2015 Public Health Grand Rounds 11/20

PUBLIC HEALTH GRAND ROUNDS Linking Research to Community Health Improvement

(audience talking)
- So good afternoon everybody,
I think we'll go ahead and get started.
Hopefully this is working.
We're a couple minutes late, but,
people are still trickling in,
so help yourself and come on in.
I'm Dr. Theresa Green.
I am the Director of Community Health Education and Policy
at the Center for Community Health,
and I, along with Dr. Lee from Public Health Sciences,
work hard to organize and put on these
Public Health Grand Rounds for you.
Public Health Grand Rounds are intended
to show how research and community health improvement
work together, to improve the health of our community.
And we have a great example of that today.
So, thank you all for coming.
Our next speaker will flash up here as well,
the first week in December, so, you're all invited to that.
You all should have received an evaluation form
when you walked in.
Please fill those out, we do read them,
and we use those to inform our speakers for the next series,
which will be in the Spring, after Dr. Grove.
Today we're thrilled to introduce our speaker,
Mr. Kevin Kennedy,
who is known as an indispensable national resource,
in healthy homes assessment.
And those are not his words, those are other experts' words.
Mr. Kennedy is the Director of the Department
of Environmental Health, at Children's Mercy Hospitals
and Clinics in Kansas City.
And he has been involved in Environmental Health Science
and Industrial Hygiene Chemistry consulting,
for over 25 years.
His unique program started 15 years ago,
to provide patients, childcare locations,
and schools with resources,
to assist them in identifying and reducing
indoor environmental exposures,
that may result in health problems.
They perform research on indoor environmental health issues,
focusing on home interventions, exposed assessments,
and recently on geo-spatial analysis
of housing and health issues.
The Department of Environmental Health Services,
as a regional partner for the Healthy Homes Training Center,
training professionals in healthy home assessment.
Mr. Kennedy serves as an instructor,
for the Indoor Air Quality Training Institute,
serves on the Curriculum Committee
for the National Healthy Homes Training Center,
and was an instructor for the CDC's
National Healthy Homes Training Center.
Mr. Kennedy received his Master's Degree in Public Health
from the Kansas University Medical Center,
and his bachelor's degree in Natural History,
and Environmental Science, from the University of Kansas,
where he also received teaching certification
in Secondary Science.
He previously worked as an environmental analytic chemist,
researcher in extraction metallurgy,
and as a restorative carpenter and woodworker.
A little bit of everything, that's terrific. (laughs)
Mr. Kennedy is also a sponsor today, additionally,
by the UR Environmental Health Sciences Center,
and Dr. Katrina Korfmacher,
Associate Professor in Environmental Medicine,
has worked extensively with Mr. Kennedy,
and has been instrumental
in having him come here today to join us.
So I'd like Dr. Korfmacher to give a few words as well.
- I don't want to take any more of Kevin's time
than necessary, because I know that,
he's got about eight different talks.
I wish you could all hear all of them.
But because of this, the community connections
to what he's talking about,
I want to set just a little bit of context,
for how he came to be here, right now.
So, as many of you know, I've been working in
Healthy Homes in Rochester for 15 years,
and many of our partners are here,
thank you for joining us.
And whenever I ask people for examples from other cities,
they always tell me to go and find Kevin Kennedy.
So I'm really thrilled that he's here.
In fact, last Spring, he sent two of his trainers here
to train our Healthy Homes,
our very first HUD-funded led in
Healthy Homes Grant Inspectors,
in how to do these kind of inspections.
And his staff were fabulous, so we're really lucky
to have him here, to share the big picture as well.
I think the theme that I keep hearing is,
I hear him talk is comprehensive and integrated system.
So, you know, he arrived yesterday morning at 5am,
and has been going ever since.
He gave a talk at the American Lung Association,
for people involved in the Community Asthma Network,
and he gave a talk at the
Monroe County Department of Public Health,
also speaking with some people from Human Services,
and then followed that on with a conversation
about healthy schools, with people who are involved in
school assessment, child health,
student performance, and absenteeism,
and how all of those things connect to school environments.
This morning, he spoke with people about doing research,
using some of the data that kind of connects
health and housing, and drawing parallels to the work
that he does in Kansas City.
And with the Safe and Efficient Housing Initiative
of Rochester, which is trying to start a similar system
here in Rochester.
So I just wanted to set that community context
for what he's going to share with us today.
But this environmental assessment,
the payer side of it, how you get this all sustained
over time, and the research, are all integrated
in what he does there.
And for all of you, I hope that it will connect
to your work in some way,
and think about how it connects to what you do here
in Rochester, and how we might learn lessons,
for what we do here.
So that's your charge as you listen to Mr. Kennedy, thanks.
- So, I'm not sure how to, okay.
Well the truth is, I'm just a guy.
(audience laughing)
I'm a guy who has a variety of passions and interests,
and I am fortunate that I was able to combine those
passions and interests into one area
where I can think about a variety of things.
So, you heard, I guess, some of my background.
Maybe a little too much, maybe.
(audience laughing)
I can tell you about my family, if you really want to know,
but, the point is that, when I came for my interview
15 years ago at the hospital,
they were looking for someone who could help
establish and lead a program on Environmental Health.
But they really wanted someone who had,
some kind of experience in Environmental Science.
And, well, I had come from the Private Sector
at an Environmental Engineering firm,
so I had some work experience, and they said,
"But, we really wanted somebody who had some lab experience,
if you could help us beef up our analytical capabilities."
I thought I turned it on.
Test, test.
Hear better?
Sorry about that.
And I, it turned out that I had years
as an analytical person.
"Well, we need somebody who knows something about housing,
'cause we want to have a Healthy Home program."
Well, I worked as a restoration carpenter and woodworker
for a number of years, and I have worked on houses
and know how they're built, and how the systems
are supposed to work.
"So, we really need somebody who can, maybe present,
and is comfortable out in the community, talking to people."
