Enterprise and Citi continued the Health Begins with Home Convening series on Nov. 17, 2020, with a look at how housing quality impacts health and wellness, and the intersectionality between the healthcare and housing sectors around housing quality needs. The link between health and conditions within a home has been well studied yet is largely overlooked as a strategy that can be utilized within our healthcare system. In this session, through discussion and art, we learned the vital importance of creating an interconnected system to support health and well-being.
Understand the Issue Through Performance
Artist Shá Cage kicked off the session with an emotional narrative of a mother living in substandard housing providing a point-of-view tour of her tiny apartment. Cage’s performance emulates the lives of residents who experience the struggles of being cost-burdened and living in substandard housing.
Cage lists the deplorable conditions of her residence – mold, peeling paint and odorous smell – but compromises with her situation because it was all that she could afford. That is… until she fell behind on rent – a relevant situation plaguing the Covid-19 era we live in – and her unempathetic landlord comes requesting back rent.
Exhibiting both verbal and visual distress, Sha Cage wears an uneasy smile in front of her children, who are represented by props, to hide the pain and uncertainty that falls upon her. Cage portrays the harsh reality of substandard housing and its impact on health especially after mentioning the coughing spells her asthmatic child suffers due to the combination of toxins and poor air quality surrounding the environment. This is the reality of how quality housing impacts health that Citi and Enterprise want to bring forth to the public eye.
Roadmap for Promoting Health Through Housing
Associate Professor of Pediatrics at Boston University School of Medicine, Dr. Megan Sandel opened the conversation sharing her experience of being with patients and wanting “to write a prescription for a healthy home” a treatment not stocked at the pharmacy of her hospital. Asthma, accidental injuries, mental health, exposure to lead and financial trade-offs impacting health are all significantly exacerbated by the conditions within a home.
Dr. Sandel brings a new perspective few may have considered that these factors and other Social Determinants of Health (SDoH) are not fixed and are not always negative. What this concept signifies is that SDoH are instead malleable and that through a health equity lens we can impact SDoH so that everyone gets his or her fair share toward health opportunity.
Levels of Health Systems Impact on Housing Quality
Dr. Sandel walked through three different levels of impact where healthcare can consider drive change in housing quality and drew on examples from her own hospital, Boston Medical Center (BMC).
Research and Screening: Hospitals can help identify individuals and families in need of housing supports. They can do this through screening tools, such as the THRIVE tool that BMC is using and integrating with their patient’s electronic medical records. This will allow BMC to track social factors that are important to patients and the impact that it has on health outcomes over time. Access to this data in aggregate largely influenced the housing initiative that BMC adopted.
Connecting and Integrating Systems: After a health system has a good understanding of the social factors of their patients, whether through screening patients, Community Health Needs Assessments or other means, this will inform the community partners to connect with for referrals to services or resources, such as medical-legal partnerships to take on housing quality needs in rental housing or a food pantry. This extends beyond referrals and can inform new program development for severe or common housing needs.
Policy and Investment: According to Dr. Sandel, the ultimate level is around policy and investment to increase the resources available to support quality affordable homes for low-income community members. This may take the form of multi-sector coalitions making clear and united policy changes to increase resources to support positive SDoH. Or it could include an investment strategy where health systems invest their own resources into partnerships or developments that lead to more housing stability.
These three levels illustrate how health systems can look both at individual hardships and connect these hardships to the upstream solutions that are needed in the community. As health systems move towards this multi-layered approach, we move towards equity. To have an equitable system, we have to treat people “unequally” and meet their unique needs. As we intentionally dismantle the impact of historic systems of racism, oppression and redlining affecting people of color in the U.S. we can move towards a society where the SDoH have a positive influence on health for all.
Integrating Community Voices into the Work
Dr. Sandel was joined by Josie Williams, executive director of Greensboro Housing Coalition (GHC), and Ruth Ann Norton, president and CEO of Green & Healthy Homes Initiative (GHHI), to share examples of how healthcare partners and housing organizations can come together and center the community voice in driving health improvement through housing quality. Both GHC and GHHI understand the importance of working closely with community to reach scale and longevity with their programs and highlighted the need to center this commitment when entering cross-sector partnerships.
Williams shared that this often requires a culture and power shift. She asked for healthcare to come to the table to first listen and understand the priorities of the community and acknowledge how systems, even healthcare has been a part of, have systematically excluded certain communities from the process of decision making and access to it. In continuing to engage in this conversation, evolving it over time, continued listening, relationship building, and empowerment that she has seen impactful and sustainable partnerships that address needs around housing.
Norton built on this in providing that listening to the community and the solutions they offer initiates change. Listening illustrates the need for an “efficient, effective and responsive system to get immediate results to the communities being served.” There are a lot of partners with a role to play in addition to health care. But healthcare definitely has a role. In determining their role, health care should not limit their focus only on solutions with a clear and defined return on investment. Health systems and payers can look to invest both in high-need patients around the SDoH where they receive a return on this investment, while also utilizing those savings to invest further in their community and the types of programs and resources that will make the population as a whole healthier.
The Future We are Working Toward
At the conclusion and throughout the convening, participants and panelists took part in a collective visioning exercise around the future we are all working toward. A theme throughout both the panelists' and participants' responses was a need to focus on our shared humanity and acknowledge everyone in our society as deserving. Williams shared that her vision of the future is when everyone takes the needs and issues of equity in this country as personal. This is personal work, and we should not accept a world where zip code is predictive of your health. All three panelists believe it is possible to build new models of working together, envision creative policies and invest together to reach this future.
This blog was authored by Damarea Crain and Mary Ayala, program director, Enterprise National Initiatives.