Stories Archive - Page 13 of 18

New York City’s Efforts to Prevent and Respond to Childhood Lead Exposure

Background

According to the New York City Department of Health and Mental Hygiene, lead paint, and the related dust, is the primary source of lead exposure for New York City children. Between November 2013 and January 2016, New York City’s Department of Housing Preservation and Development (HPD), which enforces the city’s housing code, issued more than 10,000 violations for dangerous lead paint conditions in units with children under 6-years-old.lead

Lead poisoning disproportionately affects lower-income individuals in New York City who live in older, poorly maintained housing. Half of the total violations were found in just 10 percent of the city’s ZIP codes in primarily low-income neighborhoods in northern Manhattan, Brooklyn, and the Bronx. And, more than three-quarters of all violations for lead paint hazards in units with children under age six were found in areas where the poverty rate exceeds the city’s average.

Rebuttable Presumption and Billing Noncompliant Landlords for Lead Hazard Control

In 2004, New York City introduced Local Law 1 amending its Administrative Code and replacing Local Law 38 of 1999 (additional information here). Local Law 1 requires building owners to identify and repair any unsafe lead paint conditions in units where young children live. The law applies to all buildings with three or more units built before 1960 (New York City prohibited the use of lead in residential paint in 1960 while the federal government did so in 1978). Buildings built between 1960 and 1978 are also subject to Local Law 1 if the owner knows that lead paint is present. Under the law, landlords must determine annually which units are home to children under age six and inspect them at least once a year for peeling paint.

The building owners must address whatever lead hazards they find promptly and safely. When fixing hazards and conducting general repair work that may disturb lead paint, they must use lead-safe work practices and trained workers. They are also responsible for repairing lead paint hazards in any apartment before turning it over to a new tenant. The law mandates that owners maintain records of all notices, inspections, lead paint hazard repairs, and other matters related to the law.

Local Law 1 requires the HPD to inspect deteriorated lead paint whenever they receive a complaint in any apartment occupied by young children. HPD may issue positive lead-based paint violations (if it tests the paint during the inspection) or presumed lead-based paint violations (if it is unable to test the paint during the inspection because the proper equipment is not available).

Under the law, once HPD issues a lead paint violation, the building owner has 21 days to repair the hazard or, if the presumed violation was issued, to contest the violation. If the owner either fails to meet the deadline for the repairs or is not given an extension (called a postponement), the city must try to perform, or contract for, the repairs at the owner’s expense. Repairs include remediation of peeling paint, the use of an EPA certified firm, and appropriate clearance testing.

Local Law 1 also mandates the New York City Department of Health and Mental Hygiene to investigate the potential sources of lead exposure. This includes, but is not limited to, paint inspections in a dwelling in response to a report of a person under 18 years of age with an elevated blood lead level of 15 mcg/dL or greater. The Health Department may issue a lead-based paint violation (notifying HPD), and, under the law, the building owner has to do the specified repairs. If the owner fails to complete the work, the dwelling is referred to the city’s emergency repair program as described above.

Functionally, the city’s Department of Finance bills the property for the cost of the emergency repair, related fees, and/or the cost of any repair attempts. It is likely to be far more expensive for the city to arrange repairs than if the owner had taken care of them in the first place. The added cost acts as an incentive for the owner to conduct the work before a violation is issued or, when a violation is issued, to complete it in a timely manner. This is likely the only regulation in the country in which the local government conducts lead remediation and bills the landlord if the landlord fails to do what is required.

Finally, if the owner fails to pay, the city files an interest-bearing tax lien against the property.

Results

Data from the New York City Department of Health and Mental Hygiene shows the number of children with a blood lead level of 5 µg/dL or greater has dropped over 80 percent since Local Law 1 was adopted, although in 2014, 6,550 New York City children younger than 6 still had blood lead levels at or above 5 mcg/dL.

