PROVIDENCE – Have you ever tried to make yourself heard in conversation above the din of a broken exhaust system?

Imagine that we are driving in a 12-year-old car approaching 200,000 miles, one that is dependable but prone to breakdown, rumbling down the Interstate, and our words are being drowned out by the reverberations of the ever-widening disconnect between the muffler and the exhaust pipe?

That’s an apt metaphor for how hard it can be to compete to be heard in a conversation around policies and ideas in Rhode Island, as the R.I. General Assembly enters the first week of June, chugging in a deafening roar toward the finish line, the budget still unrevealed and unresolved, and with the politics of who gets what, how much, and when in full force.

Can you hear me now? It’s hard to hear above the pumped-up [piped-in?] volume of noise about a $120 million new baseball stadium, $700 million in new truck tolls, $20 million new train stations, more than $100 million in cuts to Medicaid spending, tax-deal-treaty takeovers by the State House, school funding formula shortfalls, economic development incentives.

But this week will be chock full of significant events in the realm of health innovation and policy, many that may fall under the radar screen.

• On Monday, June 1, at 2 p.m., Providence Mayor Jorge Elorza will be holding a news conference in Burnside Park to announce that all parks, playgrounds and recreation areas are now tobacco-free. Tobacco is still a huge health scourge, and heart disease is still the number-one killer for men and women, lest anyone forget. Indeed, the tobacco-free zone in Providence parks could spell trouble for Triple AAA baseball players if and when there is a new baseball stadium in Providence – chewing tobacco would be illegal.

• On Wednesday morning, June 3, the Washington County Coalition for Children will be holding its 13th annual children’s forum breakfast at the Narragansett Village Inn, featuring Linda Katz of the Economic Progress Institute, asking and trying to answer the question: “Will this year’s budget work for our kids?” It’s to hard to do without an actual budget in hand.

• The next day, on Thursday, June 4, Rhode Island Kids Count is convening “state leaders” for a policy roundtable discussion on infants and toddlers, from 1-3 p.m. at Save The Bay headquarters in Providence. The conversation promises to be top heavy with agency directors, but no agenda has yet been released.

• That evening, again on Thursday, June 4, in Warwick, there will be a “community input” meeting for pediatricians to respond to a working definition of toxic stress in young children in Rhode Island, as part of a statewide initiative to move forward with a way to screen, diagnose, treat and refer young children and families that suffer from toxic stress.

• On Monday, June 8, in an all-day session at the Radisson Hotel in Warwick, there will be a Mental Health Summit, sponsored by the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, focused in on innovative strategies to bring about change and reform in Rhode Island.

• Perhaps the most significant event when it comes to changing policy – and, as a result, likely to be the one least reported on by traditional media – will be the first annual celebration of the Rhode Island Alliance for Healthy Homes, on Wednesday, June 3, from noon to 2 p.m., at the Rhode Island College Student Union Ballroom. The group, which has braided together a collaborative coalition of more than 80 organizations involving more than 500 people, is focused on healthy homes in Rhode Island, building a collaborative alliance that braids together resources.

At a time when those in government and within the health care delivery system are scrambling to develop strategies that both cut costs and improve outcomes, the work being done on healthy homes has a proven track record, one that addresses the root causes of so many health, educational and economic inequities: fixing unsafe and unhealthy homes.

The return on investment is nothing short of phenomenal: for asthma interventions, $14-to-$1; for lead interventions, $220-to-$1.

ConvergenceRI talked at length last week with Ruth Ann Norton, president and CEO of the Green & Healthy Homes Initiative, based in Baltimore, Md., and Betsy Stubblefield Loucks, the outcome broker in the Providence office, having them describe the next steps in the broad-based collaborative initiative in Rhode Island.

ConvergenceRI: How is Providence and Rhode Island poised to move ahead with the next phase of its green and healthy homes initiative?
NORTON: Let me first sketch in the larger picture. What we’ve done [in the past] in Providence was a pilot project, started with 135 homes, showing the ability to align and braid and coordinate multiple resources to reduce health and environmental threats and improve energy efficiency.

[In Rhode Island], we have a grant program that is providing gap funding for weatherization and healthy homes work to ensure a more complete answer for families in a more coordinated way. We’re [coordinating this work] through three different groups that are working in the green and healthy housing field. We brought the three groups together to form the Alliance; the grants support programs at R.I. Housing and the City of Providence.

Here in Rhode Island, through the Rhode Island Alliance for Healthy Homes, we are supporting a push by our on-the-ground leadership here to move past the silo-based delivery system into an integrated process for the best family impacts.

Betsy’s role is to lead the alliance and forge the collaboration and partnerships that can sustain a [statewide] standard for healthy and safe housing.

We want to move away from [the silo approach] of having just one answer, and look instead, comprehensively, at the root causes in housing, to address environmental, health and energy issues, to integrate the funding, to braid the funding together, to create longer term social outcomes.

Rhode Island has been remarkable in its collaborative efforts. More than 70 agencies and organizations have come together and agreed to work toward those goals together, and to push a platform that serves families.

STUBBLEFIELD LOUCKS: I bring with me a fresh perspective, relatively new to the Green and Healthy Homes Initiative.

