the experience in metro washington, dc stephen j. teach, md, mph impact dc children’s national...

The Experience in Metro Washington, DC

Stephen J. Teach, MD, MPHIMPACT DCChildren’s National Health System

Controlling Pediatric Asthma Past, Present, Future

Disclosures

• Grant support from Novartis for NIH/NIAID funded PROSE study (NCT01430403)

Child With Asthma

Individual & Social Factors• Genetics• Physical conditioning• Socioeconomic status• Stress• Hormone levels

Environmental Factors• Allergen sensitization and exposure

(dust, mold, roach, mice, pollen…)• Viral infections• Weather changes• Air quality (irritants)

Medical Care Factors• Access to care• Quality of care• Medication plan• Adherence• Technique• Immunizations

Low Morbidity• Few Symptoms• Few school absences• Few ED Visits

Level of Asthma Control

Conceptual Model of Asthma

High Morbidity• Many symptoms• Many school absences• Many ED Visits

Poor

Outline

• Past: Disparities in Asthma Outcomes• Nationally• Metro DC

• Present: Achieving Better Control in the Inner-city• NIH Guidelines

• Future: “Phenotypic Driven Care”• Immunomodulators

National Experience with Pediatric Asthma

• 7.1 million children <18y living with asthma in the US in 2009*• 640,000 ED visits**• 157,000 hospital admissions**• 10.5 million annual lost school days*

• Morbidity is highly concentrated in urban environments• Children’s National sees 1% of all ED visits for asthma

every year in our country!*National Health Interview Survey**National Hospital Medical Care Survey

Prevalence of Asthma among DC Residents Aged 1-17yBRFSS

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0.18

0.2

2005 2006 2007 2008 2009 2010

18%

Pediatric ED Visit Rates for Asthma0-17y, inclusive

102.375.6

274.1

441

0

50

100

150

200

250

300

350

400

450

Total 2004-5 Caucasian2004-5

AfricanAmerican

2004-5

District ofColumbia 2010

4.3x

Akinbami L. Pediatrics 2009.

IMPACT DC, 2012.

>10 fold Difference in Rate

Poverty in DC, 2000

Primary Care Access, 2005

Primary Care Access, 2005Primary Care Access, 2005

Outline




1991

1997

2002

National Institutes of HealthGuidelines for Asthma Care

2007

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf


Priorities of the NIH Guidelines

• Proper diagnosis• Patient and family education• Identification and control of triggers• Clear medical plan

• Inhaled Corticosteroids (ICS)• Effective longitudinal care

}

Child in Community with Asthma Experiences an Acute Exacerbation

ED Visit and Discharge

21% within 30 days

Opportunities for Improved Care

Primary Care Follow-up

Liberman D. Ped Emerg Care 2012.



>70% within 15 days


Teach SJ. Arch Ped Adol Med 2006.


Lung Diagram

Personalized Asthma Tools

Patient Device Education

Summary of “Present”

• Disparities in asthma care and outcomes in Washington, DC are striking and persistent

• Heavy reliance on EDs for episodic care by disadvantaged and minority kids

• Things are improving due to a relentless focus on the most “out of control” kids!!

Outline




Child With Asthma









Poor

Hypothesis – DesignICATA Trial – NEJM, March 2011

• Addition of omalizumab to treatment based on existing NIH guidelines would improve disease control among atopic inner-city children with moderate-to-severe disease

• Prospective multi-center randomized clinical trial of injected omalizumab vs. injected placebo in inner-city kids with allergic asthma

% o

f P

arti

cip

ants

wit

h E

xace

rbat

ion

s

(n=211)(n=208)

Exacerbations

Outline




National Experience with Pediatric Asthma

• 7.1 million children <18y living with asthma in the US in 2009*• 640,000 ED visits**• 157,000 hospital admissions**• 10.5 million annual lost school days*

• Morbidity is highly concentrated in urban environments• Children’s National sees 1% of all ED visits for asthma

every year in our country!*National Health Interview Survey**National Hospital Medical Care Survey

Prevalence of Asthma among DC Residents Aged 1-17yBRFSS

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0.18

0.2

2005 2006 2007 2008 2009 2010

18%

Pediatric ED Visit Rates for Asthma0-17y, inclusive

102.375.6

274.1

441

0

50

100

150

200

250

300

350

400

450

Total 2004-5 Caucasian2004-5

AfricanAmerican

2004-5

District ofColumbia 2010

4.3x

Akinbami L. Pediatrics 2009.

IMPACT DC, 2012.

