Teaching Home Environmental Health to Resident Physicians

Abstract

Healthy Homes programs seek to integrate the evaluation and management of a multitude of health and safety risks in households. The education of physicians in the identification, evaluation, and management of these home health and safety issues continues to be deficient. Healthy Homes programs represent a unique opportunity to educate physicians in the home environment and stimulate ongoing, specific patient-physician discussions and more general learning about home environmental health. The Case Healthy Homes and Patients Program addresses these deficiencies in physician training while providing direct services to high-risk households. Pediatric and family practice resident physicians participate in healthy home inspections and interventions for their primary care patients and follow up on identified risks during health maintenance and acute illness visits.

Environmental exposures in the home are key determinants of health, particularly in children and the elderly. The normal physiology and developmental behavior of children put them at increased risk for harm from environmental hazards. Compared with adults, children consume more food and water, breathe more air per body size, spend more time on the ground, place their hands in their mouth more often, and spend more time indoors, increasing exposure to household risks.^1,2 The chance of harm is amplified due to ongoing growth and development of essentially all body structures and systems during childhood, as well as the prenatal period.² Millions of children in the U.S. live in substandard housing conditions that contribute to many of the most common causes of morbidity and mortality in childhood, including lead poisoning, asthma and other respiratory conditions, accidental trauma, burns, drowning, and sudden infant death syndrome.^3–6

Many elderly people have an equally dangerous confluence of housing hazards, with increased risk due to medical conditions and loss of function. People older than 65 years of age are more likely to live in older homes that have deferred maintenance and lack safety modifications.^7–9 Environmental risks in the home are major contributors to health problems, loss of independence, and death in the elderly, particularly from falls, respiratory illnesses including chronic obstructive pulmonary disease, and heat and cold stress.^3,10–15 The expected rapid rise in the number of elderly people in the U.S. in the coming decades is likely to magnify these problems.¹⁶ Children and the elderly are likely to spend significant amounts of time in the same home environments due to provision of childcare, co-residence, and foster, adoptive, and kinship care.¹⁷ Thus, interventions targeting each group are likely to benefit the other in turn.

Physicians who care for children generally have a high level of interest in environmental health but report low self-efficacy in dealing with common environmental exposures.^18–21 The National Environmental Education and Training Foundation has promoted further integration of environmental health into medical education, and this position has been endorsed by multiple professional societies, including the American Academy of Pediatrics and the American Public Health Association.²² The accreditation requirements for residency training programs in pediatrics and family medicine include expectations for learning about environmental illness and injury.^23,24 Despite these requirements, education of physicians in identifying and managing environmental health risks in the home has lagged behind in medical school and residency training.^25,26 Interventions to promote environmental health in medical education reported in the literature include didactics and practical evaluations for medical and nursing students,^25,27–31 training of faculty to incorporate environmental health into curricula,^27,32,33 training of public health nurses,³⁴ and a few residency-based programs primarily focused on occupational health.^35–38 Education of physicians in the home setting has not been reported.

The Case Healthy Homes and Patients Program (CHHAP) seeks to address these deficiencies in training while providing meaningful services to high-risk households. The Mary Ann Swetland Center for Environmental Health at Case Western Reserve University in Cleveland, Ohio, has partnered with community environmental health and housing agencies, local health departments, and the family medicine and pediatrics residency programs to educate physicians-in-training (resident physicians) in the context of a healthy home inspection for their primary care patients while providing interventions for identified risks.

PROGRAM

After a successful pilot with medical and public health students funded by private foundations in 2005, the CHHAP received a three-year Healthy Homes Demonstration grant from the U.S. Department of Housing and Urban Development (HUD). Additional leveraged and matching funds provided the remainder of the financing. Initial goals of the program were (1) to provide home health and injury hazard assessments and interventions in 150 homes of pregnant, infant, and geriatric patients living in high-risk housing in low-income neighborhoods of Cleveland and its inner-ring suburbs; and (2) to provide resident physicians at an academic family medicine clinic the opportunity to learn about housing-related health hazards through participation in assessments at their primary care patients' homes.

