Linking housing and health in the Hutt Valley: Housing Coordinator Pilot Evaluation. Regional Public Health. April 2014

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1 Linking housing and health in the Hutt Valley: Housing Coordinator Pilot Evaluation April 2014 Andrea McDonald, Public Health Registrar Regional Public Health Better Health For The Greater Wellington Region

2 About Regional Public Health Regional Public Health (RPH) is a business unit of the Hutt Valley District Health Board providing public health services to the greater Wellington region, including Capital and Coast, Hutt Valley and Wairarapa District Health Boards. Our business is public health action working to improve the health and wellbeing of our population and to reduce health disparities. We aim to work with others to promote and protect good health, prevent disease, and improve quality of life across the population. We are funded mainly by the Ministry of Health and we also have contracts with the DHBs and other agencies to deliver specific services. We have 150 staff with a diverse range of occupations, including medical officers, public health advisors, health protection officers, public health nurses, analysts and evaluators. Author Andrea McDonald, Public Health Registrar, Regional Public Health. Acknowledgement Special thanks to all the interviewees. Thank you to all the participants who welcomed me into their homes, and who took time to talk about their experiences. Thank you to the hospital staff and providers who made time to be interviewed. I wish to thank the steering group who directed the focus of this work. Many thanks to Christine Roseveare for your advice and support with the methods, analysis, write-up and your assistance with the thematic analysis and reviewing. Thank you Vanessa Cameron for your support doing the transcribing. Thank you Nichola McCartan and Shirley Pierce for all your advice and assistance, often at short notice. Thank you to all the reviewers for all your feedback and advice with special thanks to Nichola McCartan, Christine Roseveare, Helen Topham, Kanchan Sharma, Sandra Knight, and Annette Nesdale. Many thanks to Demelza OBrien for the design and formatting of the final document. Disclaimer This report has been prepared by Regional Public Health in order to make these ideas available to a wider audience and to inform and encourage public debate. While every effort has been made to ensure that the information herein is accurate, Regional Public Health takes no responsibility for any errors, omissions in, or for the correctness of the information contained in these papers. Regional Public Health does not accept liability for error or fact or opinion, which may be present, nor for the consequences of any decisions based on this information. Crown copyright 2014 Suggested citation: Regional Public Health Linking housing and health in the Hutt Valley: Housing Coordinator Pilot Evaluation. Wellington. Regional Public Health.

3 contents Executive summary...1 Introduction...4 Summary of methods...5 Analysis of programme rationale...8 Developing the referral process...10 Enabling access to housing, health and social improvements...20 Collaboration with housing and health stakeholders...32 General satisfaction and interviewee recommendations...35 Discussion and recommendations...39 Conclusion...47 Summary of recommendations...48 References...50 Appendix 1: Further methods...52 Appendix 2: Additional literature relevant to the analysis of programme rationale...64 Appendix 3: Comparison of the Housing Coordinator Pilot to other Hutt Valley housing programmes...66 Appendix 4: Interview schedules...76 List of figures Figure 1: Programme logic model... 7 Figure 2: Estimated time invested for each coordinator visit in the HCP study Figure 3: Flow diagram of the referral process in the HCP study Figure 4: Rate of recruitment of patients over the HCP study time period Figure 5: Hospital admission diagnosis of patients eligible for the HCP study Figure 6: Age distribution of participants in the HCP study Figure 7: Ethnicity of participants invited to the HCP study from 27 households Figure 8: Housing and social referrals made in the Housing Coordinator Pilot study Figure 9: Health referrals made in the HCP study...23 Figure 10: Flowchart of insulation referral outcomes Figure 11: Housing and social referral outcomes excluding insulation Figure 12: Outcomes for health referrals in the HCP Figure 13: Healthy Homes Healthy People Programme: common housing and social referrals as a percentage of total programme referrals Figure 14: Healthy Homes Healthy People Programme: common health referrals as a percentage of total programme referrals...75

4 List of tables Table 1: Ratio of HCP enrolments to the number of admissions with eligible housing related hospital diagnoses to Hutt Hospital from March-June Table 2: Application and acceptability of eligibility criteria...18 Table 3: The housing, health and social assessment...21 Table 4: Prevalence of unmet housing need according to health and social assessment tool and database records...21 Table 5: Summary of referral outcomes...26 Table 6: Barriers to making changes & accessing interventions in the Housing Coordinator Pilot...28 Table 7: Type of evaluation in the sections of this report...52 Table 8: Sources of information for the HCP evaluation including questions asked in semistructured interviews and focus groups Table 9: Evaluation questions...61 Table 10: Sources of quantitative data to describe different Hutt Valley housing programmes...62 Table 11: Healthy Housing Assessment Projects in the Hutt Valley...69 Table 12: Quantitative comparison of housing programmes in the Hutt Valley and evaluation findings based on evaluations and housing database...70 Table 13: Housing, health and social assessment in programmes from the Hutt Valley based on housing database...71 Table 14: Demographics of participants in programmes from the Hutt Valley based on evaluations & housing database...71 List of text boxes Text box 1: Eligibility criteria...17 Text box 2: The housing coordinator visit...20 Text box 3: Mele...29 Text box 4: Euan...30 Text box 5: Strengths and weaknesses of the Housing Coordinator Pilot...36 Text box 6: Recommendations from participants and key RPH, hospital and provider stakeholders...38

5 executive summary Background The Housing Coordinator Pilot Study (HCP) was carried out at Regional Public Health (RPH) from February to June Selected children and adults admitted with health conditions that can be linked with cold, damp or crowded housing were offered a coordinator visit by a housing nurse. The coordinator visit involved a housing, health and social assessment with individualised advice and referrals to improve housing-related health outcomes in the household. The pilot was designed for a maximum of 30 participants. Aims To identify the extent to which the HCP: was designed in alignment with the available evidence developed a rapid housing referral process for use by health professionals enabled whānau/families to access housing improvement interventions [and health and social interventions] when these were requested and indicated improved collaboration with housing and health stakeholders Methods Mixed methods were used to collect qualitative and quantitative data and maximise the validity of results. A semi-structured questionnaire was used to interview participants (11 visited + 6 not visited), programme operational (3) and managerial staff (5), hospital stakeholders (6), and service providers (7). Interviews were carried out 4-8 months post coordinator visit. Audio recordings were transcribed and analysed for themes. This data was complemented with a descriptive analysis of data from the housing database, programme records, hospital admission data and referral outcome information from providers and participants. Key findings The logic of the HCP programme (Poynter, 2013) was robust and consistent with the international evidence and lessons from national programmes. The selection of patients with housing-related conditions was a feasible referral pathway and was well accepted by all involved. Substantial investment of time was required from the project team to establish and maintain the process of selecting, assessing and consenting patients on the ward. Recruitment required 2.4 hours of time per housing visit and another 7.7 hours was spent contacting, visiting, and following-up for each home visit. Households selected for the pilot had a very young age distribution and the most common diagnoses were asthma and bronchiolitis. Eligibility criteria were found to be difficult to use and were seen as excluding a number of people with housing need. A copy of the specified housing related conditions and eligibility criteria are in Text box 1. Participants found the housing nurses to be friendly, respectful and non-judgemental. Participants were particularly satisfied with the advice and referrals that were given, and the timeframes involved were appropriate. More than one-third of enrolments did not receive a coordinator visit because they could not be contacted and half of the referrals did not result in service provision from other agencies. Barriers to provision of services were frequently related to system issues such as the provider had no record of referral, there were delays, the landlord was unwilling, and there were duplicate referrals. The HCP successfully established and developed a collaborative relationship with acute medical and paediatric secondary care services at Hutt 1

6 Hospital. Collaboration with service providers remained at the pre-existing level and was generally limited to communication about referrals, apart from an insulation provider where there was improvement in collaboration because this referral pathway was newly reestablished. Interviewees made suggestions about improving the referral process, promoting the programme, broadening the eligibility criteria, improving follow-up, engaging landlords, better collaboration, providing heating, providing health promotion on housing and advocating for policy solutions. Discussion and recommendations The referral process may become more routine and efficient with incorporation of programme eligibility criteria into nursing forms and the addition of alternative referral pathways both from primary care and other DHB home visitors. Eligibility criteria could be broadened to include Housing New Zealand (HNZ) tenants, all ethnic groups, and people without a community services card (CSC) who have financial difficulty. Programme benefits may be maximised by considering targeting households with identified housing need and housingrelated health conditions. The HCP study had a much lower rate of home insulation need and provision than the other housing programmes. Formalised follow-up on referrals including routine feedback must be improved to address the barriers that can be addressed and monitor programme outcomes. Upgrade in the quality, usability and applicability of the RPH housing database used by housing nurses, should assist with more efficient follow-up. Considerations should be given to furthering specific housing collaboration with Māori and Pacific health workers, social workers, paediatric community nurses, respiratory nurses, primary care and community organisations with established community networks. Conclusion The HCP study is a great example of a housing solution that can be implemented in a short time frame with limited resources. The HCP approach is both a feasible and effective way of linking households with housing-related health conditions to housing, health and social improvements. On average it required 2.4 hours for recruitment and 7.7 hours per household visited for the visits, referrals and follow-up. To roll out the programme more widely a less time intensive and more sustainable way of recruiting is required. Maintaining the available housing nurse expertise and improvements to the programme will ensure more participants can be better reached with the available resource. This includes streamlining referrals to the programme, targeting households in need, formalising referrals follow-up, data management and on-going collaboration with key referrers and service providers. The first challenge is to re-establish a productive referral process. Recommendations 1. Make the referral process routine 1.1. Encourage referrals to the housing programme as part of routine practice for social workers, paediatric community nurses, Māori and Pacific health workers, respiratory nurses, ward nurses, and medical staff covering eligible wards Continue to promote the programme and its eligibility criteria to potential referrers, clinicians and hospital managers e.g. through meetings and presentations Work with referrers to make the programme referral form as simple as possible so that it can be completed with information that is easily available Work with clinical staff to incorporate housing questions into routine nursing forms used for housing-related admissions and prompt programme referrals for eligible patients. 2

7 1.5. Work with clinical staff to create electronic referral prompts on the hospital discharge summary or primary care electronic notes Maximise consistency and availability of the programme over time especially in regards to the information given to potential referrers Health care providers need training about housing for example at medical and nursing school to change the culture and increase the use and demand for housing referral pathways. 2. Broader eligibility criteria recommended 2.1. Retain the CSC/financial hardship criteria Expand to include HNZ tenants, additional other housing-related diagnoses and other ethnic groups Maintain focus on easy access for Māori and Pacific such as referrals through the Māori and Pacific health unit Consider simple questions or a score based on the level of housing need such as presence of insulation, warmth of the home, dampness or mould and smoking If limiting to reducing the risk of rheumatic fever restrict to the paediatric population and reconsider ethnicity criteria. 3. Streamlining follow-up and enabling access 3.1. Develop referral feedback loops for secondary care (referrals in) and external providers (referrals out) Formalise follow-up strategy of the referrals to determine their outcomes and address any barriers Develop database to assist with follow-up and evaluating referral outcomes Improve ethnicity data to ensure it is selfidentified and asked in a consistent manner Give whānau the option of a delayed assessment (e.g. three months) if they are unable to engage in the first instance because of competing priorities Consider timing and how best to contact families who are about to move homes Improve advocacy and engagement with landlords e.g. consider an agreement with the landlord to avoid rent increases following insulation installation Work with culturally specific organisations, culturally matched staff and translation services to maximise the engagement of households. 4. Maintain and improve collaboration 4.1. Maintain a participatory approach in service development e.g. engaging clinical staff to refine the referral process Maintain regular communication with referrer s e.g. regular programme updates and information sessions were particularly valued Improve collaboration with external providers to develop referral feedback about referral receipt, whether the household engaged and what was provided Agree on a commonly held programme goal which is shared by stakeholders across key partner organisations. 5. Upscale the programme 5.1. Develop additional referral pathways from other primary and secondary health care workers Streamline the housing coordinator assessments provided at RPH to maximise the number of housing assessments provided Collaborate with other services and providers to help them provide housing coordinator assessments wherever possible Incorporate a strategy for on-going monitoring of outcomes so that frequent on-going adjustments can be made to improve programme quality and productivity. 3

8 introduction The Housing Coordinator Pilot Study (HCP) was carried out at Regional Public Health (RPH) from February to June It was designed to test a way of linking hospital patients with housing-related conditions to housing, health and social interventions. Housing nurses (public health nurses with expertise in housing) carried out a coordinator visit to participant homes after discharge and provided a housing, health and social assessment. The housing nurse visit aimed to develop an intervention plan with the household to make appropriate referrals to housing, social and health providers. The expectation was that an improved physical home environment, initiation of access to health and social services, provision of appropriate physical resources through these services, and improved knowledge and behaviour would together improve housingrelated health outcomes for patients and reduce inequalities in these outcomes. The goals of the HCP are consistent with the priorities of RPH and the 3DHBs (Hutt Valley, Capital & Coast, and Wairarapa District Health Boards). RPH has focused and aligned its activities to achieve the bold goal of halving the rate of avoidable hospital admissions for Māori, Pacific and children by The triple aim for the DHBs is improved population health and reduced inequalities, a better patient journey and clinical and financial sustainability. The HCP s approach to linking people with housing-related hospital admissions to housing solutions is also relevant to the development of regional and national housing programmes to prevent rheumatic fever. The 3DHB s Rheumatic Fever Plan mandates housing improvement as a way to prevent rheumatic fever among children who are at risk. Housing was identified as a key issue in the Children s Commissioner s report on Solutions to Child Poverty (Children s Commissioner s Expert Advisory Group, 2012). This evaluation aims to identify the lessons from the HCP to inform the development of housing solutions which are more responsive to health needs and aligned with organisational goals. Findings are based on semi-structured interviews, thematic analysis, and quantitative data. The evaluation draws not only on locally collected data, but consideration is given to international literature, other NZ housing programmes and previous RPH housing programmes. The HCP builds on longstanding RPH experience with several housing programmes in the Hutt Valley including the Healthy Housing programme (HHP) for Housing New Zealand (HNZ) tenants from 2008 to June 2013, the Healthy Homes Healthy People programme (HHHP) for non-hnz tenants January 2008 July 2010 and the Older Person s Maintenance Pilot (OPMP) December 2006 June Institutional experience with multiple housing programmes was an important resource input, and this includes the lessons learnt from previous evaluations. Longstanding experience has enabled RPH to contribute to a strong housing coalition network in the region. The aims of the evaluation were to identify the extent to which the HCP: was designed in alignment with the available evidence developed a rapid housing referral process for use by health professionals enabled whānau/families to access housing improvement interventions [and health and social interventions] when these were requested and indicated improved collaboration with housing and health stakeholders 4

9 summary of methods The evaluation was designed to assess the context, inputs, processes/outputs (implementation) and impact of the HCP programme in achieving its outcomes. The evaluation was based on the CIPP model which is an acronym corresponding to context, inputs, process and product (Stufflebeam, 1983). Specific questions were developed from the programme logic (Figure 1); the HCP s evaluation plan (Poynter, 2013) and previous Hutt Valley housing evaluations (see Appendix 3). A literature review was carried out, firstly by searching the international literature for housing interventions with a focus on systematic reviews and secondly by gathering national data through personal communication through Medical Officers of Health (MOsH) at public health units around New Zealand. MOsH were asked whether they knew of housing programmes in their regions that linked patients to housing solutions. The Ministry of Health and the Energy Efficiency and Conservation Authority (EECA) were also contacted. When housing programmes were identified a brief description was requested and additional questions were asked about who funds and runs the programme how many patients access the programme annually, results of any evaluation, how it is monitored, strengths and challenges of the programme. Finally, previous evaluations of housing programmes in the Hutt Valley were reviewed. For data collection and analysis, a mixed methods approach was taken which combined qualitative and quantitative data. Qualitative data was collected from four groups of interviewees; pilot participants, RPH staff, hospital stakeholders and service providers. Data collection methods included semistructured face-to-face interviews, telephone interviews and a focus group. Interviews were conducted four to eight months after the coordinator visit. They were audio-recorded, transcribed, and analysed for themes. See Appendix 4 for interview questions. Quantitative data was accessed from the RPH housing database to describe various aspects of the HCP including; time form referral to coordinator visit, referral types and numbers, housing conditions, diagnosis and demography of participants (accessed on 30th September 2013). The database information was complemented with quantitative information from provider surveys, participant interviews, programme records, documentation about ward patients assessed for eligibility, staff hours and hospital admission data. All quantitative data were analysed in Excel with frequencies, means, medians and interquartile ranges calculated as appropriate. Data was triangulated from different sources where this was possible. Housing nurse time used in the programme was estimated using FTE employed in the July 2012 June 2013 financial year excluding annual leave allowance. In that time 217 coordinator visits were carried out and an average of 1.26 housing nurse FTE was available. This is 10.7 hours of housing nurse time per coordinator visit. These figures are mostly from the HHP and in that programme there was no requirement to recruit referrals from the wards. In the HCP programme recruitment required up to an hour a day by either the housing nurse or registrar. It is estimated that an average of half an hour a day was devoted to recruitment over 16 weeks (a total of 40 hours) to enrol 27 households and make 17 visits. An average of 2.4 hours of recruitment time was invested per household visit. The recruitment time and coordinator visit time totalled 13 hours per household visit. Operational staff were asked to estimate how the 13 hours was distributed across various programme activities including meetings and professional development. 5

10 Hutt Valley DHB admissions data was compared with the HCP enrolled participant data for the same time period to determine ratios of enrolments to hospital admissions. This was done by age category, ethnicity and diagnosis. The analysis of programme comparisons was based on the RPH housing database and two previous evaluations (Hefford et al., 2008, Proof Research and Evaluation et al., 2010). Information from the analysis (see Appendix 3) is applied to the discussion of the HCP findings. Finally, qualitative and quantitative data were compared and combined to enrich the analysis and maximise the validity of results. Further details of the methods used are given in Appendix 1. Ethics approval was not required (as advised by the NEAC secretariat) (Poynter, 2013). However, ethical considerations were taken into account and are described further in the Appendix 1. All participants gave informed consent for the evaluation when they consented to be in the HCP programme. Verbal consent was also requested when participants were approached to arrange the evaluation interview. Interviewees that were Māori and Pacific peoples were given the option of having a Māori or Pacific health worker for support at the home visit. Where unresolved issues related to the programme were identified during the interview and the interviewee wanted these to be addressed, this was arranged through the housing nurse, and mainly involved followingup on referrals. Strengths and limitations There are both strengths and limitations to the selected evaluation methods. To the author s knowledge, this is the first evaluation of the referral outcomes following a housing coordinator intervention. A range of data sources were used and triangulated to get data on aspects such as the referral outcomes. Assessment of the HCP rationale as well as its processes and outcomes, provides an idea of the likely long-term impact of this sort of HCP approach despite the lack of long-term outcome data. There was a high response rate among those who were contacted and asked to interview, with all those spoken to agreeing. However, one-third of participants were not able to be contacted for an interview in the evaluation. In some cases this was due to emigration and even death. This may make the programme appear more effective than it is because the participants who were interviewed may be more likely to engage with services and have a positive experience in the programme. However, there was a good response from those who did not get a coordinator visit because they were unable to be contacted. Their contribution to a proportion of the findings here may have assisted in balancing some of the results. The time that elapsed since the coordinator visit (3-9 months) may have made it difficult for participants to accurately recall all the important aspects of the visit and what was positive or negative. Some participants found it difficult to distinguish between the coordinator visit and other health provider visits they had had to their home. This may reduce the depth of information participants were able to provide however long-term outcomes and the most significant experiences are likely to be captured and these are most important to the evaluation. The housing database had several limitations. This Access database is a record of all housing, health and social assessments done since 2008 by housing nurses at RPH. Database entry has not been consistent over time. There were some inaccuracies in the data entered during this HCP programme which may have significantly underestimated several variables including Māori and Pacific ethnicity and the number of referrals made. The database was not designed for the evaluation of the HCP and although several new fields were added in, the database does not capture information on insulation and other important eligibility criteria. Furthermore, the database was not designed to help with following up on which referrals had been actioned and what their outcome was. 6

