Housing as Health: Leveraging Payment Reform in Service of Communities
Dr. Oxiris Barbot, MD
A s a young chief of pediatrics for a large publicly funded health clinic in Washington, DC, during the late 1990s, I was concerned when child after child tested positive for elevated levels of lead in their blood. I began to suspect that certain buildings in our community — or even individual housing units — were responsible for serial lead exposure, because most of our patients lived near the clinic. After building a rudimentary database, I realized that my suspicions were correct. Several apartment units were responsible for poisoning dozens of children who had lived there. During my collaboration with community activists to improve neighborhood conditions, we decided to share my database with an attorney in the US Department of Justice. Ultimately, that database was used to bring judgments against delinquent landlords who had exposed children to lead by failing to safely remove lead paint. The restitution from those cases provided resources for the clinic and the community to address lead screening and abatement. That was my first lesson in understanding the importance of working at the intersection of health care delivery and public health.
As a pediatrician, it’s not hard for me to understand why a parent might choose to sleep with their baby, even knowing it’s unsafe, when their apartment is plagued with roaches and mice.
In the twenty years since that phase of my career, medical providers and public health practitioners have learned more about how housing affects health. We know that health and housing intersect with each other. Diabetes, for example, is much more difficult to manage for chronically ill homeless adults,[1] while people living with HIV/AIDS who report one or more nights of homelessness are more likely to visit the emergency room.[2] In New York City, poor housing quality (eg, cockroaches, mice, significant maintenance deficiencies, mold, or secondhand smoke) is associated with increased rates of asthma-related emergency room visits.[3] A 2015 study suggested that infants in New York City may be at higher risk of sleep-related injury deaths — even when parents own a crib — due to crowded living space, lack of heat, and vermin infestation.[4] As a pediatrician, it’s not hard for me to understand why a parent might choose to sleep with their baby, even knowing it’s unsafe, when their apartment is plagued with roaches and mice.
The New York City Health Department, where I currently serve as First Deputy commissioner, has been a long-standing leader in addressing public health and housing. We have made unparalleled investments in supportive housing, affordable apartments with on-site access to clinical and social services. New York has over 10,000 units reserved for those living with serious mental illness, substance use disorders, or HIV/AIDS. We have also been a national leader in promoting healthy housing to protect the lives of children through policies and programs that prevent lead poisoning and window falls. We are building an initiative to reduce environmental triggers in homes of children with persistent asthma through intensive integrated pest management. And starting in 2016, every family living in a homeless shelter with a newborn is eligible for visits from a health worker who will provide support and help them make connections to needed services.
Advancing health equity requires improving how doctors and hospitals give care and addressing the environments in which people live, work, and play — often referred to as the social determinants of health.
While the New York City Health Department has been a leader in addressing housing issues that lead to poor health, its portfolio of interventions has remained relatively static for decades. The new landscape of health care payment reform offers an opportunity for the Health Department to leverage its existing resources to expand opportunities to address health and housing issues. In 2015, New York joined a collection of states (California, Texas, Massachusetts, New Jersey, Kansas, New Mexico, New Hampshire, and Washington) that are instituting delivery and payment reform through the federal government’s Delivery System Reform Incentive Payment (DSRIP) program.[5] New York’s DSRIP program has been investing over $7 billion to transform how the health care system approaches Medicaid-funded care, with the goal of decreasing avoidable hospitalizations by 25% by 2020. For the Health Department, the DSRIP program provides a unique opportunity to partner with the health care system to further the agency’s mission of advancing health equity in service of all New Yorkers.
Advancing health equity requires improving how doctors and hospitals give care and addressing the environments in which people live, work, and play — often referred to as the social determinants of health. Now that patient outcomes are becoming a more central focus of health care providers, the New York City Health Department has begun facilitating partnerships of regional care providers which work to improve the health not only of specific patient populations but whole communities. The goals of these provider networks (11 of which were formed specifically to implement DSRIP in New York City) are distinctly aligned with the goals of public health.
The first step was using our convening role to put the leaders of those provider networks in the same room with a leader who had successfully transformed his health care delivery system. In March the New York City Health Department held our first convening, attended by 10 of the 11 New York City provider networks, along with officials from the New York State Department of Health, the Greater New York Hospital Association, and the Local Initiatives Support Corporation. Our keynote speaker, Dr. Sam Ross, CEO of Bon Secours Baltimore Health System, illustrated how a health care system leveraged health care payment reform to reduce avoidable ER visits and hospital admissions by creating 720 affordable apartment units and making other innovative investments in its surrounding community.[6] By hearing from a health care executive who had successfully invested in housing — and reaped the benefits — we hoped to inspire local providers to explore how they might invest in housing-related services for their patients. Following the keynote, the participants attended breakout sessions on housing-related services to address substance use, asthma, chronic disease, and smoking — all disease areas that are significantly affected by housing.
