Controlling Pediatric Asthma Past, Present, Future

1. The Experience in Metro Washington, DCStephen J. Teach, MD, MPHIMPACT DCChildren’s National Health System Controlling Pediatric Asthma Past, Present, Future

2. Disclosures Grant support from Novartis for NIH/NIAID funded PROSE study (NCT01430403)

3. Conceptual Model of Asthma Child With Asthma Individual & Social Factors • Genetics • Physical conditioning • Socioeconomic status • Stress • Hormone levels Medical Care Factors • Access to care • Quality of care • Medication plan • Adherence • Technique • Immunizations Environmental Factors • Allergen sensitization and exposure (dust, mold, roach, mice, pollen…) • Viral infections • Weather changes • Air quality (irritants) Level of Asthma Control Poor High Morbidity • Many symptoms • Many school absences • Many ED Visits Low Morbidity • Few Symptoms • Few school absences • Few ED Visits

4. Outline • Past: Disparities in Asthma Outcomes • Nationally • Metro DC • Present: Achieving Better Control in the Inner-city • NIH Guidelines • Future: “Phenotypic Driven Care” • Immunomodulators

5. National Experience with Pediatric Asthma • 7.1 million children <18y living with asthma in the US in 2009* • 640,000 ED visits** • 157,000 hospital admissions** • 10.5 million annual lost school days* • Morbidity is highly concentrated in urban environments • Children’s National sees 1% of all ED visits for asthma every year in our country! *National Health Interview Survey **National Hospital Medical Care Survey

6. 18%

7. 4.3x Pediatric ED Visit Rates for Asthma0-17y, inclusive Akinbami L. Pediatrics 2009. IMPACT DC, 2012.

8. >10 fold Difference in Rate

9. Poverty in DC, 2000

10. Primary Care Access, 2005

11. Primary Care Access, 2005 Primary Care Access, 2005

12. Outline • Past: Disparities in Asthma Outcomes • Nationally • Metro DC • Present: Achieving Better Control in the Inner-city • NIH Guidelines • Future: “Phenotypic Driven Care” • Immunomodulators

13. 2007 1991 1997 2002 National Institutes of HealthGuidelines for Asthma Care

14. Priorities of the NIH Guidelines } • Proper diagnosis • Patient and family education • Identification and control of triggers • Clear medical plan • Inhaled Corticosteroids (ICS) • Effective longitudinal care

15. Child in Community with Asthma Experiences an Acute Exacerbation ED Visit and Discharge 21% within 30 days Liberman D. Ped Emerg Care 2012. Primary Care Follow-up Opportunities for Improved Care

16. Child in Community with Asthma Experiences an Acute Exacerbation ED Visit and Discharge >70% within 15 days Teach SJ. Arch Ped Adol Med 2006. Primary Care Follow-up Opportunities for Improved Care

17. Lung Diagram

18. Personalized Asthma Tools

19. Patient Device Education

20. Summary of “Present” • Disparities in asthma care and outcomes in Washington, DC are striking and persistent • Heavy reliance on EDs for episodic care by disadvantaged and minority kids • Things are improving due to a relentless focus on the most “out of control” kids!!

21. Outline • Past: Disparities in Asthma Outcomes • Nationally • Metro DC • Present: Achieving Better Control in the Inner-city • NIH Guidelines • Future: “Phenotypic Driven Care” • Immunomodulators

22. Conceptual Model of Asthma Child With Asthma Individual & Social Factors • Genetics • Physical conditioning • Socioeconomic status • Stress • Hormone levels Medical Care Factors • Access to care • Quality of care • Medication plan • Adherence • Technique • Immunizations Environmental Factors • Allergen sensitization and exposure (dust, mold, roach, mice, pollen…) • Viral infections • Weather changes • Air quality (irritants) Level of Asthma Control Poor High Morbidity • Many symptoms • Many school absences • Many ED Visits Low Morbidity • Few Symptoms • Few school absences • Few ED Visits