Well, actually, I'm certified to teach,
and I'm comfortable talking to people of all ages.
So it was, I was the only person who interviewed
who actually could answer all the questions,
and had some kind of experience.
So it was like this, perfect interview,
and I'd never had one before, and I've applied for,
I don't know how many jobs, and didn't get them,
but this was like this, perform storm,
of I could answer every question they asked.
And I walked out of there just,
uncomfortable with how easily
I could answer all of those questions.
Well, apparently it was enough that they were
willing to hire me, and we've been very fortunate
to be involved, and, full credit to the person
who hired me, Dr. Jay Portnoy,
who's the Division Director for Allergy and Immunology,
in that, he gave me the autonomy,
the charge to do what I thought needed to be done.
And he gave me the autonomy
to see if I could make it happen.
He also happened to give me a nice little budget
to start with, but once we got it going,
and got the right people hired,
the rest has been history.
So we now have a staff of seven,
including four Environmental Hygienists, including myself,
and all of those people are involved
in a variety of programs.
It turns out, most of them actually wear a hat,
and are managers of a program,
because we have so many different kinds of programs,
working in homes, schools, childcares,
training of health providers, training of the community,
outreach and advocacy, and then all of that work
supporting research of different types and kinds.
But really, fundamentally, about what we do,
and what the healthcare system is doing,
is catching up with the concept of Upstream Medicine.
With the Affordable Care Act,
there's been an intent for a philosophical change,
to put more focus on preventative care,
because the mission of the Affordable Care Act,
is to try to provide better care at lower cost,
but a better quality of care.
And part of that mission is the recognition
of the role of preventative care,
but also the role of the social determinants of health,
in that larger care model.
And I'll touch on that a little bit.
But, the first thing I want to do,
is to change your thinking about the concept
of the social determinants,
and ask you all to start using the term,
"the social contributors to health."
Because the determinants means they can't be changed,
and the contributors can.
And the things that contribute to poor health,
in the community, can be changed.
So, the reality is, that,
people don't experience
their health problems at the hospital, that I work at.
They come there for a visit,
they come there for a treatment,
but the vast majority of time,
managing a chronic health problem is spent in the community.
But especially in people's home.
So people experience illness in their homes.
And everybody in this room, in their lifetime,
will experience some kind of chronic health condition.
Whether it's chronic pain,
whether it's associated with mental illness
or mental health issues, whether it's allergies,
whatever it is, everybody, at some point in their lives,
is exposed to or deals with some kind of
chronic health problem.
So under that Affordable Care Act Initiative,
following what are called the Triple Aims,
and those of you that aren't familiar with that,
you should look that up on the web.
Triple Aims are just better health, better care,
and reduced costs.
And they're doing this implementation
of the Affordable Care Act, and this health care model,
following what's either called the
Patient-Centered Medical Home Model,
or the Health Home Model.
But fundamentally, the idea is that,
the care and the coordination of care,
is integrated around the patient and the provider.
The provider being the primary coordinator of care,
the primary care provider.
So this could be a family practitioner,
a pediatrician, whatever.
But the care is being coordinated out of the clinic
where that family, or that patient,
in our case, pediatric patients, is managed.
And that provider has a inner circle of services
that they depend on.
The pharmacy, the hospital, whatever.
But there is this outer circle,
that is now becoming more included,
as we look at those social contributors to help,
and how can we manage those?
And how can that provider have a connection
to these outside services, to the school, to the home,
to housing agencies, to community agencies
that provide service?
How can they connect with them and communicate with them,
in order to facilitate the care and quality
for their patients.
So for us, we have spent many years going into homes.
We go into homes of significantly ill kids,
or of kids with significant environmental problems.
Those are the two reasons that bring us to a home.
And so we have a very advanced level of involvement.
In some cases, in many cases,
it's a pretty straight-forward level of involvement,
and I'll touch on that.
But what's happened over the years,
we started in allergy/asthma,
and then as we've worked with asthma patients,
and more of the hospital became aware of our practices,
our ability to get into the home,
to communicate across the system,
more health conditions, the provider understood,
there was a role that the environment played,
in managing that health condition,
so, for Immunocompromised patients,
or for certain Pulmonology patients,
the environment can be a significant risk factor,
and, they found for the first time,
they have the opportunity for someone to go
and visit the home.
But we were able to move out from under the
allergy/asthma umbrella,
and now we're an independent department at the hospital,
and serve the entire hospital, and can get a referral
from anywhere within our hospital system.
So we have 7,000 employees, and any of those providers,
within that system, whether it's the physician,
whether it's the nurse, the social worker,
the respiratory therapist,
anybody can put in for and recommend
an environmental consult.
Because our experience has been, in engaging families,
they don't report everything, just to the physician.
There's information that can pop up with a social worker,
who might have gone in to visit the family,
and they get a report of significant environmental problems,
that maybe it's the kind of questions people are asking,
that elicit the information that wasn't being heard before.
So, if we have an opportunity to get that information,
there's an opportunity for them to offer that referral.
And this shows the components that are involved
in that process, once they've been referred to us.
For a number of years, we have developed and advocated
for this particular model, with emphasis that the role
environmental assessment plays
is in guiding exposure reduction.
The focus of why we go to a home,
is because there's some kind of help or harm going on,
and, traditionally, people have gone,
looking at a specific contaminate source,
and have focused on the source.
But we have advocated that, you can't just look for,
say, the roaches in the house.
You have to look at why there are roaches in the house.
So we have to look at, what are the reservoirs,
within that home, how's the home built, designed,
maintained, how are those reservoirs,
proliferating or exacerbating the contaminants
that we're concerned about that are causing the exposure,
leading to the health problem.
And then what facilitating factors contribute
to the proliferation of that contaminant?
And the truth is, if I'm gonna try to address
the contaminant sources, or the roaches,
I really need to try to address those reservoirs
that are facilitating factors.
I need to address all of them at once.
And the Healthy Home concept is to take comprehensive,
holistic approach towards how you approach issues in a home,
and the same is true here.
