Mary (not her real name) is an elementary school student with moderate to severe asthma. She struggles to manage her condition and uses her rescue inhaler frequently. Mary’s mother is concerned about several problems in their apartment, including an unresolved pest infestation and bedbugs. As Mary’s pediatrician learned during a recent appointment, the family faces eviction for non-payment of rent.
Stories like Mary’s are common in Worcester, Massachusetts, where more than one in ten children suffer from asthma. Kids with uncontrolled asthma have poor health and development, and they miss a large number of school days. Many of these children live in low-income neighborhoods where substandard housing conditions—such as mold, pests, and lack of heat—often exacerbate asthma symptoms.
Due to poverty-related instability, they often move one or more times during the year, causing them to switch schools and fall behind. Helping these children control their asthma requires both good clinical care and better, more stable housing conditions. Yet in many communities, these are often seen as separate problems.
The city of Worcester, Massachusetts is an exception. The City’s Division of Public Health and its partners in the medical and legal communities use a multi-sector approach to address housing and health needs for children at high-risk for asthma.
Both Housing And Health Matter For High-Risk Pediatric Asthma Patients
Since 2003, Community Legal Aid and UMass Memorial Medical Center have had a medical-legal partnership in which pediatric primary care staff connect patients with civil legal aid services when housing, insurance, education, or public benefit problems interfere with their health. In 2014, the partners began using the program specifically as a vehicle to address housing conditions that can trigger asthma attacks.
The Massachusetts Medical Society funded a small pilot program at UMass Memorial in which attorneys trained community health workers to screen families for housing-related civil legal problems—in particular for substandard housing conditions and threats of eviction—during home visits in the Belmont Street Community School neighborhood. The health workers then provided asthma management education and a healthy home assessment, addressing both medication management and housing conditions simultaneously. The health workers were able to initiate code enforcement actions and refer families who needed legal counsel in addressing housing conditions to the medical–legal partnership attorney.
The pilot served 30 children and gave community health workers, UMass Memorial providers, and civil legal aid partners an opportunity to build strong relationships and hone service delivery, from referral mechanisms to case feedback loops. After the pilot concluded, they received a grant from the Massachusetts Prevention and Wellness Trust Fund, scaling the asthma home visiting project from a single neighborhood intervention to a city-wide approach.
The grant project brought in new partners, including the City of Worcester Division of Public Health and Worcester’s two federally qualified community health centers — Edward M. Kennedy Community Health Center and Family Health Center of Worcester. Together, these centers provide a medical home to many of the low-income asthmatic children in Worcester. The target population of the new grant is the approximately 700 low-income children in Worcester who are listed on participating clinical sites’ asthma registries.
Improving Each Sector’s Effectiveness By Working Together
The driving idea behind this program is that these various interventions—medicine provided by clinicians, housing laws and conditions enforced by lawyers, and empowerment-focused asthma education provided by community health workers—can be more effective if their delivery is integrated.
Commonwealth Medicine and the Massachusetts Department of Public Health are currently conducting evaluations of this program; preliminary results will be available in 2016. However, the project has already played a role in reducing school absenteeism. The team has also seen early changes in its capacity to address asthma care and prevention, and in the ability of each type of professional on the team to work at the top of his or her license.
Community Health Workers
Community health workers can now do asthma education in the home setting and connect the results of the home assessment with the child’s health care provider. With the support of attorneys, they help families navigate the Inspectional Services process and advocate with housing code officials or landlords to exterminate pests causing asthma attacks. Health workers know that if the issue becomes more complex, or a family suddenly faces eviction, they can refer families to the medical-legal partnership attorney.
Legal Aid Attorneys
Legal aid attorneys traditionally dedicate their time to crises. Currently, resources are sufficient to address only one in five civil legal problems in the U.S. Where housing is concerned, this shortage has led many legal agencies to help only those individuals who show up at their offices with an eviction notice in hand.
In the Worcester program, attorneys see problems earlier based on community health workers’ screening and referrals. In addition, by building health workers’ capacity to help families before a court intervention is required, attorneys can use their resources to address the more challenging issues that require their more specialized skills — including systemic problems that impact multiple families at once.
For example, one family served by the project was living in a building in complete disrepair. By working with this family, Community Legal Aid learned that poor conditions existed in many units and is now helping other families in the same building who may never have made it to legal aid’s door. Working alongside clinical providers and community health workers, attorneys identify patterns of pest infestation, substandard conditions, and other barriers that could be addressed with targeted advocacy and the collaboration of housing code departments.
Clinical Partners
For clinical partners, an integrated approach has the potential to improve medication compliance while reducing unnecessary use of emergency rooms. In addition, as reimbursement from both public and private payers continues to shift away from fee-for-service to value-based purchasing, clinic-community linkages could impact cost-containment and quality improvement efforts.
The Role Of Local Government
In Worcester, the local public health department serves an important convening role for this project. City leadership understood that innovations in healthy living and clinical care require collaboration and dialogue across sectors. Having the local public health department involved ensures that the project is informed by city public health data and is connected to other asthma initiatives happening across the city.
It also gives clinical, community, and legal aid partners a place where they feel safe sharing the challenges of identifying and reaching families eligible for the intervention and implementing home visits. The public health department provides a forum where partners learn from the successes of others and work on process improvements together. For example, the clinical and community-based partners are currently working on Plan-Do-Study-Act (PDSA) cycles to improve home visits.
This project led to the creation of an Asthma Task Force in Worcester, comprised of the Prevention and Wellness Trust Fund grantees and other community stakeholders. Members meet regularly to discuss policy and systemic solutions to the issues identified through this collaboration. The Task Force created a policy subcommittee, currently working with educational stakeholders and in partnership with City and school officials to improve the built environment in locations where children spend time.
Public health departments and health care systems are natural choices to convene these partnerships because they have city-wide asthma data and hold the asthma registry lists that identify the individuals that most need intervention. But legal aid can play a critical role, not only as a partner in addressing asthma, but in detecting where in the community intervention is most needed. For example, in Cincinnati, when health care data around asthma admissions were coupled with legal data around housing code violations, a medical-legal partnership detected substandard housing clusters ripe for policy and population level interventions.
If health care, public health, and legal aid organizations share their data around asthma and housing, they may identify common patients/clients and common goals. Together, these potential clinical, community, and legal aid partners should investigate funding opportunities that will support multi-sector prevention work. In Massachusetts, the Prevention and Wellness Trust Fund was an important funder, but more opportunities may become available as private and public payers look for ways to pay forpopulation health interventions.
A Healthy Home for Mary
Mary was one of the first asthma patients enrolled in Worcester’s new asthma program. Her community health worker connected Mary’s mom with Community Legal Aid. An attorney interviewed Mary’s mother to identify her healthy housing goals and represented her in court. As a result of the legal intervention, the eviction was dismissed, her subsidized housing voucher was protected, and the poor conditions were addressed. Through a combination of asthma education, medicine, and better housing, the team stabilized Mary’s asthma.
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