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Are the Rewards of Health and Housing Partnerships Worth the Effort?

by Corianne Payton Scally for How Housing Matters

Housing organizations and health providers have realized they are natural allies. They serve the same people living in the same places, and are learning that their missions are aligned: improving housing quality and stability can lead to better population health outcomes. A growing emphasis on prevention within the health care sector has housing organizations eager to help. But partnering across sectors can be bumpy.

Last week, we shared best practices for engaging citizens in health and housing interventions discussed at a recent convening cohosted by the Urban Institute and the National League of Cities. But how do housing and health entities build partnerships in the first place? And how does their mutually supportive relationship work?

Community Development for All People

When Nationwide Children’s Hospital approached the city of Columbus, Ohio, for help with infrastructure for a facility expansion, the city brought the nonprofit community development corporation Community Development for All People (CD4AP) to the table to make sure the expansion offered maximum benefits for the surrounding neighborhoods. As Reverend Edgar of CD4AP recounted, the conversations “started small and grew over time as trust emerged, and we gradually realized that there was a lot we could do together that we simply weren’t able to realize independently.”

They discovered that their goals aligned and their resources were complementary. Nationwide Children’s could tap into its funds and leverage business relationships, while CD4AP could apply for government housing funds. That was the start of a 10-year partnership.

Together, they formed a subsidiary corporation owned by CD4AP and funded by the hospital, with a board chaired by Nationwide Children’s chief financial officer but made up of residents, CD4AP staff, and hospital staff. Healthy Homeshas completed the gut rehabilitation and sale of 71 vacant homes, new construction on infill lots, and 150 grants for current homeowners to undertake renovations. The partnership says it has reduced the number of vacant and blighted properties more than 50 percent, and property values have started to rise again—so much so that they are now focusing almost exclusively on providing affordable rental housing. Most recently, they completed a Low-Income Housing Tax Credit development with 2,500 square feet of job training space for the hospital to provide job readiness and skills training just a seven-minute walk from its front door.

Community Development for All People has expanded beyond housing to look at other social determinants of health in partnership with Nationwide Children’s, including neighborhood safety, neighborhood and family well-being, fresh fruit and vegetable distribution, peer health coaches, cooking classes in a demonstration kitchen funded by the hospital, and a social enterprise (a community bike repair shop). They have also launched a major initiative on reducing infant mortality where CD4AP identifies women who are pregnant or have infants and engages them through home visiting, connecting them to other resources for maternal and child health needs.

“It is housing first, absolutely,” said Reverend Edgar. “But in addition,…our priority is not just that the neighborhood looks better, in terms of housing, but that the people feel better…[with] zero displacement, in an opportunity-rich community.”

For other community development organizations, his advice was to start small by talking to the hospitals—not by telling them all the things they should be doing but aren’t, but by finding places where their goals align with yours. Show the value you bring to their work, including your legitimacy as a neighborhood advocate. As a large hospital on a national stage, Nationwide Children’s faces image risks if new programs don’t work right from the start. The partnership with CD4AP gives the hospital more capacity to try new things, especially because CD4AP is more willing to take the blame for failures and shield the hospital from negative feedback.

The Boston Housing Authority + Boston Public Health Commission Partnership

Public housing authorities provide rental housing to vulnerable individuals and families, including those who struggle with health issues. For a health organization, the local housing authority can be a valuable partner for reaching populations with prevention and treatment services. Early partnership efforts, however, should be mindful that housing authorities are often fighting an uphill battle to build a positive image and shed their recurring role as a scapegoat for all manner of neighborhood fears.

Trying to understand the source of health disparities, researchers nearly 20 years ago analyzed housing conditions within properties owned by the Boston Housing Authority (BHA), the largest landlord in Boston. Researchers found pests, mold, and dust contributing to residents’ poor health. But BHA was the subject of research, not a partner in the study. The independent study made the agency feel underappreciated and attacked. As Gail Livingston, deputy administrator for housing programs at BHA, described, “BHA’s first foray into public health issues could have been its last” if partners had not found a way to collaborate more effectively.

Fortunately, BHA cared about the findings and its residents’ health, despite its lack of voice in the initial research. As a key “impartial institutional player with a mission to make things better,” the Boston Public Health Commission (BPHC) got involved alongside BHA to launch follow-up programs and research focused on improving BHA residents’ health, including funding for BHA and the potential to improve operations rather than simply criticize them.