11 Figure 1: Programme logic model (Poynter, 2013) 7

12 analysis of programme rationale This section explores the HCP rationale and whether it is consistent with the best available evidence. The HCP was designed with a clear aim to improve housing-related health outcomes and reduce inequalities in these conditions (Programme logic model). The aim was to address the gap between housing solutions and secondary care. Long-term goals were dependent on the implementation of several steps in the logic model. The steps in the programme logic are assessed in different sections of this evaluation. Programme logic relied on these factors: 1. A referral process needed to be set up (See Developing the referral process ). 2. Selected households needed to be at risk of poor housing-related health (See How well did the eligibility criteria work?). 3. The housing nurse needed to identify risk factors for poor health in the household including housing, health and social issues and address these by providing advice and making appropriate referrals (See Enabling access) 4. Advice and referrals needed to result in positive housing, health and social changes (such as insulation and warmth) (see Enabling access). 5. Evidence that housing improvements lead to improvements in housing-related health. See evidence summarised below. International literature There is compelling evidence that access to housing improvements leads to improvement in housing-related health. Warmth and energy efficiency interventions were effective in several randomised controlled trials when targeted at vulnerable individuals (Gibson et al., 2011). Improvements in general health, respiratory health, and mental health have also been demonstrated (Thomson et al., 2013). Best available evidence indicates that housing which is affordable to heat and an appropriate size for the householders, is linked to improved health and may promote improved social relationships within and beyond the household (Thomson et al, 2013). Improved health outcomes are most likely when housing improvements target individuals with poor health and inadequate housing conditions, particularly inadequate warmth (Thomson et al., 2013). Among the 39 studies included; there were 8 studies which targeted housing solutions to people with particular health condition (Thomson et al., 2013). The health criteria used to select participants were generally diagnoses of respiratory illness or vascular disease. Three studies targeted people with asthma and the other studies used different diagnostic criteria such as Chronic Obstructive Pulmonary Disease, serious heart condition, cold related illness, respiratory disease, and housing-related diseases (specifically heart disease, cerebrovascular accident, peripheral vascular disease, with functional difficulties, COPD, or complex asthma). Different approaches were used to recruit patients, including hospital or general practice records, liaising with community organisations such as asthma societies and primary health organisations, a referral process with health criteria, and using the information on file at housing departments or with health workers such as asthma nurses and paediatricians. Among the eight health targeted studies two programmes included insulation, five included heating interventions and one included both. There were important health benefits. For example the two well-conducted New Zealand randomised controlled trials targeted housing interventions to households with inadequate 8

13 warmth where at least one household member had a pre-existing respiratory condition (Howden-Chapman et al., 2007b, Howden- Chapman et al., 2008). Results from both studies were statistically significant showing that respiratory health was better among the intervention group than in the control group. Further information is given in Appendix 2. National experience There are many lessons to be learnt from national experience in housing. Many housing programmes have been developed around the country in the last decade or so, driven by central government subsidies for insulation and more recently by the requirement for DHBs to create a Rheumatic Fever Prevention Plan. More recent programmes can be accessed by a referral from a health practitioner. The overwhelming theme from the different programmes is the variation in different models of working including method of recruitment, eligibility criteria, comprehensiveness of the interventions and the organisations involved in delivering the programmes. Key lessons from the programmes are about improving clinical engagement, utilising strong links with community services, and the utilisation of data collection to highlight gaps. The impact of health and social referrals, and housing advice and education, is not as clear because these elements do not appear to have been investigated independently of housing improvements. The extensive evaluation on the Healthy Housing Programme (HHP) in Auckland (Bullen et al., 2008b) (Clinton et al., 2006) (Jackson et al., 2011) demonstrates how the implementation of a holistic housing, health and social needs assessment, very similar to that used in the HCP study, was associated with post intervention reductions in acute hospital admissions (and housing-related admissions), particularly among 0-4 year olds (11% reduction, CI:1-21%) and 5-34 year olds (23% reduction, CI15-30%) (Jackson et al., 2011). The Auckland HHP was different however in that it was limited to HNZ tenants and there were more building alterations. There were also many co-benefits such as improved energy efficiency (Howden-Chapman et al., 2007a) and a significant return on investment. Because a whole package was provided it was not possible to dissociate the benefits of the housing improvements from the other health and social advice and referrals. Summary of rationale findings The logic of the HCP programme (Poynter, 2013) was robust and consistent with the international evidence and lessons from national programmes. Interventions that improve warmth (insulation and/or affordable heating) for people with poor health appear to be the most effective. The evidence is discussed further in the Discussion and Recommendations section. 9

14 developing the referral process After consideration of programme rationale, the next objective was to evaluate the development of the referral process. This section aims to explore the effectiveness of developing a rapid referral process for use by health professionals. The referral process is discussed in terms of the staff time, the effectiveness of recruitment, staff satisfaction, some of the timeframes involved, usability and acceptability of the eligibility criteria, demographics of enrolled participants, and a comparison of HCP enrolments with hospital admissions in the same time period. Resource inputs The HCP built on RPH s housing experience and expertise. The majority of staff time came from the programme staff and the service providers. Operational inputs Housing nurses, a public health registrar, management and administration staff were involved in implementing the HCP. There was also some input from clinical and managerial staff at the Hutt Valley District Health Board (HVDHB). The estimated time taken to recruit referrals from the ward by the housing nurse or registrar was 2.4 hours per coordinator visit. The estimated time spent on visiting, referring and follow-up averaged 7.7 hours per coordinator visit with 3 hours spent on professional development and other activities (Figure 2). Adding these together, the best estimate for the operational time invested per coordinator visit was 13 hours ( ). These figures are averages and the time invested varied between households. Thirteen hours of housing nurse time does not include all of the upfront and on-going time invested in clinical engagement and promotion of the housing programme to hospital management and ward staff. In the 2012/13 year an additional 0.3 FTE of public health registrar time was invested in the HCP for planning, design, implementation and dissemination of findings. There were also additional inputs from other staff including managers, administration and support staff. RPH housing nurses bring substantial experience to the role, particularly in terms of their local knowledge about available housing, health and social interventions. Situated at RPH, amongst a wider programme of housing work they have unique links with a variety of housing providers. Housing nurses also had previous working relationships with hospital staff. Participants, hospital and RPH staff volunteered some ideas about the value of the clinical input into the housing programme, although this question was not asked of anyone directly. One participant highlighted the insider knowledge of nurses. Recruitment - e.g. identifying eligible patients, giving information and gaining consent 2.4 h Arranging a visit - e.g. repeated calls 1 h Home visit - e.g. transport time, assessment and repeat visits if necessary 3 h Making referrals - e.g. phone calls and clinician feedback letters to GP 2.5 h Repeat contact - e.g. home visit or call 0.6 h Database entry 0.6 h Meetings and professional development - e.g. planning, networking, housing coalition 3 h 2.4 h recruitment 7.7 h visit and referrals Figure 2: Estimated time invested for each coordinator visit in the HCP study. Total time was 13 hours which includes recruitments time (based on pilot study estimates) and time for visits, referrals and other meetings (based on FTE employed and visits done in the 2012/13 financial year for the Healthy Housing Programme and Pilot Study). 10

15 [Nurse s name] is a nurse so for asthma, tips on that were helpful. She told us about the asthma kid s passport and about inhalers. Being a nurse was great because she had inside knowledge about how things work She s a lovely lady. The same participant acknowledged the limitations of the health advice; she didn t change the world with D s asthma treatment, I could ve survived without it. Hospital staff valued the clinical background of RPH staff because they were seen to be better at navigating the systems on the ward such as locating patient notes. However, non-clinical staff were also able to get permission to access clinical notes if this was required. RPH staff interviewed believed that public health nurses and doctors had the ability to put the whole picture together and were good at engaging with hospital staff. There was the view that health workers had the ability to deal with health issues as they came up. The fact that [public health registrar] was a doctor, [public health nurse] was a nurse, I know it s stating the obvious, but that tag team was very effective. She had that credibility of being a doctor, straight up so half the job was done in the job title. So the rest you know just followed. RPH staff I believe with the tool you actually need a health person to be doing it because of the health consequences that come out of it and then the social stuff that comes out of their health issues RPH staff Nursing expertise was valued because of the experience with hospital systems and community services, credibility, and the networks already established and developed with key stakeholders in secondary care. Hospital and provider inputs Hospital stakeholders were also asked about how much time they put into the referral process. The three ward nurses or clinical champions estimated that the referral process took them about 5-10 minutes a day. Other hospital stakeholders estimated their total time input as <5-6 hours for the 4 month programme. Other external inputs to the HCP were through provider services. For example there are Energy Efficiency and Conservation Authority subsidies for insulation and other funding or resource streams to external providers through volunteer time, government funding, philanthropy and private investment. Hospital staff and external provider stakeholders had a clear and thorough understanding of the link between housing and health. This contrasted with a RPH perspective that the secondary care workforce lacked knowledge about the link between housing and health. The whole knowledge of workforce in secondary care would be another barrier RPH staff The general workforce doesn t have that appreciation about housing, the importance of housing RPH staff The level of housing knowledge among staff involved in the HCP study may not represent the knowledge of other hospital staff. Furthermore, even with a thorough understanding of housing, hospital staff may remain unclear about the availability of housing referral pathways. Housing may be a lower priority than urgent daily activities. None of the hospital stakeholders could report having had training in housing and health. Sustainability Sustainability of the HCP requires more resources such as staff FTE and more leadership and ownership by clinicians and DHB management. One of the key reflections on the HCP was the unexpected resource required to make recruitment work and keep the programme running. I still think that even though there were things that were hard, that basically needed more input from me and the HCP to keep 11

16 Figure 3: Flow diagram of the referral process in the HCP study, showing identification, eligibility assessment, coordinator visit and referrals made. (*There may be overlapping reasons for not meeting eligibility criteria so reasons do not total 42) it going, I think it s a good idea, it s just about how much resource you can put into developing the programme otherwise it will fall over. RPH staff RPH staff were asked about what would make the programme sustainable and they highlighted the importance of more leadership by clinicians and management. Other identified contributions to sustainability were evidence of value for money, evidence that the programme makes a difference, evidence of household benefit not just individual benefit, and workforce development. The importance of clinical champions was highlighted. There was a perceived need for ownership by all of health, working through the existing systems and processes to avoid duplication. Referral process The referral process with secondary care was developed from scratch. Seventeen hospital patients were successfully linked with a 12

17 coordinator visit. Selected ward nurses (clinical champions) on three wards at Hutt Hospital identified patients who might be suitable for the housing programme. These names were given to the RPH housing staff who made daily contact with the ward nurses, and then met with patients face-to-face on the ward to do an eligibility assessment and carry out the consent. After discharge, the patient or their caregiver would be contacted by the housing nurse to arrange a housing, health and social assessment. The time between discharge and assessment averaged just less than two months. Figure 3 summarises the referral process demonstrating how the eligibility criteria were applied. There were 141 patients with housing related conditions and an eligible age and ethnicity admitted to Hutt Hospital in the four month HCP study period; March-June The RPH pilot team assessed 74 patients for eligibility, and 28 households (38%) were eligible (not a HNZ tenant, lived in Hutt Valley and CSC eligible) and invited to the programme (including one household accounting for two patients). Of the 28 households invited to the HCP, 17 received a home visit (61%) and 11 (39%) opted out or were unable to be contacted. Application of the referral process and eligibility criteria resulted in 17 home assessments in the four month study period. Proportion of admissions enrolled an assessed An enrolment ratio was calculated to determine the proportion of housing-related admissions that was eligible and recruited into the HCP. The ratio was calculated by comparing the number of HCP enrolments with the number of hospital admissions that met the study s diagnosis, age and ethnicity criteria. The overall enrolment ratio was 22/141 or 16% indicating that there were 22 enrolments from a group of 141 admissions to Hutt Hospital, limited to those with eligible age and ethnicity, and a diagnosis of asthma, bronchiolitis, pneumonia or rheumatic fever (See Table 1). The ratio of those who had an assessment was 17/141 or 12% of the eligible admissions. We would not expect either ratio to approach 100% because it is affected by the ability to recruit patients from the ward, by other eligibility criteria and a person s ability to participate. Only a limited number of patients with housing-related conditions diagnoses will have CSC eligibility, live in the Hutt Valley region and not be HNZ tenants. The enrolment ratio was greater for Pacific (29%) and Māori (17%) compared to other Diagnostic code Age Ethnicity Asthma Bronchiolitis Pneumonia Rheumatic Fever Ratio (%) 0-4yo Other 1/12 0/11 2/12 3/35 9 Māori 2/9 4/17 0/9 6/35 17 Pacific 3/2 1/9 1/6 5/ yo Māori 1/11 0/16 1/2 2/29 7 Pacific 2/14 1/11 3/25 12 Ratio 10/48* 7/37* 4/54 1/2 22/ (%) Table 1: Ratio of HCP enrolments to the number of admissions with eligible housing related hospital diagnoses to Hutt Hospital from March-June 2013, by age and ethnicity criteria. (The first number is the HCP participant/and the second number is the total admissions) Notes: 1. Community services card eligibility was an enrolment criteria however the admissions indicated here did not necessarily have a community services card. 2. Numbers (*) may not add up to totals because for three people ethnicity data were missing. 3. Two asthma patients did not meet the age and ethnicity criteria so were not included here in the enrolment ratio. 4. Admissions are listed where length of stay was > 3hours or in the case of bronchiolitis when there was an admission to the Children s Ward (not the Paediatric Assessment Unit). 13

18 ethnic groups (9%) (among 0-4year olds). This probably reflects the greater CSC eligibility for Pacific and Māori households (after excluding HNZ tenants). The enrolment ratio appeared to differ between different diagnoses ranging from 1/2 for Rheumatic Fever, approximately 1/5 for asthma and bronchiolitis, to almost 1/14 for pneumonia. This is consistent with pneumonia being less patterned by socioeconomic determinants. Furthermore, the enrolment ratio was greater for <5 year olds than older persons. This may reflect differences in eligibility or less likely recruitment among 5+ year olds. Staff satisfaction with the referral process RPH and hospital staff were asked about how well the referral process worked. Hospital stakeholders found the referral process to be quick and simple. All hospital staff agreed that ward nurse involvement was small and manageable. Three ward nurses estimated that the referral process took them about 5-10 minutes a day. Several nurses were reluctant to commit any more time to referring. A clinician gave this response to the question about whether the level of involvement for ward staff was appropriate: Yeah, it s the whole point, it takes the load off the nurses, the social workers, the doctors who might otherwise be running round trying to chase up Housing New Zealand or find a housing agency to fix up their patient s house Hospital staff As discussed, RPH staff found that the referral process was intensive and it required a lot more resources than expected. The initial goal was to develop a formal referral process where the ward would send referrals through to the programme, but this did not result in enough referrals within the short study timeframe. The programme team found that ward staff were usually busy with day-to-day ward activities and needed a lot of reminding. The HCP was low on their priority list. In the end it was easier for someone from the programme to do the informed consent because the ward nurses did not know enough to feel comfortable to do this. I sort of identified key people on a few wards and talked to them and they said yep that was fine but they just, they needed a lot of reminding so I was paging those people with a text page each day reminding them to review their patient lists to see if they met the eligibility criteria RPH staff The main reasons were the time that they didn t have to spend on it and that they didn t know enough about the programme in general to do an informed consent RPH staff The balance of resource input required to create referrals to the HCP study was decidedly on the side of the RPH housing staff. The referral pathway required significant upfront investment in relationships and in spite of this the number of referrals remained low. I think at the beginning there was a bit of naivety probably or hopefulness that there wouldn t need to be quite such an intensive approach, but very quickly I think it was pretty apparent that they needed to be knocking on the door asking the question, saying hello again, had to really push RPH staff One RPH staff member suggested that greater leadership by clinicians and management would go a long way to improving the number of housing referrals from secondary care. There was hospital stakeholder interest in increasing ward staff input into the referral process. The problems with that were it was never a high priority because it never came from above, the direction to do that, and I didn t have long standing links with those wards RPH staff Several hospital interviewees identified the changing landscape of housing solutions or housing insulation schemes as a barrier to 14

19 Figure 4: Rate of recruitment of patients over the HCP study time period initiating referrals. Frustration was expressed that housing referrals were not routine practice and that some staff members could not remember how to do a housing referral. Changing availability over time was said to limit understanding for both consumers and health professionals about what was available. A consistently available housing programme was seen to be necessary to encourage referrals. Questions about housing were not routinely asked in the hospital environment. Asking patients questions about housing need and a referral pathway to a housing programme are both necessary and each depends on each other. There is probably a number of patients with poor housing contributing that come to the hospital, nobody asks and it doesn t get identified or sorted. Hospital staff A referral pathway.. would make [recruitment] easier, but you ve still got to ask the questions, but there s no point in asking the questions unless you ve got an easy referral pathway RPH operational The HCP has demonstrated that intensive programme efforts are required to build a referral base from secondary care. Sustained and on-going investment and collaboration is required to develop and promote this referral pathway. Recruitment rate over time Figure 4 demonstrates how the rate of enrolment was greater at the start and the end of the study period. Referrals were less frequent in the middle of the time period with only two referrals in the months of April and May. There was very little month to month variation in housing related admissions (by age and ethnicity, not shown here) so this did not explain the fluctuation in enrolment rates which is more likely to be about intensity of recruitment. Timeframe for coordinator visit The time between first contact with the HCP (during hospital admission) and the coordinator visit was normally within just over two months and ranged from seven days to just over four months. A quarter of participants were visited within 33 days of admission, half were visited within 45 days, and three quarters were visited within 70 days. These figures are based on data available for 15 out of 17 households. 15

