From The Field J U L Y 1 6 , 2 0 1 2 Another Call to Go Upstream: Housing Is Health GEORGE ABRAHAM, M.D., M.P.H. Chairman of the Board, The Health Foundation of Central Massachusetts JANICE B. YOST, ED.D. President & CEO, The Health Foundation of Central Massachusetts I magine waking one day to the unexpected news that a a comprehensive set of access to treatment and prevention distant and wealthy relative had passed away and that her strategies. Moreover, grantees have been funded to advocate will established a $60 million trust with you appointed as for changes in public policy in order to sustain interventions trustee. The terms of the trust stipulate that the trustee should after the grant concludes. The foundation’s grants have totaled award grants to nonprofit organizations totaling approximately $22 million since 2000, making substantive impacts on oral $2.5 million per year for the purpose of improving the health health, mental health, hunger, and homelessness. of those who live or work in Central Massachusetts. After overcoming the surprise, you begin to contemplate the depth TARGET ROOT CAUSES of the charge and speculate how one could possibly improve The interventions supported by the foundation through grants the health of about 800,000 people with only approximately to area nonprofits have reached beyond improving access to $3.00 per person, per year. Would any health plan ever accept health care to address the underlying economic and social this challenge? determinants of health. Research over the decades has indi- cated that factors, such as education, income, occupation, PHILANTHROPY’S CHALLENGE TO MAKE housing, neighborhood environment, race, and ethnicity, have AN IMPACT a powerful influence on health and are often referred to as the This scenario is similar to the mission and challenge of The “root cause” of poor health. Health Foundation of Central Massachusetts, created in 1999 Thus, the foundation abides by the World Health from the sale of Central Massachusetts Health Care, a physi- Organization’s broad definition of health: “Health is a state cian-initiated, not-for-profit health maintenance plan. This of complete physical, mental, and social well-being and not situation has played out for over 200 other health conversion merely the absence of disease or infirmity.” Recently the foundations created throughout the United States since the Centers for Disease Control and Prevention highlighted the 1980s from the sale of nonprofit hospitals and health plans to need to apply a comprehensive set of interventions to improve for-profits. Created in the pub- lic sphere of transparency and accountability, these conversion Research over the decades has indicated that factors, such as education, foundations have helped lead income, occupation, housing, neighborhood environment, race, and ethnicity, grantmakers’ increasing atten- have a powerful influence on health and are often referred to as the “root tion on outcomes and impact. cause” of poor health. Following due consideration regarding how to make an impact with such limited funds, the foundation chose to focus health status, and developed the Health Impact Pyramid in its grantmaking on a few three- to five-year grant projects at 2010 to illustrate the hierarchical potency of various any given time and to emphasize the use of evidence-based interventions. interventions and an evaluation component to plan for and The base of the Health Impact Pyramid addresses socioeco- document results. Projects have been required to take a collab- nomic factors, reflecting that interventions addressing poverty, orative approach to improving health by addressing issues with education, housing, and inequality have the largest impact on health. Clinical interventions (such as treating high blood reported improved health, with fewer hospitalizations and pressure, cholesterol, or diabetes) comprise the top of the emergency room visits. In January 2011 the U.S. Interagency pyramid, reflecting their significant but comparatively lesser Council on Homelessness recognized Worcester as the first impact on health improvement (Frieden 2010). city of its size in the country to essentially end adult chronic In a national survey funded by the Robert Wood Johnson homelessness (Hammel 2011). Foundation and released in the December 2011 report Health Care’s Blind Side: The “…concentrated poverty is not only bad policy, it’s bad for your health.” Overlooked Connection between —HUD Secretary Shaun Donovan Social Needs and Good Health, physicians acknowledged that unmet social needs directly worsen the health of Americans and The foundation continues to improve poor health related to that addressing a patient’s social needs is as important as housing by supporting two new housing projects in Worcester. addressing their medical conditions. Physicians reported that The Compass Project seeks to prevent youth and young given the power to write prescriptions for social needs, such pre- adult homelessness by targeting those identified as at risk of scriptions would represent one out of every seven prescriptions becoming homeless. These youth and their families are written—or an average of 26 additional prescriptions per week. offered intensive case management, family mediation services, The most common prescriptions would include fitness pro- counseling, life skills training, educational supports, employa- grams, nutritional food, and transportation. For physicians bility training, and vocational opportunities, as well as access whose patients are mostly urban and low-income, prescriptions to physical and oral health care. A Better Life also provides would include employment assistance, adult education, and residents in public housing with a broad array of support housing assistance. services and intensive case management to assist them on a In October 2011 The New England Journal of Medicine path to move out of public housing and eventually become reported on a 10-year U.S. Department of Housing and self-sufficient. Urban Development (HUD) study regarding the negative Housing is a significant target for grantmaking because impact on thousands of women’s health resulting from living housing is health. in big city public housing neighborhoods. In Baltimore, Boston, Chicago, and Los Angeles, select groups of women were moved to higher-income neighborhoods, while compa- SOURCES rable groups remained in concentrated public housing with a high level of poverty. Those who were moved showed lower Frieden, T. R., “A Framework for Public Health Action: The rates of diabetes and extreme obesity. The study concludes Health Impact Pyramid,” American Journal of Public Health, 100(4):590-595, 2010. that the opportunity to escape poverty-stricken neighbor- hoods was associated with modest but potentially important Hammel, Lee, "PIP to Close: Homelessness Turns a Corner reductions in the prevalence of extreme obesity and diabetes under New Approach," Worcester Telegram & Gazette, (Ludwig et al. 2011). As HUD Secretary Shaun Donovan <http://www.telegram.com/article/20110123/NEWS/ deduced, “This study proves that concentrated poverty is not 101230479>, January 23, 2011. only bad policy, it’s bad for your health” (Stobbe 2011). He Robert Wood Johnson Foundation, Health Care’s Blind Side: added, “It’s not enough to simply move families into different The Overlooked Connection between Social Needs and Good neighborhoods. Instead, new ways must be found to help Health (Princeton, NJ: December 2011). families break the cycle of poverty that can quite literally make them sick.” Imm, P., and A. Wright, Evaluation Report for The Health Foundation of Central Massachusetts: Analyses of Its First Ten GO FARTHER UPSTREAM Years of Grantmaking (2000-2010) (Worcester, MA: 2011). Health philanthropy can learn a lesson from the “parable of Ludwig, J., et.al., “Neighborhoods, Obesity, and Diabetes–A the river” where villagers worked diligently for several days Randomized Social Experiment,” The New England Journal of rescuing babies floating down the river before a wise elder Medicine, 365:1509-19, 2011. urged them to go upstream to find out who was throwing the Stobbe, Mike, Associated Press, “Where You Live Can babies in the river and stop the problem at its source. Hurt Your Health,” Worcester Telegram & Gazette, With this fundamental understanding, the foundation <http://www.telegram.com/article/20111020/NEWS/ provided $2.1 million to support Home Again, a project 110209152/-1/health>, October 20, 2011. that demonstrated the efficacy of a “housing first” model by successfully housing 108 individuals in Worcester, Massachusetts, who had been chronically homeless. Home Views from the Field is offered by GIH as a forum Again participants experienced improved mental health and for health grantmakers to share insights and experiences. If you are interested in participating, please contact Faith Mitchell at 202.452.8331 or fmitchell@gih.org.