This builds upon the priority we placed on this issue in our NYC Mental Health Plan released in March, and the recent U.S. Surgeon General’s Advisory from Dr. Vivek Murthy, because we know that unregulated, unfettered access to social media and all of its content is harming our kids, regardless of potential positive attributes.

We don’t have all of the answers, which is why we held this convening to begin a serious dialogue with key stakeholders. But public health DOES offer the solutions. In NYC, we have led on the mitigation of harm from tobacco, air, lead, water, and other environmental exposures, and we must now treat unfettered access to social media as a digital toxin in our social environment, and explore paths to reducing and reshaping the exposure. We know what can work – education, research and evaluation, advocacy, policy, and regulation – of a system that currently operates without bounds, and to the detriment of our most precious resource, our kids. This convening will lead to a roadmap of actions we will take to protect New Yorkers and our children from harm. This is our commitment and our responsibility.

We’re proud to build on our strong history of public health leadership in NYC as we move into this digital frontier to keep our kids safe, healthy, and well. Thank you to The Rockefeller Foundation and Naveen Rao and Dr. Rajiv J. Shah for hosting us in your beautiful space. Thanks to the many partners who attended from across the country, including colleagues from the Boston Public Health Commission, the Philadelphia Department of Public Health, Los Angeles County Department of Public Health, and big thanks to my team for putting together a fantastic day of conversation, education, and action. And most of all, thanks to the young leaders who came on a day off from school to help guide us and offer their lived experience of growing up in the social media age. As a parent, a doctor, and public servant, I know how important your voice is in this conversation.

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At last year’s CGI Meeting in September, the NYC Health Department and its partners committed to reduce birth inequities for Black women and pregnant persons through the Birth Equity Initiative, a new and innovative umbrella effort to streamline, expand resources and improve the impact of all maternal health programs.

“CGI, in general, is extremely expert in both motivating people to act and working across silos. Those are the biggest challenges that we have in all of our work in the health department and in birth equity and health equity, specifically,” said Dr. Michelle Morse, Chief Medical Officer, Deputy Commissioner to the NYC Health Department. “Our partnership with CGI, from my perspective, is really one of the partnerships that will allow us to do those two things more effectively.”

National data shows Black women and birthing persons are three times more likely to die as a result of their pregnancy; nine times more likely to die in New York state. The main driver for these rising inequities is structural racism. According to the NYC Health Department, 75 percent of pregnancy-related deaths are preventable in Black patients compared to 43 percent in white patients. More than 50 percent of pregnancy-related deaths occur up to 12 months after the labor experience in the hospital, with cardiovascular disease, cancer and mental health issues, specifically opioid overdose and suicide, as the leading causes.

In order to address these issues, the Birth Equity Initiative has three strategic components to drive change: convene diverse stakeholders – community members, birth justice advocates, doulas, midwives, hospital leaders, insurers, health care workers – to develop collective impact goals; establish a Medicaid maternal home payment bundle model; and support the integration of primary care into marginalized communities.

Since the CGI 2022 Meeting, the NYC Health Department has convened a working group of 75 cross-sector partners who’ve developed a collective action vision statement and defined clear metrics and indicators to track progress. The Birth Equity Initiative is currently seeking funding to support the work of community-based organizations as they provide wrap-around resources like doulas, family wellness suites, postpartum home visits, and more to Black women and pregnant persons.

“We have to radically and urgently do a better job on birth equity in this city,” said Dr. Chelsea Clinton, and by leveraging the learning from the past 20 years, birth equity leaders are committed to move New York state into the next phase of maternal healthcare. We must take action by examining the drivers of preventable death in birthing people, working across silos, and building wrap-around community resources before, during, and after pregnancy. “We here at the Clinton Foundation and CGI stand ready to help and be of service in any way we can be,” Dr. Clinton said.