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In August, 2017, the Health Impact Project, a collaboration between the Robert Wood Johnson Foundation (RWJF) and Pew Charitable Trusts released: Ten Policies to Prevent and Respond to Childhood Lead Exposure. The Trust for America’s Health (TFAH), National Center for Healthy Housing (NCHH), Urban Institute, Altarum Institute, Child Trends and many researchers and partners contributed to the report. TFAH and NCHH worked with Pew, RWJF and local advocates and officials to put together the above case study about lead poisoning and prevention initiatives.

The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.

Access a story on New York State’s efforts here.

Access a story on Rochester’s efforts here.

California’s Efforts to Prevent and Respond to Childhood Lead Exposure

Background

In the mid-1980s, the California state legislature declared childhood lead exposure the most significant environmental health problem in the state and subsequently established the Childhood Lead Poisoning Prevention Branch within the state’s Department of Public Health (CDPH).

The program compiles information, identifies target areas, and analyzes data to design and implement ways to reduce childhood lead exposure. The statutes also determine a “standard of care” to evaluate children for lead-exposure risk; mandate reporting by laboratories of all state blood lead test results; and require public health and environmental services for children identified with elevated blood lead levels, including ordering property owners to remove hazardous lead conditions. The state requires the establishment of procedures and the adoption of regulations regarding residential lead paint, and lead-contaminated dust and soil. It also authorizes and administers a lead-based paint prevention training, certification, and accreditation program.

Funding

To help pay for the program, in 1993, California adopted an annual Childhood Lead Poisoning Prevention Fee, administered jointly by CDPH and the California Board of Equalization (BOE), on manufacturers and other entities involved with the production or sale of lead and lead-based products collected from businesses in the petroleum and architectural coatings industries and from facilities reporting releases of lead into the air. The department deploys a “historical market share attributions” concept to estimate each payer’s long-term contribution to environmental lead contamination and allocate fees. It then deploys collected funds (the fee generated $20.6 million in fiscal 2015) to support healthcare referrals, assessments of homes for hazards, and educational activities.

Banning Lead in Certain Products

California has led U.S. efforts to ban lead from a range of products beginning with a 1986 law, Proposition 65, which requires manufacturers, retailers, and other businesses to notify consumers when they are being exposed to toxic chemicals, including lead. The law has made consumers more aware of toxic chemicals in their environment, and advocates have successfully pressed for more regulations to ban or curtail the use of lead and other toxins in products. In conjunction with these efforts, California passed a number of strict laws to safeguard products and protect its citizens from lead exposure. For example:

In 2005, California implemented a lead-in-candy law. The state considers candies with lead levels in excess of 0.1 parts per million (ppm) to be contaminated. The Food and Drug Branch of the California Department of Public Health is required to test samples, notify the manufacturer of the adulteration, and issue a health advisory. The federal Food and Drug Administration subsequently issued national guidance in 2006 recommending that all candy likely to be consumed by children contain no more than 0.1 ppm of lead.
In 2006, California enacted the Metal-Containing Jewelry Law. This requires jewelry and components, such as dyes and crystal, that are sold, shipped, or manufactured for sale in California to meet limits set by the state under a 2004 consent judgment that applied to a number of manufacturers, retailers, and distributors in response to a lawsuit filed by the Attorney General of California and two environmental groups. The law forbids the manufacture, shipping, sale, or offer for retail sale or promotional purposes jewelry in California unless it is made wholly from one or more specified materials. It also mandates lead restrictions for certain specified materials allowed in manufacturing jewelry and establishes provisions for children’s jewelry and that used for body-piercing.
California passed additional legislation in 2006, effective in 2010, to reduce the lead content in water distribution products. The law prohibits more than 0.25 percent lead in commercial pipes, fittings, and fixtures. In 2010, the U.S. Congress amended the Safe Drinking Water Act, including provisions similar to the California standard, and, in 2014, the 0.25 percent standard for lead in pipes, fittings, and fixtures became national.
In 2009, California passed the California Lead in Wheel Weights Ban to prevent lead from wheel weights, used to balance tires in vehicles, from entering the environment. Before the ban, lead wheel weights, which can become dislodged from the wheels and end up on roads where they are abraded into lead dust and debris, were responsible for releasing 500,000 pounds of lead annually onto California roads. Since 2009, six other states, including Washington, Maine, Illinois, New York, Vermont, and Minnesota, have followed California’s lead. Also in 2009, the U.S. Environmental Protection Agency (EPA) started the process to consider banning lead wheel weights in the United States, but it has not taken formal action. The European Union has already banned lead wheel weights, while manufacturers in Japan and Korea stopped installing them in 2005.