20 Housing nurses described how sometimes it took dozens of phone calls and texts to arrange a coordinator visit. This involved a substantial amount of time and effort. It was suggested that repeating attempts to contact a household (as was the case in the evaluation interview) may improve the programmes ability to reach a greater proportion of eligible households. It was around timeframe of schooling and not holidays, for some people it was holidays and not schooling, other people it was around work hours and for some people it was the position they were in that point of time didn t suit but further down the track it might have. RPH staff We could keep their files open, people who don t engage initially, whether we could keep their notes on record and contact them three months later six months later RPH staff Acceptability of timeframe to contact The period for contacting a family after admission was acceptable to families. It appeared this was normally about one to two weeks. Participants, who had a coordinator visit said that the time between admission and contact from the housing nurse was appropriate. One person suggested that any longer than the two weeks that she waited would be too long and she may forget what it was about. One participant appreciated the option of when to be contacted. The timing was about right. When she saw me in hospital she offered a time to call me and so I agreed on the next week. It was good to have the choice Participant Housing nurses summarised the importance of good timing: We had to be careful not to ring too soon after discharge because families are quite tired...also not leaving it so long that they ve forgotten what we are and what we wanted to do. RPH staff Similarly, participants who did not get a home visit largely agreed that the time period between admission and contact was appropriate. One person said that the contact was made too soon because she was still settling back into normal life just three days after returning home from hospital. Acceptability of hospital referral Participants (including those visited and those not visited) unanimously viewed hospital referral as an acceptable way to be referred to the HCP. A theme consistently expressed by participants, RPH staff and hospital staff, was that hospital was a time of need making the housing programme relevant and more of a priority. Furthermore hospital was sometimes seen by participants as convenient with time to spare. Hospital was seen by hospital staff as an opportunity to connect with patients not linked into primary care. However, there was also a unanimous acknowledgement that hospital is a busy and stressful time for families. One participant would have preferred a phone call over hospital contact because it would be less busy. However other participants (n=3) said that they would prefer face-to-face contact in hospital rather than a phone call. It was fine while we were in [hospital]. It was probably the ideal time. GP would be a good one, otherwise yeah, before he was in hospital Participant Some participants considered hospital contact as too late if the aim is prevention. Primary care was suggested by participants and hospital staff as an alternative to hospital referral, particularly as a way of preventing hospital admissions. General practice (GP) was commonly referred to along with practice nurses, pharmacists, district nurses, caregivers, marae and other community groups were suggested as alternate referral routes. The GP was viewed as easy to access when there was already an established link between the practice and the household. RPH stakeholders highlighted the practical difficulties of engaging multiple primary care stakeholders for the HCP study. 16

21 Eligibility criteria in the Housing Coordinator Pilot Study Must meet all of the below: Admitted to Hutt Hospital with a housing-related diagnosis; defined as bronchiolitis, asthma, pneumonia or Rheumatic Fever Aged 0-4 years old or 5+ years old with Māori or Pacific ethnicity Eligible for a community services card Lives at a non-hnz property Resident in the Hutt Valley Text box 1: Eligibility criteria Eligibility criteria Usability and acceptability of criteria Usability and acceptability varied by each individual criteria. Diagnostic criteria were seen as the easiest to use by ward staff and RPH housing staff. On the other hand, ward staff reported that it was difficult and time consuming to determine HNZ tenancy, ethnicity and CSC eligibility. The tenancy and ethnicity criteria were also seen as confusing and difficult to apply by RPH housing staff (see Table 2). I didn t find it easy to use because they were very difficult criteria, because if they are this age and this culture or something else, I can t remember now, but it wasn t easy Hospital staff The inclusion of participants in the programme who were not eligible for CSC possibly indicates how difficult this was to apply. CSC eligibility data was available for 21 households enrolled in the pilot (either from database or from the interview) and three were not eligible for a CSC. Hospital stakeholders widely held the view that there were patients with equal housing need who missed out, such as five year olds and older who were not Māori or Pacific peoples. The rationale for selecting ethnic groups with the highest rates of housing-related admissions was not well understood and would require a lot of promotion in efforts to improve acceptability. RPH staff found that it was difficult to say sorry this programme doesn t apply to you or your family and explain why when clients did not fit the ethnicity or tenancy criteria. It is only fair that it is targeted but maybe with a bit broader eligibility criteria, like make the ethnicity a bit broader. And the HNZ broader Hospital staff Providers were also asked about their service eligibility criteria. Provider criteria were no narrower than the HCP criteria. Two health and social providers used ethnicity as a criterion; one provider used age; and three housing providers used CSC. The HCP was targeted to account for limited resources and a short timeframe. It was widely agreed however that ideally there should be a broader set of housing-related conditions and that the programme should include HNZ tenants, all ethnic groups, and people without CSC who have financial difficulty. 17

22 Criteria RPH operational RPH managerial Hospital staff Bronchiolitis, asthma, pneumonia, Rheumatic Fever Not a HNZ tenant Age 0-4 years old or 5+ years old with Māori or Pacific ethnicity Respiratory conditions worked quite well It was difficult to apply and explain tenancy criteria to patients Ethnicity and age criteria were confusing It was difficult to apply and explain ethnicity criteria to patients We stuck with Paediatric, respiratory a conservative group for the HCP for a very specific reason i.e. to limit the numbers and target the HCP HNZ was already addressed through the HHP programme Were applied to limit referral numbers and align with RPH bold goal No known complaints about ethnicity criteria Diagnostic criteria was easiest to use (2) Difficult/time consuming to determine on the ward Ethnicity was difficult/time consuming to determine on one ward Widely held view among clinical staff that there were people (5+ years old) who were not Māori or Pacific with equal need who missed out (5) Community Services Card (CSC) eligibility CSC not easy to understand May exclude people with high needs who didn t know if they were eligible Table 2: Application and acceptability of eligibility criteria Were targeted households at risk of housingrelated conditions? Criteria influenced by EECA criteria (CSC), we needed to live within that because we needed to be able to provide something and offer something Now EECA criteria have changed, e.g. financial hardship CSC is a very blunt instrument Difficult/time consuming to determine on the ward RPH and hospital staff thought that even though households reached were households with need, many people in the community had an unmet need. Furthermore the CSC was seen as a blunt measure of need, perhaps neither sensitive nor specific. Some participants without CSC eligibility were enrolled in the programme. This was at least partially to do with the difficulty in determining CSC eligibility. One participant was not eligible for a CSC because her husband had taken up a new job. She was frustrated because they could not access insulation even though there was a clear identified housing need. There were also families who were eligible for CSC and subsidies but they did not need insulation or curtains. Common diagnoses Application of the HCP criteria selected a group of housing-related hospital admissions with predominantly respiratory diagnoses. Half were asthma (12/24) and almost a third of admissions were bronchiolitis (7/24) (Figure 5). Figure 5: Hospital admission diagnosis of patients eligible for the HCP study The majority of participants were enrolled from the paediatric ward (n=24, 89%) and the rest came from the adult Medical Assessment Planning Unit (MAPU) (n=3, 11%). Of the ward referrals from MAPU, 3/14 (21%) referrals were enrolled in the study. The proportion of referrals enrolled from paediatrics was 24/55 (44%), about double MAPU. There were no referrals from the other medical wards. Paediatrics referrals recorded by the RPH housing team were more likely to be aligned with the HCP study criteria. 18

23 Demographics In the 17 household visits 83 household members consented to be included in the HCP. Of these, 43 were female and 40 were male. There was a very young age distribution; with 50 children (60%) aged less than ten years old; and 59 (71%) aged less than twenty years old (Figure 6). Figure 6: Age distribution of participants in the HCP study (those whom consented to the housing, health and social assessment) Ethnicity data was available for 21 patients from the 27 different consented households. Among these 9 participants identified as Māori, 7 identified as Pacific peoples, 6 as NZ European and 2 as other ethnic groups. This takes into account participants who identified to more than one ethnic group (See Figure 7, total ethnicity). Of the 21 patients, 16 (76%) identified as either Māori or Pacific peoples (prioritised ethnicity). Note that being Maori or Pacific was part of the eligibility criteria for people aged 5 years and over. Summary of findings Of the 28 households invited to the HCP, 17 (61%) received a housing visit and 11 (39%) either could not be contacted or opted out because they were moving homes or daytime was unsuitable. Of the eligible hospital admission diagnoses targeted by age and ethnicity, 16% met the eligibility assessment and were recruited into the HCP. The greatest recruitment ratios were for bronchiolitis or asthma diagnoses, Pacific or Māori ethnicities and children less than 5 years old. Targeting patients with housing-related conditions was feasible and generally well accepted by all the stakeholders involved. Primary care was also suggested as an acceptable referral pathway that may prevent admission. Significant investment, on average 2.4 hours per participant, was required from the HCP team to establish and maintain the process of selecting, assessing and consenting patients on the ward whereas much less input was required from ward staff. The recruitment rate varied over time with intensity of staff inputs. For visiting, referring and following-up 7.7 hours were invested per coordinator visit. Timeframes to contact were acceptable to participants. Stakeholders recommended a broader set of eligibility criteria to include more households with equal housing need such as HNZ tenants, other ethnic groups, people without CSC eligibility and other housing-related admissions. The eligibility criteria selected a young population who were commonly admitted with bronchiolitis or asthma. 76% of participants were Māori or Pacific people. These ethnicities were part of the eligibility criteria for people age 5 years and over. Figure 7: Ethnicity of participants invited to the HCP study from 27 households (total ethnicity - data is presented for all ethnic groups identified) 19

24 enabling access to housing, health and social improvements This section aims to explore the extent to which whānau were able access housing, health and social improvements when requested and indicated through the HCP. The process of identifying relevant needs is discussed, followed by an exploration of the referrals made, referral feedback loops, the referral outcomes, barriers to access, and two case studies which highlight the mix of successful outcomes experienced by households who were tenants with inadequate insulation at enrolment. Assessment of need The home visit and assessment by the housing nurses was based on a Joint Assessment Tool (JAT) from the Hutt Valley Healthy Housing Programme (HHP). The JAT is designed to identify housing, health and social issues which can be addressed through advice or by making a referral plan with the participant. The tool has had positive feedback and has generated many referrals in other programmes. Text box 2 provides a description of the coordinator visit and assessment. Housing coordinator visit and assessment tool Introductions with the family Informed consent: Do all family members want to be a part of the assessment? Housing questions about what is working well in the household and what is not working well i.e. any mould issues, condensation With permission any housing issues around the home are examined Options for resolving housing issues are discussed Where it is identified that the family may benefit from a referral they are asked for their consent Health questions are discussed. Some may already have come up through the housing questions and been noted down i.e. heating or lack of, making the house cold and impacting on a child s asthma. If the greatest concern for the family may be the house or one specific health issue then this might be all that is covered. Screening questions are discussed at the end e.g. screening, smoking, family violence Budgeting questions are also asked at the end if they have not already come up e.g. the family is not accessing heating, doctors, food, and bedding. The referrals are summarised and advice is given about the expected timeframes Consent is requested to send a feedback letter to the GP/referrer Contact details are provided and the visit is concluded Text box 2: The housing coordinator visit 20

25 RPH staff described how the key features of the assessment were that it included everyone in the household who was willing; it took a holistic approach including housing, health and social aspects; it was individually tailored to identify and address needs; and there was a participatory and empowering approach taken to negotiating a plan for improvements. Participants asked about the assessment gave an overwhelming positive response. They particularly appreciated the advice and tips (n=6) and finding out about services and products available to them (n=5). The assessment was appreciated for not feeling judged, and being a calm and private way to ask questions. She was able to come... face to face to us and... as well as explain to us the tips that she had... given us and the should and should not dos and um you know even being able to assist if we didn t have the curtains or if we didn t have insulation Participant Table 3 highlights the themes and identifies the characteristics of the housing nurse assessment such as including the whole household, and taking a holistic participatory approach tailored to need. The seventeen households who received a coordinator visit were asked about housing conditions (Table 4). There was a significant degree of unmet housing need with over half identifying dampness and mould. At least five homes were listed as requiring curtains and two households as requiring improved heating. Unmet need No need identified Dampness % Mould % No curtains % No heating % Table 4: Prevalence of unmet housing need according to health and social assessment tool and database records % Themes Included everyone in the household Holistic approach Tailored approach to identifying and addressing needs Participatory and empowering approach to addressing needs Housing nurse quotes we went into the home we ve always worked a whānau ora approach so it s always been offered to everyone in the household who consents it covers all the family, so you start off talking about one family member and it often gets onto lots of other family members and what s going on so it covers everything and it covers social as well, um, so that s why it s so good because it is an entire approach It was about not just one issue it was about health and social, and housing. So them all together was addressing, it was multi-pronged I guess. Some of the things that were referred for were around other requirements that the family needed as opposed to solely housing stuff. Financial issues and financial stuff is addressed right at the end, and often people then know that they can trust you and yeah that s really really sad. Budgeting is a huge thing for the majority of the people that we go to visit It s whānau ora approach it s a strength based approach its talking to the families about what their need was. The most relevant questions differed between households. Going through with the person and educating them as we walked around the home of things that they could do to live in the home better Yeah we were just trying to find a way that families could address things themselves I couldn t do anything without them. I guess it was around selling different ideas to them. Supporting them to make a decision. Just talking through the issues as they were identified, then making sure I wrapped it up by making sure I identified what was going to happen from then and making sure that that stuff that we talked about did happen Table 3: The housing, health and social assessment 21

26 Participant knowledge about the link between housing and health may help us to understand the level of need for advice and education. Approximately half of the participants interviewed were not confident they knew about the link between housing and health. The proportion was similar among those visited and those who did not receive a home visit. The limited level of knowledge among participants was consistent with a RPH view that the general understanding of housing literacy needs to be lifted. Of the seventeen homes who received a coordinator visit, three households did not require any referrals to external providers. However, in each of these home education was provided for health issues. One of these households was not eligible for a CSC and the CSC eligibility of the other two households was not recorded. There was a wide variation in the level of unmet housing need and the level of housing knowledge among participants. Although education was given, 3/17 homes did not require any referrals. Types of referrals From the coordinator visits, 33 referrals were made to housing/social agencies and 19 referrals were made to health agencies (Figure 8 and Figure 9). The most common housing and social referrals were for insulation (n=7), budgeting (n=7) and curtains (n=6). The most common health referrals were for asthma (Tu Kotahi Māori Asthma Trust) (n=6), the school dental service enrolment (n=6) and for smoking cessation (n=2). Referral feedback There was no routine feedback to RPH about the outcome of referrals from external providers. RPH did not send referral feedback to secondary care, but a copy of the letter for each household after the visit was sent to the participant s GP. Several providers said that if they had a problem contacting a client referred to them by RPH then they would contact RPH. If a housing nurse was concerned about a provider not providing a service then they took the initiative and checked on the referral s progress. Housing nurses would like more information back from providers about whether a patient has engaged or not. Information might include whether the client is eligible, any expected delays in service provision, or whether the service has been able to contact the client. Access to a shared electronic database and contracts that require feedback may assist. RPH staff acknowledged that this may create work for some services and it may not be possible. It may be more acceptable if the feedback is reciprocal. Hospital staff also said they would like feedback from RPH if a participant cannot be contacted and engaged. They would like a record of whether newly admitted patients have been seen by housing nurses in the past. They suggested the possibility of creating an electronic record for patient s participating in the housing programme which could be used as background information when patients are admitted. This could in time be part of the public health modules in Concerto like what is done for school children. Referral outcomes Three flow diagrams were constructed to summarise the outcomes from insulation referrals, other housing and social referrals, and health referrals (Figures 10-12). These diagrams combine information from participant and provider interviews, the housing database and programme records. Half of the tracked referrals resulted in service provision. The reasons that some referrals did not result in provision are discussed. Figure 10 shows four households received insulation among the seven who were referred. A total of 12/21 households (missing data for six households) had inadequate insulation at enrolment (not shown in the figure). Among the twelve with insulation need, four had insulation installed, three were referred for insulation but were not progressed and five 22

27 Figure 8: Housing and social referrals made in the Housing Coordinator Pilot study, n=33 Figure 9: Health referrals made in the HCP study, n=19 did not receive a coordinator visit because they couldn t be contacted. Where data was available; 3/9 private tenants with insulation need had insulation installed and 1/1 owner occupiers with need had insulation installation. Similarly, the installation rate by ethnicity was 1/5 for Māori, 2/4 for Pacific peoples and 1/2 for non-māori-non-pacific. insulation). Half (9/18) of the tracked referrals resulted in service provision by the time of the interview. Two households received curtains, two had assistance with WINZ, two received budgeting advice, one was linked to a home management service, one to parenting support services and another to an organisation providing a range of social supports. Figure 11 shows the outcomes for other housing and social referrals (excluding 23

28 Figure 10: Flowchart of insulation referral outcomes There were various reasons that some referrals did not end up in service provision. This included system issues where referrals had not been received or there were delays because the provider did not have the capacity to provide. The landlord relationship was important. Reasons for services not being received are explored further below. For at least two of the referrals, providers reported that the referrals had not been received. I mean we lose the odd one or two which is only natural from fax or something like that but the girls usually follow that up. Provider Figure 11: Housing and social referral outcomes excluding insulation With two additional referrals, participants did not recall having had any contact with the service provider. In one case the participant had seen her GP about smoking cessation instead and had made some progress on this, despite the lack of contact with the service she was referred to for smoking cessation. Two referrals to a provider had not yet been actioned due to the workload of the provider. (Provision had occurred by the time of this report.) This provider was unique because many of their referrals (90%) came from RPH housing programmes. They had also just moved premises. 24

29 There was an area where we had about three months of back log and I dunno we ended up with about 45 homes that we had to do under normal circumstances we ve said [it takes] about 6 weeks, now getting down to this it s probably not as long as that. But it was when we moved, it was about 3 months but we notified people of that Provider In all three cases where letters were written by housing nurses to the landlord or tenancy agent, the advocacy had not brought any change. A letter to a tenancy agent had not helped. Another letter to a landlord was still in its envelope somewhere in the tenants house because they were uncomfortable passing it on. However the landlord did organise for mats to be put in a child s bedroom and was reviewing options for heating and ventilation. A third letter was written to the landlord about heating. Changes had not yet been implemented but the landlord was making plans to do this. That s where the heat pump and stuff are coming into play, and the carpet, and mould to, extraction fan etc., which will happen. - Participant Tenants often balanced delicate relationships with their landlords and in at least two households the landlord was (or had become) a personal friend, of whom tenants did not want to upset or make any requests that might be seen as unreasonable, reportedly because of concern about the landlord s own financial situation. There were several other households (in the absence of advocacy letters) where landlords had been less than helpful in dealing with tenant requests. In one home, the landlord refused to help with the leaking roof, rodent problem and the carpets. The landlord had however agreed to the insulation but then followed this up within a few months by proposal of a rent increase from $290 to $330. This left the tenant particularly frustrated and upset. At the time of the interview there were several unmet needs in the household that may Figure 12: Outcomes for health referrals in the HCP Note: *enrolment does not mean that a dental check-up has been provided have been addressed with on-going follow-up. That s why I m just sad because he wanted to put up the rent, but he didn t want to change the carpet. Participant Figure 12 shows how of the 20 health referrals made, 16 were tracked and 8 of these resulted in service provision : 4 children were enrolled in the Tu Kotahi Māori Asthma Trust, 2 children were newly enrolled in school dental services, 1 adult received a chest x-ray and 1 child saw a public health nurse at school. In the case of dental services, six children were referred for enrolment in the school dental programme. Two children were new enrolments to the school dental service however four of the six dental enrolments were actually duplications because the children had 25

