During a heat wave in the summer of 2010, doctors in Cincinnati saw a spike in emergency room visits from children having asthma attacks. The spike was curious. Despite a city-led public information campaign to encourage residents to use air conditioners to prevent asthma attacks, the ER visits continued apace. It did not dawn on doctors to ask, “Who is your landlord?”
The lawyers on the legal aid team at Cincinnati Children’s Hospital, however, were quick to inquire. The spike, they found, was coming from 19 buildings with more than 600 apartments owned by an out-of-state landlord. To avoid paying higher electrical bills, the landlord was handing out eviction notices to tenants who requested a window air conditioner. As a result, families did without air conditioning, and asthma attacks skyrocketed. And the costs accrued to the health care system.
Just outside Cincinnati Children’s Hospital is a neighborhood with some of the highest-density housing code violations in the city. For years, doctors had simply treated (and re-treated) children for asthma attacks and other consequences of substandard housing. Physicians could not change their patients’ homes, after all. But lawyers could help. In 2008, the hospital teamed up with the local Legal Aid Society to form the Cincinnati Child Health-Law Partnership (Child HeLP). Since then, lawyers have been on call to address housing problems for patients and their families.
“A legal letter can often get a response where a doctor’s or social worker’s letter does not,” reported The New York Times in 2014.
Shortly after the heat wave, the same landlord went into foreclosure on several buildings. With support from Child HeLP lawyers, the residents formed a tenants organization to ensure the housing wasn’t lost.
Today, said Virginia Tallent, senior attorney at Legal Aid Society who led the fight, “all of the subsidized units survive [and] are still affordable, and many have been gut-rehabbed.”
Child HeLP is one of several recent partnerships the hospital has formed to address factors outside the hospital walls that land people in the hospital. Often this means looking to the neighborhoods where their highest-need patients live.
Hospitals’ New Role: Partner
Cincinnati Children’s Hospital sits in the Avondale neighborhood, home to 12,500 residents, 90 percent of whom are African American. It is one of the city’s most impoverished neighborhoods. Only about one-half of children in Avondale are considered “on track” for kindergarten. Life expectancy in Avondale is up to 20 years shorter than in mostly white neighborhoods nearby.
The hospital is investing $11 million over five years in community development in Avondale, $10 million of which is aimed at improving housing conditions and promoting redevelopment. Partners in the development efforts include the Avondale Comprehensive Development Corporation and the Avondale Community Council, according to the Cincinnati Business Courier.
In addition to building homes, the hospital supports housing rehab to prevent further blight and complement the city’s economic revitalization plans. The hospital has partnered with Uptown Consortium and the Avondale Comprehensive Development Corporation to give families who live in certain parts of the neighborhood interest-free, forgivable loans for rehab projects. Families apply for up to $35,000 and make no payments on the loan for five years. If the family lives in the home for that time, the loan is forgiven.
The hospital is also investing $1.5 million in grants over five years to nonprofits in Avondale to improve child and community health, with a focus on workforce development.
The partnership is not always easy. Hospital leaders and staff often know relatively little about life outside its walls. But with the hospital’s clout in the city, it can quickly become a bull in a china shop, imposing its vision on a neighborhood. Hospital representatives are learning to listen more closely to residents and others in the neighborhoods.
“Cincinnati Children’s is a jewel for the city,” said James Greenberg, a neonatologist at the hospital, “but we sometimes walk in and tell people what we think is best for them.” With the housing and community development initiatives, he said, “We’ve learned to exercise due diligence.”
The All Children Thrive learning network is the latest result of their due diligence. Led by Robert Kahn, a pediatrician and associate chair of community health at the hospital, and Kathy Schwab, executive director of Local Initiatives Support Corporation of Greater Cincinnati & Northern Kentucky, the network meets weekly to improve children’s outcomes by focusing on neighborhood. The network includes families, health care providers, educators, community service providers, and others to learn from one another and collaborate on systemic solutions.
“We’ve been meeting for a year, but just in the last several months we’ve come into some critical aha’s,” said Schwab.
One insight they arrived at, she said, “is that it’s mostly system change issues” that keep families from thriving. Legal issues with landlords or bureaucratic hurdles make getting ahead nearly impossible. Low-income families know all too well that, as the proverb says, it’s not the mountain ahead but the pebble in your shoe that defeats you.
In other words, said Kahn, “How do we lower the barriers to family success? How do we get the job training agencies, and the child welfare system, and education, and housing groups and clinics working hand in glove for a family? We’re working with agencies to ask, how do we surface the systems problems and change the rules?”
“The beauty of this work,” said Schwab, “is that we’re trying to co-create solutions with the very people we’re trying to help. How much can these doctors know just sitting up in a hospital? It’s not something we live day in and day out.”
A Hospital Rebuilds its Neighborhood
Like Cincinnati Children’s, Nationwide Children’s Hospital in Columbus, Ohio, is also focused on neighborhood improvement.
The south side of Columbus, where the hospital sits, was once a thriving working-class area. Deindustrialization started its decline, and the foreclosure crisis finished it. Abandoned, boarded-up homes pockmarked the neighborhood. Prices of the remaining homes plummeted, creating a vicious cycle. By 2015, about 60 percent of the homes in Southern Orchards, a neighborhood in the hospital’s footprint, were valued at less than $150,000, and 20 percent were vacant. The national average was a fraction of that. Fifty-seven percent of children under age 5 in the neighborhood were living in poverty.
