Paint

4. Substandard housing conditions linked to public health • Substandard housing conditions are “intimately linked” with “three of the leading pediatric public health concerns”: • lead poisoning, • asthma and • household injuries. • Pediatrician and environmental health expert Megan Sandel, writing with a team of colleagues in 2004

5. Substandard Housing • Substandard housing is marked by poor indoor air quality, with mold, mildew, dust, and cockroaches. • all likely triggers for asthma attacks • The presence of a waste transfer station or bus depot in a neighborhood creates outdoor air pollutants which also may trigger attacks.

6. Asthma is the most common chronic illness among children. • Over twenty-two million people are afflicted with the disease in the United States. • This group includes over six million children, making asthma the most common chronic illness among children. • Considered an “epidemic” by the U.S. Department of Health and Human Services (DHHS), asthma kills over five thousand people in this country each year.

7. The prevalence and severity of asthma. • The problems that plague low-income communities of color all contribute to the prevalence and severity of asthma. • substandard housing, • environmental hazards, • inadequate health care access, • insufficient wages and lack of job opportunities

8. The prevalence and severity of asthma in low-income communities of color. • If racial segregation and its effects (substandard housing, environmental injustices, and lack of financial resources) exacerbate asthma, then the public health response to asthma must address these problems in order to reduce the prevalence and severity of asthma in low-income communities of color.

9. Percent of Children with Elevated Blood Lead Levels* by County, Ohio 2007

10. Average Blood Lead Level By County, 2009

11. Age of Housing Units in the City of Toledo

12. High Risk Zip Codes, Lucas County

13. Solutions and ResourcesSustainable Housing and Affordability • Subsidized Housing is available to families with income at or below 50% of local median income; • Types of Subsidized Housing • Conventional Subsidized Housing – Lucas County Metropolitan Housing Authority (LMHA) • Project Based Section 8 • Housing Choice Voucher Program (Section 8 voucher) • Family pays 30% of adjusted monthly income, 10% of monthly income, or $25.00 as rent.

14. How do people apply for subsidized housing? • Conventional Public Housing and Voucher Program • Apply at the Lucas County Metropolitan Housing Authority (LMHA) 211 S. Byrne; (419) 259-9448 • Conventional applications accepted: Mondays and Wednesdays, 9:00 a.m. to 12:00 p.m.First 50 people with all documentation can fill out applications. • Voucher pre-applications accepted periodically – watch for announcements.

15. How do people apply for subsidized housing? • Project-Based Section 8 • Apply at each complex. • Contact management office forhours and documentation needed. • Subsidized housing lists available from MLPC attorneys.

16. Substandard Housing Conditions • Habitable housing is a contractual and statutory obligation for both landlords and tenants. • Housing codes set minimum standards for healthy housing. • Common violations: • Lead paint • Pests • Mold • Overcrowding • Utilities: gas, electric, water • Housekeeping

17. What remedies do tenants have when housing is substandard? • Requests for repairs should be in writing. • Rent Escrow with the Court. • Terminate lease. • Transfer to another unit. • Assistance programs for landlords to remediate housing conditions problems. • Tenants should always seek legal advice before exercising self-help remedies.

18. When is Rent Escrow an option? • The landlord must have more than three rental units. • Often used when tenant has some kind of substandard housing condition, which was caused by or is the responsibility of the landlord such as pests, leaky pipes, holes in the floor or ceiling, lead, or mold.

19. What steps does the tenant need to take before the tenant files a Rent Escrow? • All of rent must be paid. • A written notice must have been sent to the place where rent is normally paid advising the landlord of what needs to be fixed or replaced. • The tenant has to give the landlord a reasonable time (generally 30 days) to remedy the problems. • Consult with an attorney before beginning this process.

20. Childhood Lead Poisoning • Studies have shown that blood lead levels as low as 5 ug/dL can cause cognitive deficits. • Childhood lead poisoning has been linked to: • Developmental delays; • Learning disabilities; • Anti-social behavior; • Lower IQ; • Hyperactivity; • Criminal Conduct.

21. Lead Screening • American Academy of Pediatrics Bright Futures Standards for Lead Screening • Recommending frequent lead screening for children at risk for lead exposure. • EPSDT screening requirements (Early and Periodic Screening, Diagnostic and Treatment Service) • Requires screening at 12 months and 24 months for all children covered by Medicaid • Nearly 60 % of children on Medicaid are not being screened for lead exposure

22. Advocacy and follow up for Lead Exposed Children • Referral to Help Me Grow for Early Intervention Services • Referral to MLPC • Monitor developmental milestones for future testing needs • Refer child for special education testing

23. Utility Shut-Offs • Depending on the lease agreement, the tenant or the landlord may be responsible for maintaining utility service. • If utility is shut off and landlord is responsible, emergency referral to MLPC should be made.

24. Utility Shut-Offs • If tenant is responsible for utilities: • Tenant can apply for energy assistance, contact EOPA: (419) 242-7304. • If utility is needed for family member for a medical reason, physician can complete a medical waiver request. • Valid to continue services for 30 days without payment. • Can only be used 3 times in any 12 month period. • Winter Reconnect Order issued by PUCO. • Winter moratorium on Utility Shut-offs. • Summer Crisis Program.

