Background

An 18-month-old child was brought into the St. John’s health center with severe developmental delays. He was unable to lift his head, speak, or walk. His mother had brought him to see several other medical providers, but no one was able to diagnose the child.

Health center staff tested the child’s lead levels. This was not a standard practice in the area because of the predominately new housing stock; however, staff recognized that housing in Los Angeles’ low-income communities pre-dated the 1978 ban on lead paint. The test revealed extremely elevated blood lead levels. The child was successfully treated with chelation therapy at Los Angeles Children’s Hospital and the health center uncovered a critical health issue for which they had not been screening prior to this case. As a result of this diagnosis, they began to test children routinely and found that 53 percent of those tested had elevated blood lead levels.

Beyond a Case of Lead Poisoning

Inquiry: The data demonstrated the prevalence of the lead issue and St. John’s clinicians also began to observe patients with a range of housing-related skin conditions including frequent insect and rodent bites. These patient outcome trends caused them to think broadly about housing-related factors and health.

Analysis: At the time clinicians’ observations around housing- related conditions were increasing, they also began sharing their observations with community partners and learned more about housing conditions in the community. In particular, Esperanza Community Housing, a local organization, was developing a community health promoter training program to assess housing conditions at home visits and to provide patient education about low-cost, low-tech barriers to reduce health risks associated with substandard housing conditions. St. John’s partnered with Esperanza, and the two organizations began to share information and reflections. It became common for providers to refer patients to Esperanza and, in turn, health promoters would relay relevant information back to medical providers.

Action: The two organizations joined forces with Los Angeles Community Action Network and Strategic Action for a Just Economy, organizations that advocate for tenants’ rights by providing education and assisting with the process for filing building complaints. Together these four organizations formed a collaborative to address substandard housing in Los Angeles. Over time, the collaborative:

• Published a report, Shame of the City, highlighting the substandard housing conditions pervasive in the area and drawing connections between these conditions and the prevalent health issues
• Developed and pursued a strategic plan to improve housing conditions through community engagement, research, medical care, case management, home assessments, health education, litigation, and advocacy
• Pushed for the passage of local administrative policies that led to improved landlord compliance with standard housing requirements
• Secured a commitment from the City Attorney’s office to investigate and prosecute non-compliant landlords with dedicated resources and innovative criminal charges

Engaged tenants in policy and practice change efforts through health education and tenants’ rights sessions, building-wide meetings, and collection of documentation for litigation

Health Center Tactics

It also became clear that more could be done within St. John’s to consistently address the social determinants of health. Since embarking on this work, St. John’s has:

• Hired a Director of Social Medicine and Health Equity who can dedicate time to strengthening and formalizing relationships with other community organizations, local community health workers, organizers, public interest lawyers, and housing developers
• Trained staff and clinicians to screen patients for housing-related health problems and refer patients to resources
• Implemented a patient intake form that includes questions about housing-related risk factors as a routine element of patient visits

Impact

St. John’s has seen a ninety-five percent reduction in elevated lead levels as well as reductions in hospital admissions related to asthma. With providers on board, a documentation system in place to collect patient housing data, and St. John’s commitment to supporting education, socio- economic, and mental health services, the health center has become an asset to other community organizations and an example of how the Community-Centered Health Home model can be manifested over time to address root causes of health issues that affect population health.

NOTE: Information for this case study was adapted from Rishi Manchanda’s TED book, The Upstream Doctors: Medical Innovators Track Sickness to Its Source