>10 fold Difference in Rate

Poverty in DC, 2000

Primary Care Access, 2005

Primary Care Access, 2005Primary Care Access, 2005

Outline




1991

1997

2002

National Institutes of HealthGuidelines for Asthma Care

2007



Priorities of the NIH Guidelines

• Proper diagnosis• Patient and family education• Identification and control of triggers• Clear medical plan

• Inhaled Corticosteroids (ICS)• Effective longitudinal care

}



21% within 30 days



Liberman D. Ped Emerg Care 2012.



>70% within 15 days


Teach SJ. Arch Ped Adol Med 2006.


Lung Diagram

Personalized Asthma Tools

Patient Device Education

Summary of “Present”

• Disparities in asthma care and outcomes in Washington, DC are striking and persistent

• Heavy reliance on EDs for episodic care by disadvantaged and minority kids

• Things are improving due to a relentless focus on the most “out of control” kids!!

Outline




Child With Asthma









Poor

Hypothesis – DesignICATA Trial – NEJM, March 2011

• Addition of omalizumab to treatment based on existing NIH guidelines would improve disease control among atopic inner-city children with moderate-to-severe disease

• Prospective multi-center randomized clinical trial of injected omalizumab vs. injected placebo in inner-city kids with allergic asthma

% o

f P

arti

cip

ants

wit

h E

xace

rbat

ion

s

(n=211)(n=208)

Exacerbations

Housing Conditions Pro Bono Attorney Training

March 2015

WELCOME

Introduction

Housing Conditions Pro Bono Attorney Training March 2015

Welcome

• Overview of Children’s Law Center• Housing Conditions Work• Children’s Law Center’s Pro Bono Program

• Caregiver (Adoption, Guardianship, and Custody)• Custody Guardian ad Litem (CGAL)• Special Education• Housing Conditions

• Who are CLC Pro Bono Attorneys? • Case Placement Procedures• Resources and Mentoring

Housing Conditions Cases

An OverviewKathy Zeisel, Senior Supervising Attorney

Renee Murphy, Senior Staff AttorneyPro Bono Training, March 31, 2015

Outline of the Training

1. Background of CLC’s Medical Legal Partnership Healthy Together and Housing Conditions Pro Bono Partnership

2. Introduction to Housing in DC3. Typical Housing Conditions Problems4. Handling a Housing Conditions Case

What is Medical-Legal Partnership?• A healthcare delivery model that integrates legal assistance as a

vital part of the healthcare delivery system • Expanding the concept of medical care for low income families to

include legal representation• Program model based on prevention

• Removing non-medical barriers to children and families’ health and wellbeing

• Address adverse social conditions negatively impacting health through a variety of modalities

• MLPs work to address and prevent adverse social pressures with legal remedies through:• Direct Patient Contact• Provider Training• Systemic Advocacy

CLC’s Healthy Together: DC’s Medical Legal Partnership for Children

• Children’s National• One of the oldest MLPs in the country• In 2002 began with one lawyer • In 2014 we now have ten lawyers and two

investigators• A variety of CNMC clinics and programs:

• Generations• Four Children’s Health Center Locations• Large focus on teen parents and SE

residents• IMPACT DC

• Mary’s Center• Originally, federally funded through Healthy

Start, Healthy Families• Focus on immigrant community• Focus on children with asthma

• Unity Health Center• Launching 2015

CLC’s Healthy Together: DC’s Medical L“[D]ramatic

differences in …child and adult health

outcomes based on social factors such as income and wealth…

begin early in life-even before birth-

and accumulate over lifetimes and across

generations.”Robert Wood Johnson Fdn,

Issue Brief Series: Exploring the Social Determinants of Health,

March 2011egal Partnership for Children

Why Housing Conditions Cases?

• Filling a community need• Hands-on lawyering• Direct advocacy• Litigation experience• Concrete results for children• Working with families

Housing In DC:An Overview of the Basics

Basic Housing Vocabulary

• Subsidized Housing• Catch-all term that covers all publicly financed housing options

• HUD: the Department of Housing and Urban Development• Federal department that oversees all federally funded public housing.

• DCHA: DC Housing Authority• Quasi-government organization that oversees most public housing options

in DC• Is both a federal and local agency (and is neither fully)

• HQS: Housing Quality Standards• These are the HUD standards used by HUD and DCHA to inspect properties

• DCRA: Department of Consumer and Regulatory Affairs• DC Government agency that inspects residential, retail, commercial, etc.

properties.• Responsible for enforcing the DC Housing Code

Who is the tenant?