Since then, partners have worked hard together, including BHA, BPHC, and local universities. “Some people think partnerships just happen when you put people together and say ‘here is what you are doing [together],’ but it doesn’t happen like that by a longshot,” remarked Livingston. It takes slow and steady work to identify shared goals, overcome turf issues, build trust, and reach a shared understanding that solving problems together will make everyone’s jobs easier. Each partner brings important resources to the table that can be leveraged to work together, whether it is resources, expertise, or an audience with policymakers.

Just as in the case of CD4AP and Nationwide Children’s, small successes strengthened the partnership and led to larger ones. Livingston noted it started with “everyone want[ing] housing to be better and healthier for the people living there.” What began as a program on integrative pest management in a handful of BHA properties has expanded across its portfolio as part of its standard property management practices. By 2012, another major asthma trigger within its properties was eliminated when BHA adopted a smoke-free policy. The Boston Housing Authority also participates in a local partnership to house the homeless and is working with residents to combat obesity by reducing sugary drink consumption.

Local housing organizations, whether nonprofit community developers such as CD4AP or public housing authorities such as BHA, are critical partners in addressing local health needs. People usually spend more time in their home than anywhere else. If that critical environment doesn’t adequately promote health, the odds may be stacked against some of our most vulnerable neighbors. Though housing organizations have different terminology, different resources (with complicated compliance rules), and different skill sets than health providers, they are a natural ally for improving health and have proven themselves willing partners.

The Columbus and Boston partnerships started small and built on initial wins to sustain and expand their activities for the health of the people they serve. Starting such partnerships is hard work but entirely possible and definitely rewarding.

Princeton Study: Being Black Doesn’t Cause Asthma; the Neighborhood Does

By Mary Caffrey

The numbers didn’t lie, but they were hard to explain: black children are twice as likely as others to develop asthma.

There was evidence that low birth weight was a culprit, but could “being black” be a risk factor in asthma, as some believed?

Two scholars from Princeton University have concluded that it’s not race, but living conditions, that accounts for the disparity. The data are compelling, alright: they show the effects of ongoing segregation, which trap African American children in poor neighborhoods, surrounded by pollution.

Janet M. Currie, PhD, professor of economics and public affairs at Princeton, and Diane Alexander, PhD, of the Federal Reserve Bank of Chicago, made this finding after examining New Jersey health data for low birth weight children of all races living in zip codes where more than half the population was African American.

Within these neighborhoods, the racial disparities vanished: all low birthweight children had a higher risk of asthma.

Children with a low birth weight may be premature, which increases the risk for lung problems. The trigger for asthma comes from things found in aging neighborhoods with older housing: mold, rodent infestation, or air pollution. Being around people who smoke also causes asthma, even if a baby’s mother does not smoke. According to CDC, black men have much higher smoking rates (20%) than the overall population (15%), and the authors find that black women are more likely to smoke during pregnancy than white women.

New Jersey’s industrial history means many black residents live near pollution sources or close to highways that produce harmful soot. Housing in these areas is, on average, 7 years older than housing elsewhere. Currie said these conditions can cause women to have low birth weight babies in the first place.

“The United States continues to be highly racially segregated,” Currie said in a statement, “with African-American neighborhoods suffering higher poverty, lower average educational attainments, higher unemployment, higher exposure to pollution, and other ills.”

The authors state, “Our results suggest that the racial gap in asthma rates arises for three reasons: because African-American children are more likely to be low birth weight, because they are more likely to come from families with other characteristics that are associated with poorer health (such as maternal smoking and poverty), and because of where they live.”

African Americans of all ages tend to have poorer health than whites, and neighborhood divides may play a part. New Jersey, in fact, has spent decades trying to comply with a series of 1980s court rulings that called for creating more affordable housing in the suburbs, but those battles are still being fought.

The findings have widespread policy implications, if it means that investments in better housing could cut Medicaid costs over a child’s lifetime. A 2016 report from Express Scripts finds that Medicaid is the largest payer for asthma-related hospitalizations among children and adults, and asthma medications are in the top 3 spending classes, per member per month, at $62.73.

There has been some progress to improve the health of poor children in urban housing. In 2014, a study by CDC found that ending smoking in public housing would save $497 million a year, including $310 million in medical costs. In response, in November 2016, the Obama administration imposed a rule to ban smoking in all public housing.

The study covered New Jersey health data for children born from 2006 to 2010 and records from emergency department visits from 2006 to 2012, which let the researchers see which children were treated for asthma. The zip codes that included areas that were more than 50% African American covered 63% of all African American children born in New Jersey, as well as 16% children of other races.