[Text and photo courtesy of Clinton Foundation] [Photo by Megan Maher, 2023]

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Getting Medicaid to Pay for Pest Control

There’s a connection between one’s home environment and asthma. An array of home-related factors can trigger or worsen asthma: pests such as cockroaches and mice can cause allergic reactions, and secondhand smoke, air pollution, and mold can make it worse. In New York City, children with asthma who are exposed to pests are three times more likely to be hospitalized, and they account for more than two-thirds of asthma-related rehospitalizations annually, according to the city’s Department of Health and Mental Hygiene (DOHMH).

The department recently launched a pilot project to zero in on pest-related pediatric asthma by delivering comprehensive pest management to patients’ homes—and tapping a group of Medicaid health insurers to fund it, even though such nonmedical interventions aren’t typically covered. If the three-year Medicaid Together Improving Asthma Program pilot succeeds in reducing repeat hospitalizations, the insurers should reap returns in the form of direct health care cost savings—but if not, a $1.2 million fund is in place to mitigate any losses.

“The environment in which a person lives directly affects their health,” says DOHMH project manager Beatrice Mauger, launch lead for Medicaid Together. “Our hope is to have a win-win for the health care sector and their clients. That can be achieved if this model shows the health care sector that investing in housing-based improvements can generate sustainable financial benefits.”

Over the years, other programs have worked more generally to tackle home health hazards that could exacerbate asthma, such as the U.S. Department of Housing and Urban Development’s Healthy Homes Program and the National Institute of Food and Agriculture’s Healthy Homes Partnership. At Boston Medical Center, building in better asthma-trigger screening and outreach has reduced emergency room visits for acute asthma care. And in recent years, Medicaid insurers have been tapped to help finance affordable housing construction. But the Medicaid Together project is innovative in the way it harnesses the spending power of health insurers upfront to achieve not only health improvements, but measurable and sustainable health care cost savings.

[RELATED ARTICLE: Why Organizations Should Invest in Home Repairs to Improve Health]

Launched in September 2021, the pilot is a complex, collaborative operation overseen by DOHMH and involving multiple hospitals and Medicaid managed care organizations (MCOs) and a community-based nonprofit.

Here’s how it works: Participating hospitals (seven so far, and rising) implement new screening questions to identify young patients whose asthma flare-ups may be related to pests at home and who are insured by one of the participating MCOs. When such a patient comes in, the hospital connects the family to the nonprofit CABS Health Network, which functions as a single point of contact to both deploy pest management services to the patient’s home and to contact the patient’s health plan. CABS pays for the services and is reimbursed by the insurer. The insurer then continues engaging the family with additional case management.

The pilot will run for three years and be followed by a two-year evaluation. DOHMH will collect and analyze the data.

The five participating insurers together cover 87 percent of New York City’s Medicaid-insured children, and their contribution to Medicaid Together is proportional to their share of members. The idea is that if this carefully targeted comprehensive pest treatment, which costs about $1,000, successfully reduces repeat hospitalizations, which cost about $6,000 on average, according to DOHMH, it will easily pay for itself. The health department expects the pilot to reach 1,200 children, translating to millions of dollars saved. Even so, the commitment involves a financial risk that insurers might be leery of taking on, so the national nonprofit Enterprise Community Partners has committed $1.2 million to guarantee profitability for the insurers if the expected cost savings aren’t realized.

Elizabeth Zeldin, director of Enterprise’s neighborhood impact program, was closely involved with the health department in devising the project. She likens the setup to pay-for-success models that shift risk from government funders to new investors, though the Medicaid Together project is a bit of a reversal.

“In a way, it’s a ‘pay for failure’ model,” she says. “But if we succeed, it’s going to be so cool—a game changer.”

[The Green and Healthy Homes Initiative recently launched a somewhat similar asthma initiative for adults and children in which a mission-based investor takes on the upfront costs of things like pest management, cleaning supplies, and even carpet removal and plumbing repairs, and is paid back by a single insurer if cost savings are realized.]

Integrated pest management with allergen reduction, referred to as IPM-AR in this project, is a less toxic, more comprehensive pest control method that includes a range of preventive and remedial measures beyond just spraying chemicals or laying traps, including using HEPA-filter vacuums, sealing up holes and cracks, and improving trash management.