When working with patients, we have to take a comprehensive,
holistic approach to how we manage their health,
their concerns, and in our case, the exposures
that are exacerbating their disease.
Whether it's asthma, whether it's lead poisoning.
There's a variety of reasons why they're being exposed,
and we try to address all of those reasons.
So we have a couple of different ways
that families are referred to us, shown here.
And then, different types of funding sources.
So, I've been fortunate enough to, or, unfortunate enough,
to be involved in trying to advocate for preventive
care and healthy home services for 15 years.
And early in that time, we were fortunate
to have health insurance actually pay
through the HMO model.
We could advocate for a family to,
a person who was coordinating services,
and they could approve the home assessment,
and then we could go and provide that service.
But now, under the current PPO system,
where you're part of a network,
or you're in the network or out of the network,
for my kids' orthodontia, we had to travel 60 miles
to go with the in-network orthodontist,
so we could get the right care and cost.
Well that type of model has disrupted our ability
to get any kind of reimbursement through
traditional managed care.
They don't consider the service we provide
part of the approved network service.
So, now we don't get paid anymore.
So we do it mostly through grants, foundation grants,
federal grants, different types of efforts to fund it.
But also, because we are a non-profit children's hospital
that provides service without regard for ability to pay,
hospitals that are non-profit have to prove
the value of their service to the community.
You have to show you are a benefit to the community.
You have to do a community-needs assessment,
and show that you're spending money in the community,
that's why you should have that non-profit status.
Our last community-needs report showed $170 million
in free health care provided to the community,
because we are a safety-net hospital,
that provides service without regard for ability to pay.
So, fortunately, I work for a hospital
where the administrators are champions and understand
the role that social contributors to health can play
in health management.
And they allow us, and we have the philosophy,
under community benefit, that if we have a child,
that a physician says,
"We think there's an issue in this environment, and we need
your team to go there," we are going to that home.
And we're very fortunate now, to have that.
We still try to seek funding, and we're involved actively
in reimbursement through Medicaid now, locally,
and have advocated for reimbursement for asthma home visits.
But we still are going to provide that service.
So we're very fortunate for that reason,
to be able to get into homes.
These are some of the conditions that we see and deal with.
So different types of health conditions,
we're dealing with families, patients that have symptoms
that are perennial and flare on exposure,
or the environmental exposure is known to,
or suspected of triggering their symptoms,
that continued exposure is likely, and then,
the patient has some control over that environment.
And by that, I don't mean, they own the home;
we go to lots of rental properties, but that they have
an environment that they can actually actively try to change
the conditions to what they're being exposed to.
And if they can't, we're gonna find out
who does have control, and we're gonna try to help them
advocate for changing that environment.
Because it's leading to health problems for that child.
We also see patients that have symptoms that don't
respond to the regular treatment.
So those of you that are familiar with asthma,
how many of you are familiar with asthma management?
Better raise the hands higher, since it's harder to tell.
So many of you.
So you know that if you have an action asthma plan,
you have a management practice that you give them,
and for some of them, you put them on a regular treatment
because they do have persistent asthma,
but, the second bullet there,
they're responding to the treatment, but maybe
they have to be treating it constantly;
they're always in what they call their yellow zone,
and running into the red zone,
and back into their yellow zone.
So they're going into EB, coming back out,
never really adequately controlled,
and under chronic management effort
to try to manage their disease.
Which suggests sometimes, that that environment
is playing a role, and, for us,
we often see that that is the case.
A significant environmental issue
that people are dealing with.
So, I want to point out a couple of things
since this is the Grand Rounds.
I want to bring up some other things.
We've been involved nationally in a variety of efforts.
One of the problems we ran into early on,
is that there was a big chasm between,
what providers understood about the environment,
and what they understood about,
what to talk to patients about, what to look for
as far as health effects, what the interventions can do,
which ones does the research show have effect?
So I've been involved with the joint task force
for the American College and the
American Academy of Allergy, Asthma, and Immunology,
and these practice environmental practice parameters,
these are published parameters, clinical practice guidelines
associated with environmental assessment,
and these particular types of allergy sources.
So, those of you that are health practitioners,
you can look up in the Guidance Documents
for furry animals, rodents, roaches, and dust mites,
and they are very specifically,
what the health effects are, what the allergens are,
what the literature tells us the allergens are,
why people are allergic to them,
what the taxonomy in the case of roaches, or mites,
as far as, how they related evolutionarily,
and then, what we know about the health effects,
what we know about assessment,
and what we know about intervention,
and the effectiveness of different types of intervention.
So, it's a very practical document for clinicians
who are looking for the guidance.
And the mold one is an interesting story,
because it became very controversial,
because of the whole question of,
what the health effects are, associated with mold,
what people should do about mold?
It became so controversial that they,
rather than try to produce a parameter that was
full of controversy and debate,
according to some people,
we are splitting it now into six papers
that will be published in a theme-based issue in the
"Journal of Asthma, Allergy, and Clinical Immunology
and Practice," so it'll be this thematic issue about mold.
Those guidelines include, for the clinician,
some decision-making trees and algorithms.
So when clinicians don't have the ability
to get out into homes, or to engage people like me,
healthy home programs, we developed at least some
practical things they can do in the clinic,
and ask patients about, when it comes to a particular
type of exposure.
So if they've got roaches, and you're not sure
what to tell them,
"Well you just told me about roaches?
I don't know what to tell you about roaches,
I don't know anything about roaches."
So, this is a way for a clinician
who's dealing with families who might be dealing
with these different types of pests or allergens in a home,
giving them some decision-making that they can use,
both for themselves,
but also for people within their clinics.
So, maybe it's not for them to ask all of these questions,
but maybe they can ask initial questions,
and based on those answers, they can follow up,
and ask about more questions.
So for the dust mite parameter,
we gave, not only a specific questionnaire,
but also guidance based on the geography
of where a person lives.
Because, as it turns out, with dust mites,
it's really about moisture management.