30 already been enrolled onto the programme. School dental service enrolment was in the process of major developments. As referral processes improve in the future, even more of housing programme referrals to dental may be duplications. Consideration should be given as to whether RPH housing staff may be able to get access to the dentals service database to check enrolment status to try and avoid duplicate referrals. Furthermore, dental enrolment did not necessarily mean that children were seen for a dental check-up. Check-up depends on a child s age and does not normally happen until after two years old. One child (already enrolled) had been seen by the time of interview and two had not been seen (and three were not interviewed). Families spoke about how they are still waiting for the check-up and did not appear to understand the expected timeframes involved. In addition to referral duplications, the other reasons that health referrals did not result in provision appear to be about whether providers received referrals and made contact with the household. Four households did not remember being contacted by the service provider (although this does not rule out that they may have been). For at least one of these households, the provider had no record of receiving the fax referral sent through from RPH. Summary Table 5 provides a summary of referral outcomes. Action based on advice Participants frequently recalled the mould management and ventilation advice that was given by the housing nurses. For the example of mould management; eight people remembered being given the advice about using vinegar, five people had used the advice and all of these had found it to be effective. Other advice recalled and actioned included heating recommendations, carpet, vacuum cleaning, thermal curtains, cleaning linen, seeking health care, using inhalers, play group, flea treatment and a green prescription. Written pamphlets provided at enrolment were often not read or remembered. One participant specified how better information at enrolment might help people know what to expect and screen out whether the programme would be helpful for them, including written materials, websites and explanations. Full or partial provision Providers used initiative and prioritised what services were appropriate to put in place for a family. One referral had multiple requests for services to address several different health and social needs, but only some had been engaged with by the time of interview. Another referral identified just one health need and this was addressed with multiple supports far and above the immediate referral request. As already discussed, some households only had ceiling insulation installed. One family was unsure whether the installers would come back and do the floor. Households were often left with a poor understanding of the reasons for incomplete installation. Perceived barriers Participants (who were and were not visited), RPH operational staff and providers were asked about the barriers faced by participants to arranging a coordinator visit, making changes at home and to accessing provider services. Number Proportion accessed among all referrals made Proportion accessed among tracked referrals Households insulated 4 4/7 (57%) 4/7 (57%) Other housing or social service accessed 9 9/22 (41%) 9/18 (50%) Health service accessed 8 8/20 (40%) 8/16 (50%) TOTAL 21 21/49 (43%) 21/41 (51%) Table 5: Summary of referral outcomes 26

31 All the participants who received a home visit found it simple and straight forward to arrange. Those who did not get the coordinator visit identified some barriers. They were emphatic that this had nothing to do with the housing nurses and instead they talked about the other priorities they had at the time; for example they were moving homes, had limited ways of communicating, or that there were miscommunications. This group would have preferred more flexible hours to make the coordinator visit happen, but volunteered that this might not be feasible. One participant was initially unsure about how relevant the programme would be because they were renting. RPH staff found that arranging visits sometimes took several phone calls and text messages. Barriers to arranging visits included the time of the day for the appointment, time of the year, and competing priorities in the household. They found that the longer the time between consent and contact, the less a participant remembered about the programme. There was some concern that people might have opted out because they did not understand what they might get. The perspectives of participants, RPH staff and external providers were largely similar when they discussed the barriers that households face to making changes and accessing services. There were barriers with families moving homes, making contact; the cost of recommended services (participants and landlords), competing priorities, willingness to engage, cultural priorities, meeting insulation subsidy requirements, and the complexity of available providers. All groups mentioned how moving homes (transiency) was an important barrier. The anticipation of moving homes creates little motivation for physical housing improvements. One household describes the reduced motivation for the landlord to make changes knowing that the family was soon to move out; I guess procrastination on her thing, or I don t know, I think that if she thinks they re moving why should I get [insulation] done? They won t be here anymore, the kids will be gone. Or let s see if we can get away with it. I don t know. Participant RPH staff and providers identified the difficulties sometimes faced when contacting families, perhaps compounded by poor access to phone and internet (provider view). Financial barriers were commonly cited. These particularly related to the cost of heating, the cost of accessing services such as primary care, levels of debt and the willingness (and perceived willingness) of landlords to pay for housing improvements such as insulation, ventilation, heating and maintenance. At least two participants identified competing priorities as an issue; and this view was reiterated by RPH staff who said how other health issues can compete for priority. Providers talked about clients not coping and how an acute need may fade over time to become less of a priority. Competing priorities are likely to affect not only provision of services in the first instance but also whether a household receives the coordinator visit. Several providers talked about how sometimes a client was not ready or willing to engage; and one thought this was perhaps because clients said yes to referral because they thought it would help them get access to the other free services they did want. RPH staff also discussed how families sometimes appeared reluctant to admit their need even when their needs appeared quite obvious. This perhaps reflects pride, stoicism and maintaining dignity. Another household did not want budgeting advice referring to cultural reasons; But I know my culture, so many things, family members, so many things to spend the money. But we manage. Participant (Pacific) Physical and financial requirements were sometimes a barrier to receiving insulation. Several households were not able to get under floor insulation due to height requirements and 27

32 another household was frustrated with delays because of under floor dampness. I said didn t they do underneath? and [my son] goes oh they said it was too damp, and they didn t come back for months and months and months, I was ringing A and she said oh they keep on saying that it s too wet under there so it was quite annoying but never mind. Participant One family was impressed with the efficiency of the insulation provision and another family was frustrated by the paperwork required to prove their eligibility for insulation subsidies. The requirement of a CSC was also a barrier for at least one household. Three families slipped through the CSC eligibility screen at enrolment. Barriers to access are what the HCP was set up to address (Table 6). RPH staff discussed how misinformation about what can be accessed and the knowledge of the available services were barriers for both participants and hospital staff. Providers reiterated this theme by discussing the complexity of providers and a lack of participant knowledge. Participant perspectives The following case-studies introduce us to the experience of two families in the HCP (Text box 3, 4). Both households were private tenants living in rental homes with inadequate insulation and there were interesting dynamics in the landlord relationship. Each story describes the barriers and enablers to making changes and accessing interventions. In each situation there was a mix of referrals that resulted in service provision and those that did not. Sometimes this was related to whether the family still wanted the service and saw any benefit in it or that there were some substantial delays in provision. In both families insulation was installed and there were health benefits. Making contact Financial Insulation requirements Competing priorities, willingness to engage, cultural priorities Participants RPH Providers Participants moving homes Cost (4)- including specific energy costs Landlord relationship Paperwork required for application No community services card Competing priorities (2) Cultural priorities (barrier to budgeting) People moving houses Not being able to contact clients There may be delays in engaging families Cost, outstanding debt, lack of transport People may be unaware of WINZ fund for medical bills, & unaware of GP outreach services CSC may not be a good indication of financial need Being engaged in their health issues at the time - priorities Ashamed to admit need, Knowledge about available services Misinformation about whether could access, availability of home visits, promotion of services Participants moving homes Not being able to contact client (5) because no phone, no internet Language Costs Debt, fear of debt collector visiting Landlord unwilling to pay (2) Lack of response from landlord Height clearance to get access for ceiling/underfloor (3) Household already meets standards (2) Plumbing issues for insulation Community services card required and family not eligible (2) Client is unwilling to engage/not ready (3) One provider thought clients had said yes to referral because they thought they had to for access to other housing services One provider discussed how an acute need may fade over time to become less of a priority Families not coping, mental health Lack of knowledge Complexity of providers Table 6: Barriers to making changes & accessing interventions in the Housing Coordinator Pilot 28

33 Mele Mele (not her real name) is a 30 year old Pacific woman who rents a two bedroom house in Lower Hutt with her husband and three children. Mele s three year old was admitted with asthma to the children s ward; just another in a string of hospital admissions for her young family. Mele met one of the RPH housing nurses on the ward. She wanted to do something quickly to keep her children out of hospital. Many times she had felt guilty and stressed about the health of her children and wondered if she was doing something wrong. Sometimes I give up, so many times I give up and I tell my husband, oh, what has happened to our kids. She had never considered insulation as something that might help. I met Mele eight months later. She told me about how the housing nurse had explained everything, and how her family was given the tools to do something to help themselves. So many things that she tell me the main thing she told me about the house. Mele recalled advice about mould, ventilation, heating and promptly seeking health care. Although the landlord hadn t helped before with addressing the mould in the house, when Mele rung him and told him that the health department had come and visited her place, she got a prompt response. I think he think something else might happen that s why he provide everything and my husband fix the wall. There hadn t been any mould since. As well as the advice given, referrals were arranged by the housing nurse for WINZ, radiology, insulation, HNZ and budgeting. The housing nurse arranged for a CSC and a difficulty with a chest x-ray appointment was resolved. Ceiling insulation was installed although it did take six to seven months, possibly because the landlord had to first agree to pay for a portion of it. Mele was also concerned and confused about why the floor insulation hadn t been installed; they said they put some down the floor, but they say it raining and windy, I think they not done the floor. Although Mele agreed to the referrals initially, she found some services unsuitable or uncomfortable to engage with. She wasn t interested in further budgeting advice and although a house was offered by HNZ it was not seen as a good option when the family balanced it against the costs of moving and leaving their quiet neighbourhood and newly insulated property. Since the insulation was installed Mele had noticed a significant improvement in the warmth of her home. She doesn t need to use the heater as much to stay warm, although the family continues to sleep together in the lounge. Mele has noticed her children are much more healthy; it s a really big help for my kids, they are not admitted to the hospital now for a long time, but before every month, or every two weeks they admitted to the hospital but now it s long, a big gap now. Mele was very appreciative because the programme had helped her children. We are really happy now. Not like before, I always stress. If my kids happy I am happy too. Text box 3: Mele 29

34 Euan Euan (not his real name) is a 38 year old New Zealand European/Pakeha man who lives in Lower Hutt with his wife and five children, with three who are aged less than five. His youngest son was hospitalised in June with pneumonia, and that was when they met one of the RPH housing nurses. Although Euan thinks hospital was probably the ideal time to get linked with a housing programme, he suggested that general practice would be a good way of finding out about housing before his son got sick and ended up in hospital. Euan knew quite a bit about insulation and heating; but, it s easier said than done. A couple of weeks after his son left hospital, Euan received a visit at home for a coordinator visit. He was surprised by the number of referrals for services freely available; I didn t expect the insulation. I didn t expect the curtains. I didn t realise that was available to people curtain bank. Four months on, Euan recalls tips and advice about mould, ventilation, heating (including a helpful energy efficiency pamphlet) and the importance of carpets and mats. The family decided to use the night store heater less often and [now] use an oil fin heater because they were more efficient, and mats on the floor. There were some changes such as a heat pump that Euan would like to have made but the family can t afford. As well as advice several referrals were arranged including insulation, curtains, smoking cessation, social agencies, budgeting, landlord advocacy and play group. Some referrals did not go smoothly or did not eventuate. Several months later, Euan still hadn t heard anything back about the curtains that were measured up; and nothing came of the play group referral, but the children will soon be starting at kindy. The landlord letter about ventilation and heating was still in its envelope; we know the landlord, it s tricky. We knew he wouldn t necessary be able to afford insulation subsidised or otherwise. On the other hand, the referral for insulation in the ceiling was actioned quickly and Euan was very satisfied with the service provided; the fact that it was done so quickly, I was amazed. Although Euan said he was initially reluctant about some of the referrals, later on they were particularly appreciated; they re just great she comes around once a week on Tuesdays and she brings food parcels and she, oh she s just a really nice lady. She reads books to the kids and stuff, they do a whole lot of things, they give advice and follow-up things too, that TV came from there. Euan had noticed some health improvements in his son with less need for his inhaler, however there were also other things that helped like his age, better weather, and more time outside. His son had just been back in hospital but he got better really quickly, stunned the doctors and all that, and he hasn t been that wheezy I guess. Euan recommends that the housing HCP be offered more broadly and better promoted. He suggests that the government may not realise but that people do need things like curtain bank and food bank. He suggests housing programmes should include subsidised heating as well: Yeah subsidised heating as well because that does cut into the old budget. Text box 4: Euan 30

35 Summary of enabling access findings The HCP programme enabled households to access housing, social and health improvements where they were relevant and requested. The coordinator visit was strong on identifying the issues and making referrals to the appropriate services. However over half of referrals did not result in service provision. There were no formal referral feedback loops. The reasons for non-provision after referral to external providers were often related to systemic issues, including that there was no provider record of having received the referral, the participant was not eligible for insulation subsidy, provider capacity was overburdened causing delays in provision, actual and perceived landlord willingness to contribute to housing solutions, family perspectives about the suitability of the service and duplicate referrals. The two case studies help us understand the various facets of service provision and nonprovision and the health benefits identified. 31

36 collaboration with housing and health stakeholders This section aims to explore the effectiveness of collaboration with housing and health stakeholders. Data was collected to assess the level of collaboration between RPH and hospital staff, and collaboration between RPH and key external providers. Also considered was how the HCP aims were understood by different stakeholders. Level of collaboration Hospital and RPH staff The HCP led to significant improvements in collaboration between RPH and hospital staff (both clinical and non-clinical). RPH staff highly valued development in the relationships between housing nurses and ward staff, and between RPH and hospital management. This collaboration was seen as a great way of promoting housing and the broader public health work. Improvements were clearly seen. I mean for me it was really mind blowing after that allied health leaders meeting I had three people lined up after the meeting wanting to talk to me about the housing programme RPH staff It was good for me to see what is out there and to go along to RPH, to see what s in the community. I didn t even know it was there along the end of the hall. Hospital staff Furthermore, both RPH and hospital staff would like to see on-going collaboration. There was a desire for a better relationship with ward staff but an acknowledgement that a balance is required because ward staff are busy. RPH staff recommended engagement and promotion with clinical at the beginning to ensure the best referral process is developed. RPH staff would like more systemic emphasis on housing, involvement of social workers, and stronger links with Māori and Pacific health workers. It amazed me that when there were questions about housing conditions that the social workers weren t referred to more RPH operational RPH and hospital stakeholders were both asked about key aspects of the HCP study design. Clinical engagement was highlighted as a strength. Several hospital staff were appreciative of the early engagement and autonomy they were given into designing the referral process. Furthermore the use of clinical champions on each ward was seen as vital. It worked cause they tried to fit in around our schedule rather than impose a pathway on us, which isn t always as successful I find. - Hospital staff RPH staff also identified positive engagement with secondary care and promotion of housing amongst DHB staff as key aspects of the study design. The organic process of planning and talking as they went was highlighted reflecting the participatory approach in collaborating with the hospital. The close proximity of RPH and the Hutt Hospital helped to establish collaborative links. Providers and RPH staff The relationship between RPH and most of the external providers was already established at an operational level before the HCP began, through referrals from the HHP. In this way, providers did not notice any developments in collaboration with RPH, except one insulation provider where there was a new collaboration with RPH. The insulation referral pathway was newly developed for the HCP whereas it was not required for the HHP. One provider noted that they already had very good collaboration with RPH through the Regional Housing Coalition and viewed RPH collaboration efforts positively. Another 32

37 provider said there was no contact to speak of. Collaboration between providers and RPH staff generally occurred at the operational level around referrals or through the housing coalition. RPH staff also talked about collaboration at the operational level and through the wider housing work. RPH are doing a good job you know we ve all got limited budgets around the whole housing arena so you re doing a good job, always keeping relationships open, always talking and working together - Provider It s generally through the day to day referrals, although we re working together with those external providers now through some of the promotional stuff we re doing, and we re going to be aligning closely with primary health on another collaboration we are doing RPH staff The HCP referrals (and other RPH HHP referrals) generally accounted for a small proportion of referrals received by each external provider, with the exception of one small provider where referrals from RPH were the main referral route (90%). The level of collaboration with providers was mainly operational and at the level of the Regional Housing Coalition which includes many key health and housing sector agencies both in the government and other sectors. It is now important to consider views on whether that level of collaboration was seen as adequate. Several providers said that the current level of collaboration was adequate. However, some providers would like more contact around operational aspects. There were mixed messages about the Regional Housing Coalition which is a regular meeting of housing stakeholders formerly known as the Hutt Housing Forum. Some providers mentioned that it was effective for collaboration. However another provider was concerned there were too many people and not enough traction is made. Instead more operational work was suggested. We ve worked well together around housing for quite a while now, Hutt Housing Forum, we all came together in 2004 so it s been quite a long relationship - Provider I think more [collaboration] on a constant basis rather than the coalition meetings which is where we connect at the moment, I think more yeah, some more working group type meetings whether that it is just deciding and breaking down some of the tasks, some real tasks and real meetings and follow-up things that have to happen. I think that s the key to it. Provider Some RPH staff felt that they were asking for something in their collaboration with providers but giving nothing back. They suggested that an offer of reciprocity may assist such as being able to offer a service that external providers could refer back into. I guess if we could offer more housing education [to them], offer more housing packages and going out to those providers or working with them that would be helpful but otherwise we work quite well...whether or not we could support them with any of their clients RPH staff Gaps in understanding of programme aims Some aims and success indicators were shared by different RPH and hospital stakeholders and some were not shared, even within RPH. For example there were several different types of admissions referred to when discussing what the programme was designed to reduce including ambulatory sensitive hospitalisations, housing-related admissions and respiratory admissions. There was greater scope for common understandings about the aims of the pilot and the indicators of success. Shared aims included improving housingrelated health outcomes and making housing improvements. RPH and hospital staff said that success could be indicated by case studies about individuals who had positive outcomes, by improved housing conditions and by reduced hospital admissions. 33

38 Aims identified by RPH managerial staff and not expressed by others included developing working relationships with primary and secondary care, extending the HHP to non- HNZ tenants, building on RPH experience, and focusing on the needs of Māori, Pacific peoples and children. Success indicators identified were engagement with secondary care, taking a Whānau Ora approach and providing education. DHB stakeholders, instead, were interested in solving the problem of the complex referral process, finding someone to coordinate referrals to help overcome the confusion about the ever changing service availability. Several DHB stakeholders expressed a limited understanding about the HCP. Summary of collaboration findings The HCP successfully established and developed a collaborative relationship with secondary care services at Hutt Hospital. Collaboration was assisted by key aspects of the HCP design such as participatory approach and close proximity between RPH and the hospital. Both RPH and the hospital would like to continue to develop this relationship. Collaboration with external providers was already established at the beginning of the HCP, apart from one service which was a new referral pathway. Referrals from the HCP were a minor proportion of the total referrals received by many of the key providers contacted. Collaboration between RPH and external providers was mainly at the operational level and through the Regional Housing Coalition. Ideas from providers were mixed about whether more collaboration would be beneficial however some would like more communication around operational aspects. There was greater scope for shared ownership and understanding of programme aims and success indicators. 34

39 general satisfaction and interviewee recommendations All interviewee groups were asked their perceptions about continuing the programme, its good aspects, what could be improved and what the perfect programme would look like. Continue the programme There was unanimous support for continuing the HCP programme among all RPH, hospital and provider stakeholders involved. RPH staff absolutely wanted to extend the HCP programme because it was seen as fantastic, needed and a good idea. Hospital staff were all supportive of continuing. External providers were unanimous that they would all like to receive more referrals. The majority of the participants who had a coordinator visit said the programme was helpful. For some participants the programme met their expectations and for others it was more than they expected: I was really impressed. I didn t think it was going to be available to us really Yeah but the fact that it was done so quickly, I was amazed I didn t expect the insulation. I didn t expect the curtains. I didn t realise that was available to people Participant However, there were a couple of participants who did not find the HCP helpful. One person thought the programme was kind of average because she was still waiting on insulation and she did not know why they had not returned to install it (no landlord approval). One participant did not find the programme helpful because there was no need to implement anything. The household was not CSC eligible and technically did not meet the HCP s eligibility criteria. Strengths and weaknesses Interviewees were asked about what worked well in the HCP. These strengths are summarised in Text box 5. Participants and RPH operational staff highlighted the strengths around the coordinator visit. Participants talked about the tips and advice they were given and they were particularly happy with the links to services such as insulation and curtains. They liked the approach of the programme, the reassurance it brought and the opportunity to ask questions. Hospital and RPH managerial staff highlighted the importance of their newly established collaboration. RPH management identified the improvements in collaboration across the health sector to improve public health. Hospital staff were particularly appreciative of regular communication, the opportunity to have a say in the development of the referral process and that the referral process was easy on clinical staff. In discussing what did not work well, it was said that the HCP may benefit from; greater acceptance among ward staff to making housing referrals, improved follow-up for participants to address delays and landlord willingness, and a longer programme timeframe. Other weaknesses are summarised (see over). Unintended effects There were several positive and negative unintended effects from the HCP study. Several participants mentioned that they had moved or were planning to move homes. There were reports about how the decision of what house to buy or move into was at least partially positively influenced by the healthy housing messages of HCP. One participant had recently bought a rental property that was healthier than the house she was living in. We just recently bought a house renting that out, really silly, we got the, they got the better off deal, paint and new carpet. And we re staying here with no carpet. Participant 35

