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Healthy Beginnings at Home Explores a Novel Approach to Reducing Infant Mortality in Columbus, Ohio
In the summer of 2014, a task force empowered by the city council of Columbus, Ohio, reported that infant deaths in the surrounding Franklin County were disproportionately high compared with the rest of Ohio, a state with the 11th highest rate of infant mortality in the nation that year. These deaths were concentrated in neighborhoods characterized by social and economic problems such as poverty, unemployment, and housing instability. The report showed that, just as mortality was distributed unevenly across space, it was also sharply delineated by race, resulting in part from the legacy of housing discrimination in Columbus: African-American babies were nearly 2.5 times more likely than White infants to die before age 1. To address this public health tragedy, the Columbus city council established the collective impact initiative CelebrateOne in November 2014, and in 2018, the initiative and its partners launched Healthy Beginnings at Home (HBAH), a $2 million pilot program that found evidence that housing interventions improve health outcomes for homeless or near-homeless pregnant women. In 2021, CareSource, a managed care organization for Ohio Medicaid and key partner of the initiative, accepted a HUD Secretary’s Award for Public-Philanthropic Partnerships for the innovative collaboration embodied in HBAH.
Demonstrating the Value of Housing for Health
Public health researchers already knew that a connection existed between the social determinants of health and infant mortality. HBAH was designed to test whether providing housing interventions to homeless pregnant women could improve their health outcomes and those of their babies. Barbara Poppe, a former director of the U.S. Interagency Council on Homelessness who functioned as the lead consultant for HBAH, explained another reason CelebrateOne needed hard data: “We had to do this study in order to make the case for a larger intervention we could scale up.”
CelebrateOne coordinated the pilot, which enrolled 100 women who were extremely low-income residents of Franklin County in their first or second trimester of pregnancy. The women were CareSource clients recruited from neighborhoods with concentrations of infant mortality, and as a result, most were African-American. All participants were homeless or unstably housed at the time of enrollment, and most had experienced a prior pregnancy. Because the participants were CareSource members, the organization could monitor their health and the health of their infants and other family members through medical claims data and tracking the expenses incurred to Medicaid.
The 100 enrollees were randomly placed in either a control group or an intervention group. The control group received “usual care,” with access to a care manager and a JobConnect Life Coach through CareSource as part of their Medicaid benefits. Participants in this group did not receive a housing subsidy through the pilot, but they remained eligible for assistance through housing programs. The intervention group also had access to the Medicaid benefits but additionally received intensive housing assistance to stabilize their living situations. The Columbus Metropolitan Housing Authority (CMHA) and the local nonprofit Home for Families (HFF) were the primary HBAH partners involved in this stage of the pilot.
Families in the intervention group had two options for housing stabilization: a CMHA unit subsidized through project-based Section 8 housing vouchers or a private-market rental unit with a subsidy paid through the pilot and administered by CMHA. The pilot-provided rental subsidies lasted 15 months and bridged the gap between 30 percent of the women’s income and market-rate rent. Once the 15 months elapsed, participants received 3 months of step-down rental subsidies until they were paying their entire rent independently. This period was followed by an additional 3 months of HFF-administered crisis assistance for emergencies such as job loss, a child’s illness, or expenses related to the COVID-19 pandemic. All intervention group participants obtained stable housing during the pilot, although it took an average of 62 days for them to do so. Although participants in both the intervention and control groups spent time in homeless shelters during the pilot, households in the control group spent more than five times the cumulative number of days in shelters than the intervention group did.
In addition to access to affordable housing, intervention group members also received access to a Housing Stability Specialist through HFF who helped them navigate challenges such as finding an apartment, signing a lease, and resolving conflicts with landlords. The researchers chose a service delivery framework called Family Critical Time Intervention, which is particularly suited to helping families achieve stable housing after experiencing chronic homelessness or multiple episodes of homelessness, domestic violence, and other challenges, as was the case for many of the study participants.
The results of the pilot showed clear differences in outcomes for the mothers and babies who received housing assistance and the mothers and babies who received usual care, most notably in neonatal health. The intervention group accounted for 51 babies, including the child of a woman who left the program and one set of twins. All the babies in the intervention group were born alive, and 78 percent were full-term births and born at healthy birth weights. Approximately 10 percent of the babies were preterm births with low birth weights, 8 percent were preterm births but with healthy birth weights, and 4 percent were full-term births with low birth weights. Only 13 percent of the babies in the intervention group required a stay in a neonatal intensive care unit (NICU), and those who did had an average stay of 8 days.
The control group had 44 babies; 4 women experienced fetal deaths (miscarriages) but continued to participate in the pilot, and 2 women left the study before the births of their babies. Only 55 percent of the babies in this group were full-term births and born at a healthy weight. Approximately 29 percent of the babies in the control group were preterm births, and 32 percent required a NICU stay. Hospital stays for this group averaged 29 days. The average cost incurred to Medicaid for the birth and hospital stay of a baby in the intervention group was $4,175, whereas the average cost for the care of a baby in the control group was $21,521. Neither group experienced any maternal deaths.
The study found no notable differences in self-reported maternal health between the control and intervention groups, according to periodic surveys administered by Nationwide Children’s Hospital. CareSource used claims data from participating households that tracked medical visits, diagnoses, and medications to assemble a more complete picture of participants’ health. However, because of the privacy concerns inherent in anonymizing such a small sample and because this data source was not part of HBAH’s original design, only a limited range of this information has been made publicly available.
The researchers hope that the pilot program’s encouraging results will inspire others to undertake similar studies. In fact, the HBAH program was intended to be a model. “It was designed to have wider implications,” said Poppe, adding that the research team has received inquiries from several parties interested in reproducing their work, including the city of Indianapolis. The researchers also would like to repeat the HBAH study with a larger sample. In 2022, Governor DeWine awarded $2.25 million to the Coalition on Homelessness and Housing in Ohio (COHHIO) and the HBAH Collaborative through a competitive funding program called Housing Assistance to Improve Birth and Child Outcomes. Using this funding, COHHIO and the HBAH Collaborative will launch a new program based on the original HBAH study that will provide rental assistance for 90 expectant mothers and their families in Columbus and Akron. Poppe is hopeful that the effort can secure additional funding to add cohorts in Cincinnati and Dayton.