Those children were now Nationwide’s responsibility. And increasingly, the hospital staff looked to high-quality housing to help them.
“We’re in one of the highest-risk neighborhoods with some of the highest rates of violence, ER visits, asthma. We have to fix it, and it’s not going to be fixed only inside the hospital,” said Kelly J. Kelleher, director of the Center for Innovation in Pediatric Practice at Nationwide. “Housing is a big part of that,” he said.
The hospital’s efforts began with housing because a secure home with running water, heat, and no mold or roaches is fundamental to health. But housing is far more than its physical components. Stable, quality housing reduces the damaging stress on families that can directly harm health and family functioning. A study in Cleveland after the foreclosure crisis found that living in substandard housing led to lower literacy scores for children entering kindergarten and put them at higher risk of child abuse or neglect and elevated lead levels. Even living near distressed properties lowered literacy scores among kindergarteners.
Nationwide also focused on housing because the hospital had not always been a good neighbor. In the 1990s it had used eminent domain to build parking lots, which did not go over well with neighbors. “People said, ‘wow, even though we’re in the neighborhood, we’re not “of” the neighborhood,’” said Kelleher of his colleagues. “We need to be better neighbors.” They have since taken those lessons to heart. Instead of building only for the hospital, they are now seeking ways to improve and sustain the entire neighborhood.
Partnering with Church and Community Development for All People, a community development corporation, Nationwide, through its Healthy Homes initiative, part of the larger Healthy Neighborhoods Healthy Families initiative, has contributed approximately $8 million of a total $18 million in public-private money to improve housing in the nearby neighborhood over six years. In addition, the United Way of Central Ohio has become a major private investor, and City Land Bank has supported demolition where needed. As in Cincinnati, the commitment is to build and rehab homes — both owner-occupied and rentals — in the surrounding neighborhood.
Over the past six years, Nationwide has built and sold 11 homes on vacant lots, rehabbed and sold 47 abandoned homes, and provided 65 home improvement grants of $15,000 each. The hospital also funded 58 new town homes and apartments. Most recently, it launched a rental company and is rehabbing 15 rental units. The hospital plans to create 75 more rental units over the next four years and a housing project with 50 dwellings, though financing is still being assembled, said Kelleher.
The neighborhood improvement efforts have jump-started other efforts in nearby neighborhoods, including that of the South Side Renaissance group, “about a mile south of us and working to meet us,” said Kelleher. In a neighborhood directly south of the hospital, 75 families received home improvement grants funded through a private partnership.
“With different groups taking a neighborhood and working toward each other, we’ll preserve affordable housing and protect against blight,” said Kelleher.
“Preliminary evidence is that people love the neighborhood, and more kids are seeing their doctors, and substandard housing in the first census tract has been reduced by 70 percent,” said Kelleher. In the past seven years, the vacancy rate has fallen from 30 percent — three times the city average — to 6 percent in one census tract, Kelleher said.
Identifying investment partners for housing redevelopment has also gotten easier since the hospital announced Healthy Neighborhoods Healthy Families, said Angela M. Mingo, community relations director at Nationwide. “What we noticed is that as a result of the hospital’s financial commitment to the construction of safe, decent, and affordable housing, additional financial support has followed.”
In addition to money, the hospital’s expertise complements the community development programs. Nationwide has “been acquiring land for years for expansion,” said Kelleher. “We have a staff very familiar with real estate deals. We know how to get permits for street and other improvements. Those are the daily bread and butter for a hospital. We have ongoing relationships with City Hall. So when we line that up with our dollars and our politics and our marketing, the influence becomes substantial.”
Nationwide is also keying in on workforce development. The hospital has partnered with developers and a nonprofit group to use the Low-Income Housing Tax Credit to build the Residences at Career Gateway. The development includes 14 townhomes and 44 multifamily apartments, plus an onsite workforce and a career development training center. All units are affordable for people living on incomes 60 percent below the area median income. Additional funders and supporters include JPMorgan Chase and the City of Columbus.
Hospitals of the Future?
Back in Cincinnati, the Child HeLP partnership continues to fight on behalf of poor families to improve their housing, and through that to improve the health of children. Their latest effort with Children’s and another local hospital with a large obstetric practice—TriHealth Good Samaritan Hospital—focuses on helping young mothers avoid preterm births by ensuring that they have safe, stable housing during pregnancy. With this help, they “are not showing up at a homeless shelter eight months pregnant,” said Elaine Fink, managing attorney at Legal Aid in Cincinnati.
“We get 700 referrals from Children’s a year, and today doctors who have come to rely on offering patients a referral for legal advocacy don’t want to practice medicine without lawyers,” Fink explained.
But, as for most things, sustainability is a perpetual issue. “There’s initial excitement among funders about doctors and lawyers working together, but it wears off,” she said. “We’re always on the hunt for money.” Their latest innovative effort involves a dedicated attempt to secure sustainable funding through the Medicaid managed care system. If they succeed, legal advocacy would be considered a reimbursable expense to promote better outcomes and reduce health care costs. This funding, Fink said, would have exciting spin-off effects for Child HeLP.
Until then, hospitals like Nationwide and Cincinnati Children’s will continue to forge partnerships to make neighborhoods places where children and families can thrive. The hurdles to continuing and nurturing these community partnerships are high, but Kahn believes the focus on preventing poor health by starting at the neighborhood “will be hard to walk back.”