And if you can effectively manage the humidity
and the available moisture in a home,
you can almost eliminate the amount and prevalence
of dust mites in a home.
But it's really challenging, because dust mites
are highly adapted to survive,
and actually go into a dormant state,
they actually desiccate and go into a dormant state,
and can be that way for months,
until new water becomes available.
So once a room becomes humidified again,
they re-hydrate, and they will rapidly reproduce,
and then can go back into a dormant state.
It's just part of their evolution of survival.
They're just evil, nasty little creatures.
They should be eliminated from the planet!
So, we further that questionnaire by giving them
additional information about what parts of the house
they should be thinking about,
how those things might be treated,
and what the evidence says about the efficacy
of these different types of interventions
to mitigate for dust mites, or for these other parameters.
I just wanted to point that out,
that we've worked on those guidelines,
they're out there, they're available for clinicians to know,
and ask, and educate, so you can use that.
But you really want to work out in the home.
So, coming back, one of the fascinating things
we're publishing here this Fall,
is, we did an analysis of our health data,
our utilization data, defining all of the utilization
as Acute Care Visits.
So an emergency room visit, a hospitalization,
an after-hours visit, an urgent care visit.
All of those defined as Acute Care Visits,
and we took the patients for a four-year time frame,
and we looked at them 12 months prior,
and how many Acute Care Visits they had,
and how predictive of that, was a future Acute Care Visit?
In the next 12 months, what's the likelihood
of that patient coming into the clinic
with another Acute Care Visit?
And what this shows me is,
for their historical Acute Care Visits,
if they had no visits, the probability of a future visit
was pretty low.
But just by having one Acute Care Visit,
the probability was significant for them to
be likely to have future Acute Care Visits,
by having that one Acute Care Visit.
But we found this linear relationship,
and it really jumps up to the point where,
when you get to three Acute Care Visits
in the last 12 months, the likelihood of you having
a future Acute Care Visit, is in this 55 to 60% range.
At five or higher, it's 80 to 90%, almost 100% likelihood
of a future Acute Care Visit.
So that, to us, was very eye-opening.
And we now use this as part of our
high-risk asthma protocol.
One of the first we ask when a kid gets admitted
into the hospital is, what's their past utilization?
Do we have any kind of history on them
that we can look at,
and based on that, if they are above this
two-to-three range, they are in the high risk protocol.
If they're in this two range, then they get another,
they get the same services, but they're not considered
high-risk yet. (laughs)
We are monitoring them over time, so we can see.
We're fortunate to be the only pediatric hospital
in our community, so we have about 70% of the market,
so a lot of these patients, we are their primary hospital,
we also might be their primary clinic,
so that makes it very valuable for us.
So we use that step to understand their utilization,
their likelihood of a future Acute Care Visit,
and we target our services based on what we know
to be their concerns.
So we reach back out to the family within two business days,
we're out in the field a lot.
We collect an environmental history,
additional information that we have about the family.
We meet on a weekly basis to talk about the cases
that we've had; we get about 30 referrals a month,
right now, in our system.
So we talk about the case, talk about the information
we've collected, and then look at that total environmental,
or total asthma risk, that we've calculated,
to see what level of service we might offer them.
Then we'll make some determinations of what kind of
services we need to provide.
So, we have that health care utilization,
so that's that number of visits,
we do the asthma control test,
which is a fourteen-question test that looks at both,
recent symptoms and problems, as well as quality of life,
and you use that score to see
how well they're managing their disease.
So that tells us their current control;
this tells us their past, challenges,
and then we have this environmental risk test,
where we, it's called "Tell Us About Your Home,"
but we're asking a ten-question survey,
to try to characterize what the potential risks are
in their home.
And some of the questions are about the history of the home,
what are the contents of the home,
but, a key set of questions are about
recent exposures.
So, how many times have you had moisture
or water problems anywhere in your home?
And your response options are:
In the last week, in the last month,
in the last three months, in the last six months.
How many times have you had pests observed
anywhere in your house in the last week, in the last month,
in the last three months, and the last six months?
And then, that can be tabulated and scored,
and we can see, do they have any recent environmental risk
exposures, or are they all older,
or have they had no environmental risk exposures?
But we can use that environmental risk in combination with
utilization control, and we just have to try to identify
what level of the service we want to provide.
Is it a low-risk utilization,
and are we just providing education,
or is it high-risk, or poorly-controlled,
and we need to do some pretty intensive
environmental investigation?
So it's divided into these two,
generally basic assessments and advanced assessments,
but then our advanced assessments can have
levels of advanced assessment above that.
So there's a level two, level three, level four,
depending on the level of disease,
and complicated medical condition,
and then the level of environmental problems,
we may do a significant measurement and diagnostic
of the building, we may do sample collection and analysis,
and data interpretation, it just depends on
what we want to understand about the exposure.
Remember, our goal is exposure reduction,
so we need to understand how they're being exposed,
and what kind of recommendation we might make,
to reduce that exposure.
So, that's all part of a timeline.
The evidence shows that for pediatric asthma,
the most effective intervention programs
generally be between four and nine visits,
and that means touches or interactions.
That doesn't have to be a visit for
in the home specifically,
but some kind of regular communication with the family,
as you advocate for them to change behaviors,
change their practice, you need to be having
recurring conversation to verify that they're doing
what you're asking.
And sometimes that's a great challenge,
and sometimes it works very well.
We use a five visit model, and then,
typically we're involved for three to six months.
So, when we engage a family,
we ask them to enroll in a program.
So they are participating in a program,
and by participating in that program,
they get some specific services.
They get some of what we call a Healthy Home Kit,
so there's some benefits for participating in the program,
along with the education that they get.
So, the other aspect of our work, and of your work,
that I like to point out to people,
is that you're dealing with the rational side of people,
and the emotional side of people.
