How working together to improve housing is leading to better health outcomes.
Dusty carpets. Moldy walls. Insects in cupboards. Peeling paint.
For kids with health conditions like asthma, these kinds of environments send them to the emergency room every day. While health care providers often prescribe inhalers and other medicine, many families continue to return to the hospital again and again. Healthy Homes Iowa considers a different approach: What if we address the living space that causes asthma in the first place?
In existence for nearly a decade, Healthy Homes Iowa has demonstrated how making small changes to an environment can impact families' well-being. Not only are kids healthier, but family stress is reduced by not having to miss school or work to respond to medical crises. In addition, the initiative shows how cross-sector collaboration can improve community health outcomes.
“Healthy Homes continues to support the idea in the community that housing is more important than just keeping someone safe, warm, and dry,” said Eric Burmeister, Executive Director of the Polk County Housing Trust Fund.
“Fixing leaking pipes and replacing moldy carpeting with hard-surface flooring is not what people traditionally think of as health care, but it completely affects kids’ and families’ health,” said Denise Swartz, Senior Program Officer at Mid-Iowa Health Foundation. “This initiative connected a lot of systems to rally around families.”
Mid-Iowa Health Foundation was among the stakeholders that launched Healthy Homes as a tangible way of moving upstream to address the social determinants of health – the social, environmental, and economic factors that influence people’s ability to live healthy lives. In addition to planting the seeds for the initiative to take off, the Foundation has continued to support the program’s journey toward sustainability by providing leadership and resources over several years.
Today, EveryStep is leading Healthy Homes Iowa, with $3.5 million in funding to serve more families with kids who have asthma. The program also will expand to meet other needs for older adults and families with young children.
“This program is designed to make an investment in families where they live in a way that improves their health status, as well as their home environment,” said Sarah Black, Healthy Outcomes Director at EveryStep, who manages the program. “We spend a lot of time in our homes, so living in a healthy, safe space is important.”
Getting to this point has been a journey that has, at times, been uncertain and unexpected. It shows how a small idea can grow into a fully developed, sustainable program within health and social service systems. Often, the initial spark comes from a new connection.
At a meeting with Des Moines Public Schools, Suzanne Mineck, then President and CEO of Mid-Iowa Health Foundation, was among those brainstorming how to better connect families from refugee communities to health services. A mother who attended the meeting listened to the conversation and then ended with the comment that while connecting to services is nice, if families return to homes without heat, with insects, and with mold on the walls, they will never be healthy.
“It was as if someone had just punched me in the stomach,” said Mineck. “It demonstrated the power of listening and not coming with assumed ideas of what is needed or what change should look like. The power of the mom’s voice was the greatest north star of not just what would become Healthy Homes, but of the funders sitting around a table who realized that we need those voices to guide us.”
On a plane flight from Washington, D.C. to Des Moines, Mineck ran into Burmeister. She shared the mom’s comment, and they discussed the intersection of housing and health. Burmeister was just learning about the social determinants of health, and his organization recognized that it needed more partners to address safe and stable housing challenges in the county.
“We went back and forth on the plane ride home,” he said, “and decided we needed to have more discussion on ways we could pool our resources into a program that would have measurable outcomes that we could then use with the community to leverage more money.”
They landed with a plan to meet for coffee, and to invite Rick Kozin, who was then Director of the Polk County Health Department. The idea of addressing housing to improve health was not new to Kozin. His department had been leading lead mitigation efforts for several years, making home repairs that prevented kids from being poisoned. As staff members conducted house assessments, they also saw triggers that they knew were causing other health issues.
“Asthma is a really easy, clear argument to build around,” Kozin said. “You see evidence of mold and insect infestation immediately, because kids are going to the emergency room.”
Remediation is often easy and cost effective as well. It involves steps like replacing carpet with hardwood floors, putting containers on food, adding vents to bathrooms and kitchens, and buying cleaning supplies. It includes education on preventive measures, such as not letting dogs sleep in beds, going outside to smoke, and practicing effective cleaning techniques.
Believing the initiative would launch with only local resources, the three founders decided to target the specific health issue of asthma and to pilot within a narrow geographic area. Data from hospitals confirmed that children experiencing asthma at higher rates tended to live in low-income neighborhoods with poorer housing quality and more rental units.