The second step was creating consensus among the health care executives that housing significantly affected their financial bottom line and that there were opportunities to collaborate on addressing housing-related concerns. The group quickly achieved consensus that housing was a major driver of costs and one of the immediate threats to meeting their targets, such as decreases in asthma-related ER visits or decreases in preventable emergency visits among people with an underlying mental health or substance use diagnosis. In addition, they clearly agreed that the New York City Health Department was in the best position to facilitate partnerships to address various aspects of housing, including stability, quality, and services.
Convening health care executives, at first glance, may not seem like a groundbreaking strategy for achieving health equity. Yet our collaboration creates a unique opportunity to fulfill both health care and public health goals, creating better outcomes for health care’s bottom line and for communities.
The third step was to identify existing resources that the providers could draw upon and establish actionable opportunities for collaborating on housing. In June 2017 the Health Department held a second housing-focused convening, attended this time by all 11 provider networks, the Deputy Mayor’s Office, 5 New York City government agencies, and 9 nonprofit organizations — all focused on various dimensions of housing. The goal of the convening was to begin identifying how to tackle the effects of inadequate and unstable housing on New Yorkers. The keynote speaker, Dr. Megan Sandel, associate director of the GROW Clinic at Boston Medical Center and principal investigator with Children’s HealthWatch, explained the science behind housing as health care, including how a history of evictions increases the odds of poor physical and mental health for mothers and children.[7] Following the keynote, attendees were sorted into sessions on housing quality, supportive housing, and eviction prevention, based on their priorities. The 125 attendees also collectively brainstormed how government, health care systems and community-based organizations could work together on housing in a way that one agency or system couldn’t do alone, including how to
- Identify ways to assist patients who are waiting for supportive housing;
- Partner to ensure that patients leave the emergency room appropriately connected to community-based organizations, peers, or legal help that can help them meet their housing needs;
- Create streamlined partnerships with the New York City Housing Authority and homeless shelters to help alleviate housing instability and to bring additional support to patients where they live;
- Identify best practices for supporting patients at risk of eviction due to behaviors associated with mental illnesses; and
- Identify ways to remedy gaps in community-based infrastructure and service shortages (eg, eviction prevention, food pantries) to ensure successful referrals.
Convening health care executives, at first glance, may not seem like a groundbreaking strategy for achieving health equity. Yet our collaboration creates a unique opportunity to fulfill both health care and public health goals, creating better outcomes for health care’s bottom line and for communities. Since neighborhoods with high concentrations of poor-quality housing are the same neighborhoods with disproportionate burdens of uncontrolled chronic diseases, improving coordination to promote housing quality and stability is synergistic for public health and the health care delivery system. The partnership we have cultivated between health care providers, housing organizations, and us at the local Health Department has already resulted in a better understanding among all participants of how important housing is to health, how specific communities have greater housing needs than others, and how we might all collaborate to expand access to the specific housing-related services those communities need to thrive.
While we are still early in the process of determining the full extent of the value that public health can offer to housing in New York City, we already understand that the discussion will have to go beyond individual housing units or even buildings. Issues like gentrification and displacement, neighborhood rezoning, and housing supply are all unavoidable topics; and the extent to which we can or should tackle these issues is yet to be seen. The future holds great promise for wisely leveraging public health and health care investments to yield better population health outcomes faster. Housing is more than just health care; it’s prevention and treatment. In other words, housing is health.
[1] Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA. 2009; 301(17):1771–1778. doi:10.1001/jama.2009.561.
[2] Wolitski, RJ, et al. Randomized trial of the effects of housing assistance on the health and risk behaviors of homeless and unstably housed people living with HIV. AIDS Behav. 2010; 14:493–503.
[3] Bringing a Health Lens to the Housing New York Plan. New York State Health Foundation and Kresge Foundation; June 2015
[4] Chu T, Hackett M, Kaur N. Housing influences among sleep-related infant injury deaths in the USA. Health Promotion Intl. 2016; 31(2):396–404. doi:10.1093/heapro/dav012.
[5] Heflin K. Driving health care innovation through DSRIP: state of the states. Center for Health Care Strategies, Inc. Web site. Published October 20, 2016. Accessed October 13, 2017.
[6] Bon Secours housing. Bon Secours Web site. Accessed October 13, 2017.
[7] Sandel M, Sheward R, Sturtevant L. Compounding stress: the timing and duration effects of homelessness on children’s health. Insights from Housing Policy Res. June 2015. Accessed October 13, 2017.
Dr. Oxiris Barbot is First Deputy Commissioner of the New York City Department of Health and Mental Hygiene, the largest health department in the nation. She also served as Commissioner of Health for Baltimore City, Medical Director for the New York City Public School System, and Chief of Pediatrics and Community Medicine at Unity Health Care, Inc., in Washington, DC.
