Strategies to Address Housing as a Social Determinant of Health

Healthcare organizations looking to address housing insecurity and housing quality as key social determinants of health can look at their mission as a three-tiered roadmap, according to Kelly Kelleher, MD, vice president of Community Health at Nationwide Children’s Hospital and a researcher looking at the impact housing can have on children’s health.

Kelleher, a pediatrician himself, is a seasoned expert on the matter. In a recent study published in the Journal of Child Health Care, he found that housing quality—factors like cracks in the ceiling, plumbing issues, pest problems, or holes in the floor—can increase outpatient and emergency department utilization, and has a negative effect on health status overall.

“There is an ongoing debate about what about housing affects child health,” Kelleher said in a recent episode of Xtelligent Healthcare Media’s podcast, Healthcare Strategies.

“There are thought to be two main mechanisms whereby housing can affect children,” he added, noting that his study did not look into specific factors and that he can only hypothesize. “One is the direct physical implant, and that is, poor housing like this is concentrated in environments that may have increased levels of toxins, increased levels of environmental exposures, exposures to highways and large amounts of traffic where particulate matters put out through exhaust. These actual physical features also are associated with neighborhood effects, concentrated areas of poverty.”

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The second issue relates to child-rearing. Parents or adult caregivers living in these circumstances are tied up in trying to solve these livability issues or trying to move out. Much more of their income goes toward rent, Kelleher added, making it harder for these parents to be available to their children, despite best efforts. This, too, can have an impact on child health and outcomes.

Housing insecurity and housing quality have become some of the main social determinants of health organizations focus on when working out social services programming. These are measurable issues and ones behind which large health systems and hospitals can throw their capital.

“These are new roles for many health systems,” Kelleher explained, noting that the rise in value-based care models have created a financial incentive, in addition to a moral incentive, to address social determinants of health.

“Now, the new business model is keep people out of the hospital. Well, now we have motivation to make sure patients are healthy, and yet we know that patients who live in poor housing tend to have more emergency room visits, more hospitalizations.”

Organizations looking to address housing as a social determinant of health can do so in three ways. Foremost, that includes social determinants of health screenings that happen on an individual patient level.

“Are we asking these questions? In the past, we've asked about housing insecurity, but the first question is, are we screening in clinic for housing quality?” Kelleher questioned.

Housing quality has a direct impact on certain clinical issues. Mold on the walls, cracks in the floors, rodents or pests all can lead to certain clinical episodes like asthma or eczema. Without screening for these issues, clinicians cannot connect patients with important social or clinical intervention.

Which led Kelleher to the second step: getting a health system or organization involved in enforcing city health and housing codes.

Kelleher pointed out the affordable housing shortage has created an environment in which landlords can operate with free reign, something that has consequently created this quality housing problem he has researched.

Some provider organizations have started to work with cities to create maps of children with conditions like asthma, and overlapping that with some housing maps and data. That work can identify neighborhoods or areas where children disproportionately see housing-related medical issues and determining if poor housing quality and landlord oversight could be the culprit.

“Going after those particular landlords with data on housing and health can really make a difference,” Kelleher said. “And, of course, medical legal partnerships can be very effective in that, and those are legal clinics that are embedded medical centers.”

Finally, organizations, particularly those with adequate finances, are beginning to work on housing projects, themselves.

“The third level, and the level that I spend most of my time on, is really trying to help the hospital and its partners enhance the supply of affordable, high quality housing in our community,” Kelleher said. “And, finding willing banks and participants, the Mayor's Department of Development, the State government, and Housing Finance Authority, and working to build capital stacks and low-income housing tax credit deals where families can find clean, affordable housing that's not available in the market right now in many places.”

At Nationwide Children’s Hospital, Kelleher and colleagues have zeroed in on the 50,000-unit affordable housing shortage in Columbus, Ohio.

“One of the things we did was educate ourselves about projects and needs in our area that were going to be done through the Mayor's Department Development office and say, some of these should have health outcomes,” he explained. “We want to put in prenatal care in one of them. We think this one should have childcare because there are not enough childcare services in this facility. We would like to do a job training program in this one to have more hospital workers for our neighborhood.”

This approach hinges on quality community health partnerships and buy-in from city or local government. But according to Kelleher, the latter is easy to drum up considering the fact that hospitals serve as anchor institutions in most communities.

In the case of Nationwide Children’s Hospital, the Columbus government was a keen partner because the hospital’s involvement mean there would be jobs to turn to during job training, and quality childcare in targeted facilities.

“So, understanding where children are sick, and where they need to be better, and where current investments are, is something that a hospital is well positioned to do,” Kelleher concluded. “And every hospital already has extensive real estate experience, banking experience, legal experience. Those things can really facilitate your involvement in these other activities.”