24. Hypothesis – DesignICATA Trial – NEJM, March 2011 • Addition of omalizumab to treatment based on existing NIH guidelines would improve disease control among atopic inner-city children with moderate-to-severe disease • Prospective multi-center randomized clinical trial of injected omalizumab vs. injected placebo in inner-city kids with allergic asthma

25. % of Participants with Exacerbations (n=211)(n=208) Exacerbations

26. Housing Conditions Cases An Overview Tracy Goodman, Director, Healthy Together Kathy Zeisel, Senior Supervising Attorney Skadden Pro Bono Training, May 13, 2014

27. Outline of the Training • Background of CLC’s Medical Legal Partnership Healthy Together and Housing Conditions Pro Bono Partnership • Introduction to Housing in DC • Typical Housing Conditions Problems • Handling a Housing Conditions Case

28. What is Medical-Legal Partnership? • A healthcare delivery model that integrates legal assistance as a vital part of the healthcare delivery system • Expanding the conception of medical care for low income families to include legal representation • Program model based on prevention • Removing non-medical barriers to children and families’ health and wellbeing • Address adverse social conditions negatively impacting health through a variety of modalities • MLPs work to address and prevent adverse social pressures with legal remedies through: • Direct Patient Contact • Provider Training • Systemic Advocacy

29. CLC’s Healthy Together: DC’s Medical Legal Partnership for Children CLC’s Healthy Together: DC’s Medical L“[D]ramatic differences in …child and adult health outcomes based on social factors such as income and wealth…begin early in life-even before birth-and accumulate over lifetimes and across generations.” Robert Wood Johnson Fdn, Issue Brief Series: Exploring the Social Determinants of Health, March 2011 egal Partnership for Children • Children’s National • One of the oldest MLPs in the country • In 2002 began with one lawyer • In 2014 we now have eight lawyers and two investigators • A variety of CNMC clinics and programs: • Generations • Four Children’s Health Center Locations • Large focus on teen parents and SE residents • IMPACT DC • Mary’s Center • Originally, federally funded through Healthy Start, Healthy Families • Focus on immigrant community • Focus on children with asthma

30. Why Housing Conditions Cases? • Filling a community need • Hands-on lawyering • Direct advocacy • Litigation experience • Concrete results for children • Working with families

31. Housing In DC:An Overview of the Basics

32. Basic Housing Vocabulary • Subsidized Housing • Catch-all term that covers all publicly financed housing options • HUD: the Department of Housing and Urban Development • Federal department that oversees all federally funded public housing. • DCHA: DC Housing Authority • Quasi-government organization that oversees most public housing options in DC • Is both a federal and local agency (and is neither fully) • HQS: Housing Quality Standards • These are the HUD standards used by HUD and DCHA to inspect properties • DCRA: Department of Consumer and Regulatory Affairs • DC Government agency that inspects residential, retail, commercial, etc. properties. • Responsible for enforcing the DC Housing Code

33. Who is the tenant? • With a formal lease • In DC, the end of a lease is NOT good cause for eviction. • Without a formal lease • Any arrangement where money is exchanged for a place to stay. • Foreclosure • If the owner is foreclosed on, the tenant still has the right to stay and the bank becomes the landlord.

34. Common Types of Housing • Private Housing • Public Housing • Owned and operated by DC Housing Authority (DCHA) • Housing Choice Voucher Program (HCVP - formerly “Section 8”) • Tenant has voucher and the voucher moves with the tenant • Project Based Section 8 • Owned and operated by a private landlord; funding stays with unit, not the tenant • Moderate Rehabilitation Housing (MOD) • Somewhat like Project Based Section 8, but run by DCHA (HCVP Program)

35. Housing: Private • Owner-occupied (would not be our client) • Rent-to-own arrangements • Rental units where the tenant pays the full cost of the rent