And many of the calls we get,
are people who have a lack of knowledge,
or are scared because of what they've read on the internet,
"oh my god, I just read on the internet that mold
is killing everybody on the planet, and I don't know
what to do, and I think there's so mold in my bathroom,
and oh my god!"
And people just work themselves up into a frenzy,
and anxiety, and I know those of you that are clinicians,
and have people come into your office,
about an office visit, and you hear, people confide,
and all this scary stuff they've been reading,
or that they know about such-and-such.
So a lot of what we do, is deal with that emotional side,
and when we're in their home,
they're pointing things out to us,
and telling us what they have concerns about,
so our effort has to be to try to rule out their concern,
calm them down, get them to think rationally about things,
and take away some of what they've created,
the noise in their lives.
'Cause, what our social workers call it
is the "signal-to-noise ratio."
So, we may be there to teach about asthma,
that's our signal,
but if there's so much noise going on,
that they can't hear our signal,
then we're wasting our time.
We're not going to see change,
we're not going to see them respond to
what we're trying to get them to change in their lives.
And sometimes that's significant cycle-social issues.
Sometimes we have to have social work involved.
Sometimes we have to refer to
other agencies in the community.
Sometimes it's a medical/legal partnership
to help us deal with legal issues.
All so that we can help this family reduce this noise,
and focus on what their concerns are.
And when it comes to the home, we're focused on issues
that specifically might be going on in their home,
and we want that focus on what we think the issues are,
and not something they've read on the internet.
The other part of that is the importance of home
to a person's life.
If you think about all of the Christmas mornings
you've had with your family, or significant birthdays,
or Halloween parties, your home is a point of memory,
a point of reverence to many families.
It's a tremendously valuable, important place,
and when you look at the American Housing Survey
that asks people about the physical conditions
of their home,
in spite of reporting significant physical problems
with their home,
people will always rate their home,
more than 80% of the people who respond to the survey
rate their home eight, nine, or ten.
So they rate their home, in spite of the conditions,
very high.
They rate it that high because of its important value
to their lives.
You talk to homeless people,
they do not like to be homeless.
Having a home, having a place of safety and security,
is tremendously valuable to mental health,
and mental health has a direct role in physical health.
You don't have to be mentally ill to be affected by
a mental health issue.
And we are emotional people.
Spot's the rational one.
(audience laughs)
So, the process is one of comprehensive assessment.
We came, focused on asthma early on in our work,
but recognized that, when we're there about asthma,
we can't focus just on the asthma triggers.
We really had to step back and look at the whole home,
look at the home as a system,
look at all the mechanical systems in the home,
look at the components of the home,
we needed to understand about those things,
and what role they play in exacerbating exposure.
I might have air move through a house,
but what are those exposure pathways
and pressure differentials that contribute to exposure?
If I've got mold in a basement,
and I've got a kid who's mold-allergic,
but he sleeps upstairs, how is he being exposed?
What is that exposure pathway?
Can I understand it, by understanding how the house works,
and maybe taking some simple measurements
to understand pressure dynamics within that house.
I want to inform my assessment,
and be able to adequately characterize the risks
and the potential for exposure.
We follow those two big principles.
I hope most of you are aware of these
healthy home principles.
If you're not, you can download this, but
these are the seven keep-at-home principles.
Dry, safe, clean, well-ventilated, pest-free,
contaminant-free, well-maintained.
People who read this list, especially I've had
health providers tell me,
"Well, that's a pretty simple list, it seems like
kind of a simple concept."
Well that's actually the whole point.
If you think about health literacy,
and you think about the language level,
our reports that we write for families
are supposed to be written at a 3rd-grade level.
I would assume, those of you that work for a hospital,
that is your standing policy,
that anything you communicate is supposed to be
at a 3rd-grade level.
So the idea here, is to keep it simple.
You can understand the concept behind "keep it dry,"
and what cyclometric is,
and the relationship between
temperature, humidity, et cetera.
Families just need to know they gotta keep it dry.
And if they can follow that practice, they'll be doing fine.
So we translate these for our assessment process,
into these domains:
air flow circulation, allergy adjust,
moisture control, chemical exposure, taking preventions.
Again, even though we're there about asthma,
we might be there about environmental exposure.
Because we're there, and we might be the only
group to touch with that family
in the past six months and maybe for the next year,
if we see a safety issue,
then we're going to try to address that while we're there.
We feel we have that duty.
We're there about comprehensive care of that child.
So we take those domains,
and then, in our assessment protocol,
we have specific questions,
items that we look at,
and assess then characterize as we walk through a home.
So we are making observations.
This says "okay, concern, take action,"
so, is something okay, is it a concern,
or do they need to take action,
on an individual line item,
but then those are tabulated for each of the domains,
and we can get a score for each of the components
in that room, and then have a total room score.
And then we also, on the right-hand side here,
tabulate any significant hazards that we see.
And we have seen some unbelievable things
that people do in their homes.
Gas cans in their closet,
people decide they want to butcher animals in the basements,
really bizarre stuff that people decide to do.
Arsenals of ammunition that I, it's phenomenal that
a third world war is coming, in their mind,
and they're loaded and ready for it.
But it's not for us to judge.
We're there about their child's asthma stuff.
So, thinking about these domains, what do you see here?
First, what age child do you think we've got going here?
Pre-teen, 12-year-old.
Is this a typical 12-year-old?
Those of you that have 12-year-olds,
is this a typical 12-year-old?
Raise your hand.
Wow, no hands?
Or no 12-year-olds?
(audience laughing)
I could tell you, I've got four kids,
they're all adults now, they all survived,
but, pretty standard for them too.
They seem to, is this that emotional/rational?
They reach about 25 and they become rational?
It's like, wow, my house was a dump before,
I need to clean this place up.
My dorm room looked like hell.
Or, is that true of some of you?
(audience laughing)
So, do I have airflow and circulation?
Any evidence of a supply event or a recurrent event,
we don't have good air circulation.
Allergies and dust, would that be a problem in here?
Is this a cleanable room?
I heard a "yes" and a "no."
Is it cleanable?
