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

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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

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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.

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