There is a robust evidence base about the potential for transforming health and reducing costs by incorporating home-based interventions into patient care. Such interventions target social determinants of health, and investing in them has the potential to reduce the burden of preventable housing-related illness dramatically. While some states or individual managed care organizations provide Medicaid coverage for services delivered in the home environment related to asthma and lead exposure, many others are utilizing other financing mechanisms as either a complement or alternative to healthcare financing. In 2016, the National Center for Healthy Housing (NCHH) interviewed several states providing one or more home-based asthma services, childhood lead services, or healthy home services using funding other than Medicaid or grants.

The interviews provided information on the funding mechanism and how it operates, the program being funded and how it operates, outcome and evaluation information (where available), and lessons learned. These financing mechanisms can be a model for other states, and the information has been compiled into brief summaries available here by state, focus area, and funding type.

Maine

Lead Poisoning Prevention Fund
The Lead Poisoning Prevention Fund (LPPF; 22 MRSA c. 252 §1322-E), established by the Maine legislature in 2005, is administered with the help of an advisory board by the Childhood Lead Poisoning Prevention Unit (CLPPU) within the Maine Center for Disease Control and Prevention (CDC) of the Maine Department of Health and Human Services (DHHS). Resources from the Lead Poisoning Prevention Fund are used to accelerate progress toward eliminating childhood lead poisoning in Maine through statewide and community-based activities that enable the public to identify lead hazards and take precautionary actions to prevent exposure to lead. The Maine CDC awards contracts with organizations to carry out education, outreach, and capacity-building services in high-risk areas (i.e., the five areas with the highest burden of childhood lead poisoning). [pdf; NCHH, 2017]

Massachusetts

Get the Lead Out Loan Program
The Get the Lead Out loan program of Massachusetts healthcare reform legislation (Chapter 111, Section 197E of the Acts of 1993) seeks to “assist residential property owners in financing the abatement and containment of lead paint hazards throughout the commonwealth. Through MassHousing, the administrative agency, low-cost deferred financing is available for one- to four-family homes to address lead-based paint hazards either owned by a low- to moderate-income owner-occupant or in which low- or moderate-income tenants reside. The loans are managed by local rehabilitation agencies (LRA). One hundred percent of the financing available under this program must be used for lead-based paint abatement activities. [pdf; NCHH, 2017]

Lead Education Trust Fund
The Lead Education Trust Fund (LETF) of Massachusetts healthcare reform legislation (Chapter 482, Section 22 of the Acts of 1993) introduced surcharges and fees on certain professionals to fund the department of public health (DPH) to provide lead paint poisoning prevention and treatment education, training of lead paint inspectors, and homeowner training. DPH provides home visits to children with elevated blood lead levels (EBLLs), provide community-based health education, and (in specific instances) assign cases of children with lead poisoning to specially employed code enforcement lead inspectors. [pdf; NCHH, 2017]

Prevention and Wellness Trust Fund (PWTF) (Pediatric Asthma Program)
The Prevention and Wellness Trust Fund (PWTF) of Massachusetts healthcare reform legislation (Chapter 224, Section 60 of the Acts of 2012) seeks to “reduce health care costs by preventing chronic conditions.” It is designed to address four priority chronic conditions including pediatric asthma. The pediatric asthma program activities include care management for high-risk asthma patients; home-based multi-trigger, multicomponent intervention (minimum of three home visits, asthma self-management and education, trigger remediation supplies, environmental services); comprehensive school-based asthma management programs; comprehensive Head Start-based asthma management programs; and asthma self-management in primary care. In 2014, nine communities were funded to be PWTF sites: Six offer pediatric asthma interventions, and five have initiated home-based asthma visits. (Of the six PWTF sites, one had an established home-based asthma visiting program funded by another mechanism.) [pdf; NCHH, 2017]

Montana

Montana Asthma Home Visiting Program (MAP)
Nine of Montana’s 11 Asthma Control Program sites are funded with the State’s Master Settlement Agreement funds. The Montana Asthma Home Visiting Program (MAP), offered by the Asthma Control Program, was designed to address basic asthma pathophysiology and asthma medications, and it has a significant home environmental focus to address asthma triggers. The program includes six contacts with a public health nurse provided over a course of a year. It also includes help identifying potential asthma triggers in the home, custom asthma education, educational resources and referrals to community services (e.g., weatherization services, health insurance), individual help with managing the medical system, free allergen-proof pillow and mattress covers, and free air filters for those with animals or smokers present in the home. [pdf; NCHH, 2017]

New Jersey

Project ReHEET (Residential Health, Energy and Environmental Transformation) (Asthma, Lead, Mold) 
Isles, Inc. operates Project ReHEET (Residential Health, Energy and Environmental Transformation) with funding from the New Jersey Neighborhood Revitalization Tax Credit (NRTC). Project ReHEET was created to pilot the joint provision of weatherization, structural repair, and healthy homes services in Trenton. The program collaborates with community groups to identify old, substandard, leaky homes in the Trenton region. It tests and repairs occupied homes for energy and health hazards. ReHEET received funding from 2010-2016 and completed 179 units over this period. (A small number of these homes were “re-visits” for emergent issues [heating system, new roof leaks, et cetera] and not new units, which lowers the cost per unit.) [pdf; NCHH, 2017]

