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Housing and Health David Fukuzawa Laurie Stillman James Krieger Rishi Manchanda GIH March 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 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 SocHx: Damp, Moldy Home 1 Lumbar Puncture Dx: Migraines/ Sinus Blood tests… “all normal” Headaches + Allergic Rhinitis Photo taken with permission You have 10 minutes Tx: Symptom relief + Housing Case Management 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 Allergens US Homes 60 56.2 50 43.4 percent homes 42.2 40 35.5 34.6 30 20 10.2 10 0 Mold Roach Natl Survey of Lead and Allergens in Housing Dog Mite Cat Mouse Health Impact Pyramid What does this mean in terms of our work to make homes and people healthier? by Thomas Frieden 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 Care Use 30 • Urgent health care use decreases 40-70% • Exposure to triggers decreases • Return on Investment: 5.3 – 14.0 % with 1+ episodes • Caretaker knowledge and actions increase 25 20 15 10 5 0 high intensity low intensity 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 Breathe Easy Homes Old Housing New Breathe Easy Home 60 Breathe Easy units for children with asthma at High Point Public Housing site Breaths Easy Homes Outcomes 70 61.8 percent acute care in 3 mos 60 48.5 50 40 30 22.1 20.6 20 10 0 BEH HH-II • 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 Tools Incentives Identify Local Social Determinants & Population Identify Local Resources Adapt Clinic Screening & Linkage Systems Community Health Detailing -EMR 2.0 -Geomapping -Mobile apps/ Social Network Care Team Training and Intervention Evaluation Perf.Impr CME/Webinar In-Service Data Analytics Geomapping CBPR CME /CEUs/ Career Development Cash Time-credit and cashless incentives Discounts Recognition Outcomes Higher Quality Care, Satisfied Team-Based Workforce, Lower Costs, Improved Health Courtesy: Andrew Curtis, Dept of American Studies & Ethnicity, USC Geomapping Tailored Social Screening in EMR Tiers of Health Care Setting Interventions on the Social Determinants of Health III. General Population-Level II. Clinic Population-Level I. Patient-Level Source: L.Gottlieb, HealthBegins 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) 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 Healthy Homes Strategic Planning Mission Goal Goal Goal Objectives Objectives Objectives Strategies Pre-planning Building 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?