1. www.ghhi.org [ 1 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Healthy Homes: Indoor-Outdoor Environmental Interventions to Improve Asthma Outcomes Michael McKnight 11/6/15

2. www.ghhi.org [ 2 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. A GHHI Family Story https://youtu.be/rbF71lDmt4k

3. www.ghhi.org [ 3 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Recommendations from NAEPP It is essential to identify and reduce exposures to allergens and irritants and to control other factors that have been shown to increase asthma symptoms in your patient. Effective allergen avoidance requires a multifaceted, comprehensive approach; individual steps alone are generally ineffective. Focus on allergen-control education for cockroach, dust mite and rodent allergens for patients sensitive to these allergens as these have proven interventions.

4. www.ghhi.org [ 4 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Healthy homes part of effective asthma management Surgeon General’s Call to Action to Promote Healthy Homes (2009) The Community Preventive Services Task force recommends the use of home-based, multi-trigger interventions with an environmental focus for children and adolescents Cost-benefit studies show a return of $5.3 to $14.0 for each dollar invested Home-based triggers cause 40% of asthma episodes 1 1 Robert Wood Johnson Foundation Commission to Build a Healthier America. Beyond Health Care: New Directions to a Healthier America Report. April 2009

5. www.ghhi.org [ 5 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Address Root Causes at Home Unhealthy Home Asthma Episode Hospital Visit Treatment/ Inhaler

6. www.ghhi.org [ 6 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Common Home Asthma Triggers Dust Mites Cockroaches Pests Mold VOCs Tobacco Smoke Animal Allergens Smoke/Gas

7. www.ghhi.org [ 7 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Environmental Assessment & Education Together Environmental Assessor-Energy Auditor (HHS/BPI) Conduct pre-intervention environmental assessments / audits Develop comprehensive scopes of work for properties Conduct post intervention assessments and audits Community Environmental Health Educator (CHES/AE-C) Conduct asthma/HH resident education during assessment Coordinate client health surveys and data collection Distribute HEPA-Vacuum and indoor allergen reduction kit Referrals and follow-up client services Review asthma action plan Medication adherence Ongoing education, behavioral reinforcement, and band follow-up with PCP / care managers

8. www.ghhi.org [ 8 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Healthy Homes Interventions Installation of mattress and pillow covers Integrated pest management: gel baits, boric acid, glue traps, reducing entry points, cleaning/behavioral change (clutter) Mold remediation Venting kitchen, bathroom and dryer; filter replacements Removal or steam cleaning of carpets Air filtering system installed in child’s bedroom Air conditioners and dehumidifiers Provision of a HEPA-vacuum and indoor allergen reduction cleaning kit Other Healthy Homes Interventions with leveraged funding (lead, radon, asbestos)

9. www.ghhi.org [ 9 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. GHHI Baltimore Healthy Homes Program Direct Healthy Homes Program services began in 2000 Program targets asthma diagnosed children in Baltimore; priority on children with prior ED visit or hospitalization; family income ≤ 80% AMI Primary Referral Sources - MCOs, health care providers, Health Department, GHHI Baltimore partners Units Completed - 1,660 families enrolled and 1,480 Healthy Homes interventions completed by the program to date using tiered intervention strategy and in-house GHHI Baltimore Hazard Reduction Team

10. www.ghhi.org [ 10 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Healthy Homes Demonstration Project Mean Change and Percent Reduction of Key Outcomes In the past 6 months (N=139) Intake Mean (StdDev) 6 Month Mean (StdDev) Pre Post Mean Change (StdDev) One-sided t test Percent Reduction Hospitalizations 0.364288 (0.923013) 0.141791 (0.53667) 0.238806 (0.824248) 0.000865.5% ER Visits 0.942857 (1.22193) 0.701493 (1.097022) 0.261194 (1.250137) 0.01527.7% Physician Visits 1.76258 (1.462491) 1.340909 (1.413293) 0.389313 (1.460098) 0.00222% Calls to Physicians 2 (1.498792) 1.481203 (1.490381) 0.515152 (1.565296) 0.000226% Work days missed 2.76259 (1.954492) 1.736842 (1.85413) 1.037879 (2.057959) 0.000037% School/ daycare missed 2.372093 (2.008069) 1.787402 (2.091669) 0.647059 (1.998254) 0.000227% 200 units completed with 139 respondents completing 6 month post intervention health surveys Environmental Justice, Vol 7. Number 6, 2014

