housing and health david fukuzawa laurie stillman james krieger rishi manchanda gih march 8, 2012
TRANSCRIPT
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Housing and Health
David FukuzawaLaurie StillmanJames KriegerRishi Manchanda
GIHMarch 8, 2012
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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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At the Intersection of Health Care and Social Determinants of Health,
The Current Standard of Care Isn’t Good Enough
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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
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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?
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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
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Housing and Health
Housing is linked to:
Asthma
Allergies
Lung Cancer Injuries Mental Health Brain Development Respiratory
Infections
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Housing Hazards
• Biological agents allergens, mold
• Toxics lead, secondhand smoke,
carbon monoxide, radon, asbestos, VOCs, etc.
• Temperature extremes• Injury hazards• Crowding
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Housing Conditions
• Ventilation• Energy efficiency• Structural integrity• Sanitation and plumbing• Siting• Building materials
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Asthma Triggers
•Dust Mites
•Mold
•Secondhand Smoke
•Rodents
•Cockroaches
• Irritant Chemicals
•Pets
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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
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Health Impact Pyramid
by Thomas Frieden
What does this mean in terms of our work to make homes and people healthier?
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Healthy Homes: Home visits for asthma
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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
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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
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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
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The Limits of Home Visits
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Old Housing
New Breathe Easy Home
Breathe Easy Homes
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60 Breathe Easy units for children with asthma at High Point Public Housing site
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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
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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
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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
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Tailored Social Screening in EMR
Geomapping
Courtesy: Andrew Curtis, Dept of American Studies & Ethnicity, USC
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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
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Mission
GoalObjectives
GoalObjectives
GoalObjectives
GoalObjectives
StrategiesStrategies
GoalObjectives
GoalObjectives
Healthy Homes Strategic Planning
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Pre-planningBuilding Relationships and Common Understanding
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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
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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?