40 Strengths Preventative approach Alignment with RPH goals Collaboration with secondary care, regular communication, developed trust Early engagement and participation of clinical staff in designing referral process Limited burden on clinical staff Clinical expertise helped with clinical engagement and navigating the hospital system Increased public health credibility in the hospital Targeting a select group of people made it feasible Coordinator was supportive, reassuring and non-judgmental The visit was convenient and done quickly Advice and tips and simple take home solutions were appreciated Links to freely available services were appreciated Made use of existing staff and resources Good referral information was sent to providers Weaknesses Intensive input was required for the recruitment referral process Timing of recruitment conflicted with another study Information at enrolment was not always clear Delays waiting on referral outcomes One provider was overloaded with referrals Landlord may refuse to help Participants would like better follow-up Limited availability and timeframe of the programme brings confusion Text box 5: Strengths and weaknesses of the Housing Coordinator Pilot The unintended effects in another house were more worrying. The landlord had proposed a rent increase from $290 to $330 ($40 dollars or 14%) a few months after subsidised insulation had been installed. Furthermore WINZ had stopped temporary financial assistance after budgeting advice was put in place. The tenant felt powerless and extremely frustrated with her landlord. There were various reports of exacerbations and improvements in stress levels as a result of the programme. One participant was upset to have to retell traumatic health experiences which she thought should have already been available to health workers involved in her care. Some households felt powerless when they heard about the effects of poor housing on their children and did not have the financial capacity to do anything about it. Another household however suffered much less stress after insulation was installed and she had noticed reductions in hospital admissions for her children. 36

41 Interviewee recommendations Participants, RPH staff, hospital stakeholders and providers made many suggestions about what the perfect housing programme would look like. There were consistent themes across the different groups of interviewees about making the referral process more routine, broadening the eligibility criteria, formalising follow-up, improving collaboration with a more diverse set of groups many of whom are within the DHB, upscaling the programme to improve its availability, and advocating for better housing policy. There were ideas about providing affordable heating, better engaging landlords, promotion in the community and housing education. These recommendations are summarised in the text box (below). Summary of interviewee recommendations Make the referral process routine Continue to have a housing coordinator on the ward Nurse champions with housing part of nursing competency development Invest intensive resource until workforce and system support this as business as usual Automate referrals e.g. using ICD codes or discharge summaries Include housing on all clinical pathways Ensure it is easy on ward staff Improve promotion to ward staff at the start of the programme Broaden the eligibility criteria Broader eligibility criteria would improve the reach of the programme and avoid usability issues Should include HNZ tenants, people without CSC who have financial difficulty, all ethnicities, and other respiratory diagnoses such as bronchiectasis and COPD Should be anyone with a respiratory condition as a result of cold damp housing Requires at least some financial criteria Retain flexibility to refine criteria over time Get MoH direction on who to prioritise for housing Get CSC eligibility data from MSD and target based on that Improve follow-up Repeat visits Check on referrals, advocacy and use of advice If no engagement initially repeat coordinator visit offer in six months Contact hard to reach in collaboration with services they are already involved in Engage landlords and better support them to make housing improvements Improve collaboration Link in right stakeholders; primary care, medical, nursing, public health, pharmacists, community nurses, schools, public health nurses More formal relationship and regular contact between providers and DHB 37

42 Shared responsibility with hospital Workforce development of hospital staff, embed housing in nurse and health worker training Upscale Increase DHB funding for housing Promote and make the programme more widely available Build on what is started and relationships already established Broaden the use of health assessments to the wider workforce Consider primary care as an alternative referral route Get GPs to prescribe insulation Promote housing messages to households and communities Ensure programme can deliver what is promised Advocate for better policy All houses should meet the modern building code Make insulation free for landlords or a requirement for rentals Make housing more affordable Make respiratory conditions a health target Make heating more affordable e.g. with subsidies Work with businesses e.g. to address unflued gas heaters Text box 6: Recommendations from participants and key RPH, hospital & provider stakeholders Summary of satisfaction findings The majority of participants found the HCP helpful and stakeholders were unanimous in the view that the programme should continue. The main strengths were considered to be the coordinator assessment and newly established collaboration with secondary care. The main weaknesses were the intensity of input required to develop a new referral process and problems with service provision such as delays and landlord reluctance. Suggested improvements were to make referrals more routine, broaden the eligibility criteria, formalise follow-up with repeat visits, improve collaboration among groups within the DHB, upscale the programme to improve its availability and advocate for better housing policy. 38

43 discussion and recommendations In this section the evaluation findings above are summarised and discussed in light of the literature, other New Zealand housing programmes and RPH s regional experience. Recommendations are synthesised from the findings and summarised at the end of each sub-section. Referral process The referral process from hospital into the programme was feasible and generally well accepted by all the stakeholders involved. It did however, require a significant upfront investment to establish relationships and then maintain selecting, assessing and consenting patients on the wards. Estimates here were that the day-to-day visits to the ward required 2.4 hours of time per housing visit and another 7.7 hours was spent contacting, visiting, and following-up per each coordinator visit (and 3 hours of meetings and professional development makes a total estimate of 13 hours). The time required by ward staff for referral is dependent on many factors such as simplicity of eligibility criteria, number of patients recruited, and whether housing referrals are incorporated into routine practice. Key referrers may include social workers, paediatric community nurses, Māori and Pacific health workers, respiratory nurses, ward nurses, medical staff covering paediatric and respiratory wards. A senior clinician acknowledged that ward input is worthwhile because the whole point is that the programme reduces hospital admissions in the future. The short timeframe of the pilot may have limited its ability to establish a formal referral pathway however long-term investment may make this more likely. As suggested by hospital staff, housing questions could be incorporated into routinely used nursing forms and electronic discharge summaries. Housing questions should be linked to specific prompts for ward staff to identify eligible households and refer them to the housing programme. This approach has already been implemented on a paediatric ward in Northland as part of the Healthy Homes Tai Tokerau programme (personal communication). Any general practitioner (GP), nurse, or social worker who is engaged with whānau who notices cold, damp conditions can do a referral to the programme. This includes referrals from hospital. Admission forms for children have been designed with a question about whether the house is dry and warm, would the whānau benefit from insulation and whether a housing referral was done. GPs can refer through the electronic system and this is being set-up for anyone working in health to refer electronically to Healthy Homes Tai Tokerau. Primary care is an important referral pathway highlighted by many of the interviewees. Different primary care stakeholders referred to were GPs, PHOs, pharmacists, and practice nurses. The pilot team noted that the fragmented nature of primary care makes it difficult and resource intensive to engage and develop the collaboration required establishing primary care as a routine clinical pathway. In other DHBs in New Zealand, PHOs and GPs are playing more of a key role in making referrals to housing programmes. GP prescriptions for insulation have been more forthcoming in the Wairarapa than in Wellington according to one provider (personal communication). Primary care is a potential avenue to increase the number of referrals to the programme. It was considered important for prevention but may not be as good at detecting the most severe cases of illness or illnesses among families with poor or low access to general practice. The rate of recruitment fluctuated over the time period of the HCP programme. This is likely to be a reflection of the time that was available 39

44 to invest in connecting with the ward nurses while balancing the pressures of simultaneously carrying out another housing programme. Continued face-to-face collaboration with potential referrers and regular visits to the ward should assist in making referral pathways more routine. Engaging with clinical leadership and hospital management is important to establish a programme mandate and promote referrals to the housing programme. The paediatric ward was an appropriate place to identify a large number of housing-related admissions. Several hospital interviewees identified the changing landscape of housing solutions as a barrier to initiating referrals. Frustration was expressed that housing referrals were not routine practice and that some staff members could not remember how to do a housing referral. Changing availability over time, further limits understanding what is available for both consumers and health professionals. The prerequisite for housing referrals from the ward or primary care is the on-going presence of available housing solutions with a programme that has the capacity to meet the housing needs of referred clients. Sustainable funding and consistent programme availability are required to encourage referrals. Furthermore, incorporation of housing and health training within curriculums, for example at medical and nursing school, may increase awareness about the importance of housing and increase the use and demand for housing referral pathways. Other housing programmes have also used public health nurses to conduct in-home environmental assessments and provide education (Bullen et al., 2008b, Krieger et al., 2002, Krieger et al., 2000). Housing nurse skills valued in the pilot study were similar to the nurse s skills identified in the Auckland Healthy Housing Programme and include the ability to develop and sustain effective relationships with other agencies, building rapport and confidence, being non-judgmental, having good listening skills and negotiating the best solution despite institutional and system barriers (Bullen et al., 2008b). Alternative skillsets used for housing programmes have included community health workers to apply a housing checklist and public health workers to promote healthy homes principles (Krieger et al., 2002, Krieger et al., 2000). The programme team s clinical skills were valued and useful in the HCP. 1. Recommendations for the referral process 1.1. Encourage referrals to the housing programme as part of routine practice for social workers, paediatric community nurses, Māori and Pacific health workers, respiratory nurses, ward nurses, and medical staff covering eligible wards 1.2. Continue to promote the programme and its eligibility criteria to potential referrers, clinicians and hospital managers e.g. through meetings and presentations 1.3. Work with referrers to make the programme referral form as simple as possible so that it can be completed with information that is easily available 1.4. Work with clinical staff to incorporate housing questions into routine nursing forms used for housing-related admissions and prompt programme referrals for eligible patients 1.5. Work with clinical staff to create electronic referral prompts on the hospital discharge summary or primary care electronic notes 1.6. Maximise consistency and availability of the programme over time especially in regards to the information given to potential referrers 1.7. Health care providers need training about housing for example at medical and nursing school to change the culture and increase the use and demand for housing referral pathways Eligibility criteria There were concerns expressed that selected pilot criteria excluded certain groups with equal housing need such as HNZ tenants, participants with other housing-related conditions, non-māori-non-pacific ethnic groups and households not eligible for a CSC. The number 40

45 of households recruited (n=27) and visited (n=17) was less than expected. In each of the four previous RPH housing programmes; design and eligibility criteria had a critical impact on the households that were reached and the improvements that were put in place (See Appendix 3). Compared to the other programmes, the HCP reached a group of younger families who were more likely to be private rental tenants than home owners. This is important because children under five are particularly vulnerable to housing-related conditions. Engaging with midwives to make connections for families with housing need may be an important referral route not yet explored. Broadening of the criteria is recommended. With the completion of the HHP for HNZ tenants and the degree of financial need of families in social housing, it is important that HNZ tenants should be eligible for future programmes. This will require collaboration and the development of pathways to housing improvement through HNZ action. Although the definition of housing-related illnesses is not clear, it would seem reasonable to include other preventable housing-related conditions such as other respiratory infections like bronchiectasis and meningitis. Other housing related admissions might also be considered like skin infections, hepatitis A, tuberculosis, cardiovascular disease, and mental illness. The Auckland Wide Healthy Homes Initiative (AWHI) targets children at risk of Rheumatic Fever by selecting households of hospital admissions with Rheumatic Fever (if siblings in households), infectious respiratory conditions (including bronchiolitis, pneumonia, other lower respiratory tract conditions such as bronchiectasis) and meningitis. Referrals are also received from families of children enrolled in the school-based RFPP with evidence of GAS transmission in the household (e.g. 3+ GAS positive swabs) and those with a child with a past history of Rheumatic Fever, ie those receiving the monthly bicillin injections. Inclusion of all ethnic groups over five years old would make the criteria easier to use. Broader ethnicity eligibility will help the programme address more housing needs including among disadvantaged refugee and migrant groups at risk of housing-related illness. Hospital staff found that there were many elderly with housing need but few actually met the HCP criteria. The programme s focus on being easily accessible to Māori and Pacific peoples who have high rates of housing related conditions should be retained. This may include taking referrals from the Māori and Pacific health units and/or from Māori and Pacific providers. There are some limitations with the CSC as a criterion. It is seen as a blunt instrument to assess financial need and it is difficult to determine whether a household is CSC eligible. EECA has now broadened the financial criteria and will accept a cited CSC or health professional sign-off on financial hardship. Some financial criteria are necessary in targeting limited resources. To ensure that a housing programme is able to provide access to insulation it is important that eligibility criteria align with EECA criteria for the insulation subsidy. For this reason it is recommended that CSC eligibility criteria be retained with the addition of financial hardship in line with EECA criteria. In a recent systematic synthesis of the literature, it was shown that health outcomes are most likely when housing improvements targeted individuals with poor health and inadequate housing conditions, particularly inadequate warmth (Thomson et al., 2013). The impacts were less clear for housing improvements which targeted geographical areas regardless of individual need (Thomson et al., 2013) (Gibson et al., 2011) such as in the HHP. The Thomson review identifies eight studies targeting individuals with housingrelated health conditions such as respiratory illness or vascular disease and type II diabetes. The interventions were insulation (three studies) and/or heating solutions (six studies). Two of the studies were based in New Zealand (Howden-Chapman et al., 2007b, Howden- 41

46 Chapman et al., 2008) and the other six were from the United Kingdom (Osman et al., 2010), (Woodfine et al., 2011), (Allen, 2005a), (Allen, 2005b), (Somerville et al., 2000) (Health Action Calderdale Kirklees and Wakefield, 2005). In the New Zealand insulation study only uninsulated houses were targeted (Howden-Chapman et al., 2007b). The New Zealand heating study targeted houses where the main form of heating was plug in or unflued gas (Howden- Chapman et al., 2008). In both studies the intervention group had statistically significant improvements in respiratory health compared to the control group. The HCP was similar to these successful housing interventions because it was offered to households with housing-related conditions. In fact the selected patients were those with illness serious enough to require hospital admission and so are likely to have a high level of health need. Targeting to health need was a strength of the HCP. On the other hand the HCP approach was inconsistent with the best evidence because it did not specifically target households with housing need such as inadequate warmth. Less than half of the enrolled HCP households required insulation. The proportion of homes insulated was much lower than in other housing programmes at RPH for non-hnz tenants. In previous programmes insulation was a main focus. Insulation is important because the evidence is particularly clear about the costbenefits and its effectiveness in improving health. Insulation was not the only intervention on offer in the HCP and there may be many other health benefits from other referrals to smoking cessation, social supports and better access to health services. In three households there were no referrals required, highlighting that there is scope to better target the programme to housing need. Tightening of the CSC eligibility criteria may also assist. To improve programme responsiveness to housing needs, questions about housing could be considered when assessing eligibility. Kelly et al. (2013) have developed a questionnaire that could be shortened to be used to target housing interventions. Dampness and mould (33%), colder than preferred in the last month (50%), uninsulated (50%), overcrowded (20%) and exposure to second hand smoke (38%) are common among acute admissions to paediatrics. These factors are particularly important to address because these factors are modifiable and they are closely related to housing-related disease and inequalities. Ethnic disparities can be addressed by targeting the modifiable risk factors that contribute to the ethnic differences. Māori and Pacific children had (statistically significant) greater odds of exposure to all these factors that was up to a sixteen fold difference in some cases. One complicating factor of this screening approach is that the number of questions would make it difficult to apply on the wards and this may discourage referrals. A simplified approach was applied in Northland by asking whether the house would benefit from insulation. However, the HCP is offering more interventions than just insulation, so more questions would be required. Perhaps the housing nurse could contact a household to get the additional information required and minimise the input required from the referrer. It is also difficult to select which criteria should define the threshold of need that would be addressed. The threshold may change over time according to the programme capacity so a points system may help prioritise coordinator visits to the most in need. In conclusion, it is recommended to retain the CSC/financial hardship criteria, and expand eligibility to include additional housingrelated diagnoses such as bronchiectasis and meningitis, all ethnic groups and all tenancies. If narrower criteria are required, consideration should be given to simple questions and/or a score based on level of housing need such as written up by Kelly et al. (2013). Further refinement would be required to identify households at risk of Rheumatic Fever such as restriction to the 0-14 year old age group and 42

47 reconsideration of ethnicity criteria because Rheumatic Fever is almost exclusively limited to Māori and Pacific peoples. 2. Broader eligibility criteria recommended 2.1. Retain the CSC/financial hardship criteria 2.2. Expand to include HNZ tenants, additional other housing-related diagnoses and other ethnic groups 2.3. Maintain focus on easy access for Māori and Pacific such as referrals through the Māori and Pacific health unit 2.4. Consider simple questions or a score based on level of housing need such as presence of insulation, warmth of the home, dampness or mould and smoking 2.5. If limiting to risk of rheumatic fever restrict to the paediatric population and reconsider ethnicity criteria Enabling access The coordinator visit was good at identifying and making a plan to address housing, health and social concerns. A third of enrolled participants however did not get a coordinator visit and half of the referrals did not result in service provision. This signals the importance of improved follow-up. In the HCP, just 4/27 (15%) of eligible referrals received insulation whereas in the other programmes the proportion of houses insulated was 53% (HHHP) and 63% (OPMP). The reason for comparatively low rates of insulation in the HCP can be explained by the lower need for insulation among the HCP participants (44% versus 96% in OPMP), some of those households who did have unmet insulation need missed out on a coordinator visit (5/12), and there was a low rate of service provision from the insulation referrals made (4/7 in the HCP). Insulation rates may be improved by better targeting but also by better focus on minimising barriers. Reasons that enrolled participants were not visited were mainly due to inability to contact but also because of moving homes and daytime being an unsuitable time for the visit. Intensive effort was made to contact participants and make the programme easily available by a home visit with no cost. Participants mainly talked about how it was because they had too many other priorities. A delay in the visit may be appropriate to maximise access. A contact plan is also required for the common scenario where families are living in temporary arrangements or shifting homes. Patient engagement may be assisted by working more closely with culturally specific organisations with networks in their communities. Collaboration with the Māori and Pacific DHB health workers and other culturally matched staff and providers may improve the ability of the programme to contact some households. Ensuing the availability, offer and use of translation services may also assist in this way. Reasons that referrals led to non-provision were no provider record of receiving referral, participant not eligible for insulation subsidies, provider capacity was overloaded causing delays in provision, actual and perceived landlord willingness to contribute to housing solutions, family s perspective about the suitability of the service and duplicate referrals. The first follow-up step to address is to develop a feedback loop with external providers. This could be designed to ensure that housing nurse referrals are received, to gather results about whether the service was provided, and information about what, if any, barriers were there that could be addressed, either by the housing nurse for that particular family or by the housing team for on-going quality improvement. The second step is to formalise the household follow-up. For example a routine timeframe should be selected (e.g. three months) to make contact with all visited participants, address any barriers to engagement or mishaps in communication. For complex cases a repeat visit may be necessary. Repeat visits are a feature of other housing improvement interventions (Krieger et al., 2002, Krieger et al., 43