In 2010, both California and Washington passed legislation restricting the use of heavy metals including lead in motor vehicle brake pads. In 2014, in California, and 2015 in Washington, brake pads sold in those states could not contain more than 0.1 percent by weight. The legislation also limits the levels of asbestiform fibers, cadmium, chromium, copper, and mercury in the brake friction materials. In January 2015, brake manufacturers signed a memorandum of agreement with the Environmental Protection Agency and the Environmental Council of the States declaring that all brake pads sold in the United States will meet the California/Washington standards. The brake- pad standards were adopted immediately, while standards for copper are being phased in.

In 2003, California passed the Toxics in Packaging Prevention Act, which limited harmful substances in packaging and reduced the levels of toxins contaminating soil and ground water near landfills. While the original law exempted lead paint or applied ceramic decoration on glass bottles, a 2008 amendment banned such uses if the lead content exceeds 600 ppm.

California passed a law in 2013 that made it the first state to require the use of only lead-free ammunition be used for hunting with a firearm in California. The regulations, which began to phase in in 2015, will be fully implemented in 2019. Lead ammunition for hunting waterfowl was banned nationally in 1991, but the California law extends the ban to hunting for all wildlife. The main purpose of the law is to protect endangered wildlife, including the California condor, from lead exposure. However the legislation should have the added benefit of reducing lead exposure for the families of hunters.

Results

The number of children from 0 to under 21 years who have been identified with blood lead levels at and above 4.5 mcg/dL has been decreasing significantly. In 2013, 1.7 percent of tested children had blood lead levels in this range. In 2007, 6.5 percent tested above 4.5 mcg/dL.

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In August, 2017, the Health Impact Project, a collaboration between the Robert Wood Johnson Foundation (RWJF) and Pew Charitable Trusts released: Ten Policies to Prevent and Respond to Childhood Lead Exposure. The Trust for America’s Health (TFAH), National Center for Healthy Housing (NCHH), Urban Institute, Altarum Institute, Child Trends and many researchers and partners contributed to the report. TFAH and NCHH worked with Pew, RWJF and local advocates and officials to put together the above case study about lead poisoning and prevention initiatives.

The case study does not attempt to to capture everything a location is doing on lead, but aims to highlight some of the important work.

How Embedding Health Access and Nurses in Schools Improves Health in Grand Rapids, Michigan

For more than 20 years, Grand Rapids Public Schools (GRPS) has partnered with Spectrum Health to improve educational and health outcomes for their students through Spectrum’s School Health Program. Started in 1995, the School Health Program will be expanded to its 14^th additional school districts in 2017.

The GRPS Model

The GRPS program utilizes school health teams comprised of registered nurses (RNs), licensed practical nurses (LPNs), and health aides to provide direct services to students in 48 schools. GRPS’ branch of the School Health Program currently employs 34 RNs, 11 LPNs, and 34 health aides and operates four full-service school-based health centers.

In the GRPS model, school teams operate under the supervision of a school nurse whose primary responsibility is oversight of health care delivery to students during the school day. The district has established policies and procedures to describe how care is to be delivered by the team under the supervision of the Registered Nurse. The nurse may delegate care to other school staff.

School nurse responsibilities include: identification of students who have health conditions; developing a plan for care during the school day; training and oversight of staff for safe delivery of medications and treatments; providing services that cannot be delegated; establishing medical response teams to respond to emergencies; telephone triage and support; surveillance and reporting of communicable diseases; connecting students to medical, dental, and mental health care through referrals; promoting health; health education; health screenings and follow up; and assisting students in obtaining immunizations.