If you get rid of all the stuff.
Could I walk in today with a vacuum?
And vacuums are very, very great devices,
everybody should have one.
Don't sweep.
So I've got lots of allergen reservoirs.
So, when I have lots of layers of bedding.
If I add moisture to this room,
I've got lots of items that can hold moisture,
it's called a moisture source strength.
So these things can hold a lot of moisture content,
so if I've got high humidity,
then I've got this dynamic moisture cycle,
and I can have a lot of available moisture
for all sorts of microorganisms to thrive for quite a while.
So if I add dampness, and I have reservoirs,
and it's not a cleanable space, and dust can build up,
now I've created ideal conditions
for a whole lot of exposure.
And if I've got a chronic health disease,
where I respond to what I'm exposed to,
then it's gonna be difficult to manage my disease,
if I've got all of these conditions.
But what a lot of families do
is just plug in an air freshener,
because it doesn't smell so good,
so I'm gonna plug in these air fresheners,
and add this kind of chemical vapor,
and I'm thinking I'm making it better,
when it turns out that makes it significantly worse.
And actually there's a synergistic effect
of the combination of being exposed to the fragrances,
and to the allergens, and you become more sensitized,
and likely to react to the allergens themselves.
We've converted all that into software,
so we have this web-based version,
and we can do this off of a tablet,
and collect a whole bunch of information.
Point that out.
This is what the files look like.
So families get a copy of this checklist.
We found out early on through our process,
we've been at it long enough,
that when we did just a checklist,
and we came up with what our deficiencies were,
what the problems were, and we sat down the families
to talk about all the problems,
and we said,
"Well, there's this issue with your house,
and this issue, and we've got this problem,
and you're not doing this right,"
they would just shut down.
"You're just telling me my house sucks, go away,
I don't want to talk to you anymore.
Anything you tell me is of no value to me."
Because our goal here is to build a rapport,
a relationship, trust, so I've got to be encouraging
in order to get them to change.
So this is written in a way, and scored in a way,
that we can tell them things that are green, and good,
"you're doing these things well, this is great!
But we have this concern, and we scored this in yellow,
because we have a concern about the guttering,
or we have this concern about allergies and dust."
Or we have things that are color-coded supposed to be red,
but they're pink here,
meaning you need to take action.
This is significant enough, it is very likely
contributing to your health problem,
or will at some point in the future,
and should be addressed immediately.
And any of those tabulated acute hazards,
these are immediately dangerous,
and we see immediately dangerous conditions
in people's homes.
Gas leaks, carbon monoxide,
threats that we are able to measure and show,
that they have.
Somebody could die today,
if they didn't change the conditions
that we're finding when we're there.
So we've found this to be very effective,
in getting them to work with us,
to try to change their conditions.
We do the same with quantitative data,
and measurements data, we use color coding
so they can see which things they should be concerned about,
which things are okay, and educate about,
what these things mean.
They need to know why we're collecting this information.
We use that information to develop a Healthy Home Report,
an action plan.
So we tell them what the issues were,
and then give them a guide, or action,
for what to do that can change those conditions.
We use that information to decide what interventions
we might recommend, what repairs we might recommend.
We tabulate those interventions based on the domain,
and over the years, we've developed a list
of about 130 common home repairs we find
that are beneficial, when changing a condition
associated with the domain.
But we also know what the average cost is for those things,
and we can come up with, at our case review,
what our projected cost for repairs and things
we're recommending to reduce exposure.
Remember, our goal is to reduce potential exposure
leading to health problems.
That's used to generate a scope of work.
So we write a specific description.
We have housing partners, we can share this information,
or they even participate in our case reviews,
and they can agree with us on what recommendations
would be made, for making those changes.
We use that information, but then go do the work orders,
get the work done,
and then, if you look at that timeline close enough,
we have a follow-up assessment,
verification the work was done,
verification that the environment has been changed,
and we're monitoring the health of the child
through the whole program.
So this shows the average cost of all of the interventions,
not that healthy, we give every family a Healthy Home Kit,
so we give them a kit they can,
if it's a rental, they can take those things with them.
It's evidence-based things, like a vacuum, like I said,
very good to have.
Vacuums, mattress encasements,
furnace filters, high-efficiency filters,
a cleaning kit, a safety kit, but the evidence says
that you need to use these things together,
multi-faceted, target interventions for asthma management.
So, if you look at the
Community Guide for Asthma Control CDC website,
the research is very clear, it has to be multi-faceted.
Mattress encasements by themselves do not work.
The are not effective without the combination
of moisture management, regular vacuuming, regular cleaning,
you've got to do all of these things in combination.
This is just an example of all of the different
types of interventions we've done.
We've found a tremendous number of homes,
where there's just a lack of servicing and maintenance
of basic components of the home.
People just don't understand the value of that
air-handling system, and how it impacts their health.
And actually, the air conditioning contractors
don't understand the value of that air-handling system,
and how affects health.
And there's been a real effort nation-wide
to try to get them to understand,
the significant impact that can have.
So, 93% of the homes we visit
have not had the furnace serviced,
since that person has lived there.
I mean, we've had homes, where they didn't know
they had a furnace filter, and they've lived there 18 years.
"There's a filter in that thing?"
So, because we do this work, we also support research, so,
this shows that we found that when we did do the service,
and when we did de-humidify,
and did use an enhanced filtration,
that the overall health improvement of asthmatic children
was significant.
We saw an improvement in health,
improvement in quality of life.
For here, we saw specific,
when patients were followed
by a pediatric allergy specialist,
and referred to a case management process,
and then the case management for the education,
regular clinic visit, environmental assessment,
and just care coordination and interventions,
we saw significant drops in ED visits, hospitalization,
and a drop in clinic visits, but,
ideally for asthma management, you don't see a drop
for all patients in the clinic business,
because really good asthma management
means regular visits to the doctor.