48 2000). At the three month phone call questions could also be asked about whether a household was able to make any changes based on the advice that was provided. Improved follow-up on advocacy efforts and the option of contacting the landlord directly may strengthen the advocacy aspect of the housing intervention. Lack of landlord resources to make housing improvements or lack of interest is a problem also faced by other housing programmes (Krieger and Higgins, 2002). Advocacy from public health workers assisting tenants in making requests of their landlord has been shown to be more effective, than a tenant making the request on their own (Krieger and Higgins, 2002). In some housing intervention trials, agreement from landlords was sought to avoid increasing the rent and unnecessary eviction as a result of remediation (such as insulation). This may be a strategy to try and avoid rent increases. It is uncertain how often this occurs and whether it is purely due to insulation installation. However, this study does provide one example of a rent increase that followed a few months after insulation installation. Follow-up could be better facilitated with an upgrade of the RPH housing database. An upgrade would improve efficiency, facilitate follow-up, identify the reasons for nonengagement/non-provision, monitor on-going issues for improvement and make it easier to evaluate programme outcomes. Improved consistency in data entry is important. Completion of the feedback loop with secondary care could be established by attaching a letter to the electronic patient records of each household member which specifies housing programme involvement and outcomes. 3. Enabling access 3.1. Develop referral feedback loops for secondary care (referrals in) and external providers (referrals out) 3.2. Formalise follow-up strategy of the referrals to determine their outcomes and address any barriers 3.3. Develop database to assist with follow-up and evaluating referral outcomes 3.4. Improve ethnicity data to ensure it is selfidentified and asked in a consistent manner 3.5. Give whānau the option of a delayed assessment (e.g. three months) if they are unable to engage in the first instance because of competing priorities 3.6. Consider how best to contact families who are about to move homes 3.7. Improve advocacy and engagement with landlords e.g. consider an agreement with the landlord to avoid rent increases following insulation installation 3.8. Work with culturally specific organisations, culturally matched staff and translation services to maximise the engagement of households Collaboration The HCP successfully established and developed a collaborative relationship with secondary care services at Hutt Hospital. Collaboration was developed through a participatory approach, regular communication and it relied on the close proximity between RPH and the hospital. Additional time and attention to networking would be required to develop collaborations with other DHBs to role out this programme regionally. Both RPH and the hospital would like to continue to develop this relationship. The substantial progress already developed at Hutt Hospital is an important strength at the ward and manager levels and this relationship should be maintained. The intensity required to develop this clinical engagement is consistent to the challenges faced by at least two other New Zealand housing programmes. Collaboration with external providers was already established at the beginning of the HCP and referrals from the HCP were a minor proportion of the total referrals received. Collaboration between RPH and external providers was mainly at the operational level and through the Regional Housing Coalition. 44

49 Some providers would like more collaboration particularly around operational aspects. It is recommended that collaboration be further developed with the relevant service providers in the community which focusses on developing feedback about receipt of referrals, whether the household engaged and what services were provided. One of the strengths of the Auckland Wide Healthy Housing Initiative (AWHI) is its strong relationships with dynamic and diverse communities and knowing what services are in the community (personal communication with Bronwyn Petrie, Ministry of Health). The HCP housing nurses contribute an important resource of relationships built up with community providers over many years. These relationships directly influence what referrals are made to address household needs. Finally, there is a greater scope for more common understandings of programme aims and success indicators. Developing agreed direction about the programme logic, rationale and goals is recommended. This is likely to help focus the efforts of RPH and other organisations more efficiently towards a common goal. 4. Collaboration 4.1. Maintain a participatory approach in service development e.g. engaging clinical staff to develop the referral process 4.2. Maintain regular communication with referrers e.g. regular programme updates and information sessions were particularly valued 4.3. Improve collaboration with external providers to develop referral feedback about referral receipt, whether the household engaged and what was provided 4.4. Agree on a commonly held programme goal which is shared by stakeholders across key partner organisations Upscaling Any efforts to upscale this programme should include a greater number of households visited. Consideration should be given to how the transfer from Housing New Zealand of social housing services to the Ministry of Social Development will impact on this and other housing programmes, particularly in terms of collaboration and referrals for housing services. The current referral process is as simple as possible for hospital staff to refer in and the programme however it is resource intensive for programme staff. This could be improved over time by incorporating referrals to the housing programme into routine processes (as discussed above). The HCP provides a comprehensive housing, health and social assessment, education and advice, referrals based on need, and a degree of follow-up for each household. This requires on average 7.7 hours per household. There may be ways to reduce the time required by automating or standardising referrals and feedback, creating a database to improve follow-up, and even perhaps narrowing the coordinator visit to prioritise the discussion to the most important risk factors for housing-related health. Scaling up could also be done by incorporating housing interventions into the regular duties of primary and secondary health care home visitors (Krieger and Higgins, 2002). Options for scaling up may be linked to some elements of the housing coordinator assessment provided by social workers, paediatric community nurses, Māori and Pacific DHB health workers, respiratory nurses, practice nurses, health promoters and/or community providers. Collaboration with these groups should be considered to develop sustainable housing referral pathways. One approach is to contract providers to do the housing coordinator assessment and retain coordination of the process. This approach is closer to the AWHI model where community providers are contracted to visit households and complete a list of standardised questions about housing and health. Household information is then captured and used to make referrals to the appropriate services. Referrals are followedup through careful data collection. The model remains to be evaluated and potentially 45

50 creates additional transaction costs. However efficiencies may be gained by working in conjunction with community providers already working with whānau through their other programmes. Close community links may make this model more responsive and appropriate to cultural and community needs. The HCP visit appears to provide a much broader assessment of need, taking a holistic strength based approach which incorporates housing, health and social issues and their interactions. Advice and education is provided directly based on individual needs. Housing nurse skills, experience and resource are available at RPH which is ideally placed to take a lead on housing aspects of the Rheumatic Fever prevention plan. Improvements to the housing coordinator programme such as streamlining referrals to the programme, better targeting households in need, following-up on referrals and data management may help reach more participants with the available resource. The first challenge is to re-establish a productive referral process. The benefits of a housing programme should be weighed against the cost and compared with the cost-benefits of other secondary care interventions. 5. General 5.1. Develop additional referral pathways from other primary and secondary health care workers 5.2. Streamline the housing coordinator assessments provided at RPH to maximise the number of housing assessments provided 5.3. Collaborate with other services and providers to help them provide housing coordinator assessments wherever possible 5.4. Incorporate a strategy for on-going monitoring of outcomes so that frequent on-going adjustments can be made to improve programme quality and productivity 46

51 conclusion The HCP study is a great example of what housing solutions can be implemented in a short time frame with limited resources. On average it required 2.4 hours for recruitment per household visited and 7.7 hours for the visit, referrals and informal follow-up. In the four month timeframe only 17 housing visits were carried out. To roll out the programme more widely a less time intensive and more sustainable way of recruiting is required. The HCP demonstrates the feasibility of a referral process that identifies patients with housing-related conditions and to offer households housing solutions. The HCP successfully established and developed a collaborative relationship with secondary care services at Hutt Hospital. The referral process could be improved with incorporation of programme eligibility criteria into nursing forms and the addition of alternative referral pathways both from primary care and other DHB staff such as Māori and Pacific health workers, social workers and paediatric community nurses. Eligibility criteria could be broadened with consideration to more directly targeting individuals with housing needs. The health and social assessment was appreciated and participants particularly valued the advice and links to housing, health and social providers for things like insulation and curtains. Approximately a third of the enrolled participants did not get coordinator visits and half of the referrals did not lead to service provision. Formalised follow-up is recommended to address the preventable systemic barriers to access. An upgrade in the usability and quality of the database may assist with follow-up and on-going monitoring. 47

52 summary of recommendations 1. Make the referral process routine 1.1. Encourage referrals to the housing programme as part of routine practice for social workers, paediatric community nurses, Māori and Pacific health workers, respiratory nurses, ward nurses, and medical staff covering eligible wards Continue to promote the programme and its eligibility criteria to potential referrers, clinicians and hospital managers e.g. through meetings and presentations Work with referrers to make the programme referral form as simple as possible so that it can be completed with information that is easily available Work with clinical staff to incorporate housing questions into routine nursing forms used for housing-related admissions and prompt programme referrals for eligible patients Work with clinical staff to create electronic referral prompts on the hospital discharge summary or primary care electronic notes Maximise consistency and availability of the programme over time especially in regards to the information given to potential referrers Health care providers need training about housing for example at medical and nursing school to change the culture and increase the use and demand for housing referral pathways. 2. Broader eligibility criteria recommended 2.1. Retain the CSC/financial hardship criteria Expand to include HNZ tenants, additional other housing-related diagnoses and other ethnic groups Maintain focus on easy access for Māori and Pacific such as referrals through the Māori and Pacific health unit Consider simple questions or a score based on the level of housing need such as presence of insulation, warmth of the home, dampness or mould and smoking If limiting to reducing the risk of rheumatic fever restrict to the paediatric population and reconsider ethnicity criteria. 3. Streamlining follow-up and enabling access 3.1. Develop referral feedback loops for secondary care (referrals in) and external providers (referrals out) Formalise follow-up strategy of the referrals to determine their outcomes and address any barriers Develop database to assist with follow-up and evaluating referral outcomes Improve ethnicity data to ensure it is selfidentified and asked in a consistent manner Give whānau the option of a delayed assessment (e.g. three months) if they are unable to engage in the first instance because of competing priorities Consider timing and how best to contact families who are about to move homes Improve advocacy and engagement with landlords e.g. consider an agreement with the landlord to avoid rent increases following insulation installation Work with culturally specific organisations, culturally matched staff and translation services to maximise the engagement of households. 48

53 4. Maintain and improve collaboration 4.1. Maintain a participatory approach in service development e.g. engaging clinical staff to refine the referral process Maintain regular communication with referrer s e.g. regular programme updates and information sessions were particularly valued Improve collaboration with external providers to develop referral feedback about referral receipt, whether the household engaged and what was provided Agree on a commonly held programme goal which is shared by stakeholders across key partner organisations. 5. Upscale the programme 5.1. Develop additional referral pathways from other primary and secondary health care workers Streamline the housing coordinator assessments provided at RPH to maximise the number of housing assessments provided Collaborate with other services and providers to help them provide housing coordinator assessments wherever possible Incorporate a strategy for on-going monitoring of outcomes so that frequent on-going adjustments can be made to improve programme quality and productivity. 49

54 references ALLEN, T. (2005a) Evaluation of the housing for healthier hearts project April 2003 March Bradford: University of Bradford. ALLEN, T. (2005b) Private sector housing improvement in the UK and the chronically ill: implications for collaborative working. Housing Studies, 20, BULLEN, C., KEARNS, R., CLINTON, J., LAING, P., MAHONEY, F. & MCDUFF, I. (2008a) Bringing health home: householder and provider perspectives on the healthy housing programme in Auckland, New Zealand. Soc Sci Med, 66, CHILDREN S COMMISSIONER S EXPERT ADVISORY GROUP (2012) Solutions to Child Poverty in New Zealand: Evidence for Action, Wellington, Office of the Children s Commissioner. CLINTON, J., MAHONY, F., IRVINE, R. & AL., E. (2006) The Healthy Housing Programme: Report of the Outcomes Evaluation (year two). Auckland, University of Auckland. GIBSON, M., PETTICREW, M., BAMBRA, C., SOWDEN, A. J., WRIGHT, K. E. & WHITEHEAD, M. (2011) Housing and health inequalities: A synthesis of systematic reviews of interventions aimed at different pathways linking housing and health. Health & place, 17, HEALTH ACTION CALDERDALE KIRKLEES AND WAKEFIELD (2005) Initial analysis on the Health Action Calderdale Kirklees and Wakefield Project. Health Action Calderdale Kirklees and Wakefield. Kirklee, Calderdale, and Wakefield Council. HEFFORD, R., BAKER, A., CURTIS, A., DAVIES, C., GALL, B., JONES, M., HENDRICKS, G., RYAN, L., VIGGERS, H. & WALKER, E. (2008) Healthy Homes Healthy People, Older Persons Pilot Project 06/07 Review. Prepared for Hutt Housing Steering Group. HOWDEN-CHAPMAN, P., MATHESON, A., CRANE, J., VIGGERS, H., CUNNINGHAM, M., BLAKELY, T., CUNNINGHAM, C., WOODWARD, A., SAVILLE-SMITH, K. & O DEA, D. (2007a) Effect of insulating existing houses on health inequality: cluster randomised study in the community. BMJ, 334, 460. HOWDEN-CHAPMAN, P., MATHESON, A., VIGGERS, H., CRANE, J., CUNNINGHAM, M., BLAKELY, T., O DEA, D., CUNNINGHAM, C., WOODWARD, A. & SAVILLE-SMITH, K. (2007b) Retrofitting houses with insulation to reduce health inequalities: results of a clustered randomised study in the community. BMJ, 334, HOWDEN-CHAPMAN, P., PIERSE, N., NICHOLLS, S., GILLESPIE-BENNETT, J., VIGGERS, H., CUNNINGHAM, M., PHIPPS, R., BOULIC, M., FJALLSTROM, P., FREE, S., CHAPMAN, R., LLOYD, B., WICKENS, K., SHIELDS, D., BAKER, M., CUNNINGHAM, C., WOODWARD, A., BULLEN, C. & CRANE, J. (2008) Effects of improved home heating on asthma in community dwelling children: randomised controlled trial. BMJ, 337, a1411-a1411. JACKSON, G., THORNLEY, S., WOOLSTON, J., PAPA, D., BERNACCHI, A. & MOORE, T. (2011) Reduced acute hospitalisation with the healthy housing programme. Journal of Epidemiology and Community Health, 65, KRIEGER, J. & HIGGINS, D. L. (2002) Housing and health: time again for public health action. Journal Information,

55 KRIEGER, J. K., TAKARO, T. K., ALLEN, C., SONG, L., WEAVER, M., CHAI, S. & DICKEY, P. (2002) The Seattle-King County healthy homes project: implementation of a comprehensive approach to improving indoor environmental quality for low-income children with asthma. Environ Health Perspect, 110, 311. KRIEGER, J. W., SONG, L., TAKARO, T. K. & STOUT, J. (2000) Asthma and the home environment of low-income urban children: preliminary findings from the Seattle-King County healthy homes project. Journal of Urban Health, 77, OSMAN, L. M., AYRES, J. G., GARDEN, C., REGLITZ, K., LYON, J. & DOUGLAS, J. G. (2010) A randomised trial of home energy efficiency improvement in the homes of elderly COPD patients. European Respiratory Journal, 35, POYNTER, M. (2013) Hutt Hospital Housing Coordinator: A Pilot Study Regional Public Health. PROOF RESEARCH AND EVALUATION, ROBERTSON RESEARCH & AKROYD RESEARCH AND EVALUATION (2010) Healthy Homes Healthy People Programme Evaluation. Wellington, For the Hutt Housing Forum. SOMERVILLE, M., MACKENZIE, I., OWEN, P. & MILES, D. (2000) Housing and health: does installing heating in their homes improve the health of children with asthma? Public Health, 114, STUFFLEBEAM, D. (1983) The CIPP model for program evaluation. IN MADAUS, G., SCRIVEN, M. & STUFFLEBEAM, D. (Eds.) Evaluation Models: Viewpoints on Educational and Human Service Evaluation. Boston, Kluwer-Nijhoff. THOMSON ET AL (2013) Housing improvements for health and associated socioeconomic outcomes (Review). Cochrane. THOMSON, H., THOMAS, S., SELLSTROM, E. & PETTICREW, M. (2013) Housing improvements for health and associated socio-economic outcomes p39. The Cochrane Library. WOODFINE, L., NEAL, R. D., BRUCE, N., EDWARDS, R. T., LINCK, P., MULLOCK, L., NELHANS, N., PASTERFIELD, D., RUSSELL, D. & RUSSELL, I. (2011) Enhancing ventilation in homes of children with asthma: pragmatic randomised controlled trial. British Journal of General Practice, 61, e724-e

56 appendix 1: further methods The evaluation assesses the context, inputs, processes/ outputs (implementation) and impact of the HCP programme in achieving its outcomes. Different types of evaluation are covered in the different sections of this report which in turn are structured around the evaluation objectives (Table 7). Mixed method data collection was carried out. Evaluation type Programme rationale Referral process Access to services Collaboration Comparing programmes Context x x Input x x x Process & output x x x x Impact/outcomes x x Table 7: Type of evaluation in the sections of this report The evaluation plan was developed in the design phase of the HCP (Poynter, M) and is derived from two evaluation models which help to determine the necessary evaluation data. The CIPP evaluation model (Stufflebeam, 1983) has four components (Context, Inputs, Process, Product) and these components are compatible with the four steps of a logic model (inputs, activities, outputs, outcomes). Evaluation data was collected by mixed methods. Qualitative and quantitative data were compared and combined to maximise the validity of results. Data collection centred around qualitative semi-structured interviews of four groups of interviewees; participants, RPH staff, hospital stakeholders and service providers. A full description of the questions to be evaluated was developed based on the programme logic, the HCP evaluation plan and previous housing evaluations (see Evaluation questions section below). Qualitative data Qualitative data collection methods included face-to-face interviews, telephone interviews and a focus group. Interviewees included participants, operational and management staff at RPH, key stakeholders at Hutt Hospital and providers in the community (Table 8). All eligible participants who consented to the HCP study were invited to be interviewed, whether or not they received a health and social assessment. External providers were selected for interview if they had more than one referral from the HCP. Semi-structured interviews were carried out by one interviewer face-to-face with HCP participants (who received a coordinator visit), RPH operational staff (n=3), stakeholders at Hutt Hospital (n=6) and service providers (n=7). All RPH, hospital and providers that were approached consented to be interviewed. Participants who had a coordinator visit (n=17) were contacted by telephone to arrange an interview at their home. Three attempts at contact were made on different days, at different times of the day, using all of the phone numbers available. 11/17 were contacted and all of these consented to an interview. 8 interviews were face-to-face, 2 were on the telephone and 1 answered questions via . 6 were not contacted including 1 person who had passed away. Interviewees were 4-8 months since the coordinator visit with a median of 5 months. Māori and Pacific participants were offered support from one of the nurses(?) from the Māori and Pacific Health Units at Hutt Hospital. This was done to maximise the cultural connection and improve the rapport for the interview. Interviews were electronically audiorecorded wherever possible and permitted. 52

57 All participants contacted agreed to interview however one was over the telephone, and one was via communication. Participants who did not receive a coordinator visit but who had consented to the HCP study (n=8) were contacted to do a semi-structured telephone interview. 6/8 were interviewed, 1 had moved overseas and 1 was not contacted. Two additional participants had been enrolled but we did not have consent to contact them for the evaluation. Interviews were 5-8 months after the original hospital admission and enrolment with a median of 5 months. Notes were written during the phone call to record participant answers. A focus group was carried out for 5 RPH management staff and the dialogue was recorded both electronically and by an observer. The focus group occurred 5 months after the HCP programme ended on the 3rd December For each group of interviewees interview questions were selected from the Evaluation question list as appropriate (Table 9). A semistructured format was used that included open and closed questions. Interview schedules were reviewed and tested before they were used. The participant interview schedule was reviewed and piloted with Māori health workers to maximise its cultural appropriateness. The questions were kept consistent across different interviewee groups as much as possible. The topics of the questions are summarised in Table 8 according to interviewee group. All electronic recordings were transcribed word for word. Transcriptions and interview records were coded for themes. The themes were recorded for each interviewee on a spreadsheet. Themes were interpreted by one evaluator, with review by a second evaluator (CR). A summary of the themes for each group by each interview question was the basis for the results presented in the body of the evaluation. Two case studies were selected based on participants where particularly rich information was identified and who experienced the common strengths and flaws of the HCP programme. The steering group of RPH Housing Group members will ensure that conclusions are sufficiently backed up by the gathered evidence. The case study interviewees had the opportunity to review the script and both gave their permission for the case study to be published. 53

