LSA Family Health Service & CHWs Ray López Director of Programs, Director, Environmental Health Services (646) 672-5233 rlopez@lsafhs.org

History The “Little Sisters” Founded by the Little Sisters of the Assumption, a nursing order of nuns from Paris dedicated to helping the “sick poor.” Established in East Harlem in 1958 and incorporated as nonprofit organization. Programs evolved organically around the core services of home nursing and early childhood care.

Client Demographics Average Annual Household Income: $15,600 Primary Language: 51% Spanish 34% English 8% Indigenous Languages 7% Other Housing type: 33% Doubled-up (more than one family sharing a home) 23% Single Family Rental 22% Public Housing 21% Other (Assisted Living, Shelter, Section 8, Group Home, Unknown) Family Makeup: 60% have 3 or more members 40% of all clients have children 4 years or under

Housing Conditions & hospitalizations Why did I become a CHW?

Asthma in East Harlem Childhood asthma is a prominent health issue in East Harlem 6th highest rate of child asthma hospitalizations in NYC (2x the citywide rate) Rate of asthma-related ED visits among children in East Harlem is 2.4x the citywide rate (620 vs. 255 per 10,000) Asthma is the leading cause of missed school days Pollution is a major contributing factor 9.7 micrograms per cubic meter air pollution (ranks 16th out of 59 community districts) 76% of renter-occupied homes in East Harlem with at least one maintenance defect (6th out of 59 community districts) water leaks, cracks and holes, inadequate heating, presence of mice or rats, toilet breakdowns and peeling paint. Structural issue: Public housing accounted for more than one-third of the neighborhood’s rental apartments. Data from NYC Department of Health

Environmental Health & Family Asthma Program CHWs and Caregivers identify and mitigate asthma triggers CHWs educate families about asthma and coach caregivers to maintain healthy home CHWs and Caregivers advocate for home repairs CHWs identify and work with community leaders to organize and improve housing conditions   Crisis: Identify asthma triggers & reduce exposure (Build Trust & Self Esteem by offering concrete help) Skill Building: Educate and assist families to maintain healthy homes Skill Building: Advocate for tenant repairs that affect health (Capacity Building) Community Building: Identify & work with community leaders to improve housing conditions

HEPA-filtered Vacuum & Air Purifier

IPM for Cockroaches

IPM for Bed Bugs

Housing Conditions Before

Housing Conditions Before

Verification

Occupant & Worker Protection

Remediation

Housing Conditions After

Housing Conditions After

Community Health Worker model CHW model works! Cost-effective Save $1135 per patient per year For every dollar invested in CHW, the hospital system saves $2.30 Positive health outcomes Successful in management of many chronic illnesses 80% of school children in LSA’s Environmental Health program had fewer or no urgent care or emergency room visits as a result of asthma Goal: Provide sustainable, healthy changes to clients’ homes and reduce the negative impacts of asthma Rachel - A 2012 study of CHW programs in the Bronx found that CHWs saved the city $1135 per patient per year, and that every dollar invested in CHWs saved the hospital system $2.30 - Data from ASTHO and LSA

Our Research Partners NY Academy of Medicine, Columbia University Housing and Urban Development Mount Sinai Health System, Institute for Family Health, City Health Works Patient Centered Outcomes Research Institute Mount Sinai, Enterprise Community Partners, National Center for Healthy Housing JPB Foundation -CAHR: Controlling Asthma Through Home Remediation -SAMBA: Supporting Asthma Management Behaviors for Adults -Green: Evaluation the Effects of Affordable Green Renovations on Children with Asthma

Medication and Health Care Use

CHW Scope of Practice Outreach/Community Mobilizing Preparation and dissemination of materials Case-finding and recruitment Community Strengths/Needs Assessment Home visiting Promoting health literacy Community advocacy Case Management/Care Coordination Family engagement Individual strengths/needs assessment Addressing basic needs – food, shelter, etc. Promoting health literacy Goal setting, coaching and action planning Supportive counseling Coordination, referrals, and follow-ups Feedback to medical providers Treatment adherence promotion Documentation System Navigation Translation and interpretation Preparation and dissemination of materials Promoting health literacy Patient navigation Addressing basic needs – food, shelter, etc. Coaching on problem solving Coordination, referrals, and follow-ups Documentation Home-based Support Family engagement Home visiting Environmental assessment Promoting health literacy Supportive counseling Coaching on problem solving Action plan implementation Treatment adherence promotion Documentation Community/Cultural Liaison Community organizing Advocacy Translation and interpretation Qualities •Shared experiences Peer relationships Trustworthy •Community connection •Non-judgmental •Resourcefulness •Creative •Empathic Health Promotion & Coaching Translation and interpretation Teaching health promotion and prevention Treatment adherence promotion Coaching on problem solving Modeling behavior change Promoting health literacy Harm Reduction Participatory Research Preparation and dissemination of materials Engaging participatory research partners Facilitating translational research Interviewing Documentation CHW Network of NYC