Conversations continued over several months, until Kozin became aware of The BUILD Health Challenge designed to support collaborative partnerships between health systems and nonprofits. A smaller grant would support planning, while a larger grant would go toward implementation. The team decided to apply for the larger grant, using an initial investment from Mid-Iowa Health Foundation to prepare.
Getting the three major hospitals on board to support the initiative and refer patients was critical with the goal of embedding the intervention into the health system to reach the entire community. Already, hospital leaders were learning about the social determinants of health as they formed accountable care organizations. Kozin had been asked to present on the social determinants of health to UnityPoint’s Board of Directors, and a separate public presentation led to a cover story on the topic. The concept of Healthy Homes offered a tangible example of how the hospitals and others could tackle social factors that impacted health outcomes.
In addition, neighborhood and community development partners were invited to participate. The group focused on the East Bank area – three neighborhoods east of the Capitol where data showed higher incidences of pediatric asthma and the Viva East Bank revitalization effort was underway.
About 10 stakeholders began meeting regularly to plan, each committing to different roles. The Polk County Housing Trust Fund assumed leadership as the grant applicant.
“This was something where we could get a double bang for our buck,” said Burmeister. “We could not only repair homes and keep them livable, but also improve health at the same time. I think that is what sold the board on going forward with the program – that and it leveraged a quarter of a million dollars if we participated.”
“It’s a great example,” said Mineck, “of the power of authentic and humble collaboration. Of coming together and posing some questions, listening to the voices, and really drawing on the different capacities and assets of those around the table.”
With the major BUILD grant secured, Healthy Homes launched. The grant supported the Polk County Housing Trust Fund in hiring a contractor to coordinate the pilot. Doctors within the three major hospitals referred families with kids who had an asthma diagnosis that wasn’t controlled. The Health Department then completed the housing assessment. Healthy Homes coordinated the process of making repairs, using Housing Trust Fund dollars, and provided education to families.
Over two years, the group saw a significant impact on children’s health and family well-being. The initial grant supported 62 families in receiving at-home asthma education and 42 homes in receiving a combined total of $150,000 in housing repairs. An additional $17,000 went toward cleaning supplies.
The outcome: Children in the program experienced 6.2 more asthma-free days per month.
In addition, the pilot initiative represented the first time that different sectors were in the same planning space together. Project planners discovered that they needed time to learn how each system operates, the language used in each sector, and how to interact with each other to be successful. For example, while housing stakeholders wanted to collect health data, the hospital system had to follow HIPAA regulations and other policies that made sharing data difficult.
The planning team also had to adjust the model. While the team expected doctors to refer families to the program, many doctors were just beginning to consider addressing social factors that impacted their patients’ health. Referrals increased when they began to coordinate with school nurses.
The initiative also quickly expanded to serve Des Moines, and eventually, all of Polk County as referrals were made from families in need of the services who lived just outside of the East Bank area.
After two years, the contractor running Healthy Homes left. With another two-year BUILD grant secured, the Polk County Housing Trust Fund decided to move coordination of house assessments and repairs to Rebuilding Together, a nonprofit that works to repair homes of Central Iowans who need support. Meanwhile, the planning team considered what sustainable funding could look like.
The initial idea was to demonstrate that Healthy Homes was effective and then have hospitals pay for the program as a part of how they provide care. Ongoing evaluation continued to show significant clinical improvements in asthma control, fewer missed days of school and work, and parents reporting less stress with caring for their child with asthma than before entering the program.
Yet, hospitals did not have a financial incentive to own the program. Financial ownership, the team learned, needed to come from organizations paying for health services, which in most cases, was Medicaid.
As part of her HealthConnect Fellowship with Mid-Iowa Health Foundation, Becky Miles-Polka built a case for Managed Care Organizations (MCOs) that ran Medicaid to pay for Healthy Homes services and fostered relationships with MCO leadership. Each time the team was close to getting an MCO to agree to pay for Healthy Homes services, the company would pull out of the Iowa market or the leader would leave.
“All we needed was a billing code,” said Kozin. “We could not figure out who makes billing code decisions.”