GRPS uses funds from a variety of sources to support their school nurses including:

the district budget;
their local intermediate school district;
the State Department of Education—including grants and 31A funds (for students deemed at high risk); and
Spectrum Health.

The full-time equivalent (FTE) for the nurses for each school is adjusted based on the health needs of the student population and the availability of funds. Even though some funding for school nurses is still provided through Title I, GRPS has largely moved to alternative funding streams due to cumbersome reporting requirements.

While RNs serve as the cornerstones in the model, GRPS also braids together funding streams from both public and private entities to allow for reimbursement and service provision under a variety of health delivery models beyond the traditional school nurse reimbursement model. Coordinating funds and services across the spectrum of health providers and sources enables GRPS to provide services outside of the traditional school nurse model—such as dental services.

GRPS has also partnered with Cherry Health Services a local Federally Qualified Health Center (FQHC) to deliver health services in their school-based health centers and through a traveling dental program. Because these services are provided through an FQHC, they are eligible for Medicaid reimbursement and receive the FQHC enhanced reimbursement rate.

While data systems and privacy concerns have hindered data sharing and integration in the past, GRPS is actively moving towards linking education and health data under one system. The new data system is built upon the district’s student record system and has the potential to more easily link school health metrics to attendance and academic data. These system improvements are crucial steps to helping Spectrum Health and GRPS track and accomplish both its short-term goals to improve attendance and reduce chronic absenteeism and its long-term goals to improve graduation rates, workplace readiness and college entry.

Consultative RN Hub Model

In more rural districts, Spectrum Health has developed a consultative RN hub model for service delivery. Nurses are able to serve students utilizing telemedicine through its MedNow program—reducing travel time for school nurses and costs for the district. The Regional program will serve 13 districts in 2017 with 14 RN and two LPN.

Results

The partnership between Spectrum Health and the school districts have produced significant improvements in important school health indicators. Key accomplishments from FY 2015 included:

97 percent of students at participating schools met current immunization requirements to attend school;
98 percent of problems identified were resolved on-site by the school health care team;
195,092 visits occurred to the school health office; and
28,864 students were served across 7 school districts.

For more information, please visit http://www.spectrumhealth.org/healthier-communities/our-programs/school-health-program

It Takes a Village: How Mancelona, Michigan Worked Together to Improve Health and Education

By Mike Swain, MPH, Community Health Coordinator, Health Department of Northwest Michigan

In the early 1990s, residents of Mancelona (a northern Michigan town) had limited access to healthcare, social services and higher education and there were sparse employment opportunities.

With the lowest per capita income in the immediate area, most families lived in poverty, and were underinsured, uninsured altogether or enrolled in Medicaid.

Some of the community’s youngest were hardest hit: the area had the state’s highest rates of youth physical and sexual abuse, teen pregnancies, drinking and drug use. And as could be expected, these health risks had a significant impact on academic performance – with behavior problems in the classroom, low grades, and high dropout rates. In the 1994-95 school year, 39 percent of Mancelona high schoolers dropped out and just 64 percent of the senior class graduated.

Terry McCleod, the Middle School Principal at the time, recognized the critical role of student health and wellness in academic success – and he led the charge for change in Mancelona.

First, he brought together a grassroots network of public and private service providers. Along with a three year grant from the W.K. Kellogg Foundation, they built Project S.H.A.R.E. (School Home Alliance for Restructured Education) to provide a comprehensive assessment and evaluation of the gaps and needs in Mancelona.

The results made it clear that any successful, lasting intervention would need to improve the environment and families by addressing the underlying, interconnected issues of poverty. The layout of the community’s schools—all three were essentially on the same campus—allowed for a unique solution: building a dedicated family resource center right next to school grounds. With thoughtful outreach, community advocates and the public health administration were engaged in the cause, and the land for this building was secured.

The group secured a grant from the Michigan Department of Health and Human Services (MDHHS) to fund the beginning of construction, with the Mancelona Family Resource Center (MFRC) officially opening in 1996.