Home assessments are performed by a certified Healthy Homes practitioner employed by Environmental Health Watch (EHW), a local community-based environmental health organization. The assessment focuses on child and/or elderly health and injury hazards, including lead risk, respiratory illness triggers, pesticide exposure, carbon monoxide (CO) risk, accidental injury risk, safe sleep environment for infants, and potential for infant exposure to toxigenic mold. Specific elements of the inspection include an occupant interview; visual paint condition assessment; collection of dust and soil samples for lead analysis; visual evidence of smoking, mold, roaches, rodents, dust mites, pets, pesticides, space heaters, faulty combustion appliances, and smoke and CO detectors; tap water and refrigerator temperature measurements; observations of child and elderly fall and injury risks; and infant sleep environment. Inspection items are tracked using a personal data assistant-based tool. Items in the tool incorporate elements developed and refined in prior home environmental health projects performed by the Swetland Center and partner organizations.³⁹

The leadership teams of the family medicine and pediatrics residency programs expressed strong interest prior to the start of the program, and faculty coordinators for the program were identified in each department. During their first year of training, residents in family medicine and pediatrics are provided a formal orientation to the program and a basic introduction to home environmental health hazards. They also receive written materials on general home environmental health principles and aspects specific to the Cleveland area. In their continuity clinics, they identify an infant patient (<6 months of age) to which they will provide ongoing primary care. Geriatric patients are identified through a program providing primary care in the homes of house-bound elderly run by the Department of Family Medicine. Nearly all families attending these clinics and involved in the house-call program are low income. After enrollment of the family, the residents accompany the home environmental health specialist on an inspection of the patient's home. After completion of the inspection, the inspector reviews identified hazards with the resident physician and the home occupants and discusses corrective actions. Based on the identified hazards, the resident physicians provide ongoing assessment, family education, and behavior intervention during subsequent routine primary care visits.

In-home interventions provided directly to the family by the program include education and advice on behavior change, a set of health and safety items tailored for the identified needs, low-level building interventions, and referral to appropriate agencies for more extensive interventions. EHW staff and resident physicians provide education and advice on behavior change throughout the inspection as hazards are identified. They also identify actions that family members are capable of taking and provide printed educational materials on specific items. The set of health and safety items made available to the family includes an allergen vacuum, fire extinguisher, smoke and CO detectors, digital thermometer (mercury thermometers are taken for disposal if identified), door mats, cleaning supplies, child gates, window guards, cabinet locks, allergen-barrier pillow and mattress covers, electric heaters, and roach baits. Based on the inspection, the home environmental specialists also perform low-level building repairs and modifications and hazard remediation. Examples include installation of safety items, environmental cleaning to reduce lead dust and other contaminants, moisture-reduction measures, cockroach and rodent integrated pest management, and repair of simple fall hazards.

RESULTS

During the initial three years of the program, 150 homes with a total of 570 family members were inspected (Table). For each of the 150 patients in the program, there were generally two to five home visits by the EHW staff (mean of 2.8 visits, range of 1–5 -visits). In addition to the initial hazards assessment with the physician, there were follow-up visits for further environmental sampling, to deliver additional health and safety items, to conduct low-level remediation, to explain sampling results, and to assist the family in completing referral forms. About half of the occupants were <18 years of age, and about one-third of family members were <6 years of age. Nearly 500 occupant and non-occupant family members were educated on environmental risks in the home.

Table.

Households inspected, number and age of occupants, and home interventions provided, by patient type: Case Healthy Homes and Patients Program, Cleveland, 2006–2008

CHHAP = Case Healthy Homes and Patients Program

Program staff implemented low-level interventions in most homes, with home safety improvement; reduction of mold, moisture, and allergens; installation of CO detectors; and reduction of lead risk being the most common (Table). The mean direct cost per household for building interventions carried out by the program was $860. This included $477 for health and safety items (provided free of charge) and $383 for low-level interventions performed by program staff. Mean costs were $927 (range: $509–$4,197) for pediatric patient home inspections, health and safety items, and interventions, and were $577 (range: $247–$936) for geriatric patient home inspections and interventions. Visits for pediatric patients were more expensive due to the larger number of health and safety items provided.