Healthy Homes continued to provide services but in a less robust way. Miles-Polka coordinated technical support from Green & Healthy Homes Initiative, a national organization focused on healthy housing efforts. She also reviewed the program’s operating structure to determine how it could be streamlined while growing. Eventually, EveryStep agreed to assume coordination, with the ability to potentially grow the program statewide, making the model more appealing for MCO support.
In January 2022, EveryStep received a $2 million federal grant under the U.S. Department of Housing and Urban Development (HUD) to expand Healthy Homes Iowa. With match funds from the community, including a grant from Mid-Iowa Health Foundation, the program now has $3.5 million for three and a half years.
“For EveryStep, this was an amazing opportunity,” said Jen Stout, Vice President of Community Health Services at EveryStep. “Part of EveryStep’s success is that we blend and braid talent and funds to make sure we are filling gaps in the community. We have the footprint to help and to serve those who are most vulnerable.”
Placing the program under EveryStep also allows the organization to link families to other services and to serve families who speak a variety of languages and have diverse cultural practices.
“We are thinking about that overall coordination of care,” said Black. "Eighty percent of kids with asthma have additional medical conditions, so when we talk to families, the support and the resources that are needed certainly go beyond housing.”
Seeing the need beyond just asthma, EveryStep will also provide home assessments and repairs for senior Iowans to safely stay in their homes and for families with young children to prevent unintentional injuries. Two assessors are being trained to focus on these areas and EveryStep is preparing for an increase in referrals.
Federal grant guidelines limit who EveryStep can serve. Families must have an income at or below 80% area median income. EveryStep also must consider whether the home is in a historical district or needs greater repairs beyond what the program can manage.
EveryStep continues to work with partners to implement. The Polk County Health Department refers families and continues to manage lead mitigation. Polk County Public Works handles the process of bidding, supervising, and inspecting the renovations.
A pharmacist by trade, Polk County Health Department Director Helen Eddy said Healthy Homes is a model that demonstrates the importance of a public health approach to addressing health triggers – something that can be easily overlooked when you are focused solely on medical and pharmaceutical interventions.
“Housing is health. Transportation is health. Addressing the social determinants of health is foundational for us to help people live their healthiest and best lives and fulfill their well-being,” said Eddy. “I’m really proud of the tenacity of the original group in coming together to fight and find a sustainable way to do this work.”
While the HUD funding will likely be renewed, the initial grant is just 42 months to support 100 housing units a year. EveryStep and the planning team recognize the importance of embedding the intervention more fully into how medicine is practiced.
“We never could really convince the MCOs that this was something that was good for them, good for their clients,” said Burmeister, even though other states’ Medicaid programs cover Healthy Homes interventions.
The initiative, however, demonstrated how hospitals can think about addressing the social determinants of health through community partnerships. While the concept was not widely known or accepted in the pediatric asthma community at the time, hospitals and providers increasingly view this approach as an important way to improve health outcomes. MercyOne, for example, has implemented a social determinants of health survey and integrated community health workers into some of its clinics.
Still, Kozin believes that hospital leadership never fully owned the Healthy Homes program after the initial push to launch and narrative change is still needed. “That’s where the potential was from my perspective,” he said, “That in addition to reaching more kids, it was really grounding the conversation that health has to be thought of more than clinically.”
Without that shift, stakeholders worry about maintaining the effort long-term as a part of the system of care.
“The system does not have to change that much,” said Burmeister. “It just has to recognize this as equivalent to intubating a kid in an emergency room. We can’t just treat them and let them go.”
As Burmeister prepares to retire from the Polk County Housing Trust Fund this year, he notes that Healthy Homes is among the top five achievements he’s most proud of. “I think how we talk to people now and the relationships our organization has today were not there before Healthy Homes,” he said.
For Mid-Iowa Health Foundation, Healthy Homes has shown what addressing the social determinants of health can look like, and the diverse partners who should help develop solutions and share resources. It also has demonstrated how progress is never a straight line. While the Foundation can help launch innovative projects, it also has an opportunity to fill gaps in resources and to support as stakeholders work to leverage more resources and create lasting change.
“Healthy Homes was one of the first really intentional programs that connected systems – hospitals, certainly philanthropy, neighborhood revitalization projects, and technical assistance from national providers,” said Swartz of Mid-Iowa Health. “It connects systems that families need to live healthier lives.”
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