11. www.ghhi.org [ 11 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Outcomes and Impact A look at GHHI Philadelphia’s impact: 70% fewer asthma-related client hospitalizations 76% fewer asthma-related client ED visits 62% fewer asthma-related client doctor’s office visits 53% fewer asthma-related client missed days of school or daycare 55% fewer uses of Albuterol Pump A look at GHHI Cleveland’s impact: 58% reduction in asthma-related client hospitalizations 63% reduction in asthma-related client ED visits

12. www.ghhi.org [ 12 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Reduced Costs = Cashable Savings 1 asthma-related hospitalization on average costs $7506 in Baltimore 1 asthma-related emergency room visit on average costs $820 in Baltimore Asthma hospitalizations and ED visits Cashable Savings [2009-10 data]

13. www.ghhi.org [ 13 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Challenges Funding sources: HUD, DOE, CDBG, philanthropy, utilities, state and local housing funds. Healthcare investment for home remediation services has not been significant. Currently no standard set of codes for Healthy Homes measures and approved costs for services – Now working on a guidance manual and reimbursement recommendations including payment models Reimbursement traditionally only for licensed clinical providers – Medicaid Rule Change adjusted “Who” is available to be reimbursed, not “What” services are reimbursable Coordination of care between medical providers and community based services is still improving

14. www.ghhi.org [ 14 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. A Fractured Delivery System

15. www.ghhi.org [ 15 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. GHHI - A Model That Benefits Families

16. www.ghhi.org [ 16 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Opportunities Medicaid Rule change for reimbursable professionals Waivers and State Plan Amendments Hospital community benefit investments - can encompass “physical improvements and housing” and “environmental improvements” Community health worker certifications and expanding role; new home performance professional certifications for health Education Funding Connections - Costs school districts $29 per child per school absence Pay for Success / Social Impact Bonds

17. www.ghhi.org [ 17 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. & Other Guarantors (Baltimore foundations) GHHI Baltimore Asthma PFS Model Upfront capital Success payments Re- payment Target setting Evaluation Risk mitigation & Other Investors Service delivery funding

18. www.ghhi.org [ 18 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Draws Intervention Evaluation Savings & Success Payments $$$ Guarantee Payments Guarantee Timeline

19. www.ghhi.org [ 19 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. LocationHealthcare OrgService Provider Springfield, MABaystate HealthPartners for a Healthier Community Memphis, TN Le Bonheur Children’s Hospital Habitat for Humanity of Greater Memphis Buffalo, NY Monroe Plan for Medical Care Community Foundation of Greater Buffalo & Heart of the City Neighborhoods, Inc. Grand Rapids, MISpectrum Health Health Net, Healthy Homes Coalition, & Asthma Network of West Michigan Salt Lake City, UT University of Utah Health Plans Salt Lake County Office of Regional Development GHHI selected to participate in Social Innovation Fund’s first PFS cohort with asthma PFS feasibility studies in 5 locations:

20. www.ghhi.org [ 20 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. GHHI National Scaling

21. www.ghhi.org [ 21 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Our National Partners

22. www.ghhi.org [ 22 ] ©2015 Green & Healthy Homes Initiative. All rights reserved. Follow us on Twitter @HealthyHousing@HealthyHousing Like us on Facebook GHHINationalGHHINational Learn more on YouTube GHHI VideosGHHI Videos Follow us on LinkedIn green-and-healthy-homes-initiativegreen-and-healthy-homes-initiative Questions? Michael McKnight Vice President of Policy and Innovation mmcknight@ghhi.org 202-769-5763 @McKnight_GHHI