And a lot of these patients, part of the problem
is they don't do regular visits,
so, by us starting to interact with them,
they realize the value of their visits
in good, effective asthma control,
so many of the patients start going on a regular,
or their family takes them to the doctor,
on a more regular basis.
(student speaking off microphone)
Yeah, that's, these are specifically visits
for their asthma management.
So what, you mean, well visits for asthma?
(audience member speaking off microphone)
(audience member speaking off microphone)
Yes, and no.
So, they can have a regular checkup
that might be outside of their regular asthma management,
it just sort of depends on the provider,
and how they manage their patients.
But some of them will have a standard routine,
a physical or something, that isn't necessarily
a part of what's supposed to be their regular asthma visit.
But, yes, they're included in that.
So, here, is from the last year,
just looking at the patients that we worked with
using that risk gratification model based on utilization
and environmental risk.
And then, providing that healthy home education
and environmental intervention.
Here, we're looking at the Acute Care Visits,
the four 12 months before, and six months after,
and just that, see significant reduction.
Just looking at the most recent data, before I came here.
I wanted to point out a little bit
of the other research we're doing.
So, we are working with
the University of Missouri - Kansas City,
Center for Economic Information,
so these are econometricians,
and they have been in the unique position of studying
various socio-economic issues around the city,
including housing conditions, and actually,
in the year 2000, because of their work,
and their expertise in geo-spatial analysis,
the city hired them, actually,
to look at the code violations and housing conditions,
in the Kansas City community.
So they developed this survey, and this survey,
you can see, these are the different conditions
that they rate, and they rate them on a scale one to five,
so this is, things are good, this is things are bad.
And it gets progressively better, or progressively worse,
depending on which way you look up and down the chart.
But if you look specifically, so, for example,
for a roof, you've got your worst-case,
where there's holes, saggy, and rotten,
no holes, serious deterioration, slight deterioration,
or no deterioration.
So, from the streets, using a portable device,
they can record the information
about the housing condition,
and then move to the next house,
and they can do a rapid assessment and characterization
of housing conditions in the neighborhood.
And they have mapped all the neighborhoods in Kansas City.
The urban neighborhoods.
So 110,000 properties have been mapped
for their physical conditions, at about $6 a house.
So this shows, for example, taking that map,
and you can't see it real well,
but this is the city of Kansas City on the Missouri side.
This shows the level of sub-standard conditions,
so you can see that, the large majority
of sub-standard conditions, were in this area, here.
This is of our urban areas.
There's an urban area here for Kansas City, Kansas,
and Kansas City, Missouri.
It tends to go down through here,
and down through that area.
But this is just a map showing just one section.
And you can see a clustering of specific kinds.
In this case, it was the structural conditions in general.
So we're using their expertise,
and have worked with them to do some pilot work,
and now have a HUD technical study grant,
that we've been working on a couple years,
and they are geo-coding the health data,
from our hospital, for the last 14 years,
for asthma, lead-poisoning, and injuries.
And this is some of that asthma data,
that we have some preliminary maps on,
just showing the encounters based on diagnosis.
So this is any kind of encounter at one of our hospitals
and clinics; we have two hospitals and 23 clinics
around the community.
The interesting thing is this line right here.
That's Troost Avenue in Kansas City.
So why this dramatic difference, on that street?
(audience member speaking off-microphone)
(Kevin laughing)
Dang it.
Are you talking on my phone?
(audience laughing)
It's probably more obvious than that, sadly.
And we're trying to do the research to support it.
What would be the difference for the,
our hospital's located about right here.
These are neighborhoods, this is a neighborhood survey.
Well, unfortunately, this is the primary area of poverty,
in our community.
It's also predominantly African American,
with, up here, a different migrant population,
and Hispanic population.
So, this is well-known in Kansas City as the racial divide.
Troost Avenue.
Significant disparity, significant environmental injustice.
Historical racism in this community.
A pattern that has not been overcome, even now.
There's very little business development,
and economic development over here.
Significant number of vacant properties,
very little, I think one grocery store,
in this entire multi-block region.
I just lost my battery.
So, there's clear evidence,
and we've done a little bit of this work,
and found some fascinating stuff,
related to,
it isn't specifically about race,
there is a difference in genetic predisposition for asthma.
But when you adjust for race, poverty actually
can play a significant role in the level of asthma,
and the ability, as you might expect, to mange asthma.
And we've actually, will be publishing some work
showing some difference in genetic markers.
You see difference in genetic markers
for global methylation, for certain genes
for asthma and inflammation.
And one of the biggest differences we found
was in poverty.
Looking at the socio-economic level,
we saw a very big jump,
in the statistical difference
in these genetic markers,
because of something related to socioeconomic status.
Whether it's having the wherewithal to pay for medicines,
or to pay for insurance, or whatever the reason.
That's something that we need to tease through.
So, just looking a little bit more at some of that data,
so this is showing the asthma encounters
overlaid on top of the housing conditions survey.
So, you can see that there's a nice overlay of the data.
But we're gonna have the ability to look at
the specific encounters by block-level,
so you can see, this is asthma encounters,
and looking at the individual street locations,
and then we'll be able to tabulate
the number of asthma encounters,
versus the, this is the number represents,
the number of housing conditions
that are below the median conditions,
so there's more housing problems in these neighborhoods,
than there might be in some other neighborhoods.
So that's part of this analysis that we're trying to do.
We're also very involved in the whole idea
of the microbiome,
and the role the microbiome can play in health.
So, those of you that have read anything
about the microbiome,
this just shows the taxonomic orders,
the different types of diversity, of microorganisms
that are found on people, the bacterial DNA
from different parts of your body.
So we've been studying the environmental role
of the microbiome,
and how it relates to the health of different people.
So, here's a distinct difference.
The primary thing we are finding is a difference
in the diversity of bacteria in a home.
So, a home that has good diversity,
typically, it's just a good, diverse ecology.
But when you change the environmental conditions,
it narrows the ecology,
and we're finding that, it seems to be affecting
certain types of bacteria that are more pathogenical
and potentially cause more health problems.