• With a formal lease• Without a formal lease

• Any arrangement where money is exchanged for a place to stay.

• Foreclosure• If the owner is foreclosed on, the tenant still has the right

to stay and the bank becomes the landlord.• Ending the tenancy

• Must have good cause• In DC, the end of a lease is NOT good cause for

eviction.

Common Types of Housing

• Private Housing• Public Housing

• Owned and operated by DC Housing Authority (DCHA)• Housing Choice Voucher Program (HCVP - formerly

“Section 8”) • Tenant has voucher and the voucher moves with the

tenant• Project Based Section 8

• Owned and operated by a private landlord; funding stays with unit, not the tenant

• Moderate Rehabilitation Housing (MOD)• Somewhat like Project Based Section 8, but run by DCHA

(HCVP Program)

Housing: Private Rental Housing

• Rental units where the tenant pays the full cost of the rent

Housing: Project Based Section 8

• Private landlord receives direct funds from HUD to operate subsidized housing.

• The subsidy stays with the unit.• For most properties, oversight is by HUD

Office of Multifamily Programs and the local HUD office.

Housing: Project Based Section 8

• Project Based Section 8 Properties• Must apply to each property, which maintains their own

waitlist.• Waitlists are generally shorter• Housing may be for a specific population (ie: families,

disabled, elderly)• No transfer between properties without a HUD waiver• You can find the lists of project-based section 8 on the

HUD Office of Multifamily Programs:• http://www.hud.gov/apps/section8/

DCHA Housing: Getting into It

• DC Housing Authority Waitlists• There are currently 60,000 people on the waitlists for

Public Housing and HCVP combined• For some housing, it will be a 20-43 year wait• Other housing come available more frequently (seniors,

VASH, some local homeless and mental health vouchers)• Preferences for: Homeless, veterans, seniors, DV survivors

• DCHA Waitlist Closed on April 12, 2013

Housing: Public Housing

Owned and operated by DCHA• Regular DCHA inspections of the

property• Units are located throughout the city• People placed in public housing from

the central waiting list maintained by DCHA (1133 N. Capitol St NE)

• Transfers from one unit in one neighborhood to another unit in a different neighborhood are possible

• Tenant recertifies at DCHA

Public Housing Relationship

Tenant

DCHA

Housing: HCVP

Relationships of HCVP

Tenant

DCHA Landlord

HCVP operates several programs within DCHA

Housing choice vouchers (also still called Section 8 vouchers) are far different from other public housing options: A voucher allowing recipients to seek

a place to rent on the open market. Recipients pay 30% of their income

toward rent. The government covers the rest.

Voucher is portable

Housing: Moderate Rehabilitation Properties (MOD Rehab)

• Administered by DCHA• Operates like project-based Section 8• Typically, there are no transfers out of the

program into other types of housing. • These are many of the worst properties in

the city.

Who Oversees Whom…Department of

Housing and Urban Development (HUD)

Federal agency

DC Housing Authority

Housing Choice Voucher Program

Housing Choice Voucher Program

(aka Section 8 Voucher/Tenant-Based Voucher)

Moderate Rehabilitation

Properties (MOD Rehab)

Public Housing

Project Based Section 8

Housing Conditions: The Law

Common Housing issues

• Infestations of mice, rats and/or cockroaches• In food/kitchen areas• Damaging furniture/mattresses• Crawling on children/biting children• Allergies from urine/feces/dander

• Mold/Moisture• Allergies• Unsafe structurally- Ceiling/Walls collapsing

Common Housing Issues

• Needs repairs or repairs are inadequate• Screens missing or improperly installed• Fridge leaks coolant into food• Toilet does not work properly

• Sewage overflow

• Accessibility• No wheelchair access• Broken elevator


• DCMR Title 14, Chapters 1-15 outline the Housing Code in DC

• DC has now adopted the International Property Maintenance Code with some local adaptations• Unified document:

http://www.ecodes.biz/ecodes_support/Free_Resources/2013DistrictofColumbia/13PropertyMaint/13DCPropMaint_main.html




IPMC > Title 14

• 102.4.1 Code precedence. If a conflict arises between the Housing Code,Title 14 DCMR, Subtitle A and the Property Maintenance Code, theprovisions of the Property Maintenance Code shall take precedence.


• Warranty of Habitability: A landlord has a duty to provide habitable apartments or houses and to repair housing code violations. A landlord cannot waive this duty in a lease.