58 Participants visited Participants - not visited RPH operational RPH managerial focus group Hospital staff External providers Number of interviews 10 (of 17) 6 (of 8) Overall General e.g. initial statements General e.g. initial statements General e.g. initial statements General e.g. initial statements General e.g. initial statements General e.g. initial statements Role and organisation Role at RPH and role in HCP Role at RPH and role in HCP Role at DHB and role in HCP, time involved, changes Role and experience Are routine questions asked about housing? Services & educ they deliver Housing responsibility & referrals Normal referral pathways to their organisation Training & interest in housing & health Knowledge Knowledge of housing & health link Knowledge of housing & health link Knowledge of housing & health link Knowledge of housing & health link Design of HCP Aim & purpose: problem that HCP aimed to address Aim & purpose: problem that HCP aimed to address Aim & purpose: problem that HCP aimed to address Design: development Design: development Design development Indicators of success Indicators of success Indicators of success Referral process Hospital referral & other potential options Hospital referral & other potential options Hospital referral vs. other potential options Hospital referral vs. other potential options Hospital referral vs. other potential options Info. provided in hosp & written materials Info. provided in hosp & written materials Info. Provided e.g. consent & written materials Expectations Expectations Referral process: division responsibilities, time involved Referral process: how well did it work, recommended improvements Referral process: level of involvement, who was referred, strengths and weaknesses Development of referral process & eligibility criteria Development of referral process & eligibility criteria Development of referral process: changes over time Usability of eligibility criteria Eligibility criteria: usability, appropriateness, narrow or broad Did it meet their eligibility criteria? 54

59 Participants visited Participants - not visited RPH operational RPH managerial focus group Hospital staff External providers Number of interviews 10 (of 17) 6 (of 8) Was the intended target group reached? Was the intended target group reached? improvements Target group: Were greatest needs referred? Coordinator visit Coordinator visit: good & bad Interest in future coordinator visit Coordinator visit: strengths, length, relevant aspects, improvements Coordinator visit: role of the housing, health and social assess. Advice/tips/education received & actions taken Common tips given Access to interventions Number of referrals & length of visit Number of referrals & length of visit Timing and capacity to act on referrals Referrals made: how decided, time spent incl. follow-up Satisfaction with referrals, suggested improvements, any duplication? Arranging visit: any problems, hours, timing Why visit didn't happen: any problems, hours, timing Arranging visit: methods used, barriers, timing Barriers to change & changes still to make Referral outcome barriers: access, waiting time Barriers Engagement & barriers Referral outcomes Were all aspects of a referral fully addressed? Health outcomes Subjective health outcomes Collaboration Interaction between hospital & housing Interaction between provider and health Collab. with hospital: develop., adequacy, relations with the wards Collab. with hospital: new relations, improvements Collab. with RPH: development & adequacy Collab. with providers: develop., adequacy, feedback Collab. with providers: new relations, improvements Collab. with RPH: current level, changes & adequacy Feedback given to hospital referrers Feedback given to referrers General comments Opinion on continuing HCP: sustainability, risks Opinion on continuing HCP: sustainability, risks Opinion on continuing HCP Opinion on continuing HCP 55

60 Quantitative data Hospital staff External providers Participants visited Participants - not visited RPH operational RPH managerial focus group Number of interviews 10 (of 17) 6 (of 8) Positives; what worked well? Positives; strengths Positives; what worked well? Satisfaction Positives; what worked well? Positives; Was it helpful? Positives; what doesn't need improved Negatives; improvements Negatives; improvements, didn't work well? Negatives; weaknesses Negatives; things didn't work so well to be improved Negatives; what could be improved Negatives; Bad or not so good effects Unintended effects Unintended effects Unintended effects Unintended effects Unintended effects Unintended effects Suggestions and ideas for perfect programme Suggestions and ideas for perfect programme Suggestions and ideas for perfect programme Suggestions and ideas for perfect programme Suggestions and perfect programme ideas Suggestions and ideas for perfect programme Table 8: Sources of information for the HCP evaluation including questions asked in semi-structured interviews and focus groups. Quantitative data for the housing HCP was collected from the RPH housing database, participants and provider referral outcomes, programme documentation on eligibility assessments and the routinely collected hospital admissions data. A copy of the live RPH housing database was taken on the 30th September Data was exported to excel for analysis. The database was used to describe various aspects of the HCP including time to assessment, referral numbers and types, housing conditions, diagnosis and demography of participants. However demography data was based on database figures triangulated with participant data. At interview, participants (visited and not visited) were asked structured questions about ethnicity, CSC eligibility, insulation need at assessment and household tenancy. This data was used to confirm or adjust the database figures. The database was particularly useful to calculate indicators that could be used to compare the HCP to other programmes (see below). The housing database has been used to track the housing health, and social assessment aspects of three different RPH housing programmes. Both participants and service providers were asked about referral outcomes. Providers were ed a written survey with a simple set of five questions for each consented HCP referral made: Was this referral received? Were you able to contact this family? Were they eligible for your service? Were they offered the service? Has the service been delivered? All 7 providers gave this feedback. To maximise the validity of this data, participants were also asked about the outcomes from the individual referrals that had been arranged for their household s members. This was done asking each household about the referral recorded in the housing referral database. 56

61 The RPH housing database figures were complemented with the additional referral information that was gathered from the interviews, the provider s survey and the participant s hard copy notes. Data from providers and participants was entered into a spreadsheet, checked for discrepancies and presented in flow diagrams. Where there were discrepancies prioritisation was given to the participant s experience of the process if available. Triangulation of data aimed to maximise its validity. Data was available (notebook) for a list of patients who were assessed for eligibility. This programme information was used to assess the number of patients assessed, and the reasons that they were not eligible for the HCP programme where these were available. The data was presented in a flowchart summarising the journey of patients and their households from the time of ward referral to whether they had a coordinator visit. Hutt Valley DHB admissions data was compared with the enrolled HCP participants to determine the ratios of HCP enrolments to the number of admissions to the hospital with the same diagnoses. Admission data was available by diagnosis, month, age and ethnicity; but not by CSC eligibility. Housing coordinator time investments were calculated based on the July 2012 June 2013 financial year when two housing nurses were employed at RPH with 1.5 FTE devoted to the housing programme. Taking into account the four months that the 0.7 FTE position was vacant, there was an equivalent of 1.26 housing nurse FTE over the full year. In that time 217 coordinator visits were carried out for either the HHP or HCP. This was 171 household visits per 1.0 FTE. This averages to be approximately 10.7 hours per coordinator visit (assuming 229 working days in a year). These figures are mostly from the HHP and in that programme there was no requirement to recruit referrals from the wards. In the HCP programme this took up to an hour a day by either the housing nurse or registrar. If we estimate that half an hour a day over 16 weeks (a total of 40 hours) was invested to enrol 27 households and 17 of these were visited; then 2.4 hours of patient recruitment time was invested per household visit. The patient recruitment time and coordinator visit time total 13 hours. Evaluation questions The following evaluation questions were developed pre-interview and structured according to the logic and CIPP models and the three main objectives of the evaluation. The questions were designed to align with previous evaluations of housing programmes in the Hutt Valley so that a comparison between the HCP study and these evaluations could be made. Interview schedules were developed from these evaluation questions. 57

62 Programme logic step Proposed indicator (Hefford et al., 2008) (Proof Research and Evaluation et al., 2010) Information to identify strengths, barriers, successes, improvements Context: Assessment of design & logic Were important needs addressed? N/A Start and end-date What was the timeframe of project/ programme? Description of purpose and logic Resources (funding and organisational inputs) Comparison of design Why was the programme introduced? Why did it finish? What is the purpose of the programme? What is the programme s philosophy and programme logic? What resources were available? (including time, staffing, 3rd party providers) How does the programme design compare to the Auckland HHP design? Inputs: Formative evaluation Was a feasible design employed? 30 Hutt Hospital inpatients met referral criteria with; primary diagnosis of asthma, pneumonia or RF; Māori or Pacific peoples or 0-4yo; CSC eligible; and non-hnzc house Selection criteria Participants demography (age, socioeconomic status, ethnicity) Proportion of households who completed the housing, health and social assessment who were Māori or Pacific Proportion of housing, health and social assessment participants who were homeowners Proportion of referrals who had a community services card Time elapsed from referral to housing, health and social assessment completion Who was the intended target/eligible population? Who was referred to the programme? (numbers, demographics, time of year) What do individuals think of the referral process into the HCP programme? Was it easy for clinical staff to remember to refer eligible patients? What changes are needed to the referin process? What was the timing of crucial time points through the system? Process/Outputs Process evaluation Was the design well executed? How well was programme implemented? (How efficient was the programme?) Patient invitation to participate in the study after discussion with study staff Identification of appropriate patients by clinical staff Resources required Referral tool Referral criteria understood Proportion of housing related admissions referred, by ethnicity/ses Ratio of health and social issues identified to the number of housing, health and social assessments?? What resources were used to implement the programme? How many staff FTE were involved? How many housing, health and social assessments can were carried out each week per FTE committed to doing this? Was a rapid housing referral tool for use by health professionals developed? How well did the referral tool work? How many of the referred patients were eligible and invited into the study for housing, health and social assessment? What are the local rates of housing related admissions? Did the programme recruit from the target population? Does the referred group differ from the eligible population? What is the level of health, social and housing need identified among participants? Data source for HCP Evaluation Project report Evaluation steering group Auckland documents Key stakeholder interviews Project report Housing database Housing database Key stakeholder interviews Participant interviews Housing database Key stakeholder interviews Participant interviews Project report Project report Stakeholder interviews Project report HCP programme database DHB population statistics National minimum dataset Housing database 58

63 Programme logic step Proposed indicator (Hefford et al., 2008) (Proof Research and Evaluation et al., 2010) Information to identify strengths, barriers, successes, improvements Data source for HCP Evaluation Home visit and assessment by housing coordinator (with patient after discharge) Ratio of housing, health and social assessment completion to eligible referrals invited to the programme, by ethnicity How many health and social assessments were carried out? How many weren t carried out? How long after discharge did the housing, health and social assessment visits occur? Project report Attempts at housing, health and social assessments before abandonment How much time and what number of contacts was required to plan a housing, health and social assessment visit? What were the barriers to arranging housing, health and social assessment visits? Stakeholder interviews Participant interviews Coordinator referrals for 3rd party provider services Ratio of (health, social and housing) referrals made to number of housing, health and social assessments How many health, social and housing referrals were made? (Consider recipient agency types, date, time delays) What changes would improve the referral process? Participant interviews Key stakeholder interviews Short-term outcomes Impact evaluation Did the efforts succeed short-term? Clinical staff satisfaction with the referral process Degree of housing and clinical staff satisfaction - thematic analysis Was collaboration established with housing and health stakeholders in the Wellington region? Were housing, clinical staff and provider agencies satisfied with the programme? What were the good aspects? What could be done better? What were the unintended effects? How well does HCP fit with hospital setting, housing setting, current government priorities? What will determine whether it is a sustainable programme? What is the opinion on extending the HCP programme? Key stakeholder interviews Appropriate housing intervention initiated Number of houses with housing need identified that were referred for housing intervention e.g. Insulation, curtains What health needs were identified? How many and what sort of referrals were initiated? Housing database Appropriate social intervention initiated Number of household members with social need identified that were referred for social intervention e.g. budgeting advice, food package Proportion of household members who received education for social issues Appropriate health intervention initiated Number of household members with health need identified that were referred for health intervention e.g. GP contact, Asthma trust Proportion of household members who received health education Patient engagement Have stakeholders (including participants) been informed of the results and planned actions of the HCP project? Evaluation report dissemination Medium-term outcomes Impact evaluation Did the efforts succeed medium-term? 59

64 Programme logic step Patient satisfaction with the process Third party satisfaction with the process Improved physical home environment Appropriate physical resources such as food and linen Householders have access to required social services Improved access to health services Proposed indicator (Hefford et al., 2008) (Proof Research and Evaluation et al., 2010) Proportion of participants who were satisfied - thematic analysis Proportion of stakeholders who were satisfied - thematic analysis Proportion of households that received a housing intervention of those - Who were referred to the HCP programme - Who had a health and social assessment (housing, health and social assessment) - Who were tenants and owner occupiers - Who were referred to a housing intervention, by ethnicity Proportion of household members who received social intervention (of those referred) Proportion of household members who received health intervention (of those referred) Reasons that housing (and/or health/social) intervention was not completed Information to identify strengths, barriers, successes, improvements Were participants satisfied with the referrals and the assessment? What were the good aspects? What could be done better? What were the unintended effects? Do you feel the time taken to implement the stages of the HCP was appropriate? Do you feel that information about the HCP was explained to you so that you understood what was involved? Do you feel that at all stages of the HCP you were treated with respect and that you were able to address any questions or concerns you may have had? Was collaboration established with housing and health stakeholders in the Wellington region? Were agencies satisfied with the referrals? What were the good aspects? What could be done better? What were the unintended effects? How well does it fit with housing setting, current government priorities? What will determine whether it is a sustainable programme? To what extent were whānau/families able to access housing improvement interventions when this was requested and indicated? Did participants receive any of the following services since referral to the HCP project? - Assessment of the home? - Retrofit insulation? Did you receive any of the following services since your referral to the HCP project? e.g. (align with services the household was referred to) WINZ funds for heating Food package Linen Budgeting advice Did you receive any of the following services since your referral to the HCP project? e.g. GP contact What were the barriers to accessing housing, social and housing interventions? Data source for HCP Evaluation Participant interviews Key stakeholder interviews Participant interviews Housing database (to identify referrals in, housing, health and social assessments, tenants and referrals out) Participant interviews Housing database (to identify those referred) Participant interviews Key stakeholder interviews 60

65 Programme logic step Proposed indicator (Hefford et al., 2008) (Proof Research and Evaluation et al., 2010) Information to identify strengths, barriers, successes, improvements Data source for HCP Evaluation Householders able to minimise housing related illness through knowledge and behaviour Householders able to minimise illness through knowledge and behaviour Participants able to give example of a change in behaviour to minimise housing related illness e.g. that helps keep home warm, dry, and not crowded Has the household acted differently to reduce risk of housing-related admissions, in light of the health and social education provided to household members? Were the health education messages acted on and what has changed? Was the message to seek health care early understood? Participant interviews Long-term outcomes Impact evaluation Did the efforts succeed long-term? Improved housing-related health outcomes for patients Reduced inequalities for housing-related health conditions Perceived health benefits, by ethnicity Following the housing, health and social assessment and/or insulation of your home have you noticed any health improvements/benefits among the occupants? Yes/No, If yes please detail where you have noticed any health improvements/benefits Since the housing, health and social assessment and/or new insulation was done to home have members of the household needed to visit the doctor or increased their medication due to respiratory complaints? Yes/No please explain Participant interviews Table 9: Evaluation questions Programme comparisons The HCP was compared with other housing programmes in the Hutt Valley in which RPH was a key player. Comparisons were made with these programmes: Healthy Housing Programme (HHP) in conjunction with Housing New Zealand - Hutt Valley Healthy Homes Healthy People Programme (HHHP), Jan 2008 July 2010 (Proof Research and Evaluation et al., 2010) Older Person HCP Evaluation/Maintenance HCP evaluation (OPMP), Dec 2006/Jan 2007 June 2007 (Hefford et al., 2008) It was intended that the HCP would be compared with the other programmes according to the following design features and indicators: Timeframe of each project (start and end date) Resources (funding and organisational inputs) Stakeholders Why was the programme introduced? And why did it finish? Selection /referral process Eligibility criteria Participants demography (age, socioeconomic status, ethnicity) Level of need identified e.g. ratio of the number and type of health and social issues per housing, health and social assessment carried out Timing of crucial time points through the system Referrals made (health, social and housing) e.g. ratio of the number and type of referrals per assessment Result of housing referrals e.g. ratio of insulation installation per referral made Results of referrals for health and social outcomes e.g. issues identified, education provided 61

66 Design feature or indicator Descriptive design features e.g. timeframe, referral process, eligibility criteria Strengths, weaknesses, recommendations Housing Coordinator Pilot Study HCP report Healthy Housing Programme No evaluation available Programme documents Healthy Homes Healthy People Previous evaluations Older Person s Maintenance HCP Previous evaluation Evaluation Previous evaluation Previous evaluation Overview on number of visits Evaluation Database Previous evaluation Previous evaluation Timing of crucial time points Evaluation / Database Insulation referrals and outcomes Housing conditions and the number of (social & housing, health) referrals made Participants demography (age, ethnicity, tenancy, csc) Previous evaluation Evaluation Previous evaluation Previous evaluation Database Database Database Evaluation Database Database Previous evaluation Table 10: Sources of quantitative data to describe different Hutt Valley housing programmes Barriers to accessing interventions Stakeholder and participant satisfaction Additional fields were added to summarise the strengths, weaknesses and recommendations from the evaluation findings where these were available. The data for the comparisons comes from relevant evaluations, programme documents and from the RPH housing database (Table 10). Effort was made to determine the outcomes from the HHP by using HNZ data but for example the data did not show clearly how many houses had been insulated for the programme period. Ethical Considerations Ethical issues that may be relevant were considered during the development of the HCP study (2013 HCP Report). Informed consent for involvement in the HCP study included a discussion about the planned evaluation, and participants gave consent to be telephoned to arrange an interview during the evaluation phase of the study. When participants were contacted for the evaluation they were asked for their permission to be interviewed and given the option to do the interview on the phone/by if they did not want or could not do a home visit for the interview. Participants interviewed at home were compensated for their time with a $20 grocery voucher given at the end of the interview. The two participants selected for a case study were specifically rung to obtain their permission. They were given the opportunity to see a draft of the case study and make any changes they thought were relevant. Their additional time was compensated with another $20 grocery voucher. Interviewees that were Māori and Pacific were given the option of a visit from both the interviewer and a Māori or Pacific health worker if they were willing to have this. In several cases this enabled the interview to be conducted with support from someone speaking the participant s own language. If any questions remained or there were incomplete referrals that the household would like to have addressed, this information was pursued by the housing nurses. When enrolled participants who had not received a coordinator visit were interviewed, they were offered further contact from the housing nurses and a coordinator visit was arranged if they were agreeable to this. 62

