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


Healthy Homes = Healthy Kids: Housing Advocacy Strategies for Medical Providers Dawn Bolyard, APN, Mercy Children s Hospital Children s Pulmonary Center – PowerPoint PPT presentation

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

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.
  • 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.

Common Housing Conditions and their Health
Substandard housing conditions linked to public
  • 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
  • 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
  • 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

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
  • 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
  • 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, 900 a.m. to 1200 p.m. First 50
    people with all documentation can fill out
  • 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 forhours and
    documentation needed.
  • Subsidized housing lists available from MLPC

Substandard Housing Conditions
  • Habitable housing is a contractual and statutory
    obligation for both landlords and tenants.
  • Housing codes set minimum standards for healthy
  • Common violations
  • Overcrowding
  • Utilities gas, electric, water
  • Housekeeping
  • Lead paint
  • Pests
  • Mold

What remedies do tenants have when housing is
  • 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
  • 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

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
  • 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

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
  • 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, N ENGL J MED 1989
Benefits of a Healthy Home for the asthmatic
  • 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

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

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

  • 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
  • Landlord immediately rectified the problems
    leading to the improvement in childs 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
  • Made recommendations to improve the homes
  • 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
  • Increased physician knowledge about what dangers
    patients faced in the home by seeing it first
  • 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.

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Collaboration between health practitioners and
  • 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

Innovative collaborations between health
practitioners and lawyers can be developed to
serve the broad needs of asthma sufferers.
  • Collaborative efforts should be expanded and
  • 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
  • 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.

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