Organizing with Caregivers and partners Regular meetings from 2001 to 2011 with NYCHA’s Borough Director, CHWs & resident leaders to address unresolved repairs. Some early success: Ended use of Ficam Plus (2001) Adopt green cleaning products (2002) Create Centralized Call Center (2006) Focus on local repairs (’07- ) Clustering of repairs (’11- ) We start by helping individuals, but our aim is to identify potential leaders, and train them to work with others. We identify & work with community leaders to improve housing conditions. We want to build community power to improve lives. (Greater Impact)

Baez v NYCHA In the housing context, a reasonable accommodation is a change in a rule, policy, practice, or service that may be necessary to allow a person with a disability the equal opportunity to use and enjoy a dwelling. Failure to provide a reasonable accommodation may be construed as discrimination.

Baez v NYCHA December 2012: Request for Accommodation June 2013: Negotiations with City Hall & NYCHA December 2013: Reached Settlement April 2014: Settlement Certified by Federal Judge May 2014: Implementation & Verification July 2015: Motion to Enforce December 2015: Motion upheld January 2016: Appointment of Special Master Jan ‘16 to April ‘18: Meetings with NYCHA & Special Master June 2018: Pre-motion Conference with Judge

Baez v NYCHA Basic Terms of Original Settlement (Dec ’13) Plaintiff class New Mold & Moisture Policy NYCHA will modify its forms and informational materials related to disabilities and mold to inform residents that asthma may be a disability entitling residents to accommodations. NYCHA will periodically report to plaintiffs’ lawyers Court will enforce settlement for at least 30 months.

Baez v NYCHA Basic Terms New Mold & Moisture Policy Abate flooding within 24 hours Dry standing water within 48 hours Fix simple repairs within 7 days Fix complex repairs within 15 days Follow-up contacts & inspections NYCHA supervisors Training of NYCHA staff on new policy Moisture meter pilot Within an average of … for 90% of all complaints made to NYCHA. Simple Repairs: repairs that can be done by a maintenance worker; usually a condition within the apartment unit Complex Repairs: repairs that require specialized trades; usually a condition affecting multiple apartments This is about addressing damp indoor spaces; moisture and mold conditions that affect people’s respiratory health. There are many other housing issues out there, but this one needed more attention.

The impact of poverty on asthma Dateline documentary January 2014 “Breathless” The impact of poverty on asthma http://www.nbcnews.com/id/3032600/vp/53993240#53993240

Published in Volume: 8 Issue 5: October 22, 2015

Here’s the link to the report on our site to share: https://www. nyam   Please use this bitly link for social media: http://bit.ly/2xjqrcD Published September 2017

Preferred CHW Attributes Connected to Community Resourceful, Creative Mature, Prudent, Persistent Empathetic, Caring, and Compassionate Open-minded, Non-judgmental, Relativistic Respectful, Honest, Patient Friendly, Outgoing, Sociable Dependable, Responsible, Reliable Foundations for success Qualities that make one a good CHW Employer priorities Hiring CHW Network of NYC

Fungal Exposure in New York City Low-Income Housing Pre and Post Intervention Photographs of Controlling Asthma through Home Remediation (CAHR) intervention to reduce exposure to mold Pre-Intervention -------------Intervention-------------- Post-intervention

Fungal Exposure in New York City Low-Income Housing Pre and Post Intervention To date, dust collected from 29 homes that participated in an intervention 2-5 years ago and 15 newly recruited homes that qualify for an intervention Compared to NAAS Manhattan homes (n=46), 7/36 species more common in intervention homes (all P<0.001) Genera Aspergillus, Eurotium, Cladosporium and Epicocum. Lopez, Acosta, Realmuto, Divjan, Weiss, Perzanowski.

DSRIP Asthma Project CHWs serve medical and non-medical roles medical services in-home interventions, education data sharing, case management community health workers address basic needs, connect to resources, education, coaching, advocacy, community organizing, clinics households

Little Sisters of the Assumption Family Health Service Ray López Director of Programs, Director, Environmental Health Services (646) 672-5233 rlopez@lsafhs.org Relationships are foundational Go beyond cost-benefit analyses CHW potential for structural change