New York State Healthy Neighborhoods Program
1) is managed at the state level and implemented at the community level (capitalizing on the power of locally designed programs and the resources of a state agency).
2) is unique in scale and geographic scope, serving thousands of homes and individuals in high-risk urban and rural communities each year.
3) has a primary emphasis on management of the home environment that enhances case management and clinical care provided by partners.
4) has innovative partnerships that improve delivery of services and integration of environmental management throughout the continuum of clinical care.
5) has a robust and dynamic program evaluation that allows for assessment of improvement in individual patients, but also across differences in delivery systems.
The NYS Healthy Neighborhoods Program (HNP) is a healthy homes program that provides in-home assessments and interventions for asthma, tobacco cessation, indoor air quality, lead and fire safety and other environmental health hazards in selected communities throughout NYS. The program targets housing in high-risk areas that are identified using housing, health and socioeconomic indicators from census and surveillance data. The HNP uses a combination of door-to-door canvassing and referrals to reach residents in these high-risk areas. During a visit, the home is assessed for environmental health and safety issues. For problems or potential hazards identified during the visit, outreach workers provide education (written and verbal), referrals and products to help residents correct or reduce housing hazards related to: tobacco control, fire safety, lead poisoning prevention, indoor air quality, carbon monoxide poisoning, radon, ventilation, cleaning and clutter, pests, mold and moisture, structural issues, asthma and other health and safety issues (e.g., injury prevention). About 22% of homes receive an optional revisit, scheduled 3-6 months after the initial visit. During a revisit, the home is reassessed and any new or ongoing problems or hazards are addressed. Ten counties are currently funded to provide services to residents in target neighborhoods. Between October 2007 and April 2011, the program provided services to over 58,000 residents in roughly 20,000 homes. About 15% of these homes have one or more resident with asthma.
Strategic partnerships with clinical organizations
The HNP has a primary emphasis on control of environmental factors and relies on strategic partnerships with clinical providers and organizations to assure appropriate clinical care and follow-up for residents with housing-related medical needs. For residents with asthma, these partnerships are critical to receiving comprehensive care. The goal of these partnerships is to improve targeting of environmental interventions to at-risk populations, to increase access to environmental services for people with poorly controlled asthma and to integrate home environmental management into usual medical care for asthma. Local Health Departments use a variety of strategies and partners to achieve these aims, including collaborations with managed care plans, partnerships with regional asthma coalitions and relationships with individual providers in the community, including initiatives that bring medical residents into the home setting.
Evaluation
Evaluation is integral to the HNP. Data is used dynamically to monitor progress and refine the approach. At each visit the program collects information about housing characteristics, resident demographics, housing conditions and, for residents with asthma, patient level measures of asthma symptoms and self-management. Program evaluation focuses on assessing whether resources are reaching the intended target population and on tracking improvements in housing conditions between the initial visit and revisit. The asthma component of the intervention uses pre/post-intervention evaluation to assess improvements in the following: presence of triggers or conditions that promote triggers in the home environment; asthma knowledge and self-management—knowledge of triggers and avoidance strategies, medication usage and the use of asthma action plans; and asthma morbidity—number of days with worsening asthma and visits to a doctor, ER or hospital. The state-led evaluation allows for comparisons across local initiatives to look for the impact of different approaches on targeting the intervention to the most at-risk populations, and on the magnitude of improvement in trigger reduction, asthma knowledge, self-management behaviors and asthma morbidity. The state’s central management role in the program helps to ensure that promising and transferable strategies for targeting home visits are shared across local program grantees.
Local programs often collect or acquire additional data (e.g., medical claims data), but the primary data source for evaluation is the HNP four-page dwelling assessment form. The form includes demographic information about the primary respondent; characteristics of the dwelling; characteristics of the residents; physical conditions of the dwelling; and education, referrals and products provided. A one-page asthma form is completed for each resident with asthma at each visit. Completed forms are faxed to the state, which scans the data and saves it in a database. The data system automatically generates quarterly reports for the program as a whole and for individual local health departments.
A recent program evaluation indicates that the NYS HNP was able to reduce the overall number of hazards per home and demonstrate statistically significant improvements in fire safety, indoor air quality, tobacco control, lead poisoning prevention, pest control, mold/moisture and other housing hazards. While there were improvements in nearly all of the 42 conditions assessed, the following hazards showed the largest magnitude of improvement (ordered from the maximum improvement, 94%, to 50%): placement and functioning of smoke detectors, rats, plumbing leaks, malfunctioning appliances, blocked exits, mice, cockroaches, CO detectors, furnace filters, mold/mildew, electrical hazards, roofing/structural leaks and improperly stored flammables. For residents with asthma, there were significant improvements in key self-management measures and a significant reduction in the number of days with worsening asthma or asthma attacks.
Management and structure
The HNP has operated in NYS since 1985 and has been funded through the NYS General Fund since 2008. The program began systematically addressing asthma and asthma triggers in 1997 and continues to have a strong emphasis on improving asthma control for residents in target communities as part of holistic, healthy homes program.
The HNP is centrally managed at the state level, but services are delivered through grant-funded local health departments. The state health department manages the overall program—bringing the strengths of its surveillance, evaluation and other resources – and articulates a framework of core objectives, operating procedures and measures to ensure consistency across local programs. Local health departments are selected through a competitive grant application process and submit workplans that incorporate this core framework, but that build on local resources and infrastructure to deliver services in a way that in most meaningful and effective for each individual community. The central role for the state provides standardization across core program design elements, such as what housing conditions are assessed and how they are assessed and mitigated, evaluation metrics, and a perspective that allows for fast recognition and dissemination of best practices across the program. Design and delivery of the program at the local level allows for tailoring to meet local needs; access to credible, community-based partners; and strong partnerships with local clinical care providers and organizations.
Field staff responsible for the home assessment and intervention are environmental health specialists (sanitarians, health educators, public health nurses or other public health professionals) with training in healthy homes concepts. However, the HNP is not a case management program and to achieve its objectives, the program relies on an extensive network of partners at the state and local level.
Currently 10 LHDs, in five regions of NYS are funded to implement the program. This includes both urban and rural areas of the state.
