Chattanooga Healthy Homes Program

In-Home Asthma Prevention

The challenge

When poorly controlled, asthma can lead to emergency department (ED) visits, hospitalizations, school absenteeism, and, in some cases, death. In 2019, Chattanooga ranked 4th in the United States for estimated asthma prevalence and 21st in the top 100 most challenging cities in the United States to live with asthma. 1

In 2016, the asthma prevalence rate for children enrolled in TennCare was 15.1% compared to 5.9% for children statewide. 2 In 2010, hospital charges for asthma totaled $178.8M in Tennessee, of which TennCare was charged $55M (31%). 3 Annually in Chattanooga, there are 188 hospitalizations and 1,937 ED visits attributable to asthma.4

However, the challenge that asthma presents is not evenly distributed. The five zip codes that green|spaces Empower program and LifeSpring Community Health services are ranked 600, 596, 595, 594, and 591 in all of the 600 zip codes in the state of Tennessee for Asthma risk factors based primarily on environmental factors rather than clinical. 5 Most of the homes in these neighborhoods were built before 1940, most are privately owned rental housing, and most lack adequate insulation, air sealing, waterproofing, heating and cooling systems, and quality finishes. Furthermore, most of the residents in these neighborhoods are minorities. Because of the overlap of these issues, in Hamilton County, black individuals are three times more likely than white individuals to have an asthma-related hospitalization and seven times more likely to have an asthma-related ED visit. 6

The Solution

In 2015, green|spaces assembled a team to address this problem including LifeSpring Community Health, EPB’s Home Uplift Program, Erlanger Children’s Hospital where asthma patients go for the emergency room or hospitalization, and recruited the Green and Healthy Homes Initiative from Baltimore, MD who is a national leader in addressing home-related health risks like asthma and lead poisoning to lead a feasibility study and then a pilot program. Additional partners were included to build the feasibility plan and outline the potential for scaling the program.

Together, the team developed a three-step strategy:

1. Invest in LifeSpring’s Community Health Workers who provide supplies and educate patients in their homes about common asthma triggers and preemptive treatment.

2. Invest in green|spaces Build it Green workforce and leadership development program, EPB’s Home Uplift Program, and Habitat for Humanity, who can make needed improvements like mold remediation, air sealing, insulation, duct sealing, carpet removal/replacement that can directly address the causes of asthma.

3. Pay for these investments by simply sharing the savings received by TennCare when the rate of emergency room visits and hospitalizations drops, either through value-based payments from TennCare’s Managed Care Organizations, or through a pay-for-success contract between social impact investors and TennCare’s MCOs.

Research suggests that 40% of asthma risk may be attributable to residential triggers, which cannot be fully addressed in the clinical setting.7 The evidence-base for home-based, multi-trigger, multi-component asthma interventions is strong, showing an improvement in health and reduction in health care utilization. Implementation of such programs has been shown to reduce acute care visits by .57 per person per year8 and return $5.30 - $14.00 for every $1 invested9. Given that asthma-related hospital costs totaled $178.8M in 2010,10 the potential reduction in total cost of care is significant. Despite the strong evidence of health benefits and significant cost savings, Medicaid typically does not reimburse providers for asthma home visiting and trigger remediation services, severely limiting the reach of effective programs. 

Chattanooga Healthy Homes Pilot

In 2019, the Chattanooga Healthy Homes Team piloted the program with 26 patients thanks to funding provided by the Corporation for National and Community Service (CNCS). Home improvements were provided through green|spaces’ Build it Green program and EPB’s Home Uplift which had funding support at the time from a partnership between EPB, TVA, green|spaces, and the Federal Home Loan Bank of Cincinnati. (Home Uplift is currently available directly through EPB with funding from TVA and TDEC). The program proved to be effective but highlighted the need to provide relocation assistance in cases where the quality of the rental housing was so poor that improvements were infeasible. green|spaces and the City of Chattanooga assisted LifeSpring’s Community Health Workers with relocation navigation for the patients. After the program, LifeSpring saw measurable improvements in the Asthma Control Tests of several patients and received feedback from patients that received home improvements through EPB Home Uplift including: "...I immediately noticed the changes in the air quality of my home. With three asthmatic children and two, including myself, that suffers from various allergies, maintaining a clean home (especially preventing dust from accumulating) can be a daunting task. Now, I can honestly say this is no longer an issue!"

The Research

Many studies have linked social and environmental determinants to the health and well-being of populations. In 2022, Program Director and Associate Professor Amir Alakaam and Graduate Research Assistant Emory Evans from the Master of Public Health program at the University of Tennessee Chattanooga authored a comprehensive report providing a review of this data and literature, with a lens turned toward specific neighborhoods in Chattanooga, Tennessee.

The determinants of health, especially those driven by neighborhood, housing, and built environment, are examined, including how these factors are associated with chronic diseases such as asthma and cardiovascular disorder.

The unique health and social needs of individuals in Chattanooga, Tennessee, are specifically acknowledged to better understand the health status of Tennessee and Hamilton County.

The report titled Scaling Regenerative Design: An Overview of Social Determinants of Health and their Impact on Chronic Diseases in Tennessee can be downloaded for free.

The Kendeda Fund and green|spaces supported the completion of this report.

Next Steps

Currently, the team is working with TennCare and TennCare’s Managed Care Organizations to negotiate a value-based payment or pay-for-success contract with impact investment support from the Lyndhurst Foundation, Benwood Foundation, and Footprint Foundation. Once these contracts are established, referrals will be possible through healthcare providers.

Partners

green|spaces

LifeSpring Community Health

Green and Healthy Homes Initiative

EPB

TVA

Erlanger Children’s Hospital

University of Tennessee at Chattanooga Master of Public Health Program

Habitat for Humanity of Greater Chattanooga

Hamilton County Department of Education

Lyndhurst Foundation

Benwood Foundation

Footprint Foundation

The Kendeda Fund