Housing and Health: Helping Families Improve Their Health Through a Home Assessment Process

Transcription

1 Housing and Health: Helping Families Improve Their Health Through a Home Assessment Process Kevin Kennedy, Environmental Hygienist Managing Director, Center for Environmental Health Dept. of Allergy, Asthma, Immunology

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3 Why Do Healthy Homes Matter? Young children spend nearly 80%-90% of their time inside. Housing affects health both directly and indirectly: Physical, chemical, biological exposures Psychological from National Center for Healthy Housing (NCHH)

4 Known/Suspected Health Effects Associated with Housing Conditions Respiratory infections Asthma Injuries and burns Reactions to extreme cold and extreme heat Irritations, allergy, rashes Poisonings, asphyxiation Neurotoxic exposures Cancer Death from National Center for Healthy Housing (NCHH)

5 CDC 4th Rpt on Human Exposure to Chemicals Blood and Urine analysis from random samples of participants in the National Health and Nutrition Examination Survey (NHANES) Analysis for 212 chemicals and their metabolites from the chemical groups described previously First samples collected in 1999, new sample analyses and report generated ~every 2 years. Latest out April,

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7 Primary Housing-related Hazards Home-related Contaminants: Asbestos & Vermiculite Below ground Contaminants Building Products/Materials Emissions CO & Other Combustion Emissions Environmental Tobacco Smoke (ETS) Garage Pollution Sources Lead Moisture (Mold & Other Biologicals) Ozone Pests Radon Wood Smoke Emissions EPA, Healthy Indoor Environment Protocols for Home Energy Upgrades, Nov. 2011

8 Primary Housing-related Hazards Critical Building Systems: HVAC Equipment Combustion Safety (Vented & Unvented) Source Ventilation Whole House Ventilation Multi-family Ventilation Safety: Home Safety EPA, Healthy Indoor Environment Protocols for Home Energy Upgrades, Nov. 2011

9 An Epidemiologic Triangle for Healthy Homes

10 Example: Asthma Prevalence Source: National Health Interview Survey ; National Center for Health Statistics, Centers for Disease Control and Prevention 2010; MMWR May % or 24.6 million people (7.3%, 20.3 million-2001) Prevalence among children - 9.6% poor children- 13.5%, African-American- 17% $56 billion annual health care costs-direct and indirect Ethnic differences in prevalence, morbidity and mortality correlate with poverty, urban air quality, indoor allergens, lack of patient education and inadequate medical care

11 Components of Asthma Management NHLBI Guidelines Stepwise Approach Asthma Control Reduce Impairment Reduce Risk

12 2007 NHLBI Asthma Guidelines Exposure of patients who have asthma to inhalant allergens or irritants to which they are sensitive has been shown to increase asthma symptoms and precipitate asthma exacerbations For successful long-term management of asthma, it is essential to identify and reduce exposures to relevant inhalant allergens and irritants A multifaceted, comprehensive approach is required Single steps to reduce exposure are generally ineffective National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. National Heart, Lung, and Blood Institute, August 2007

13 2007 Asthma Guidelines Teach patients with asthma to: Use multi-faceted approach. Reduce, if possible, exposure to allergens to which the patient is sensitized and exposed. Avoid exposure to environmental tobacco smoke and other respiratory irritants, including smoke from woodburning stoves and fireplaces and, if possible, substances with strong odors. Formaldehyde and volatile organic compounds (VOCs) have been implicated as potential risk factors for asthma and wheezing. Avoid exertion outdoors when levels of air pollution are high. National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. National Heart, Lung, and Blood Institute, August 2007

14 EPA- Communities in Action for Asthma Friendly Environments Asthma Health Outcomes Project- EPA and U of Mich. Mobilizing 1000 communities to develop Asthma Programs across the country EPA National Asthma Forum Change Package Home Visits A Key Component of Successful Programs

15 Asthma Education, Home Assessments, and Interventions Pay for Themselves

16 A Model for Reducing Health Inequities in Housing: Multnomah County, OR Healthy Homes Coalition

17 Economic Evaluation of Home-Based Environmental Interventions to Reduce Asthma Morbidity Tursynbek Nurmagambetov, Sarah Beth Link, Verughese Jacob, Sajal Chattopadhyay, David Hopkins, Deidre Crocker, Gema Dumitru, Stella Kinyota December 2009, CDC Webinar Home-Based multi-component interventions with environmental focus reduce symptom days and improve quality of life. Economic Evaluation Cost-benefit studies show net positive returns on investment - Benefit/cost ratio from 5.3 to 14 Health Benefit in symptom free days and reduced health services compared to the costs of interventions implemented 17