I have been involved in lots of different collaborations, from health care reform to economic development strategies, with different teams of people.

One of the amazing things I’ve found in this work is that it is a really positive approach, with a willingness by people to put their own skin in the game, to come to the table and do the work.

A lot of the credit goes to Mark Kravatz, who did much of the original organizing.

ConvergenceRI: How does this initiative fit in with efforts underway to create 11 health equity zones in Rhode Island, with a focus on social determinants of health?
STUBBLEFIELD LOUCKS: We have a lot of partners that are deeply involved in our effort. We are trying to drive the same social determinants of health, but we are looking at housing as the platform to address issues such as lead poisoning, asthma on school attendance, and economic security issues around energy efficiency.

I don’t know much about all the specific projects, but we are in conversations with people in Pawtucket, who are interested in learning more about our “Pay for Success” model in asthma intervention.

NORTON: We are in conversations with Memorial Hospital. [Currently], we’re in 5 hospital systems around the country with Green & Healthy Homes for specific asthma programs, financed through a $1 million grant from the Corporation for National and Community Service. 

In addition, we are working to complete a $10 million social impact bond to serve some 1,800 patients seen by Johns Hopkins Health Care System. We’ve seen a 65 percent reduction in hospital admissions and 34 percent reduction in [patients] going back to the emergency room.

Our Green & Healthy Homes model works directly with a health care clinic. It conducts a comprehensive assessment of [the family’s] housing, and it then eliminated the root causes of asthma in housing – addressing allergens, moisture, indoor air quality, and integrated pest management, and structured roof repairs.

That’s a model that’s being looked at [here in Rhode Island]. Green & Healthy Homes does not provide the direct services itself, but we help fund the system and help to put the system in place, in partnership with nonprofit and other government providers of services.

Memorial Hospital has applied to do a feasibility study of using the social impact bonds to finance the work through private investment. We’re looking at the feasibility of how to fund that work with Memorial and other entities in Rhode Island.

STUBBLEFIELD LOUCKS: I don’t know how many medical practitioners in hospitals ask about the home and the structure of the home of patients. The focus is on the body in front of them, not the environment that the patient exists in.

We are looking at the question of how we engage health providers in conversations about these issues.

ConvergenceRI: In addition to hospitals, are you working to expand the way that insurers will reimburse for doctors and nurse practitioners for prescribing a green and healthy home solution for remediation of asthma?
NORTON: Yes, we are trying to push for evidence-based practices. One of our ultimate goals is to get Medicaid to reimburse for housing interventions for the root causes of asthma and increase funding for energy efficiency. Health care through managed care should be a major investor in this work.

It will have a massive impact on the economic health of a community.

CONVERGENCERI: Have you spoken with R.I. Treasurer Seth Magaziner and the potential collaboration of your work with the newly proposed Infrastructure Bank, which is targeting investments in improvements in housing for energy efficiency, environmental remediation and renewable energy. There seems to be a natural synergy there.
STUBBLEFIELD LOUCKS: We spoke with one of his top aides a while ago, but we need to follow up.

ConvergenceRI: How does this work fit in with the push for patient-centered medical homes and increased primary care interventions for chronic disease care?
NORTON: Right now, there’s a big push for community-based interventions to address [the costs] of chronic conditions and lower readmissions to hospitals and emergency room care.

The focus is often on short-term interventions for asthma, and there is some amount of reimbursements for education and home visiting.

But we are looking to create a more integrated approach [focused on housing]. We are looking at the [federal department of] Health and Human Services’s own guidelines, which includes environmental assessment and intervention; they have it in their guidelines.

We want to build the payment model [through which] physicians can write a script for the assessment and for the identification of the triggers of asthma [in the home], and that Medicaid would pay for that.

It would be terrific to merge that kind of [preventive] care into [green and healthy] housing. That is the overarching goal.

There is very fast movement in the reimbursement field; the evidence is mounting.

ConvergenceRI: What is the rate of return on housing investments for asthma?
NORTON: The return on investment is $14 for every $1 invested; the return on investment in lead [removal] is $220 for every $1 invested.

ConvergenceRI: In Baltimore, in the aftermath of Freddie Gray’s death, there has been some excellent reporting about the pervasiveness of lead poisoning and how that can affect a child’s future educational achievement and economic attainment. Can you talk about the benefits of an investment strategy for remediation of housing to remove the triggers for asthma and the elimination of lead as part of comprehensive approach to economic development?
NORTON: Lead poisoning has a dramatic impact on cognitive skills and social ability, including speech delays, hearing loss, with more aggressive and violent behavior. It limits the trajectory of a child as a learner and as an earner.

With asthma, it is the leading health cause of absenteeism from school; it's also a factor in children being unable to sleep through the night. It impairs a child’s learning ability.

You’ve got a prescription for failure, when we can do so much by investing in healthy housing. It’s an investment in children at the very core – in the home.

Healthy housing is a more strategic investment for children, if you care about their future.

In our work, we care deeply about bringing people and organizations together, to braid the resources together, to work collaboratively. We are trying to have real collaborative, collective impact.