MFRC housed health, social, daycare, educational, and economic services, offering a unique and comprehensive suite of services to support Mancelona’s students and their families. Staffing and programs were brought in with continued support from Project S.H.A.R.E., including the Michigan Works! Association – which resided in a dedicated wing of the MFRC.

Michigan Works! played a critical role in turning the tide of poverty by strengthening the employability of adults with workforce development services and mobilization of local businesses.

Still, quality healthcare was at the heart, with the local Health Department providing previously unattainable care, including a Dental Health Clinic, on site. Additionally, the MFRC team provided convenient and confidential, family planning, reproductive health services, and education. And working closely with the school, this innovative approach included the development of a dedicated class for pregnant mothers to help improve the health of future Mancelona generations.

Over time, partnerships and additional resources were added within the center, the school and the community. In 2001, Communities In Schools (CIS) began providing programs and services in Mancelona. Founded on the national CIS model, this non-profit organization provided new programs for before/after school activities, mentoring and tutoring.

The CIS team worked in collaboration with the MFRC, providing care coordination and referrals for students and their families. And, when the state of Michigan expanded school-linked health center qualification requirements to include areas with rural status, the MFRC leadership were among the first applicants in line. Mancelona was included with the first round of funded centers under this new qualification.

In 2006, with this additional funding, the Mancelona school-linked health center opened, called the Ironmen Health Center, was opened. The Center offered services to students aged 10-21 regardless of health insurance status. In addition, social work and behavioral health services were provided.

By blending and braiding different funding sources and bringing to bear all community resources to link families to important social services and interventions, the community is much improved.

In fact, rates of teen pregnancy, drug and tobacco use, and child abuse are all down. And, high school graduation is up—to 91 percent, a 42 percent increase from the inception of project.

The benefits of this innovative care model doesn’t stop there: 60 percent of the 2013 graduating class enrolled in college that fall. And nearly 100 percent of the 2015 seniors are making plans to pursue some form of higher education or technical skills training post-graduation. What was once and ending is now just the beginning of a story.

Here you can find a timeline and more information on the model, including details on the Women’s Resource Center, Communities in Schools and the Ironmen Health Center.

How an Entire Community Can Come Together to Help Control Asthma

By Karen Meyerson, MSN, APRN, NP-C, AE-C, Manager, Asthma Network of West Michigan

In 1994, a group of concerned health professionals in West Michigan recognized the alarming rise in pediatric asthma morbidity and mortality, locally as well as nationally. Significant disparities are also associated with asthma. For example, asthma deaths in Michigan occur six times more frequently in Black children than in White children. In response, the Asthma Network of West Michigan (ANWM) was formed as a grass-roots coalition with initial funding from the (then) three acute care hospitals and two local foundations.

To reach and improve the lives of the nearly 100,000 people in Western Michigan—24 percent of whom are children—who have asthma, ANWM created a direct service arm of its coalition and implemented a home-based asthma case management program for school-aged children who had uncontrolled asthma. ANWM, believed to be the first grassroots asthma coalition in the nation to receive reimbursement for asthma education and case management services from health insurance plans, has since expanded its services to adults as well as children under the age of 5.

Our model relies on a few core components: home visits, care conferences and school/daycare visits and social worker services.

Home Visits

Research and common sense says that the environment around a child, particularly the home, is an important factor in preventing and controlling asthma. Consequently, a home visit provides the ideal setting to educate, review medication plans, and help families identify environmental factors that may contribute to the severity of asthma. If there are issues in the home that are triggering asthma attacks, we connect the family to our partner, the Healthy Homes Coalition, that provides environmental remediation.

To help educate families, we send a certified asthma educator—a nurse (at the RN level) or respiratory therapist (at the RRT level)—into the homes of patients for up to a year to perform environmental assessments and teach them about asthma attack trigger identification and avoidance/reduction, medications, proper use of devices and other self-management techniques. The asthma educator’s home visits are typically biweekly for the first three months and then monthly thereafter, as necessary, to provide a continuum of care.

