Helping Children with Asthma

I just became aware of an interesting program that works to repair homes in Southeast Washington, DC and Maryland. The initiative, called the Healthy Housing Virtual Home Visiting (VHV) Program, seeks to improve the living conditions of residents in some of the lowest income parts of the District and surrounding areas. Since this program is happening in my city, and because it aims to improve health outcomes for children in particular, I thought it was worthy of note.

The backstory is this: Children’s National Hospital (CNHS) in Washington, DC won an Innovation Challenge contract award through Fannie Mae to help improve the health of children with asthma in low socioeconomic areas by cutting down on the level of allergens in their homes. The award helped the project team accomplish the following:

  • Hire a project coordinator, a program lead, and a physician to lead all virtual health visits.
  • Pay for remediation equipment and work, including HVAC filters and vacuums, mattress bedding, and roofing and plumbing repairs.
  • Evaluate outcomes of the virtual visit program.
  • Write a paper evaluating the program using key performance indicators.

According to the American Lung Association, “Asthma is the most common chronic condition among children, currently affecting an estimated 6.1 million children under 18 years.” Further, according to the Fannie Mae website, “In Washington, D.C., pediatric asthma rates are highest in Wards 7 and 8, an area southeast of the Anacostia River where the District’s greatest share of older, poorly maintained housing is also concentrated.”

This is no coincidence, says the website, since, “according to doctors at Children’s National Hospital…substandard housing conditions can act as environmental triggers for asthma.” That’s a serious problem that might prompt someone to ask, “So why don’t folks just move out of these old, run-down buildings?” Aside from the fact that members of lower socioeconomic groups often don’t possess the capital to simply pick up and move, there is also a deep sense of dislocation that comes with leaving a home where, in some cases, the same family has lived for generations.

And if that’s not enough reason, on the political front, these DC wards are undergoing redistricting. That means that shifting political boundaries will likely be accompanied by vibrant economic expansion. So while these changes may usher in challenging times, they may also herald opportunities. For example, as the article notes:

“When advisory neighborhood commissions negotiate community benefit agreements with developers constructing new buildings in the District, they sometimes include clauses requiring the developer to preferentially hire residents of the ward where the building will be built. If developers on the Wharf or in Navy Yard have to hire residents of Ward 8, lower-income communities could benefit.”

For the uninitiated, the Wharf is a “mile-long stretch along the Potomac River…with restaurants, retailers, residences, and businesses,” and the Navy Yard is “an area that has been reborn as a haven for sports fans, nature lovers and foodies.” The bottom line is this: by staying put, residents might be able to land a good job, becoming upwardly mobile without having to uproot their family.

All this talk of politics and economics is taking us a little afield from the scope of this blog, so let’s regain focus on what’s most important from a population health standpoint: this program seeks to improve the health of a specific patient population ‐‐ children dealing with asthma ‐‐ so that they can live happier, more productive lives.

But how to ensure this group is equipped to change with the shifting landscape, and stay healthy while doing it? That’s where the VHV project comes in. Program stakeholders represent a wide gamut of specialties both within and outside of medicine, and to me illustrate how coordinated care can overcome social determinants of health and improve the wellbeing of specific populations: in short, they agreed on a goal, worked in close collaboration to achieve it, and then assessed population-level outcomes at the conclusion of a set time period (comparing numbers of sick patients six months before and six months after the intervention) to ensure that they were on track with their objectives.

How It Works

The project team consists of both medical and housing experts who understand the unique needs of populations throughout the Washington, DC area: IMPACT D.C. Asthma Clinic and Child Health Advocacy Institute, an award-winning pediatric asthma program run through Children’s National Hospital; a nonprofit housing remediation organization called Yachad; Local Initiatives Support Corporation (LISC) DC; and the Institute for Public Health Innovation (IPHI).

To start the program rolling, stakeholders agreed on a working hypothesis: can asthma-related illnesses in children be improved by identifying possible triggers inside the home and connecting families to remediation resources? The project’s initial objective was to reduce the number of asthma-related hospital visits by identifying indoor asthma triggers and establishing remediation plans, though it’s not clear to me if at the outset they had any firm numbers in mind for target goals.

That said, one thing I really like about this program, and a prime reason why I think it could scale to other settings, is that it leverages a telehealth approach in assessing the overall state of a given home. Each Virtual Home Visit includes a visit from a medical provider, a VHV coordinator, and two housing specialists from Yachad, with each VHV lasting about 30 minutes. According to the Fannie Mae website:

“Using a telehealth platform on their smartphones, families connect with providers who conduct virtual medical and home assessments. Once housing conditions that trigger asthma, such as mold or pest infestations, are identified, families receive education and a remediation plan.”

Once a remediation plan is agreed upon by residents and the project team, that’s when the Yachad organization seems to get more involved:

“Yachad provides remediations ranging from new furnace filters and dehumidifiers to extensive roof repairs. The remediations improve the quality of housing and reduce the risk of future displacement of long‐term residents.”

Program Success

During its first year in existence, the VHV program seems to have been a success. A number of children in affected homes have seen their health improve. According to an overview of the program, “The frequency of emergency visits, hospitalizations, and oral steroid courses dramatically decreased in the six months following the VHV, compared to the six months prior.”

As the resulting paper chronicled, the team provided remediation support to 46 homes, with most participants receiving two or more remediations. Further, “The most commonly provided home remediation services were dust mite covers (100%), pest control (52.1%), and HEPA vacuums (52.1%)…In total, the pilot program completed over 112 home remediation services.”

In one example of program success, Yachad was able to provide a family with “two treatments for roaches and mice, advised them to remove all the carpeting in the house, and repaired the roof and a leaking sky light.” On the medical front, children in the household “are being treated with daily doses of prescribed asthma medication.”

Progress made in improving children’s health was reflected in satisfaction surveys administered 72 hours, one month, and six months following the VHV. According to the paper, these results “clearly highlight the acceptability of this format by patients and their families. Nearly all families would recommend the VHV to another person (98%) and expressed overall satisfaction (100%). Most families felt the VHV had a positive impact on their child’s health (76%).”

Future Plans

Although Fannie Mae has agreed to extend the award contract by a year, it sounds like CNHS is already exploring ways to finance home remediations beyond the length of the contract via reimbursement models through Managed Care Organizations. In the meantime, here are their short term goals for the next year:

  • Sustain the Virtual Home Visit (VHV) model by completing 75 virtual home visits and 100 home remediation measures
  • Develop an interactive property-level map for Washington, DC that identifies high morbidity properties and their remediation needs
  • Estimate the projected healthcare savings that could result from remediation at problematic properties
  • Collaborate with Fannie Mae’s Multifamily Asset Management to review property inspection guidelines and identify opportunities to enhance them using findings from the mapping project

This is encouraging news, and I’ll be sure to keep checking in to see how it goes. If they can build on what they’ve accomplished here and make this a sustainable program over the long haul, I don’t see any reason why it can’t scale to other cities.

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