“There’ve been a lot of studies throughout the country about the connection between pests and asthma, and small pilots here and there. The idea of using IPM as a health intervention has been building up momentum over many years,” Zeldin says.

In her view, the real game changer will be proving that funding these health-preserving measures results in sustainable cost savings for insurers.

“This pilot ties the actual financial beneficiary to the work. That’s where it gets exciting,” Zeldin says. “It alleviates the ‘wrong pocket’ problem that we often talk about in the health and housing space.” “Wrong pocket” describes what happens when an investment produces savings but those benefits go to entities who are not paying the cost.

For Insurers, Potential Cost Savings and Enhanced Member Relationships

Claribel Blake, program director for quality management at Empire Blue Cross Blue Shield and its designated lead for the Medicaid Together partnership, says that when DOHMH reached out to insurers in 2019, it was clear that Enterprise’s funding would provide a financial guarantee, but she suggests that Empire would be interested in such preventive investments in any case.

“Over the years, we have invested in innovative asthma prevention programs and in a community health workers program. Therefore, we were excited about this opportunity to address the social drivers that impact our asthmatic children,” Blake says. “The belief is that this project could sharply reduce repeated visits and result in cost savings. These savings will allow us to continue to invest in new and ongoing programs.”

Empire has seen two referrals of member asthma patients so far. Blake cites the positive impact of not only the pest management itself, but the resulting interaction between the health plan and its members.

“When we get the info, right away we communicate with the member to make sure they are connected to our case management services and to other resources—food, housing, assistance in making doctor appointments. It could be that we have tried to contact them before, but now that there’s been a hospitalization, parents may be more receptive to receiving services.”

The MCOs provided input on the pilot project design and on tools, ongoing processes, communications materials, and billing codes, and continue to meet regularly.

“Collaborating is a good thing,” Blake says. “Although we each have our own focus and programs, we can learn from each other and share ideas and best practices.”

Nonprofit Serves as Central Point of Intake

The Brooklyn-based CABS Health Services has been working for more than 40 years to address health inequities in disenfranchised populations and jumped at DOHMH’s spring 2020 request for proposals, says Belinda Freeman, CABS project manager and point person for the Medicaid Together program.

CABS had previously participated in a pediatric asthma self-management program through a five-year Delivery System Reform Incentive Payment program that served as a foundation for the Medicaid Together pilot.

“We saw how working on the home conditions that exacerbate asthma is really effective, so we knew we wanted to be involved,” she says. “We are the central point of intake. We receive referrals. We check a database to make sure they have active insurance with the health plan. We get consent from the guardian. We let them know the pest management will be free of charge to them.”

CABS had processed referrals of around 25 asthma patients as of early May.

And if a hospitalized asthma patient is not a member of one of the participating health plans? At this point, CABS would be unable to serve the family, Freeman says.

“What makes this program sustainable is that it’s being paid for by the insurers. There’s no mechanism for us to do this as charity cases,” she says, adding that CABS is working to find other ways to provide service for those not eligible for this program.

The Pilot Does Not Involve Landlords

The Medicaid Together program bypasses landlords. Though landlords are responsible under local law for pest control, Enterprise says there often is little incentive for them to carry it out as comprehensively as integrated pest management with allergen reduction does.

DOHMH’s Mauger notes that the health plans’ continued case management may include referring families to the city’s Healthy Homes Program, which often does involve landlords. In emailed responses to questions, Mauger explains, “If they see that there is mold in the home when conducting their home environment assessment, or if there are some structural changes in the home that were too big for the IPM vendor to address, the family’s consent would then be obtained to contact the landlord in order to have that problem fixed.”

Tips for a Successful Partnership

For other cities or organizations considering similar projects, Mauger advises, “Give yourself plenty of prep time.” Beyond the two years or so of designing the project and gathering the partners, it took DOHMH an additional year to get all the contracts signed. “With the health plans, the project entailed negotiating a contract with their legal teams, though there was buy-in for the project. This ended up being a lengthier process than expected,” Mauger said.

