Updating and Evaluating Lead Poisoning Case Management Policies

Project Funder: Teresa and H. John Heinz III Foundation

Project Partner: The Alliance to End Childhood Lead Poisoning

Project Contact: Carol Kawecki, ckawecki@nchh.org, 443.539.4158

Project Description: The National Center for Healthy Housing (NCHH) and the Alliance to End Childhood Lead Poisoning (later the Alliance for Healthy Homes) collaborated on a groundbreaking report that was made possible by a grant from the Teresa and H. John Heinz III Foundation. Another Link in the Chain: State Policies and Practices for Case Management and Environmental Investigation for Lead-Poisoned Children comprehensively analyzed survey responses and reviewed all 50 states’ (and Washington, DC’s) progress on key indicators to pinpoint the need for specific program improvements. As the title suggests, case management and environmental investigation are but two links in the chain for protecting children from lead poisoning. The report revealed numerous weak links, as well as some bright spots, and makes recommendations for policy and program changes at the state and national levels. Among the key findings from the 1999 report follows:

  • Case management services vary widely from state to state and sometimes even within states. At the time of the report’s release, just 29 states reported having written standards for case management.
  • While some states continue to rely almost exclusively on XRF detection of lead paint, 33 states reported providing lead dust testing as a routine part of their investigations — an encouraging finding that shows state programs are evolving in response to research confirming the danger of lead-contaminated dust.
  • The majority of state Medicaid programs had yet to establish mechanisms to fund case management and environmental investigation for lead-poisoned children, an important deficiency. For states having Medicaid reimbursement, rates varied tremendously, even accounting for variation in services.
  • Most states didn’t monitor the outcome of their interventions for children or keep track of the corrective measures taken to control lead hazards in the home. Some states couldn’t provide even basic information on the number of children needing follow-up care or the number of those who actually received services.
  • The majority of states do not have legal authority to order remediation of homes with identified lead hazards, even in the case of a lead-poisoned child. Almost half the states indicated that no funding is available for hazard control.

Lead poisoning can cause permanent damage to a child’s nervous system, IQ loss, learning disabilities, behavior problems, and – at very high levels – coma, convulsions, and death. Usually, children are poisoned in their own homes by lead-contaminated dust from chipping and peeling paint or home improvement projects that stir up lead dust. For most lead-poisoned children, the only treatment is to identify the lead source (environmental investigation) and to take steps to protect the child from further lead exposure, which usually requires that lead hazards in the home be controlled. Most families of lead-poisoned children also benefit from case management to coordinate the necessary follow-up services.

Another Link in the Chain focuses on the services provided once a lead-poisoned child is identified, usually through the public health or environmental agency. The report did not address primary prevention (actions to prevent children’s lead exposure in the first place) or blood lead screening to identify poisoned children. Similarly, a detailed examination of corrective measures taken in response to environmental investigation and case management was beyond the scope of the report.

Another Link in the Chain Update, a revision of the original report, based on a 2000 survey, is also available online. NCHH can provide assistance and counsel in the review, revision, and evaluation of current state and local case management policies.


Alliance to End Childhood Lead Poisoning & National Center for Lead-Safe Housing. (1999, June). Another link in the chain: State policies and practices for case management and environmental investigations for lead-poisoned children. Washington, DC: Authors.

Alliance to End Childhood Lead Poisoning & National Center for Healthy Housing. (2001, November). Another link in the chain update: State policies and practices for case management and environmental investigations for lead-poisoned childrenWashington, DC: Authors.

Another Link in the Chain (1999) is no longer available in hard copy.