Housing and Health

David FukuzawaLaurie StillmanJames KriegerRishi Manchanda

GIHMarch 8, 2012

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?

At the Intersection of Health Care and Social Determinants of Health,

The Current Standard of Care Isn’t Good Enough

SocHx: Damp, Moldy HomeDx: Migraines/ Sinus Headaches + Allergic Rhinitis Tx: Symptom relief + HousingCase Management

SocHx: Damp, Moldy HomeDx: Migraines/ Sinus Headaches + Allergic Rhinitis Tx: Symptom relief + HousingCase Management

Current Standard of Care

• 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

Photo taken with permission

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?

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

Housing and Health

Housing is linked to:

Asthma

Allergies

Lung Cancer Injuries Mental Health Brain Development Respiratory

Infections

Housing Hazards

• Biological agents allergens, mold

• Toxics lead, secondhand smoke,

carbon monoxide, radon, asbestos, VOCs, etc.

• Temperature extremes• Injury hazards• Crowding

Housing Conditions

• Ventilation• Energy efficiency• Structural integrity• Sanitation and plumbing• Siting• Building materials

Asthma Triggers

•Dust Mites

•Mold

•Secondhand Smoke

•Rodents

•Cockroaches

• Irritant Chemicals

•Pets

Significant Exposure to AllergensUS Homes

56.2

10.2

42.2

35.5

43.4

34.6

0

10

20

30

40

50

60

Mold Roach Dog Mite Cat Mouse

per

cen

t h

om

es

Natl Survey of Lead and Allergens in Housing

Health Impact Pyramid

by Thomas Frieden

What does this mean in terms of our work to make homes and people healthier?

Healthy Homes: Home visits for asthma

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

Healthy Homes Outcomes

• 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 0

5

10

15

20

25

30

high intensity low intensity

% w

ith

1+

ep

iso

de

s

Urgent Care Use

CDC Community Guide Meta-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

The Limits of Home Visits

Old Housing

New Breathe Easy Home

Breathe Easy Homes

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

Breaths Easy Homes Outcomes

61.8

48.5

20.6 22.1

0

10

20

30

40

50

60

70

BEH HH-II

per

cen

t ac

ute

car

e in

3 m

os

• 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

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

Equip Clinics to Change the Conditions that make Patients sick

Activities

CME /CEUs/ Career DevelopmentCashTime-credit and cashless incentivesDiscountsRecognition

Incentives

Tools

Identify Local Social Determinants & Population

Care Team Training and Intervention

EvaluationIdentify Local Resources

Community Health Detailing-EMR 2.0-Geomapping-Mobile apps/ Social Network

Adapt Clinic Screening & Linkage Systems

Outcomes Higher Quality Care, Satisfied Team-Based Workforce, Lower Costs, Improved Health

Perf.ImprCME/WebinarIn-Service

Data AnalyticsGeomappingCBPR

Tailored Social Screening in EMR

Geomapping

Courtesy: Andrew Curtis, Dept of American Studies & Ethnicity, USC

Tiers of Health Care Setting Interventions on the Social Determinants of Health

III. General Population-Level

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

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. Patient-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

Source: L.Gottlieb, HealthBegins

Mission

GoalObjectives

GoalObjectives

GoalObjectives

GoalObjectives

StrategiesStrategies

GoalObjectives

GoalObjectives

Healthy Homes Strategic Planning

Pre-planningBuilding Relationships and Common Understanding

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

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?