New York

Childhood Lead Poisoning Primary Prevention Program
The New York State (NYS) Childhood Lead Poisoning Primary Prevention Program (CLPPPP) was funded as a pilot program in 2007, and made a permanent program in 2009. Created by an amendment to PHL § 1370-a, it was designed to “identify and designate a ZIP code in certain counties with significant concentrations of children identified with elevated blood lead levels for purposes of implementing a pilot program to work in cooperation with local health officials to develop a primary prevention plan for each such ZIP code identified to prevent exposure to lead-based paint.” The original allocation funded local health departments of the eight counties that accounted for almost 80% of all known cases of childhood elevated blood lead level (EBLL). Nineteen counties (including the five counties served by the New York City Health Department) are currently funded to provide primary prevention. [pdf; NCHH, 2017]

Healthy Neighborhoods Program (Asthma and Lead) 
The New York State Healthy Neighborhood Program (HNP) seeks to reduce the burden of housing related illness, and asthma in particular, through a holistic healthy homes approach and strategic partnerships with clinical services. As a healthy homes program, it provides in-home assessments and interventions in selected communities throughout New York State. During a visit, the home is assessed for environmental health and safety issues. About 22% of homes receive an optional revisit, scheduled three to six months after the initial visit. The program targets housing in high-risk areas that are identified using housing, health and socioeconomic indicators from census and surveillance data. The HNP uses a combination of door-to-door canvassing and referrals to reach residents in these high-risk areas. To be eligible for funding, a county health department must have both environmental and nursing services. As of 2016, 20 county health departments operate the HNP in New York State. [pdf; NCHH, 2017] COMING SOON

Lead Poisoning Prevention Program 
The New York State Lead Poisoning Prevention Program (LPPP) was established by public health law, PHL § 1370-a (enacted in 1992; amended in 2007 and 2009). The program is implemented by all local health departments, and is responsible for establishing and coordinating activities to prevent lead poisoning, including requirements for blood lead testing and follow-up of children and pregnant women, establishment and maintenance of a statewide registry of children’s blood lead levels, development and implementation of public education and community outreach activities, and coordination with other agencies and programs. All children with elevated blood lead levels receive home-based services including inspections and addressing lead hazards. Environmental interventions are required for children with elevated blood lead levels. All county health departments are automatically eligible for funding. Only one county has turned down funding due to a low caseload. [pdf; NCHH, 2017] COMING SOON

Regional Lead Resource Centers
The New York State Department of Health (NYSDOH) funds three Regional Lead Resource Centers (RLRC) across the state that support efforts to promote a standard of excellence statewide among healthcare providers (HCPs), local health departments (LHDs), and communities to prevent childhood lead poisoning within their region. The program provides comprehensive consultations for clinical treatment for lead poisoning, comprehensive clinical care and care coordination for lead poisoning, and hospitalization and chelation for lead poisoning. Also, healthcare providers develop/participate in regional/community lead poisoning prevention coalitions. The three RLRCs in New York are academic medical centers with expertise in lead poisoning. [pdf; NCHH, 2017] COMING SOON

Oregon

Multnomah County Lead Poisoning Prevention Program 
The Multnomah County Lead Poisoning Prevention Program is jointly funded by the Portland Water Bureau (PWB), State of Oregon Health Authority, and Multnomah County. The program works in partnership with other community groups and government agencies in the greater Portland metropolitan area to eliminate lead poisoning and make Multnomah County housing lead-safe. Services provided include the Leadline, a telephone information and referral line for questions about lead, lead testing, and lead in drinking water; community outreach and education, including participation in community health fairs and community presentations; home investigations for families who have children with high blood lead levels to assist with identification and reduction of exposure to lead; lead screening for children and those at greatest risk for lead poisoning; and coordination of services with other agencies to create an efficient program designed to prevent lead poisoning from all sources. [pdf; NCHH, 2017]

Washington

Weatherization plus Health (WxPlusHealth)
In 2015, the Washington State Legislature passed House Bill (H.B.) 1720, which expanded the purpose of the Matchmaker Low-Income Residential Weatherization Program to include healthy housing improvements. Healthy housing improvements are defined by the Washington State Legislature as “increasing the health and safety of a home by integrating energy efficiency activities and indoor environmental quality measures, consistent with the Weatherization plus Health initiative of the federal Department of Housing and Urban Development.” The primary purpose of Weatherization plus Health is to integrate weatherization and healthy homes improvements in order to reduce respiratory symptoms of low-income citizens. The outcome of this program is to ensure that these homes meet minimum health and safety requirements and reduce disease and injury from housing-related hazards. [pdf; NCHH, 2017] COMING SOON