Blake says, “For this to be successful, a lot of communication had to take place, with our members and also between the project partners. From the beginning, it’s important to come together to review workflows, and put in place expectations and a process to review outcomes on a monthly basis, between all the entities engaged. That allows an opportunity to identify gaps and make improvements.”

Freeman suggests creating a project portal that all partners can access. “That would be helpful, working with different hospitals, and different health plans. CABS doesn’t have capacity to create a new piece of technology like that. Right now it’s a lot of spreadsheets and emails. A central portal would simplify things.”

Freeman also emphasizes the importance of ensuring that partners are all in on the project’s goals.

“One lesson learned is that for a program of integrated pest management, having a success story—even just one—showing pictures of the before-and-after, is one of the most impactful pieces to get the buy-in you need from multiple players. If there’s a way to really paint the picture, it brings everyone to the same level of understanding: ‘We are here to help this child and family be healthy.’ From there, working out the details should be easier,” she says.

Buy-in must come from the families, too. “No one wants someone to come into their home,” Freeman says. “They may be mistrusting; some don’t want to admit they have pests. But when they see how it works, it really makes a difference. You need champions at every place.”

A Gateway to Other Health and Housing Targets?

The final outcomes of Medicaid Together won’t likely be known until 2026, but Zeldin envisions this pilot sparking other initiatives—from wider asthma prevention projects to eviction prevention or aging-in-place efforts—that could be funded by health insurers.

The Medicaid Together pilot intentionally targeted one concrete intervention to one narrow subset of patients. That could be important in laying groundwork for other projects.

“If we want to demonstrate something at scale, the pilot needs to be successful,” Zeldin says. “With any sort of innovation experimentation, you start with one cohort—and then if that’s successful, you figure out ways to scale it up. It’s a matter of fiddling with the box once it’s established.”

She adds, “We want insurers to say, ‘Wow, this really worked. Let’s do it more broadly, let’s do this in other markets,’ and without needing the financial guarantee. The idea here is to prove the case.”

Article courtesy of Shelterforce.

Visit the NYC Health Department’s website for Asthma-related resources.

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On behalf of the FPHNYC Board of Directors and the entire staff, I would like to acknowledge the departure of Dr. Oxiris Barbot and thank her for her extraordinary leadership during these last two years as Commissioner of the NYC Department of Health and Mental Hygiene and the President and Board Chair of the Fund for Public Health in NYC.  

Dr. Barbot led the Health Department with an unwavering commitment to public health, health equity, and racial justice. We have been proud to work with her and the Health Department on projects addressing public health challenges. These have ranged from substance use, social cohesion, and immigrant wellbeing, to implementing new technological systems, supporting the health of mothers and babies, and fighting epidemics. It has been an honor to work with her and have her serve as our Board Chair.

Partnering for public health

FPHNYC is proud to be a critical partner to the NYC Health Department and share a mission of advancing public health for all New Yorkers. Over the last 20 years, we’ve established an impressive track record of fostering public-private partnerships that support innovative public health programs, and ensuring those programs deliver effective interventions. In times of transition, we provide continuity for our funding partners as well as our partners at the Health Department to keep our programs running smoothly.

Welcoming Dr. Chokshi

I would also like to offer a warm welcome to Dr. Dave Chokshi who was named Commissioner of Health on Tuesday, August 4, 2020.  Dr. Chokshi most recently served as Chief Population Health Officer at NYC Health + Hospitals, where he built and grew an award-winning team dedicated to health system improvement. He has taken care of patients as a primary care physician at Bellevue Hospital since 2014.

Dr. Chokshi’s prior work experience spans the public, private, and nonprofit sectors, including positions with the New York City and State Departments of Health and the Louisiana Department of Health, before and after Hurricane Katrina. Dr. Chokshi served on the FEMA delegation to New York City after Hurricane Sandy in 2012. He also served as a White House Fellow and was the principal health advisor to the Secretary of Veterans Affairs.