Program staff made referrals for more extensive repairs (i.e., lead abatement, weatherization, moisture control, and electrical/plumbing/carpentry) for 95 of the 150 families. Referrals were made directly to local health departments and affordable-housing organizations for their home repair and remediation programs. Staff assisted families in completing required forms and obtaining necessary documentation. Despite this assistance, for many families, completing the referral process was daunting and not always successful. Barriers included multiple eligibility requirements; the need to verify income, home ownership, and occupancy; difficulty in securing cooperation from the landlord; and long waiting periods. We were able to complete the referral process on far fewer units than anticipated primarily because of refusal by the landlord, failure by the landlord to provide information and documentation, or disqualification of the landlord because of referral program criteria. Overall, 38% (n=36/95) of referrals resulted in repairs or improvements to the homes, ranging from a few hundred to several thousand dollars in value, including repairs to roofs, railings, and stairs; lead hazard abatement; weatherization and furnace repair/replacement; and electrical and plumbing repairs.

Home inspections were conducted by 143 health professionals, including 95 resident physicians, 38 medical students, and 10 social workers (Figure). A small number of resident physicians participated in visits for two different households. While resident physician education is a primary goal of the program, relationships with other training programs allowed for inclusion of other health professionals. Social workers in the geriatrics clinical program were already involved in home visits as part of the care and were included to provide specific environmental health education. In a brief survey of participating physicians, 100% rated the program as a “useful experience” or better, with 61% rating it as a “very useful experience.” A majority (79%) indicated that the experience had changed their clinical practice: “I found the Healthy Homes visit very helpful … [to] get a better sense of how my patients live and what kind of things I could ask about in order to improve their child's home safety.”

Figure.

Number and type of health professionals, by patient type, educated by the Case Healthy Homes and Patients Program, Cleveland, 2006–2008

Challenges for the program arose from the busy schedules of resident physicians, the often chaotic lives of low-income families, uncooperative landlords, years of deferred maintenance, and the coordination of referred work that was beyond the direct scope of the program. The program relied on residents to recruit their own primary care patients, which required monthly reminders to maintain priority among the myriad demands of their 60- to 80-hour work week. Scheduling with families was occasionally complicated by last-minute cancellations or no one present in the home at the scheduled time of inspection, prompting additional reminder calls prior to visits from the program staff and sometimes the physicians. Under Ohio landlord-tenant law, landlord approval is not required for inspection for environmental home health hazards, but property owners needed to be notified prior to any significant repair efforts and were often uncooperative. Lastly, the geriatric patients included later in the program often lived in homes requiring more extensive interventions due to many years of neglected maintenance. These interventions were provided through referral to an affordable-housing agency with funding for repairs to homes owned by the elderly.

DISCUSSION

The formalization of a federal commitment to integrated management of environmental health and safety risks in the home began in 1999 with the funding of the Healthy Homes Initiative within HUD's Office of Healthy Homes and Lead Hazard Control.⁴⁰ In a draft strategic plan from 2008, the program's stated mission was “to reduce health and safety hazards in housing by supporting and promoting applied research, assessment and intervention protocols, policy guidelines, outreach, and capacity building for partners, practitioners, and the public” (emphasis added).⁴⁰ At the same time, multiple professional organizations have called for improved education of physicians in the identification and management of health risks within the home.²² CHHAP seeks to integrate these two sets of goals through the education of resident physicians in the context of inspections, family education, and direct interventions in the homes of primary care patients of physicians-in-training.

Robust partnerships with a wide variety of stakeholders have been essential to the development and maintenance of CHHAP. The family medicine and pediatrics residency programs invest in educating their trainees in environmental health, provide an established recruitment population from their primary care clinics, and integrate follow-up into routine care. A community-based environmental health organization, EHW, provides home health inspectors who inspect homes, educate families, educate physicians, perform low-level interventions, and make referrals to other agencies. Local departments of health provide intervention and follow-up for identified hazards beyond the scope of CHHAP's low-level interventions through their lead hazard control programs, and, similarly, affordable housing agencies provide services for weatherization, water conservation, and other home repairs.