Care Conferences and School/Daycare Visits

Care conferences—which are reimbursable visits—are held with the primary care physician and, if indicated, the asthma specialist soon after a new patient enters the program. These conferences tackle issues surrounding adherence, including psychosocial barriers to asthma management and access to care, and elicit a written asthma action plan, if none exists. If necessary, we provide spacers, a device to use with inhalers, to all patients who do not have them.

School/daycare visits – also reimbursable visits – are conducted in order to educate those caring for the children throughout the day about asthma and the child’s asthma in particular. We share the asthma action plan with staff and discuss asthma triggers in those settings.

Social Work Services

Lastly, we connect patients to our Licensed Masters-level Social Worker’s services (LMSW), which help families link the clinical recommendations they receive in the hospital or at the doctor’s office with the social services in their community. This is a vital service because many of our patients and families typically have multiple stressors, ranging from environmental to financial to socio-legal and LMSWs are uniquely capable of identifying and assisting with this range of problems. By blending social support with clinical support, ANWM makes the appropriate referrals or contacts to financial resources, mental health agencies, food banks, hospitals, landlords and others.

Successes

With this type of intensive, personal care, we have had demonstrated success in controlling asthma and reducing healthcare utilization (including emergency department visits and hospital admissions due to asthma). Patients often “graduate” from our program after just 6 to 12 months when their asthma control has improved.

When reviewing data over the past 19 years, we find that there have been significant reductions (64 percent) in the number of hospitalizations, days hospitalized for children and emergency department visits (from 60 percent to 35 percent). And, for low-income children with moderate to severe asthma who remained in the original case management study for at least 1 year, we saw an estimated average savings of $1,625 in hospital charges per patient. In total, we estimate the program results in approximately $800 in net healthcare savings per child per year, with a return to society—over two years—of $1.53 for every $1 invested.

We also hear from those we serve. The mother of a 5-year old boy with asthma told us that, “working with the Asthma Network has really made a big difference – his asthma is controlled now. They gave me education and made sure that I understood what asthma meant…they made me feel like no one was judging me.” Mom added, “I thought he had asthma ONLY when he got sick so I didn’t give him his inhaler until he had symptoms. If I had never had that education, who knows how many more asthma attacks or emergency room visits he would have?”

Another important, but perhaps overlooked success, is merely being paid for our services by health insurance plans. Most similar programs aren’t so lucky to receive reimbursement for their hard work. We get reimbursed by Medicaid managed care plans, Medicare and other commercial insurers. We have also been successful in raising grant funds and community benefit funds from local hospitals. It takes a lot of different funding streams, braided and blended together, to support our program, even with the insurance reimbursement. The funding is out there, you just need to spend the time to find it and combine the various streams to succeed.

ANWM owes our success to intentional collaborations with local health insurance plans, hospitals and schools, the people and entities helping patients (public health nurses, physician practices, community clinics, and our local healthcare HUB, Health Net of West Michigan) and our unique ability to blend different funding sources

Because of our success, other Michigan coalitions have formed and begun replicating our model—and they have also been successful in securing payment for similar services in their respective communities.

For more than 20 years we’ve worked hard to prevent adverse asthma events among our most vulnerable populations. We wouldn’t have been successful without the network of community resources and funding we’ve been able to marshal – and the ability, through home visits and social work services, to connect families to those services. Asthma cannot be cured, but it can be controlled. Individuals with asthma should expect nothing less.

Improving Lives & Saving Money by Extending Care from the Clinic into the Community

By Brenda Rueda-Yamashita, Chronic Disease Program Director, Alameda County Public Health Department

Asthma Start, which delivers in-home case management services, began nearly 14 years ago, when our local health officer wanted to intentionally address and prevent asthma—at the time, Alameda had the third highest rate of asthma in the state.

At the same time, First Five/Every Child Counts grants became available to organizations that wanted to focus on preventing adverse asthma outcomes for 0- to 5-year-olds.

In short, there was funding and a will to improve lives—and it can be magical when those two factors match-up.