• No one has to live in unsafe, hazardous, or unsanitary conditions

• Landlords must repair all conditions that are violations of the Housing Code or IPMC

• Landlords may not ignore any problem that constitutes:• a fire hazard, or • a serious threat to life, health, or safety of tenant

The Mold Law

• The Air Quality Amendment Act of 2014 creates requirements for landlords to remediate mold

• Role of DDOE Regulations• Will define indoor mold contamination

• Hiring a consultant expert to develop regulations• Might include visible mold, air test results

• Will define methods for mold assessments• Will define best practices and work standards for

remediation• For remediation above and below threshold• Models available in the field

• Will develop licensing and certification requirements• May recognize license/certification from neighboring states

The Mold Law• Portions of the Law in Effect Now

• LL must inspect within 7 days of written notice from Tenant• LL must remediate visible mold within 30 days of

inspection• Note: this is not dependent on DDOE regulations

• Court finding violation based on professional mold assessment may reimburse assessment costs and award fees and costs

• Tenant must provide written copy of the report in order to request reimbursement

• DCRA may issue a NOV based on professional mold assessment

• Business/professional engaging in mold assessment or remediation must be licensed and certified by DDOE

• Note: DDOE has not established licensing scheme yet

The Mold Law

• Portions of the Law Dependent on DDOE Regulations• LL disclosures to prospective tenants must include

information about indoor mold contamination within the past 3 years

• Note: exception if mold was professionally remediated

• Below the DDOE threshold, owner may remediate on his own but must follow DDOE standards

• Above the DDOE threshold, only a professional may remediate and must follow DDOE standards

• DDOE may require owner to provide a professional remediation report to DDOE and the tenant

The Mold Law

• Portions of the Law Dependent on DDOE Regulations• Professional mold assessment finding indoor mold

contamination creates a rebuttable presumption of violation of Housing Code / Property Maintenance Code

• Note: but only if owner received written/electronic notice of report

• Court may award treble damages when: • Tenant discovered the mold; • Professional mold assessment found mold above DDOE

threshold; • Owner received written/electronic notice of the assessment;• Owner did not remediate the mold within 60 days; and • Owner acted in bad faith

Handling a Housing Conditions Case

Challenges that Face our Clients

• Income• Education/Literacy• Reliance on public

transportation• Barriers to communication:

• Inflexible job• Transportation Costs• Time commitment for using public

transportation• Caring for an infant or other relative• Cost of cell phone minutes

2015 Poverty Guidelines for the 48 Contiguous States and the District of Columbia

Persons in family/ household

Poverty guideline

1 $11,7702 15,9303 20,0904 24,2505 28,4106 32,5707 36,7308 40,890

For families/households with more that 8 persons, add $3,960 for each additional person

Representing Low Income Clients• Get lots of ways to contact client

• Cell phone, family member’s cell phone• Email address

• If your client falls out of contact, write a contact letter.

• Offer assistance with transportation or meet in your client’s neighborhood/home

• Do NOT use legalese (written communication should be at an 8th grade level)

• Explain what a lawyer is and your roles

Working up your case

1. Document the problems: You can go and/or you can send a paralegal or someone who could testify in court.

2. Request any prior inspection reports (from DCRA or DCHA).

3. Determine if you need any supplemental reports (ie: from a mold inspector).

Who is the landlord?

• To find the landlord, look at the lease AND check DCRA’s PIVS website:

http://pivs.dcra.dc.gov/PIVS/Search.aspx• Property management companies often sign

the leases.• BUT the owner has the ultimate legal

responsibility and provides the funds for repairs, so you want to sue the owner.

http://pivs.dcra.dc.gov/PIVS/Search.aspx

http://pivs.dcra.dc.gov/PIVS/Search.aspx

Send a Demand Letter

• You may want to send a demand letter to the landlord listing all of the problems.• For mold cases, you should send a demand letter.

• This ensures that there is notice prior to filing.• You do not have to do this if the tenant has

notified the LL of all the problems and you decide it is not a good legal strategy.

• You may not want to do this if a TRO is needed or there is another emergency.