36. Housing: Project Based Section 8 • Private landlord receives direct funds from HUD to operate subsidized housing. • The subsidy stays with the unit. • There are NO transfers between properties unless a waiver is granted by HUD. • For most properties, oversight is by HUD Office of Multifamily Programs and the local HUD office. • However  DCHA oversees a few project-based Section 8 properties in DC

37. Housing: Project Based Section 8 • Project Based Section 8 Properties • Must apply to each property, which maintains their own waitlist. • Waitlists are generally shorter • No transfer rights to properties with different owners • Housing may be for a specific population (ie: families, disabled, elderly) • You can find the lists of project-based section 8 on the HUD Office of Multifamily Programs: • http://www.hud.gov/apps/section8/

38. DCHA Housing: Getting into It • DC Housing Authority Waitlists • There are currently 60,000 people on the waitlists for Public Housing and HCVP combined • For some housing, it will be a 20-43 year wait • Other housing come available more frequently. • Preferences for: Homeless, veterans, seniors, DV survivors • DCHA Waitlist Closes on April 12, 2013 • Once it closes, it looks like it will be a hard close • No exceptions for homeless individuals or families, or youth aging out of foster care

39. Housing: Public Housing Public Housing Relationship Tenant DCHA Owned and operated by DCHA • Regular DCHA inspections of the property • Units are located throughout the city • People placed in public housing from the central waiting list maintained by DCHA (1133 N. Capitol St NE) • Transfers from one unit in one neighborhood to another unit in a different neighborhood are possible • Tenant recertifies at DCHA

40. Housing: HCVP Relationships of HCVP Tenant DCHA Landlord • HCVP operates several programs within DCHA • Housing choice vouchers (also still called Section 8 vouchers) are far different from other public housing options: • A voucher allowing recipients to seek a place to rent on the open market. • Recipients pay 30% of their income toward rent. The government covers the rest. • Voucher is portable

41. Housing: Moderate Rehabilitation Properties (MOD Rehab) • Administered by DCHA • Operates like project-based Section 8 • Typically, there are no transfers out of the program into other types of housing. • These are many of the worst properties in the city.

42. Who Oversees Whom…

43. Housing Conditions: The Law • DCMR Title 14, Chapters 1-15 outline the Housing Code in DC • DC has now adopted the International Property Maintenance Code with some local adaptations • BUT there is no unified document yet • IPMC is here: https://law.resource.org/pub/us/code/ibr/icc.ipmc.2012.html • DC rulemaking is here: http://www.dcregs.dc.gov/Gateway/IssueHome.aspx?IssueId=486

44. IPMC > Title 14 • 102.4.1 Code precedence.  If a conflict arises between the Housing Code,Title 14 DCMR, Subtitle A and the Property Maintenance Code, theprovisions of the Property Maintenance Code shall take precedence.

45. Housing Conditions: The Law • No one has to live in unsafe, hazardous, or unsanitary conditions • These conditions include: mice/rats, roaches, bed bugs • lead paint, mold, holes in the wall or ceiling • leaky pipes or electrical problems, • lack of heat and/or hot water • Landlords may not ignore any problem that constitutes: • a fire hazard, or • a serious threat to life, health, or safety of tenant

46. Common Housing Issues • Needs repairs or repairs are inadequate • Screens missing or improperly installed • Fridge leaks coolant into food • Toilet does not work properly • Sewage overflow • Accessibility • No wheelchair access • Broken elevator

47. Common Housing issues • Infestations of mice, rats and/or cockroaches • In food/kitchen areas • Damaging furniture/mattresses • Crawling on children/biting children • Allergies from urine/feces/dander • Mold/Moisture • Allergies • Unsafe structurally- Ceiling/Walls collapsing

48. Pending Mold Legislation • Legislation is pending in the DC Council that will require landlord to remediate mold • This will hopefully be in effect in the fall

49. Handling a Housing Conditions Case

50. Challenges that Face our Clients • Income • Education/Literacy • Reliance on public transportation • Barriers to communication: • Inflexible job • Transportation Costs • Time commitment for using public transportation • Caring for an infant or other relative • Cost of cell phone minutes