While the initial grant was incredibly important, we’ve been able to grow and continue to implement the program by blending and braiding funding streams. For instance, we are supported by reimbursements from managed care organizations and funding from the hospital community benefit programs, private grants, tobacco settlement funds and sales tax revenue. As can be the case, promising programs disappear when an initial grant runs out, which makes braiding all these funding sources—which can be difficult—absolutely necessary to sustain the program over time.

Creating our approach

To inform our approach, we worked closely with local hospitals. They were uniquely able to provide referrals but also educate us on what questions (e.g., do you have mold, vermin, cockroaches, etc.) we should be asking of patients.

We quickly learned that the biggest benefit we could provide would be an in-home approach – you can’t separate someone’s health from the health of the environment they live in. Also, at the time, we spoke with a local doctor who knew her patient’s family was following her recommendations, yet no one was getting better and there were more and more adverse asthma events. Finally, the patient’s mother asked if the attacks could be because of the mushrooms growing in her home. When you hear that story, clearly a light bulb goes off: health is just as much about outside the clinic as inside.

In essence, Asthma Start sends social workers to meet with individuals and families affected by asthma to determine why medication isn’t working. We use social workers because addressing asthma, often, is not just about the disease but is psychosocial as well.

During these home visits, we make sure they have medication and are taking it correctly and outline the most common asthma triggers and how to address them. If needed, we also supply cleaning supplies, ranging from vacuums to dust mite covers to non-bleach-based mold cleaners. We also ask if they have stable housing, jobs, food, a doctor and insurance.

If we identify that a patient requires additional interventions, we can make referrals to our partners at Alameda County’s Health Homes program or other appropriate community resources, programs and organizations. Throughout the years, we have formed deep partnership with many local landlords, our housing authority, the district attorney’s office, schools, the biggest local managed care organization and many others.

Landlords

Clearly, we knew home triggers and poor living conditions were driving asthma attacks. The trick then is to get these alleviated. So, we sent letters and helped tenants send letters and we got issues addressed, sometimes. Seems simple, but it worked.

Housing Authority

In those instances where we couldn’t get a landlord to take appropriate action, it was incredibly important to connect with Healthy Homes and our code enforcement.

Now, Asthma Start, Healthy Homes and code enforcement meet monthly to conference on the existing cases. We identify the housing issues that are affecting a patient’s health and refer those to Healthy Homes which can, if necessary, work with code enforcement to make sure the poor living conditions are addressed.

District Attorney and Truancy Court

Our local district attorney found that many parents were in truancy court for chronic absenteeism because they said their children were having asthma attacks and couldn’t make it to school. These weren’t delinquent parents or children—they had legitimate issues.

Once we identified this issue, the district attorney began to refer every family to us that had asthma issues and they would complete our program, and usually start going back to school and never see the truancy court again.

The district attorney also does a training once a year when school starts to help school officials understand chronic absenteeism and how to refer kids to appropriate health services.

Schools

A lot of school districts have a School Attendance Review Board, which is a board of people who review why folks aren’t making it to school. We sit on many of these boards and if any health issue—asthma or not—is identified, we handle it. We make sure the case follows a similar structure and we get kids back in school. Research indicates that schools/society save about $40 a day per child that attends. If you take the 30,000 children in the U.S. that are out of school every day due to asthma, you are talking huge cost savings.

Chronic absenteeism is silently crippling the country: missing 10 percent of the school year is a huge risk factor for academic failure and, nationwide, more than one out of 10 students miss that much school every year. Asthma alone accounts for around 14 million absences each year and children with persistent asthma are more than three times as likely to have 10 or more absences than their peers.

Managed Care Organization

In around 2003, Alameda Alliance of Health (our main Medicaid managed care organization) wanted to leverage our asthma program. First, they had to find a code to pay for our work and found one related to health and behavior assessment.

We signed a contract with a specific amount of money that we had to bill against. This modest, but successful model, worked well for several years. Alliance, about a year ago, decided it might be easier to expand the program and refer all children that are seen in the emergency room to us and the program on a regular basis receives 20 referrals a week—children with asthma-related conditions are referred to Asthma Start, children with other conditions are referred to public health.

