healthy homes = healthy kids: housing advocacy strategies for medical providers
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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 CenterRobert Cole, Esq., Advocates for Basic Legal Equality, Inc.
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.
Overcrowding Behavioral consequences
Common Housing Conditions and their Health Impacts:
AsthmaMold, Pests, Carpeting,
High-Dry Heat
Mobility Disabilities Stairs
Sickle Cell, Asthma, InjuryInsufficient Heat
Lead Poisoning, Developmental Delays,
Behavior ProblemsLead Paint
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
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.
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.
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
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.
Percent of Children with Elevated Blood
Lead Levels* by County, Ohio 2007
Average Blood Lead Level By County, 2009
Age of Housing Units in the City of Toledo
High Risk Zip Codes, Lucas County
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.
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.
How do people apply for subsidized housing?
Project-Based Section 8 Apply at each complex. Contact management office for
hours and documentation needed. Subsidized housing lists available
from MLPC attorneys.
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: Overcrowding Utilities: gas, electric, water Housekeeping
Lead paint Pests Mold
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.
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.
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.
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.
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
Advocacy & 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
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.
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.
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.
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, cockroaches, pest droppings
Childhood 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
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
Childhood Asthma: An Approach to the Difficult to Manage Patient
1. Is it asthma? (R/O anatomic lesion, sinusitis, GER, or other)
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
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
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
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
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.
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
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.
Estimated Child Asthma Prevalence in Toledo Area Counties and Ohio, 2004
11.9
10.7
26.3
12.6
17.1
7.4
17.1
19.8
14.9
6.7 7.
4
17.2
7.2
11.9
11.9
7.4
17.2
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Estimated Current Asthma Prevalence by Income, Ohio & US, 2004
16.3 8.8 5.2 5.612.6 9.5 7.7 7.4 6.713.2024
68
1012
141618
<$15,000 $15,000-24,999 $25,000-34,999 $35,000-49,999 $50,000+
Income
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Ohio
US
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.
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.
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.
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.
Acknowledgments
Boston Medical Legal Partnership for Children
Toledo Lucas County Department of Health
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