Or are related to certain conditions, so,
we're not quite sure.
Here, this is the difference in smokers,
and we know that certain chemicals,
if you, under controlled conditions,
you take certain chemicals that are found in cigarettes,
like acetylene, is a common product,
or bi-product, of second-hand smoke.
If you put acetylene into a petri dish,
it kills everything in the petri dish pretty quickly.
Some of these things are very highly toxic.
Nicotine is actually very highly toxic,
and is used in pesticides.
So here, we're looking at the,
the DNA, the bacterial diversity in the homes of asthma
versus no asthma,
and you can see, just from the pattern,
that the controls, there's a,
specific type of bacteria
that are found in controls,
and this spread-out type of,
populations in the asthma homes,
and, primarily what we found more of cyanobacteria,
and other bacterias that are associated
with moisture and dampness.
So, we're seeing a high level of,
we see an association between dampness and asthma,
and actually the development of asthma
in sensitized individuals,
and it may be related to this bacterial function.
This is the environmental relative Moldiness Index,
it's a specific index using a DNA for 23 different molds.
And the black dots represent
samples from the American Housing Survey.
The others are from different Health Home programs.
And we provided some of them and just shows that,
homes with kids with asthma had a higher level
of environmental relative moldiness,
in the accumulated dust in a home,
than in the background of the American Housing Survey.
So this shows, for Kansas City,
if you look at the American Housing Survey,
this is from the American Housing Survey,
that's from our Kansas City Homes,
where we submitted some dust,
and we saw significant difference
in their ERMI value.
The higher the ERMI value, the more moldy the environment.
And this shows kids with intermittent asthma,
persistent asthma, that's a physically significant
difference in those persistent asthma kids,
having a higher ERMI index.
So just a little bit of the research
we're getting involved in.
I wanted to, hopefully I've left time for questions.
- [Dr. Green] Questions?
- Yes?
I'm curious about when you go into a home,
and you do the assessment,
and then you make your recommendations for improvements,
who pays for them?
Well that actually is from a grant,
we've been fortunate enough to have a variety of grants,
that have supported the home interventions.
That showed $1887, there's also the Healthy Home Kit,
which is another 500 bucks, so really it's $2300 per home,
for those, these are the advanced cases.
So for the basic level assessments, lower-risk,
we aren't paying for the home repairs,
it's more for the advanced asthma cases.
And, right now, because of our long partnership
with the community partners, and through those grants,
they have been our housing partner,
and we've given them money for the home repairs.
Now, they're looking at their dollars,
for community development block grants.
Money they get every year for supporting
housing maintenance and repair,
and they're looking and working with us to develop a,
what we're calling the Fast-Track Healthy Home Fund,
or a portion of their dollars,
where if we can document a child
A, lives in the neighborhood, and
B, has a significant health problem
that would benefit from housing interventions,
if they'll move them to the front of the line,
quote unquote, and let's get those repairs done,
because they'll see a health benefit
and a reduction in their utilization of health problems.
But we're working towards that,
and that is one of the challenges in many communities.
And we've talked, been involved in active conversations
with the health insurance community.
They're very nervous.
They like this idea of case management, and home visits,
but "we're not in the home repair business," you know,
"don't get us trying to fix a home," now we're not
gonna use health insurance dollars to pay for that,
although, there are literature and research that show,
if they did, actually it would save them money.
And under the capitated payment model,
which is what a lot of managed care is going to,
and we do that kind of work, we have a subsidiary,
so we get paid, we manage 100,000 patients,
and they give us a block for all patients.
If we are effective in that management,
we're reducing the cost of the care, and we make the money.
So if we, and when they do actually,
our home assessments are paid for, for free,
under that managed care system
called Pediatric Care Network,
so that's part of the service that's provided,
because it can reduce the utilization as you saw,
we're knocking down their Urgent Care visits,
so the total cost to the system is lower.
They make money, and they can actually
give money back to Medicaid,
because they've had that savings.
(audience member speaking off-microphone)
Oh boy.
(audience laughing)
So, should we sit and talk about that,
because, that's a long conversation.
So just very simply, when we work with a rental property,
historically what we've done,
is do everything like we would no matter who owns it,
then parts of the report are separated to go to a landlord
or management company,
or we can even sit down with the property owner
and go through what we've seen.
Then, we advocate for the actions,
and say these are what we think the repairs are gonna be,
and then we divide it into what are often code violations,
that they have a duty to repair anyway,
and the piece that we're willing to pay for
is the incentive, so we say, "we'll do these $2000 worth of
repairs if you'll take care of these $2,000 worth of
code violations that you should have taken care of anyway.
We could turn you in, or maybe not turn you in,
and let's take care of these things
that are going to help this family."
So, that's our landlord model.
The problem with the absentee landlords of course,
is that you're dealing more with a property management
company, and it just, for us it's just varied
from landlord to landlord.
About 80% of the landlords are receptive,
because they are getting something for,
they seen an improvement to their property.
But many of them certainly are indifferent,
they could care less, as long as they're making their income
that's all they, the whole place can literally crumble
in dust, for all they care,
as long as they've gotten their payout on it, so.
That is one of the big challenges.
And we have a lot of landlords who are completely resistant,
and won't change a thing,
and the environmental conditions are horrific.
So, in those cases, we advocate with the doctor
to write a letter saying "this family cannot live here,
get them out of their lease."
But we have a couple of people we work with
in our medical legal partnership,
and one of them is a doctor and lawyer,
and he's written both letters, and he says,
"I write a letter as a doctor,
but when I write a letter as a lawyer, things happen."
(audience laughing)
So, we often pull in that medical/legal partnership
and let them try to force change.
And the best case, if we can just get them
out of that property, it's all about exposure reduction, so.
- [Dr. Green] I think we're out of time,
so I'm going to stop,
- Oh yeah. Happy to hang around.
(audience clapping)
- [Dr. Green] Please complete your evaluations,
and turn those in.