Dr. Chokshi will also be our new Board Chair. We’re excited to welcome him as part of our team and look forward to working closely with him.

The Fund for Public Health is the nonprofit partner to the New York City Health Department. Learn more about our work and how you can support the advancement of public health for all New Yorkers.

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Dear Friends of FPHNYC,

Though COVID-19 is a novel virus, its patterns of devastation are all too familiar. As race and ethnicity data in relation to the virus continue to be made available, we are seeing that Black and Latino communities across this country are disproportionately impacted.

This stark contrast in outcomes is not unexpected. Despite the pioneering work we have taken on to promote health equity, and despite our best efforts to contain and mitigate the spread of COVID-19, we are yet again seeing how health threats are exacerbated by underlying inequities and existing health disparities affecting neighborhoods in our beloved city.

The COVID-19 pandemic has shown the fissures in our society and wreaked havoc on those who have been deliberately left to fall through the cracks caused by generations of structural racism. And it is those same communities that we are committed to serving the most. At the Health Department, we are doing all we can to mitigate the pandemic’s repercussions on our hardest-hit communities and to interrupt the equally threatening long-term consequences.

We launched an Equity Taskforce as part of our emergency response. The taskforce is convening subject matter experts from across our Incident Command System to identify, analyze, and address equity considerations in this pandemic. We are also actively implementing an Equity Action Plan that allows us to tailor and focus our messaging and engagement with community and clinical partners in neighborhoods most impacted by COVID-19. In doing so, we will make sure that these communities receive the information, resources, and support they need.

As our friends from Race Forward have said, “Structural racism is a co-morbidity.” While every corner of our city is experiencing the burden of this virus, the burdens of Black and Latinx New Yorkers are compounded by social and economic forces that long preceded it. In addition to contending with this virus, we must also push back against decades of divestment, neglect, abuse, and oppression. This is our mission; we cannot be deterred. If there was ever a time to help our fellow New Yorkers and the rest of the world better understand the terrible consequences of social inequity, it’s now – when we are all living the truth that we are only as healthy and secure as our least healthy and most under-resourced community.

I am incredibly humbled to serve with my Health Department and FPHNYC family, some of whom we have lost to this global tragedy. I can think of no nobler way to honor their memories than to remain steadfast to our core values and to lead with equity.

Stay safe,

Dr. Oxiris Barbot

If you’re interested in learning  more about our equity work, please join our next Public Health Talk on May 6^th and consider supporting FPHNYC by making a donation.

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Nora Landis-Shack, Senior Associate – Strategic Partnerships & Fundraising

Changing laws, policies, and funding priorities means that interdisciplinary collaboration is more important now than ever before.  Speakers at several of the sessions I attended spoke about the power of public-private partnerships to enact real, sustainable, and powerful change in public health. The Fund for Public Health is uniquely able to connect individuals and private philanthropy to innovative projects that make us healthy and makes New York City’s Health Department one of the best in the country, if not the world. As I reflect on APHA, I’m thinking about how we can continue to support those relationships to ensure continued innovation is made possible.

Sydney Sasanow, Financial Analyst

The sessions I attended at APHA emphasized the importance of incorporating community feedback into program development and design to build trust and encourage buy-in. This is especially important in the fight against epidemics like opioid use and vaping. Community-partnered efforts can help us more directly and meaningfully address not only the symptoms of epidemics, but also their root causes in the social determinants of health like access to housing, healthy food, and clean, safe environments.

Aviva Goldstein, Senior Director – Strategic Partnerships & Institutional Philanthropy

The field of public health is becoming increasingly diverse with stronger representation from people of color and people of all ages and genders. Several presenters focused on men’s health and one panel focused on unorthodox ways of reaching Black men – barbershops, churches – and how to develop messages that resonate.  It reminded me of a comment our former commissioner, Dr. Mary Bassett, recently made about how white men and women and Black women achieved life expectancies over 70 by the 1970s. Black men didn’t achieve this until 2004. The Fund has helped the Health Department develop innovative programs focused on men’s health and men’s role in women and children’s health.