Currie’s and Alexander’s article appears as a working paper in the National Bureau of Economic Research and will be published in the Journal of Health Economics.

Your ZIP Code Might Be As Important To Health As Your Genetic Code

By Kristian Foden-Vencil

When a receptionist hands out a form to fill out at a doctor’s office, the questions are usually about medical issues: What’s the visit for? Are you allergic to anything? Up to date on vaccines?

But some health organizations are now asking much more general questions: Do you have trouble paying your bills? Do you feel safe at home? Do you have enough to eat? Research shows these factors can be as important to health as exercise habits or whether you get enough sleep.

Some doctors even think someone’s ZIP code is as important to their health as their genetic code.

That’s why Shannon McGrath was asked to fill in a “life situation form” this spring when she turned up for her first obstetrics appointment at Kaiser Permanente in Portland, Ore. She was 36 weeks pregnant.

“When I got pregnant, I was homeless,” she says. “I didn’t have a lot of structure. And so it was hard to make an appointment. I had struggles with child care for my other kids, transportation, financial struggles.”

The form asked about her rent, her debts, her child care situation and other social factors. On the strength of her answers, Kaiser Permanente assigned her what is called a “patient navigator.”

“She automatically set up my next few appointments and then set up the rides for them, because that was my No. 1 struggle,” McGrath says. “She assured me that child care wouldn’t be an issue and that it would be OK if they came. So I brought the kids and everything was easy, just like she said it would be.”

McGrath’s navigator helped her get in touch with local nonprofits that helped her with rent, a phone and essentials for the baby — such as diapers and bottles — all in the hope that making her life easier might keep her healthier and, in turn, keep Kaiser’s medical costs lower.

McGrath says her patient navigator, Angelette Hamilton, was a bureaucratic ninja, removing paperwork obstacles that kept her from taking care of herself and her family.

Patient navigators have been around for a while. What is new is the form that McGrath filled out and how hospitals are using the socioeconomic and other data the forms glean to serve patients. The details now go into a patient’s file, which means providers such as Dr. Sarah Lamberthave more information at a glance.

“I find it incredibly helpful because it can be very hard to find out,” says Lambert, who is McGrath’s OB-GYN and works at Kaiser Permanente Northwest. “Having it coded right there — we have this problem list that jumps up — really can give you a much better understanding as to what the patient’s going through.”

Federal officials introduced new medical codes for the social determinants of health a few years ago, says Cara James, director of the Office of Minority Health at the Centers for Medicare and Medicaid Services.

“More providers are beginning to recognize the impact that the social determinants have on their patients,” she says.

Nicole Friedman, a regional manager at Kaiser Permanente Northwest, agrees. But she goes one step further.

She hopes giving doctors more information about the home life of each patient will push health care in a new direction — away from more high-priced treatments and toward providing the basics.

“My personal belief is that putting more money into health care is a moral sin,” she says. “We need to take money out of health care and put it into other social inputs like housing and food and transportation.”

Linking health organizations like Kaiser with nonprofit social services such as the Oregon Food Bank will help governments and medical providers see where their money can make the biggest difference, Friedman says.

For example, spending more on affordable housing for homeless people can also have health benefits, in turn saving the government money down the line.

Friedman says that when Kaiser started addressing people’s social needs, one study found a 40 percent reduction in emergency room use.

McGrath was initially skeptical when doctors offered to help her with things like rent and transportation.

“I didn’t want someone to see my situation and have it raise alarms,” she says.

But ultimately she was glad to have shared that information.

“I’m able to look at life and not feel overwhelmed or burdened,” she says, “or like I’ve got the whole world on my shoulders.

This story is part of NPR’s reporting partnership with Oregon Public Broadcasting and Kaiser Health News, which is an independent journalism organization and not affiliated with Kaiser Permanente.

Health Department’s New Response to Climate Change

By Catalina Jaramillo

It wasn’t too difficult for the crowd of around 40 seniors gathered at the McPherson Public Library in Kensington on Wednesday to get into the right mindset for the evening’s discussion: How to prepare for emergencies caused by climate change.

Thermometers read 90 degrees in Philadelphia, but it felt like 96. There were heavy rains and thunderstorms scattered throughout the day. And the entire metro area was hit with a Code Orange air quality alert, meaning unhealthy air pollution concentration for people with asthma, heart or lung diseases, children, and the elderly.

That might explain why seniors came from all across the city to attend the extreme heat workshop.