Legal Options: DCRA Inspection• Contact the Department of Consumer and Regulatory Affairs

(DCRA): (202) 442-9557

• How it should work:• First inspection occurs within 1-2 weeks (except if no heat or water)• If housing code violations exist, inspector will serve a notice of violation on

landlord• NOV will have time limits for repairs• Re-inspection by same inspector after repairs should have been completed• Fines issued if not in compliance

• Pros: • You have an inspection report

• Cons: • Delays case• Inspector is not always as thorough as Court’s DCRA inspector• Weak enforcement power, so LL may not make repairs

Legal Options: DCHA Inspection

• Contact the DC Housing Authority• (202) 535-1000

• DCHA makes annual inspections of all its properties• DCHA Inspections are based on Housing Quality Standards (HQS)

sent by HUD, not the DC Housing Code• Can inspect more frequently upon request• Pro:

• This may help you if you want to request a transfer or accommodation

• Con:• This may not be considered fully by the Court since it is not a

housing code inspection

Legal Options: ADA/Fair Housing Request

• A Reasonable Accommodation Request pursuant to the Americans with Disabilities Act may be appropriate when there is a reasonable change that would allow a person with a disability to have equal use or enjoyment of the property. • Common requests include:

• Removal of carpet• Transfer to a unit without carpet• Permission to make modifications to address needs of a child• Transfer to a larger unit because child’s medical equipment will not fit

or a child needs his own room due to disability

• HUD DOJ Joint Statement on RA under the Fair Housing Act is a useful reference

Legal Options: Court

• Landlord Tenant Court• Civil Cases• Small Claims Court• Housing Conditions Calendar

Legal Options: Housing Conditions Calendar

• A Calendar within Civil Court• Provides Tenant a way to affirmatively bring

their Landlord into court regarding conditions.• In landlord/tenant court, a tenant can withhold

rent, but must wait to be sued for eviction to get before a judge.

• Court is ONLY for housing conditions repairs• No rent, lease violations, or other issues• Court will generally not deal with any money issues


• Filings:• There are Court forms that you can use to file the

Complaint and Summons .• Temporary Restraining Order and/or Preliminary

Injunction: You can use forms or draft your own.• In forma pauperis: Most of your clients will qualify

for an IFP.• If they do not qualify, it is $15 to file the case and

$10/motion.• E-filing: After the initial filing, you should plan to file

online. If your client has an IFP, you will need to set up a separate IFP account with DC Superior Court.


• Examples of when to file a TRO/PI:• No heat• Severe flooding• Constructive eviction

• You may also consider a PI where there is

evidence you want in front of the judge prior to the first court date, such as pictures or reports.


• Once you file:• Court is always on a Monday morning• You will get a court date 3-4 weeks from the date

of filing• Serving the landlord:

• Even though the Court will serve if you have an IFP, you should personally serve the landlord

• File affidavit of service prior to return date if possible


• First Court Date:• If there is a dispute, the Court will likely order the

Court’s DCRA inspector to the unit.• You may be able to get the landlord to agree to

some repairs• You usually have to ask for a written order —the

Court does not regularly do them.


• DCRA Inspection• Court inspector will go to the unit on a date set in court• You or a representative can attend the inspection• You may be able to email the inspectors and get a copy prior to

the court date

• Subsequent Court Dates:• Court will set a return date 3-6 weeks later to review DCRA

inspection report and/or to check on repairs

• How long in Court?• Cases can last a few months or over a year depending on the

speed and quality of the landlord’s repairs.


• Moving a case forward in the HCC• The Judge generally treats HCC like a settlement

court—meaning that very few trials are conducted and few orders are given.

• BUT the Rules of the Civil Court apply and you can file motions, request orders or evidentiary hearings and sanctions.

• You can hire experts (ie: mold, plumbers, electricians) if you want to present evidence on either the underlying problem or the proper repair for it.

Contact Information• Nancy Drane, Director, Pro Bono

T: 202.467.4900 x502 [email protected]

• Tracy L. Goodman, Director, Healthy TogetherT:(202) 467-4900 x503 [email protected]

• Kathy Zeisel, Senior Supervising AttorneyT: 202-467-4900 ext. [email protected]

• Renee Murphy, Senior Staff Attorney T: 202-467-4900 ext. 580 [email protected]

mailto:[email protected]




Children’s Law Center fights so every child in DC can grow up with a loving family, good health and a quality education. Judges, pediatricians and families turn to us to be the voice for children who are abused or neglected, who aren’t learning in school, or

who have health problems that can’t be solved by medicine alone.

With 100 staff and hundreds of pro bono lawyers, we reach 1 out of every 8 children in DC’s poorest neighborhoods – more than 5,000 children and families each year. And, we multiply this impact

by advocating for city-wide solutions that benefit all children.

Visit childrenslawcenter.org to learn more.

the experience in metro washington, dc stephen j. teach, md, mph impact dc children’s national...

Documents

asthma care

future slide

primary care followup

rate slide

asthma outcomes

episodic care

primary care access

ed visits poor slide