Jay Portnoy, MD, Children’s Mercy Hospital

Jim Sublett, MD, Family Allergy

Kevin Kennedy, MPH, CIEC, Children’s Mercy Hospital

Carl Grimes, CIEC, Hayward Healthy Homes

Using Home Environmental Assessments for Effective Patient

Care: A Panel Discussion

Environmental Assessments are part of upstream thinking

Are you anUpstreamist?

Pathways Linking Sources of Dampness with Health

From- WHO Guidelines for IAQ: Dampness & Mold, p.4-5, 2009

Home Environmental Assessment to Guide Exposure Reduction

From Center for

Environmental Health,

Children’s Mercy

Hospitals and Clinics.

From Center for Environmental Health, Children’s Mercy Hospitals and Clinics.

Typical Home Assessment Report

Case Discussion• 5 year old Hispanic male accompanied by

mother and grandmother.• Chief complaint: cough and nasal congestion

since age 1. • Symptoms are year round, worse this fall. • Referred by school nurse after missing

several days of school since starting Kindergarten this year.

• Teacher reports “wheezing” when running.

Environmental History:

• Patient Medical History• Patient’s symptoms and Health

Concerns• Environmental History

– Home, Work,• Relevant Clinical Testing

Case discussion 1 (continued)

• Past Medical History: Negative• Family History: Mother has frequent

bronchitis that seems to have gotten worse this past year. She never had this problem when she lived in Columbia.

Case discussion (continued)

• Lives in apartment with mother, father, grandmother and 2 younger siblings (all the children share a bedroom)

• Indoor cat• Grandmother smokes• Father is an exercise rider at horse track• Forced air gas furnace• Window air conditioner• Use vaporizer in bedroom for younger

siblings nose congestion

More Environmental History

• Have lived in second floor apartment, owned by the race track, for about two years.

• Wall to wall carpeting which they shampoo with a rented scrubber about every 6 months.

• Furnace in closet; not sure about the filter, but know the maintenance man has changed it about 6 months ago.

• Had a pipe leak in the bathroom that was repaired.• In August 2009, after a 10” rain the entire

neighborhood and lower floor of the building was flooded during flash floods.

Indicators for the need of an Environmental Assessment:

• Patients have symptoms that don’t respond to “regular” treatment.

• Patient’s symptoms respond to treatment, but require it to be continued. (Remain aware of patient compliance with treatment / therapy issues)

• Unique environmental conditions reported that suggest an assessment is warranted.

Physician/Environmental Professional Referral and Consult:

Physician and Health Care Providers:• Education and triage• Health & Environmental History• Referral and Communication

Environmental Professional• Visual Assessment & In-home Education • Environmental Measurement & Sampling• Assessment Reporting with Issues & Actions

Both• Hypothesis Generation• Follow-up & Case Management

Finding Qualified Home Environmental Assessment Professionals

Key things to look/ask for:–Certification from established

organizations–References–Samples of scope of work,

contracts, and assessment reports

Communication Between Health Care Providers and

Environmental ProfessionalsBEFORE the Assessment

• Important information to share• HIPAA issues to consider

– Can you share health information?

Professional Assessors First Finding

Communication Between Health Care Providers and

Environmental ProfessionalsAFTER the Assessment

• Important information to share• Can Env. Prof. share home

assessment information?

The Future of Health Care

Centers for Medicare and Medicaid Services are reorganizing the US health care system using the “Triple Aim” approach:

• Reduce per capita health care costs

• Improving the experience of care by addressing quality and satisfaction

• Improve the health of target populations.

Berwick, Institute for Healthcare Improvement, 2008

Health Care System-Wide ChangeCommunities must focus on six essential

approaches, including:

• Family-centered medical homes• Health Care practice redesign• Care plans and care planning • Greater support for patient self-

management • Organized health care systems• Sharing resources.

Berwick, Institute for Healthcare Improvement, 2008

Essential Benefit Rule Change New Language- Preventive services must be

recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under state law

Dept. of Health & Human Services, Final Rule on Essential Health Benefits, February 2013

Preventive services means services recommended by a physician or other licensed practitioner of the healing arts acting within the scope of authorized practice under State law to - 1) Prevent disease, disability, and other health conditions or their progression; 2) Prolong life; and 3) Promote physical and mental health and efficiency

The Future of Health Care is Changing

For Medicaid patients, the proposed new rules allow for home assessment services by a non-clinical, licensed person, such as:• Asthma Educator• Community Health Worker• Environmental Professional

Dept. of Health & Human Services, Final Rule on Essential Health Benefits, February 2013

This means reimbursement is available for home assessments

Reimbursement for Home Assessments?

• Wide range of fees

• Promising pilots of evidence-based practice show:– Team approach is effective and has paid for itself– Multiple Visit model best– In-Home Education on Asthma combined with

healthy home environmental assessment

New Tools to Help You

• Standardized approaches for home assessment– Have been developed– Being taught to environment assessment professionals– Certified laboratories– Database software tool for environmental assessment

• Environmental practice parameters to clinical guidance– Furry animals (Annals of Allergy Asthma & Immunology, 2012, Vol.

108)

– Rodents (Annals of Allergy, Asthma & Immunology, 2012 Vol.109)

– Cockroaches (Jour. of Allergy & Clinical Immunology, 2013 Vol.132)

– Dust mites (Annals of Allergy, Asthma & Immunology, 2013 Vol.111)

– Fungi (planned for Summer 2014)

Jay Portnoy, MD, Children’s Mercy Hospital

Jim Sublett, MD, Family Allergy

Kevin Kennedy, MPH, CIEC, Children’s Mercy Hospital

Carl Grimes, CIEC, Hayward Healthy Homes

Thanks for Attending!