The Housing Stability Vital Sign How Health Care Can Screen and Intervene to Address Housing Instability Megan Sandel, MD, MPH Co-Lead Principal Investigator Richard Sheward, MPP Deputy Director of Innovative Partnerships
Roadmap u About Children’s HealthWatch u Explore: u How adverse housing circumstances affect our health u Three forms of housing instability and caregiver/child health u The Housing Stability Vital Sign u Housing Prescriptions as Health Care
Dr. Deborah Frank with Duvon Haughton, then Dr. Deborah Frank with Duvon Haughton, now around three or four years old an eighteen year old college freshman
u Founded: 1998 u Non-partisan, pediatric research and policy network u Collect data in urban hospitals across the country on infants and toddlers from families facing economic hardship u Inform public policies → improve health & development of young children → alleviate economic hardships u Difficulty affording enough food (food insecurity) u Unstable housing (housing insecurity) u Trouble keeping heat/lights on (energy insecurity) u Foregone health care/health care trade offs (Health care hardships) u Provide policy makers with evidence from the frontlines to develop policies that protect young children’s health and development
Where our data come from: • Collecting real-time data in frontline healthcare settings: • Boston, Baltimore, Philadelphia, Little Rock and Minneapolis • Interviews - caregivers with children 0 to 4yrs • More than 60,000 surveys in our data set - “ invisible ” group - critical window of time
Why infants and toddlers? Human ¡Brain ¡Development ¡ ¡ __________________ ¡ Most ¡Vulnerable ¡Period: ¡Birth ¡– ¡ Age ¡4yrs ¡ ___________________ ¡ Synapse ¡forma>on, ¡ ¡ neural ¡networks ¡– ¡ ¡ “brain ¡architecture” ¡ ¡
Brain architecture physical structure, interconnections, & neural networks “Blooming and Pruning” First 3 years, child’s brain will have twice as many synapses as it will in adulthood Years 0-3 largely set trajectory: • cognitive/socio-emotional development • school readiness • academic achievement • educational attainment
Toxic stress and why it matters Source: Center on the Developing Child at Harvard University
Toxic stress and why it matters Source: American Academy of Pediatrics
Toxic stress and why it matters housing instability food insecurity An interpretation of Maslow's Hierarchy of Needs
How adverse housing circumstances affect health Photo credit: Witnesses to Hunger
Conceptual framework for adverse housing circumstances HOMELESSNESS HOUSING INSECURITY: • Crowding • Multiple moves UNAFFORDABLE HOUSING
Conceptual framework for adverse housing circumstances HOMELESSNESS HOUSING INSECURITY: • Crowding • Multiple moves UNAFFORDABLE HOUSING
Timing of Homelessness matters
Conceptual framework for adverse housing circumstances HOMELESSNESS HOUSING INSECURITY: • Crowding • Multiple moves UNAFFORDABLE HOUSING
Children in housing-insecure families more likely to be • Food insecure • In fair/poor health • At risk for developmental delays • Seriously underweight (compared to children in housing-secure families) Cutts et al, 2011
Behind on rent Strong indicator of other household hardships 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Food Child food Energy HH foregone Child Health care insecurity insecurity insecurity care foregone care trade-offs Not Behind on Rent Behind on Rent
Multiple moves Strong indicator of other household hardships
Revised conceptual framework for adverse housing circumstances Housing Instability • behind on rent • multiple moves • homelessness Unaffordable Housing
Stability: The Housing Iceberg HOMELESS HIDDEN HOMELESS: HOUSING INSTABILITY behind on rent • multiple moves • UNAFFORDABLE HOUSING
Exploring three forms of unstable housing with caregiver and child health Among 22,234 families, 34% had at least one adverse • housing circumstance: 27% behind on rent • 8% multiple moves • 12% history of homelessness • Each circumstance individually associated with adverse • health and material hardship compared to stable housing Accepted for publication, forthcoming
Little overlap among three adverse housing conditions Accepted for publication, forthcoming
Outcomes of unstable housing with health and material hardship outcomes 6 5 4 3 2 1 0 Child fair/ Maternal fair/ Maternal Food Energy Health care poor health poor health depression insecurity insecurity trade-offs Stable Housing Behind on Rent Multiple Moves Homelessness Accepted for publication, forthcoming
HOUSING STABILITY Vital Sign ™ Since [current month] of last year, 1. Was there a time when you were not able to pay the mortgage or rent on time? Answer is yes/no, positive screen if answer is yes 2. How many places have you lived? Answer is # of places lived, positive screen if answer is 3 or more (i.e. multiple moves ≥ 2 in 12 mos.) 3. Was there a time when you did not have a steady place to sleep or slept in a shelter (including now)? Answer is yes/no, positive screen if answer is yes
Timing is everything! Final Notice to Vacate – Immediate Risk of Opportunities for prevention Homelessness! Received Court Summons Owes 2 Months Rent Received 14-day Notice to More than 50% Quit Income Spent on Rent + Utilities Heading to the “Legal Emergency Room” Source: Medical Legal Partnership Boston
Avoidable ¡Costs ¡in ¡Health ¡Care ¡ Overview and ¡Educa5on ¡for ¡Mothers ¡ and ¡Children ¡ ¡ • Mental ¡health ¡costs ¡linked ¡to ¡ maternal ¡depression ¡largest ¡ contributor ¡to ¡cost ¡ • Other ¡costs ¡associated ¡with ¡ increased: ¡ • Hospitaliza>ons ¡ • Ambulatory ¡visits ¡ • Dental ¡procedures ¡ • Medica>ons ¡ • Special ¡educa>on ¡ services ¡ ¡
Overview Designing and Stocking the Housing Pharmacy to Improve Health Outcomes and Utilization Pilot RCT at Boston Medical Center funded by The Boston Foundation Goals: Enroll 100 families over next 18 months • Reduce housing instability among families with young children • Improve child health • Improve predictors on the pathway toward better child health outcomes, • including food security and maternal mental health status
u Design and stock a “housing pharmacy” of new therapies and combinations of therapies developed through a collaborative of partners across the heath, housing, social and legal professional service sectors u Project partners include: u Project Hope u Nuestra Comunidad u Medical-Legal Partnership | Boston u Boston Housing Authority u Learn more at childrenshealthwatch.org/housing-prescriptions/
Partners
Randomization u Resource List group u Current standard to care u Packet of resources with information on housing agencies, affordable housing waitlists, rental housing search tools, housing support resources, and legal assistance u Intervention group u Intensive housing case management and Problem Solving Education from Project Hope u Financial Counseling and Benefit Maximization from Nuestra Comunidad u Legal Services from Medical-Legal Partnership u Priority on Boston Housing Authority waitlist of public housing (50 units available for this project)
Case Example u Family characteristics at baseline u Referred from DSTI u Single, working mother, three children (two disabled – one with g-tube, one in a wheelchair), and disabled grandmother also in wheelchair u Rent and utility arrearages u Living in subsidized apartment that was not handicap accessible u Housing Prescriptions as Health was able to: u Leverage funding from Lend a Hand to pay >$1,000 in utility arrearage u Leverage flexible funding to pay rent arrearage u Negotiate with management company to move family to handicap accessible unit u Connect mother to financial counseling services
And the moral of the story is… “Children thrive when we respond to their realities”
Thank You! The mission of Children’s HealthWatch is to improve the health and development of young children by informing policies that address and alleviate economic hardships. Contact us: megan.sandel@bmc.org richard.sheward@bmc.org allison.bovell-ammon@bmc.org www.ChildrensHealthWatch.org @ChildrensHW
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