In addition to this reimbursement, Asthma Start is supported with funding from hospital community benefit programs, private grants, tobacco settlement funds and sales tax revenue. Braiding all of these funding sources together to finance the program isn’t easy, but is necessary to sustain the program over time.

Results

I think we’ve been so successful because we were the missing link in the continuum of care from the doctor’s office into the home and community. One recent Alliance patient was referred to us – we saw her at 5 and helped address her asthma. Now, she is 12 and her asthma is a problem again. They were referred to us and immediately the family felt at ease and a conversation started. The problem? Her new allergy medication pill was too big to swallow, so she couldn’t take it. In that one example, we realized part of what we do is just make it okay to talk.

We’ve also saved money, reduced symptoms and improved lives. Our interventions return about $5.00 to $7.00 for each dollar invested. The program has greatly reduced emergency department visits and hospitalizations with 95 percent of children maintaining/reducing their symptoms. And, through these reductions the program has been able to measure a cost savings of up to 50 percent for Alliance.

The bottom line: kids are getting to school and living healthier, happier lives due to Asthma Start. And this work is possible and sustainable because we did the difficult work of blending all the diverse funding sources available to us.

Western North Carolina (WNC) Healthy Impact

WNC Healthy Impact is a partnership between hospitals, health departments, and key regional partners working together to improve community health in western North Carolina. The initiative began with investments by hospitals and health departments in 16 western North Carolina counties. It brings together local health care partners in the health improvement process to jointly assess health needs, develop collaborative Community Health Improvement plans, take coordinated action, and evaluate progress and impact. Since 2012, WNC Health Impact has led efforts to standardize and collect data, create reporting and communication templates and tools, encourage collaboration, and provide training and technical assistance across the western North Carolina community. To read more about this innovative program, see this brief summary [link].

West Baltimore Primary Care Access Collaboration

The West Baltimore Primary Care Access Collaboration (WBPCAC) is a group of sixteen organizations that aim to improve the overall health of the residents of west Baltimore. The mission of the Collaborative is to create a sustainable, replicable system of care, reduce costs and expand the primary care and community health workforce. In January 2013, the WBPCAC was awarded a five million dollar grant from the Maryland Community Health Resources Commission to reduce cardiovascular disease in west Baltimore in the four zip codes with the highest disease burden and most intense social needs of any other community in Maryland. To date, this is being accomplished by improving access to and the quality of healthcare by hiring 23 health care providers and providing training to many others. The WBPCAC has also deployed 11 Community Health Workers into these neighborhoods to partner with 172 community members to maximize their utilization of health and social services. To read more about this innovative program, see this brief summary [link]

Wake Forest Baptist Health’s Supporters of Health

Wake Forest Baptist Health is working in Forsyth County, N.C. to improve health and reduce re-admissions and charity care costs for the hospital. In 2014, the hospital trained former environmental service workers as community health workers. The community health workers receive referrals from hospital staff when patients are discharged and from agencies outside the hospital, and then work with the referred patients, connecting them to community resources. Partners include faith communities, social services agencies, safety-net clinics, and the hospital’s care transitions and pastoral care staff. The program has reduced hospital re-admissions. Wake Forest is funding this work through its foundation. To read more about this innovative program, see this brief summary [link].

Visiting Nurse Service of New York Population Health Management

The Visiting Nurse Service of New York (VNSNY) is the largest free-standing home and community-based nonprofit health system in the country. VNSNY has established a population health division to provide care coordination to at-risk populations, employing strategies such as transitions of care, health coaching, caregiver support, community-based peer workers, hot-spotting, motivational interviewing, and behavior activation. The Institute for Healthcare Improvement (IHI)/Rockaways Wellness Partnership with VNSNY is an innovative, community-based intervention for improving the health of “at-risk” populations through proactive client engagement and self-empowerment. To read more about this innovative program, see this brief summary [link].