25. Reasonable Accommodations • Federal fair-housing laws require subsidized housing providers to consider reasonable accommodations requested by tenants. • Reasonable accommodations are requests that the landlord do something different for the tenant because of a mental or physical disability so the tenant can use and enjoy his or her housing. • Must show that there is a disability and that there is a link between the disability and the need for accommodation. • Request should be in writing • Refer theses cases to MLPC.

26. Home should be a place of refuge, a place where a child can be safe and healthy • For Children with asthma even the best of homes provide dangers to their overall health. However homes that are substandard can be a deadly combination when a child has asthma • Common triggers in homes include things like • Cat and dog allergen • Dust mites • Areas of water intrusion (Molds) • Poor ventilation and /or weatherization • Odors • Cockroach • Pest droppings

27. Child Hood Asthma Approximately 60% of asthmatics have an allergic component to their disease. We know that as IgE levels rise in a patient the risk of asthma increases. We also know that repeated exposure to an allergen increases IgE levels. Benjamin Burrows, et.al. N ENGL J MED 1989; 320:271-277

28. Benefits of a Healthy Home for the asthmatic child Children who live in a healthy environment: lead healthier lives, have less illness, have less school absenteeism and have a greater chance for economic improvement. Healthy homes saves dollars to society by : increasing the productivity potential for the child and the family. Decreases unnecessary ER and hospitalizations Impacts health of the child’s lungs as they grow decreasing morbidity and improving mortality

29. Childhood Asthma: An Approach to the Difficult to Manage Patient 1. Is it asthma? (R/O anatomic lesion, sinusitis, GER, other medical condition) 2. Adherence/Technique 3. Did they run out of medication and not realize it or not tell you? 4. Continual exposure (environmental, occupational, diet) 5. Refer or obtain second opinion from a specialist

30. Consider this Case 6 year old male suffered from uncontrolled asthma; high dose inhaled and p.o. steroids Frequent missed school days; mother’s ability to keep job threatened VNA home visit mold secondary to leaky water pipe; old wall to wall carpeting positive for dust mites Mother, nurse, physician asked landlord to fix pipe, clean mold and remove carpet – no response New specialist consulted Within 6 weeks child was symptom free; meds greatly reduced; perfect attendance in school

31. Outcome The Specialist was a lawyer; a new member of the healthcare team Attorney reviewed local and state sanitary housing code regulations Called and mailed a formal letter stating the family would seek redress in court if he didn’t comply Landlord immediately rectified the problems leading to the improvement in child’s symptoms

32. What you can do Ask What triggers are evident Evaluate the home environment for safety issues What deficits does the home have (improper heating, ventilation, cooling) Educate Trigger abatement Provide resources Letters for utilities/air conditioners Referrals to public agency for assistance MLP Advocate Patient specific Policy development and implementation

33. An example of systemic advocacy Cuyahoga County Healthy Homes initiative Multidisciplinary, collaborative coalition that joined healthy homes and the asthma coalition to create a healthier environment for people who live in public housing Included infants under one year, elderly over 65 years and any one with the diagnosis of asthma Provided a comprehensive, integrated evaluation of the home for safety and environmental issues with in the home Patient identified in clinic by physician as living in a potentially unhealthy home, clinic physician, sanitarian, building inspector, nurse went to the home and did the evaluation of the home. Made recommendations to improve the homes environment Replaced, removes, improved existing home to eliminate health hazard and move the home to a more sustainable, green living environment.

34. Why involve the physician in the visit? Participants reported: Better able to identify patients who may be living in substandard housing (increased Awareness) Increased physician knowledge about what dangers patients faced in the home by seeing it first hand. Improved care by training physician on what to ask in the office about home environment. Increased awareness of importance for education and empowerment of patients they served Increased awareness of need for collaboration and advocacy for this patient population

35. Other project outcomes 52% reduction in lead exposure Creation of faith based hubs that are educating the people in the communities about the importance of a healthy home and how to advocate for themselves to attain that goal.

39. Collaboration between health practitioners and lawyers. Asthma is a public health problem that is profoundly affected by environment and financial resources and thus disproportionately affects low-income communities of color. Given the nature of this disease, community members, public health officials, medical professionals, and lawyers have good reason to come together to tackle asthma as an issue of justice.

40. Innovative collaborations between health practitioners and lawyers can be developed to serve the broad needs of asthma sufferers. Collaborative efforts should be expanded and replicated. Housing, government benefits, environmental justice, and disability rights laws can serve as the focus of these collaborative efforts.

41. Collaborate to challenge the effects of racial and socioeconomic injustice. Public health officials, medical practitioners, hospitals, lawyers, and community advocates can collaborate to challenge the effects of racial and socioeconomic injustice that contribute to severe asthma in low-income communities of color.

42. Advocacy Tips • Document unhealthy housing conditions. • Advise patient to notify the landlord in writing of conditions problems and to continue paying rent. • Write a letter to landlord on behalf of patient. • Advise patient to apply for subsidized housing and utility assistance. • Speak out about public health issues • Get involved in systemic advocacy initiatives and advocate for meaningful programming and policy reforms at the local, state and national level. • Make a referral to the MLPC.

43. Acknowledgments • Boston Medical Legal Partnership for Children • Toledo Lucas County Department of Health