18 A New Kind of House Call: Health Plan Reimbursement for Home Assessments

19 1996: Reality of Asthma Care at CMH Audit for quality of asthma care 1 patient seen in ED 17 times and never in outpatient clinic Outcomes documented in only 2 cases ED was Primary source of asthma care Patient disease management primarily through ED, most lost with no follow-up Consistent asthma education either was lacking or not documented In effect, no real disease management system Miller, Kelly RN, MSN, Peggy Ward-Smith, RN, PhD Karen Cox,, RN, PhD Erika Jones, RN, & Jay Portnoy MD. Pediatric Allergy and Immunology, 2003 (3):

20 Developed KC Children s Asthma Management Program (KCCAMP) Goal of Program: Reduce freq. of admissions and ED visits Provide more cost effective care to those patients who were admitted. Develop clinical practice guidelines that encourage providers to use best known treatments and in doing so, reduce the quality gap between patients Miller, Kelly RN, MSN, Peggy Ward-Smith, RN, PhD Karen Cox,, RN, PhD Erika Jones, RN, & Jay Portnoy MD. Pediatric Allergy and Immunology, 2003 (3):

21 KCCAMP - Multi-faceted Approach Provider Office Training in their clinics Improve the Level of Asthma Education per Patient Develop Asthma Patient Health Utilization Database Stratify Data by Medical Utilization Establish levels of risk based on frequency ED Visits, Hosp. visits, Pharmacotherapy Low, Medium, High Risk Offer increasing intensive case management including a home environmental assessment Miller, Kelly RN, MSN, Peggy Ward-Smith, RN, PhD Karen Cox,, RN, PhD Erika Jones, RN, & Jay Portnoy MD. Pediatric Allergy and Immunology, 2003 (3):

22 Referral Process PCP or Specialist can refer Provide Diagnosis Medical Criteria Justification

23 Advocate for Patient Summarize Assessment Scope of Services Seek Approval for Reimbursement

24 CMH KCCAMP results- Patients who receive case management were at lower risk for subsequent utilization

25 CMH Asthma Management Program Percentage of High Risk Patients Reduced over time because they were at lower risk for subsequent utilization

26 Reduced Clinic, Emergency Room & Hospital Utilization After Home Environmental Assessment and Case Management Barnes CS, Amado M, Portnoy J, Allergy Asthma Proc Jul;31(4): Pediatric patients received home assessment after referral for case management by pediatric allergy specialists in a hospital-based clinic Case management included education, clinic visits, environmental assessment, and a single person responsible for following the subject's care. Preliminary data from 25 subjects. 72% asthmatic, 12% diagnosed with allergic rhinitis. Year before entering study- subjects experienced 47 ED visits, 22 hospitalizations, and 279 clinic visits. Year after participation- experienced 18 ED visits, 3 hospitalizations, and 172 clinic visits. 26

27 Managed Care Challenge One Plan: 8000 Pediatric Asthma Patients in Plan 5000 Diagnosed (3000 not seeing PCP) 80% or 4000 Intermittent 20% or 1000 Persistent 1-2% Severe or ~200 Patients

28 Managed Care Challenge Health Plans focused on managing health through traditional medical procedures and pharmacotherapy Health System struggles with home assessment concept Limited by what service can be uniformly offered I have 300 patients that fall in my high risk stratification category EVERY WEEK!

29 Indicators for the need of an Environmental Assessment: Diagnosis Asthma Rhinitis Hypersensitivity Pneumonitis Aspergillosis Sinusitis Other Respiratory Conditions Other Criteria Symptoms are perennial & flare on exposure Environment exposures has (or may have) been suspected of triggering symptoms Continued exposure is likely Patient has some control over environment

30 Indicators for the need of an Environmental Assessment: Patients have symptoms that don t respond to regular treatment. Patient s symptoms respond to treatment, but require it to be continued. (Remain aware of patient compliance with treatment / therapy issues) Unique environmental conditions reported that suggest an assessment is warranted.

31 Participant Information 57% have asthma 91% of Level 2 s have asthma 72% of Level 1 s have asthma 56% have allergies What Kind of Health Issues Do Our Patients Have? 44% have allergy symptoms 13% other health issues 22% presence of smokers in homes 25% of children tested showed elevated cotinine levels

32 Healthy Homes Issues in Kansas City Largest portion of Kansas City housing (46%) was built prior to % was built before % have basements 32,000 homes with moderate or severe problems 40% of severe housing problems are moisture-related 94% of homes with severe problems in KC had warm air furnaces

33 Healthy Home Environmental Assessment Principles 1. Initial contact and collect general information. 2. Take an Environmental History to determine the level of need. 3. Establish a clear purpose for the assessment. 4. Formulate initial hypotheses. 5. Site visit and walk-through. 6. Qualitative and Quantitative Assessment. 7. Generate Assessment Report. 8. Report findings and provide a Healthy Home Action Plan