The initial phase of the program was funded as a demonstration to show the feasibility of integrating these often-separated goals and stakeholders. Future challenges will include expansion to more trainees, measuring discrete outcomes, and sustainability. The program began with a family medicine residency program that has approximately eight resident physicians per year. With renewal of funding, the program has been able to include an additional 30 pediatrics and combined internal medicine-pediatrics resident physicians. The second round of funding is allowing for the measurement of outcomes in both the pediatric and geriatric arms of the program. Children in participating households are being compared with matched controls from the same primary care clinics for serum lead levels, acute respiratory illnesses in general, asthma exacerbations specifically, and injury-related primary care and emergency department visits. Elderly patients participating in the family medicine home visitation program are being enrolled in a randomized controlled trial with the environmental health home visit as an intervention in addition to typical physician home visit care. Outcomes for this trial include maintenance of interventions, falls, chronic obstructive pulmonary disease exacerbations, admission rates to long-term nursing facilities, quality-of-life surveys, and length of time of independent living. Both arms will measure the environmental home health knowledge of participating residents in a pre-post design. Sustainability of the programs beyond the current grant support and planned private foundation applications will depend on demonstrating the value of both the infant and elderly programs as effective patient service activities. If effectiveness can be demonstrated, local government and community agencies could incorporate home environmental screening by health personnel already going out to the homes, such as those involved in newborn and infant home visitation programs and home health-care agencies. Provision of home health and safety items will continue to depend on grant funding and/or donations until cost-effectiveness might justify payment by Medicaid or another third-party payer.

Opportunities for replication of the physician education portion of the program are likely to exist anywhere there is an existing relationship or the prospect for a relationship between a residency training program and a department of health and/or a community-based organization that performs home environmental health evaluations and interventions. Potential partnerships include programs that perform newborn home visits for at-risk families, lead abatement, weatherization and energy efficiency improvements, home-based asthma interventions, and broader Healthy Homes interventions, as well as environmental justice advocacy groups. Alternatively, residency and other health professional training programs that are implementing their own home visits with the goal of education in a community setting could use a Healthy Homes inspection as a framework for the visit that balances direct benefit to the families with the educational goals.

In addition to meeting training requirements for environmental health, the program meets more general expectations for “community and child advocacy experiences”²³ in pediatric residency programs and “community medicine”²⁴ in family medicine residency programs. The pediatrics residency at Rainbow Babies and Children's Hospital/University Hospitals of Cleveland applies CHHAP toward the community experience requirement, and the family medicine residency at University Hospitals of Cleveland incorporates CHHAP in community medicine and home visitation requirements. While this program was targeted to pediatric and family practice residents, the structure can be applied for other residencies (e.g., internal medicine and preventive medicine), as well as other professional trainees (e.g., public health, nursing, and social work). This program was housed in a department of environmental health science of a medical school, which provided the opportunity for leveraging multiple existing relationships with a department of health, a community organization with extensive experience, and targeted physician training programs. Investments from the training programs for physician education involved time commitments from faculty to provide an orientation to the program and generate recruitment reminders and to make adjustments to resident physician schedules that allowed for the home visits. The Swetland Center had a 50% full-time equivalent (FTE) coordinator and scheduler who also maintained the database and Institutional Review Board protocols. In addition to the healthy house specialist (70% FTE) who conducted the inspections and low-level interventions (whose time is included in the intervention costs cited previously), EHW staffing included a program manager (25% FTE), health educator (15% FTE), and data manager (15% FTE).

CONCLUSION

The recognition of the home environment as a key determinant of health-care outcomes calls for innovative approaches that produce meaningful benefits for families and individuals in settings with the highest burden of risk. Integration of education for physicians and other health professionals in Healthy Homes projects will help spread awareness of the importance of the home environment to health care and, ideally, help generate significant improvements in health and decreases in health-care costs.