Healthy Homes = Healthy Kids: Housing Advocacy Strategies for Medical Providers

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Healthy Homes Healthy KidsHousing Advocacy
Strategies for Medical Providers
Dawn Bolyard, APN, Mercy Childrens Hospital
Childrens Pulmonary Center Robert Cohn, MD,
Mercy Childrens Hospital Childrens Pulmonary
Center Robert Cole, Esq., Advocates for Basic
Legal Equality, Inc.
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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.

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Common Housing Conditions and their Health
Impacts
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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

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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.

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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.

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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

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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.

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Percent of Children with Elevated Blood Lead
Levels by County, Ohio 2007
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Average Blood Lead Level By County, 2009
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Age of Housing Units in the City of Toledo
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High Risk Zip Codes, Lucas County
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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.

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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 [phone]
• Conventional applications accepted Mondays and
  Wednesdays, 900 a.m. to 1200 p.m. First 50
  people with all documentation can fill out
  applications.
• Voucher pre-applications accepted periodically
  watch for announcements.

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How do people apply for subsidized housing?

• Project-Based Section 8
• Apply at each complex.
• Contact management office forhours and
  documentation needed.
• Subsidized housing lists available from MLPC
  attorneys.

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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

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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.

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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.

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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.

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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.

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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

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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

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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.

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Utility Shut-Offs

• If tenant is responsible for utilities
• Tenant can apply for energy assistance, contact
  EOPA [phone].
• 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.

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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.

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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

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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
320271-277
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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 childs lungs as they grow
  decreasing morbidity and improving mortality

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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

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Consider this Case

• 6 year old male suffered from uncontrolled
  asthma high dose inhaled and p.o. steroids
• Frequent missed school days mothers 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

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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 didnt
  comply
• Landlord immediately rectified the problems
  leading to the improvement in childs symptoms

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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

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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.

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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

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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.

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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.

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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.

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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.

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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.

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Acknowledgments

• Boston Medical Legal Partnership for Children
• Toledo Lucas County Department of Health