Sara Gardner, Executive Director

There’s a growing body of evidence suggesting that structural racism is a leading driver of racial disparities in health, particularly sexual and reproductive health. But there is a lack of literature focused on what can be done to address these disparities. Thankfully, APHA featured many presentations focused on advancing racial and health equity. I saw many promising examples of local and state jurisdictions building organizational capacity and investing in transformational leadership needed to address structural racism and implement racial equity agendas, and also attended several presentations focused on empowering community voices. I was struck by a presentation focused on #ListentoBlackWomen, a community-based approach to understand and address structural racism by focusing on and highlighting the experiences of Black women with health and social justice. These programs reminded me of work being done by the Health Department here in NYC to advance justice for all New Yorkers, particularly when it comes to our health.

We look forward to staying in touch with and continuing to learn from all the incredible presenters, organizations, and partners we met at APHA 2019. Interesting in learning more about the Fund? Sign up for our newsletter!

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In 2000, when there were only 86 cases in the United States, measles was declared eliminated from the US, meaning there was no continuous transmission of the disease for more than 12 months. Nationally, the rates of people vaccinated against measles have been very stable since the Vaccines for Children program, which began in 1994. However, even in areas with high vaccination coverage, pockets of unvaccinated people can exist and measles can  spread easily in those communities. On July 10, FPHNYC invited friends and supporters to join a conversation with Dr. Jane Zucker, Assistant Commissioner for the Health Department’s Bureau of Immunization, to explore the resurgence of measles and what’s being done to stop the epidemic. Dr. Zucker’s insights are summarized below:

The majority of cases (72%) remain confined to the neighborhood of Williamsburg (ZIP codes 11205, 11206, 11211, 11249), with 93% of cases occurring in the Orthodox Jewish community. Measles is a highly contagious disease from which every case can spread to 15-18 new individuals. The median age of infected individuals is 3 years old, with 80% of confirmed cases occurring in children, of whom 90% have never been vaccinated.

On March 27, 2019, the Health Department activated its Incident Command System for the measles response to mobilize needed staff and resources throughout the agency. Onset of the disease can be prevented with post-exposure vaccinations, but they have to be administered within 72 hours after exposure, so the Health Department works around the clock. For every reported case of measles’ infection, Health Department employees contact lists of individuals who may have been exposed. The Health Department also provides alerts to providers, uses the press to spread the word, and engages in community outreach.

To end the outbreak, the Health Department has worked with and supported the work of community partners. The Health Department has placed ads in Yiddish-language publications and worked with trusted community partners such as Hatzalah, yeshivas, and women’s groups to reach community members. New services, including a hotline for requesting home vaccination, have also been introduced. Additionally, for the first time since a 1940s smallpox epidemic, a Commissioner’s Order was issued requiring vaccination. The order requires people who live, work, or go to school in delineated ZIP codes to be vaccinated with the measles, mumps, and rubella vaccine (MMR). In June, the State of New York removed the option for religious exemption to vaccination, and all schools and child care facilities must exclude unvaccinated children unless they have a medical exemption.

As a result of these efforts, reports of new measles cases have been decreasing. Between April 9 (the date the Commissioner’s order was issued) and July 29, 2019, 5,513 vaccinations were administered to children from Williamsburg, a 72% increase from the same period last year. However, activation and emergency measures remain in effect.

NYC’s strong public health infrastructure has made this comprehensive and innovative disease control response possible. For information on what you can do to support NYC’s fight against epidemics, whether communicable diseases like measles or dangerous conditions or behaviors such as obesity, opioids, and tobacco, please contact Aviva Goldstein at agoldstein@fphnyc.org.

The post Disease Detectives: Combating New York City’s Measles Epidemic appeared first on Fund for Public Health in New York, Inc..

You can access the article here.

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