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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?
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