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37 Healthy Home Assessment Family Interaction Timeline Home assessments are most often a multi-visit process

38 Five Essential Factors to Consider During Healthy Home Environmental Assessments Health & Medical History of the Patient One Touch Comprehensive Approach Sources of Environmental Hazards Pathways of Exposure Recognize Building as System

39 Home Assessments Should Promote- Keep It: Dry Clean Safe Well-Ventilated Pest-Free Contaminant-Free Well-Maintained

40 Home Assessment Goals Always START and END with people Provide education for self-efficacy Teach the Healthy Home Principles Always ask the occupants if they have a goal for the assessment Target occupant concerns Give information families can use

41 Home Assessor s Goals Systematic and Objective Driven by an exposure hypothesis Rule out concerns by documenting what was observed; good and bad. Identify legitimate risks and true hazards Always communicate about dangerous hazards Obtain sufficient information for liability protection

42 Homes are Systems From, Care for Your 42

43 Qualitative or Visual Assessment Items to Assess: Exterior Building Components Mechanical Components Appliances Room by Room Visual Assessment Floor Plan Form from the Community Environmental Health Resource Center (CEHRC)

44 Site & Building Assessment

45 Visual Assessment Mechanical Components: Furnace/AC Window AC Water Heater Main Plumbing Kitchen Plumbing Bathroom Plumbing

46 Mechanical & Appliance Assessment

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49 Assess Both Obvious and Not Obvious Indoor Combustion Sources (CH4, CO, NO 2, H 2 O? ) Gas Appliances and Water Heaters Gas Furnaces Gas/Fuel Space Heaters Candles and Incense

50 Top Asthma Triggers Reducing Indoor Allergens Improves Asthma Control

51 Room by Room Assessment Qualitative Assessment: Keep It: Dry Clean Safe Well-Ventilated Pest-Free Contaminant-Free Well-Maintained Form from Children s Mercy Hospitals & Clinics

52 Acute Hazards: Hazards that require immediate attention due to the potential for posing an imminent danger to life and health for children. Examples include: Imminent physical hazards: (unsound stairs, child access to crawl spaces, roof collapse, structural deterioration or significant damage etc.), Biological hazards: (contamination from sewage leaks, standing water in basements, rotted flooring and major pest infestation, etc.), Chemical hazards: (fire risks posed by improper storage of large quantities of chemicals, lead paint/dust hazards, detectable carbon monoxide and gas leaks, etc.

53 Chronic Hazards: Hazards which do not pose an immediate danger to life and health to the occupants but do promote allergies, asthma, lead poisoning, pesticide exposure, or other chronic health conditions. Examples include: Physical: Poor HVAC maintenance, windows in dis-repair, foundation cracks, minor roof damage, plumbing leaks Biological: Observed/reported pests, condensation and microbial growth, open cracks/gaps in siding, wet/damp drywall Chemical: poorly operating stove, lack of ventilation/ exhaust fans in bathrooms and over gas stoves

54 What Healthy Home Hazards Have We Observed? 29% high humidity 9% high dust mite results 3% high TVOCs 8% high CO 11% high CO2 40% high particles

55 What Healthy Home Hazards Have We Observed? 65% have moisture stains - 37% observed in bathrooms - 38% observed in basements 34% poor ventilation - 4% no vents - 56% blocked - 25% low flow 1% have gas leaks

56 What Healthy Home Hazards Have We Observed? 14% have observed/reported mice 1.3% have observed/reported rats 10% have observed/reported roaches 12% have observed/reported ants 12% have observed/reported spiders 40% have pets

57 CMH Assessment Report Indicate Limitations

58 Assessment Report: A Scope of Work Hypothesis of assessment The limitation of the assessment Summary of any test results Interpretation of any measurements Photos of issues identified Recommendations References

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60 Develop a Healthy Home Action Plan Plan needs be realistic and feasible Plan should be do-able Cost Effective Consider the type of home Might involve lifestyle changes Behavior changes take time, so do them slowly Start in child s room and work your way out Should consider your ability to control the environment and sources (school, house, apartment) When families know where contaminant sources are, they can learn how to control them.

61 Report includes Healthy Home Action Plan- Connects Home Assessment to Interventions Identifies what our HH program will do and what the family is asked to do Prioritizes interventions based on hazard risk Hardest part of report to generate

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63 Health Care is Vital to All of Us Some of the Time, but PUBLIC HEALTH is Vital to All of Us ALL the TIME!! -C. Everett Koop, US Surgeon General Kevin Kennedy, Center for Environmental Health Children s Mercy Hospitals & Clinics