“Have you experienced expressions of climate change first hand?” Drexel University’s Alison Kenner asked the audience.

They replied with loud yes. It’s hotter, one said. It’s wetter, another added. I’ve had health issues, one woman said. I’ve had more asthma, agreed someone else.

“I have asthma and I’m trying to find what I can do [when it is] so hot and muggy,” attendee Sharon Williams said. She doesn’t have air conditioner at home, so she comes to the library whenever it’s really hot. “It affects my breathing,” she said.

Hot and muggy summers in Philadelphia are not new. And for years, the Philadelphia Department of Public Health has run heat awareness campaigns, stressing the health impacts it can have on vulnerable populations and advising citizens to “stay cool” during extremely hot and humid days.

What’s new is the Health Department explicitly connecting the health impacts from excessive heat to climate change. Local health departments in the whole country are only now beginning to expressly make that connection. But according to the U.S. Climate and Health Alliance, the Philadelphia Health Department is ahead of many of their peers.

“Summers in Philadelphia have always been hot, but now they’re getting hotter and wetter,” Health Department’s Marialisa Ramirez said on the workshop.

Philadelphia’s Health Department is one of 12 local health departments participating in a national Climate and Health Learning Collaborative for urban health departments. And a team lead by preparedness manager Jessica Caum has been working with community associations and city agencies to coordinate efforts through a Climate Change and Health Advisory Group.

Wednesday’s “staying cool in a climate change” workshop, one in a series of three held in south, west and north Philadelphia, was one of the products of that.

Clear Air Council’s Russell Zerbo said this is the first time the Health Department is coming out to communities and saying, explicitly: Climate change may impact your health.

“The news is really the Health Department walking into cooling centers and saying: This is a cooling center, we want you to be safe this summer because of climate change,” Zerbo said. “It’s sort of putting them in a service base position, which was not, I don’t think, before.”

Cooling centers are public spaces with air conditioning. They can be libraries, recreation centers, senior centers, or other cool, public buildings. But the Health Department does not publish an active list of them because sometimes the air conditioning in a given building might not working. Ramirez recommended that the audience call 311 before heading to a nearby library or rec center.

Zerbo said until this year, the department was announcing the health impacts of climate change through their website or in the news, sending people to the heatline (215-765-9040) “but in terms of physically going out and doing it, that wasn’t happening.”

In an email, the Health Department’s James Garrow confirmed this was their first time participating in these events.

“While working with the Office of Emergency Management to update the City’s heat response plan, we heard about these types of events and thought we could use them to help further our existing efforts to distribute information about excessive heat and what Philadelphians can do to help survive the heat,” Garrow said.

Zerbo doesn’t blame the department for not directly talking with the communities before about the connection between the dangers of heat and climate change. Climate change is a really complex issue, he said, and a lot of organizations are struggling on how to communicate its impacts and solutions. Drinking more water or keeping an air conditioner on full blast are not real solutions for climate change, he said. They only address the symptoms, not the underlying predicament.

The workshop addressed that problem through different angles. The audience was told staying hydrated and cool is vital, but experts also mention that air conditioners could be creating more of a problem by making cities get hotter.

Julia Menzo from Liberty Lutheran spoke about the importance of establishing ways to contact your family and have enough food and water in cases of power outages. Deepa Mankikar from the National Nurse-Led Care Consortium told people how to keep healthy indoor environments avoiding toxic cleaning products and keeping pests away. And Thomas Flaherty from the Energy Coordinating Agency offered tips for reducing energy conservation, like painting your roof white or disconnecting appliances when they’re not in use.

Drexel’s Kenner has been doing this workshops, independently, for four years. She said there’s three things she’s learned from them. First, that people appreciate someone breaking climate change down and bringing it to a neighborhood scale, showing them how they will be affected. Second, how difficult it is for renters to negotiate things like windows painted shut by their landlords. And third, that difficulty breathing is one of the first issues people mention.

“Changes in weather also trigger asthma attacks,” said Keener, who is writing a book about asthma and climate change. “Because the climate is changing and ecology is changing, people who have lived with asma their whole lives, may be unprepared for new environmental conditions.”

Gloria Marrero has had asthma since she was 14 years old. “Heat leaves me with no air,” she said in Spanish. “That’s why we came, searching for answers.”

According to a index, Philadelphia ranks number 10 among cities that will feel the impact of climate change the most. And the Asthma and Allergy Foundation of America says Philly is the third most challenging city to live with asthma in the country.