67 Limitations Limitations included missing data, interviewer bias, database limitations and inability to assess long-term impact. Missing data One-third of participants with or without a coordinator visit did not get interviewed for the evaluation. This group may differ from the other participants. For example they may be less likely to engage with services. This would bias some of the evaluation findings. What is presented here (particularly about referral outcomes) may be a more positive picture than the true reality for those who did not do an interview for the evaluation. Interviewer bias Methods, analysis and interpretation of qualitative research are influenced by the researcher and it is important to acknowledge personal perspectives. My lens for writing this analysis is that of a Pakeha woman trained in medicine, epidemiology and public health with an interest in the social determinants of health. Data gathering does not occur in a vacuum. The process of collecting the information for this evaluation may have contributed to some of the responses. For example the housing nurse suggestion to delay follow-up was influenced by the success of following up participants after their interviews. We had discussed how, after a period of time, participants were more open to a coordinator visit than at the original time of the hospital admission. Many of the interviewees found out about programme developments in discussion with the interviewer and other RPH staff which may have influenced what they had to say about the programme. The evaluation was carried out at the same time as further housing programme development at RPH which may have influenced the discussion of these results. Database limitations The housing database is a record of all housing, health and social assessments done since 2008 by RPH housing nurses. In the process of analysing data for the evaluation I came across several limitations with the data. For these reasons it is important not to put too much weight on the figures calculated from the database. Database entry has not been completed consistently over time. Several different housing nurses and technical officers have used the database. Much of the 2008 and some of the 2009 data was entered retrospectively and this is thought to have over-recorded the number of referrals by including some of the education delivered by the housing nurse as a referral. The referral fields are open-ended and so referrals can be recorded any number of ways. The database is not fit for purpose. It seems to be overly thorough and have important deficits. The database does not include fields for things like whether the person s house has adequate insulation and other important eligibility criteria. It remains unclear how exactly the database is meant to be used and for what purpose. Some fields have a single tick box e.g. for heating. An unselected tick-box may mean the field has not been completed or it may mean there is no heating in the house or that perhaps the heating in the house is inadequate or inappropriate. It is unclear at what threshold education is entered into the database. The database is not aligned with the assessment tool that the nurses are currently using. It does not create any alerts for follow-up or make any space for recording follow-up outcomes on referrals. Furthermore there are some inaccuracies in the data that is entered. For example the ethnicity data entered in the database for the small HCP study cohort significantly underestimated the proportion that identified as Māori and Pacific people by interview. There were also several referrals found in the participant s hard copy notes that were not recorded on the database. Long-term impact When considering the impact of the HCP on long-term outcomes we were limited by both a small number of HCP participants and a limited ability to link participants or their homes with long-term improvements in hospital admissions. 63

68 appendix 2: additional literature relevant to the analysis of programme rationale Do housing improvements improve health outcomes? The link between poor housing and poor health is well established (Thomson et al., 2013). There is compelling evidence about the effectiveness of warmth and energy efficiency interventions targeted at vulnerable individuals (Gibson et al., 2011). Data from studies of warmth and energy efficiency interventions suggest that improvements in general health, respiratory health, and mental health are possible (Thomson et al., 2013). Best available evidence indicates that housing which is affordable to heat and an appropriate size for the householders, is linked to improved health and may promote improved social relationships within and beyond the household (Thomson et al, 2013). An effective health and social assessment Extensive evaluation that has been done on the Healthy Housing Programme (HHP) in Auckland (Bullen et al., 2008b) (Clinton et al., 2006) (Jackson et al., 2011) and shows how the implementation of a housing, health and social needs assessment, very similar to that used in the HCP study, led to significant reductions in housing-related hospitalisations (Jackson et al., 2011). The HHP was first piloted in the Counties Manakau DHB (CMDHB) region in 2000 with a focus on prevention of meningococcal disease. It was targeted to HNZ tenants (decile 10, almost all Pacific) rather than those that met particular health criteria. There was no direct referral links from primary or secondary care health practitioners to the housing intervention. The programme applied a similar assessment tool to that used in the HCP study. The Joint Assessment Tool (JAT) was used to provide advice and create referrals for other housing, health and social needs, and to determine priority for housing improvements. The HNZ area coordinator focussed on the property including the suitability of the house, maintenance, presence of mould and damp and so on. The public health nurse focussed on the health (including mental health and disability) of the family and their linkage with appropriate health and social support agencies (Clinton et al., 2006). This approach was associated with post intervention reductions in acute hospital admissions (and housing-related admissions), particularly among 0-4 year olds (11% reduction, CI:1-21%) and 5-34 year olds (23% reduction, CI15-30%) (Jackson et al., 2011). There were many co-benefits and a significant return on investment. Additional benefits including improvements in housing stock, increased coordination between sectors and organisations, strengthened community networks (Bullen et al., 2008a) and improved energy efficiency (Howden-Chapman et al., 2007a). In this study a whole package was provided so it was not possible to dissociate the benefits of the housing improvements from the other health and social advice and referrals. What is the impact of housing interventions targeted to health and inadequate warmth? International literature Interventions that improve warmth to people with chronic health conditions appear to be more effective than interventions targeted to certain areas (Thomson et al., 2013). Thomson et al. systematically reviewed housing intervention studies to assess the health and social impacts following housing improvements (Thomson et al., 2013). Among the 39 studies included; many targeted social tenants, certain neighbourhoods or socioeconomic criteria. There were eight studies however which targeted the housing solution to people with particularly health conditions. It is important to consider these studies when developing housing approaches that are responsive to health need. Two of the studies were based in New Zealand 64

69 (Howden-Chapman et al., 2007b, Howden- Chapman et al., 2008) and the other six were from the United Kingdom (Osman et al., 2010), (Woodfine et al., 2011), (Allen, 2005a), (Allen, 2005b), (Somerville et al., 2000) (Health Action Calderdale Kirklees and Wakefield, 2005). These studies all examined the health impact of interventions that improved warmth and energy efficiency in homes. Three programmes included insulation and six included heating interventions. The health criteria used to select participants were generally diagnoses of respiratory illness or cardiovascular disease. Three studies targeted people with asthma, and the other five studies used different diagnostic criteria; COPD, serious heart condition, cold related illness, respiratory disease, and housing-related diseases (specifically heart disease, cerebrovascular accident, peripheral vascular disease, type II diabetes with functional difficulties, COPD, or complex asthma). The studies used several different processes to select patients for the interventions, including hospital or general practice records, liaising with community organisations such as asthma societies and primary health organisations, a referral process which included health criteria, and using the information on file at housing departments or with health visitors, asthma liaison nurses and paediatricians. A summary of these studies demonstrates the health benefits that can be achieved (Table 13). For example two well-conducted New Zealand randomised controlled trials targeted a housing intervention to households with inadequate warmth and where at least one household member had a pre-existing respiratory condition (Howden-Chapman et al., 2007b, Howden-Chapman et al., 2008). Respiratory health was better among the intervention group compared to the control group (statistically significant). The Thomson et al.2013 review demonstrates that interventions most likely to report health improvement are those which target individuals with inadequate warmth and individuals with chronic respiratory disease (Thomson et al., 2013). The impacts were less clear for housing improvements which target areas rather than vulnerable households (Thomson et al., 2013) (Gibson et al., 2011). The HCP referral process is at an advantage because is based on targeting health need; however the HCP did not directly target individuals living in homes with inadequate warmth. New Zealand housing solutions In the last decade, many housing programmes have been developed around the country, driven by central government subsidies for insulation and the requirement for DHBs to create a Rheumatic Fever prevention plan. In more recent times several programmes have developed which can be referred to by health practitioners. There were at least ten recent and current programmes with links from health to housing solutions, and likely others that were not identified here. Several different models of working were found. Recent programmes were often focussed on children, i.e. those at risk of rheumatic fever. Key strengths of the programmes were about clinical engagement, links with the community, and data collection. 1. Clinical engagement Addressing clinical engagement and appropriate referral Getting housing questions put on paediatric Admission to Discharge nursing form 2. Community relationships Strong relationships with dynamic and diverse communities Knowing what services are in the community Utilising existing providers to engage and support families 3. Data collection Good data collection to highlight gaps and provide rich data for monitoring and evaluation 65

70 appendix 3: comparison of the Housing Coordinator Pilot to other Hutt Valley housing programmes This section aims to compare the HCP with other previous housing programmes at RPH, including the HNZ Healthy Housing Programme (HHP), the Healthy Homes Health People Programme (HHHP) (Proof Research and Evaluation et al., 2010) and the Older Person s Maintenance HCP (OPMP) (Hefford et al., 2008). Summaries of the HCP design and its outcome data are compared with previous housing programmes in the Hutt Valley to understand the strengths and weaknesses of the HCP study in comparison to different study designs. Firstly, a comparison was made by programme design, evaluation findings and recommendations. Secondly the differences between the programmes were considered by quantitative indicators. Regional Public Health s housing experience RPH is experienced in coordinating healthy housing activity in the Hutt Valley region. In addition to the HCP there has been RPH involvement in three other housing programmes that will be considered here. The HNZ Healthy Housing Programme focused only on HNZ homes. The Older Persons Maintenance HCP and the Healthy Homes Healthy People (HHHP) projects were designed alongside the HNZ programme and included non-hnz tenants. The HCP was compared with the other Hutt Valley housing programmes using data collected from previous programme evaluations, and analysis of the RPH Housing database. A list of pre-set criteria formed the basis for this comparison. Comparison of designs, strengths and weaknesses RPH has contributed to four different housing programmes designs in the Hutt Valley from (Table 10). There were differences in the way that the programmes recruited participants and the eligibility criteria that they used for this. For example the HHP was limited to HNZ tenants in selected neighbourhoods whereas other programmes focussed on private tenants and home owners. The most recent HCP was the only programme that focussed on recruiting from among housing-related hospital admissions. The health and social assessment, advice and education provided and participants were consistent strengths across the programmes. Interviewed participants were satisfied and consistently appreciated the insulation and other products they received. Some recommendations have come up several times in evaluations. All three evaluations recommend improvements to promotion with suggestions for better marketing, providing an information pack, and providing more information about the available services. Barriers to engagement were highlighted as important factors to understand and address. Improved follow-up on referrals was consistently recommended for the programmes using the health and social assessment. The data collection system was also seen as important. 66

71 Programme Hutt Hospital Housing Coordinator Pilot Study Healthy Housing Programme HNZ Healthy Homes Healthy People Programme Older Person s Maintenance HCP Evaluations (this report) Not done in Wellington, see Auckland evaluations (Bullen et al., 2008a, Jackson et al., 2011) (Proof Research and Evaluation et al., 2010) (Hefford et al., 2008) Aims The HCP aimed to link high rates of housingrelated admissions to existing housing interventions. The HNZ project aims to assess and link the hardest to reach households with the greatest needs to vital health, social and housing services. The programme aimed to coordinate efforts of the health sector, insulation providers and funders to maximise the benefits of the Energy Efficiency Conservation Authority subsidised insulation scheme toward priority groups with high health need in the Hutt Valley The aim was to leverage off Energy Smart funding Timeframe Feb 2013 June 2013 March June 2013 Jan 2008 July 2010 Dec 2006 June 2007 Short term HCP study Contract with HNZ ended in July 2013 External funding was unsustainable and programme put on hold from 2009 Short term HCP study Eligible referrals Funding and leadership HVDHB funded Housing nurses at RPH up to 0.2 FTE over 4 months Public health registrar 0.3 FTE Involved staff at Hutt Hospital HVDHB funded Housing nurses at RPH 1.5 FTE In collaboration with Housing New Zealand HVDHB funded housing nurses at RPH Funding for full time project coordinator from MSD Coordination function hosted by EnergySmart and subsequently Tu Kotahi Māori Asthma Trust Hutt Healthy Housing Forum provided planning, evaluation and operational support and within this RPH took a lead role Healthy Housing Forum developed the HCP. Membership included: RPH (played a lead role), Hutt Valley District Health Board, the University of Otago, and local PHO s, EECA, EnergySmart, the Hutt Mana Charitable Trust and local insulation providers Project Coordination by Energy Smar Recruitment Identification of patients admitted to Hutt Hospital with housing related conditions, with a focus on paediatric admissions HNZ tenants were selected on a preplanned street-by-street basis which prioritised suburbs with greatest health needs Providers ensured families met eligibility criteria and helped families fill out the application form for the programme. Focus on low income owners and renters in the private market in the Hutt Valley Target older persons on low incomes, Aim for 50% of participants Māori and Pacific people 50+yo and 50% other ethnicities aged 65+yo Referrals from multiple secondary care, primary care and community organisations; predominantly via Tu Kotahi Māori Asthma Trust Eligibility criteria Home owner or private tenant Housing-related health condition Community services card eligibility Māori /Pacific or <5yo NOT living in a HNZ home HNZ tenant Living in the Hutt Valley in a selected suburb with the greatest needs Housing-related illnesses Community services card NOT living in a HNZ home High health needs HNZ tenants (33),living in their own home or private tenancy (88) 67

72 Programme Hutt Hospital Housing Coordinator Pilot Study Home visit and assessment process Housing, health and social assessment, using an adjustment of the Joint Assessment Tool (JAT) done by housing nurse Referrals out Referrals to housing, health and social providers including insulation and curtain providers Advocacy to landlords by a letter given to tenants Strengths Responsive to health care needs Partnership approach to collaboration with secondary care Advice and education appreciated Products and services appreciated Weaknesses Small time-limited project Intensive efforts required to get referrals into the programme Half of the referrals did not result in service provision Many barriers to engagement identified Healthy Housing Programme HNZ Healthy Homes Healthy People Programme Health and social assessment, using the Joint Assessment Tool (JAT) done by housing nurse Housing assessment was done simultaneously by HNZ representative Housing assessment done separately Health and social assessment done by Housing Nurse Referrals to health and social providers Advocacy to HNZ for housing improvements such as insulation, heating and maintenance prioritised based on health criteria Installation of insulation (under floor and ceiling in most cases) Health and social referrals Not formally evaluated Holistic housing, health and social assessment well received Education particularly valued Customer satisfaction, 41% found it beneficial, 79% felt treated with respect Wiki database Successfully identified and made referrals for unmet health and social needs Positive behaviour change Health benefits from insulation Interagency collaboration Not formally evaluated Barriers to accessing the programme with a significant drop-off rate Landlord reluctance Participants believed the assessment was to justify their need for insulation, or was an add on Ad hoc follow-up of referrals Families wanted additional products such as curtains, heating Older Person s Maintenance HCP Maintenance check and insulation measures No health and social assessment Energy efficiency education at the time of assessment Maintenance for HNZ homes (19/33) Insulation measures for homeowners and private tenants (70/88) Clients felt respected by assessors Positive feedback about insulation Innovative maintenance and safety measures were well received Positive feedback about community education workshops Many referrals received did not meet the criteria. Excessive delays in receiving insulation or maintenance, particularly for HNZ tenants Many clients who have not received insulation were left confused No heating intervention, no health and social assessment and therefore no referral linkages to agencies 68

73 Programme Hutt Hospital Housing Coordinator Pilot Study Recomme n -dations Make referral process more routine Broaden eligibility criteria Formalise follow-up on referrals Maintain collaboration with referrers and external providers Implement a database to improve efficiency of follow-up and on-going quality improvement Upscale Table 11: Healthy Housing Assessment Projects in the Hutt Valley Healthy Housing Programme HNZ Healthy Homes Healthy People Programme Not formally evaluated Equip providers to work with those experiencing barriers to the health and social assessment Convince landlords to invest in insulation (advocacy to landlords, for policy change, empowering tenants) Promote scope of health and social assessment, more than insulation Make health and social assessment accessible to those with insulation Collect data on reasons for declining the health and social assessment Ensure nurses have info for families on community activities both social, exercise, nutrition People will continue to use unflued gas unless there is a cheaper option Develop a process for follow-up post assessment and collect data on this Follow-up surveys and regular monitoring of the programme Data entry soon after visit Older Person s Maintenance HCP Better provider education to filter appropriate referrals Develop an application tool and information sheet explaining criteria Develop a marketing strategy Workshop before programme for referral agencies and another for programme participants Develop a workflow chart that could track referrals from initial referral to completion to avoid assessing houses which do not meet the criteria Invite local HNZ managers to steering group Explore access to WINZ funds to address heating To access other funding pools to assist householders Provide a broader range of education including safety Continue to provide energy efficiency training to enable one on one education by providers Adapt the HHP Joint assessment tool Develop an appropriate and useful data collection system that improves reports to stakeholders Follow-up visit to ensure all needs are met. 69

74 Overview Housing Coordinator Pilot Study Healthy Housing Programme HNZ Healthy Homes Healthy People Older Person s Maintenance HCP Number of referrals to the programme n 70 NA Referrals that met eligibility criteria n Coordinator visits n (325 on database) Proportion of eligible referrals who received coordinator visit (%) Time elapsed from referral to coordinator visit (days) % 63 (17/27) Average Median % done: % done: Range HOUSING CONDITION & INSULATION Insulation installations n 4-192# 70 Eligible referrals with inadequate insulation n Proportion of eligible referrals whose homes were inadequately insulated Insulation installed among eligible referrals with inadequate insulation Insulation installed among eligible private tenants referred with inadequate insulation Insulation installed among those who had coordinator visit Insulation installed among all eligible referrals % 44 (12/27) % 33 (4/12) % 33 (3/9) % 24 (4/17) % 15 (4/27) (107/111) (70/107) - 57 (38/67) - 77# (132/172) - 53 (192/365) Is the house mouldy?^ % Is there dampness & condensation?^ % No/inadequate heating^ % No/inadequate curtains^ % (70/92) 63 (70/111) Notes: * Earlier on 08/09, some recommendations were also recorded as referrals which may inflate referrals in these two programmes] ^ These figures are based on a tick box that may or may not have been completed. Although records that were obviously incomplete were removed from the analysis, mould and dampness may be underestimates and heating and curtain may be overestimates. This is expected to be the case across all programmes. # In this study the coordinator visit and insulation were done separately not subsequently Table 12: Quantitative comparison of housing programmes in the Hutt Valley and evaluation findings based on evaluations and housing database 70

75 HOUSING AND SOCIAL ISSUES Housing Coordinator Pilot Study Healthy Housing Programme HNZ* Healthy Homes Healthy People* based on 325 visits Housing & social issues identified n Number of housing & social issues identified per coordinator visit ratio ^ Housing & social referrals out n Number of housing & social referrals per coordinator visit Housing and social education topics addressed per coordinator visit and recorded ratio ^ ratio HEALTH ISSUES Total health issues identified n Number of health issues identified per coordinator visit ratio Total health referrals to other providers n Number of health referrals per coordinator visit ratio Health education topics addressed per coordinator visit and recorded Mean Notes: * earlier on 08/09, some recommendations were also recorded as referrals which may inflate referrals in these two programmes ^ does not include insulation which was installed in most homes Table 13: Housing, health and social assessment in programmes from the Hutt Valley based on housing database DEMOGRAPHICS Housing Coordinator Pilot Study Healthy Housing Programme HNZ Healthy Homes Healthy People Older Person s Maintenance HCP Proportion of coordinator visits where participant identified as Māori or Pacific (prioritised ethnicity) % 76* (16/21) 55^ (641/1160) 58^ 49 [of eligible referrals] Age of household participants Age 63% 0-10yo 10% 11-20yo 28% 21-50yo Participants who were homeowners % 20 (3/15) Households with a community services card 23% 0-10yo 17% 11-20yo 31% 21-50yo 18% 51-65yo 10% >65yo 0 [all HNZ tenants] 19% 0-10yo 9% 11-20yo 25% 21-50yo 13% 51-65yo 34% >65yo 74 (68/92) [selected to be high] 31% 51-65yo 69% >65yo [person referred not incl other household members] 79 (63/79) % Notes: * There was a difference between this evaluation figure presented (76%) and the database figure which was much less at 50% (9/18) for the HCP study, showing that the ^database figures may significantly under estimate Māori and Pacific ethnicity Table 14: Demographics of participants in programmes from the Hutt Valley based on evaluations & housing database 71

76 Hutt Valley Housing programme indicators As well as the different referral pathways, the four Hutt Valley programmes vary in size and in the timeframe in which they were implemented. The key results from the programme indicators are discussed here and summarised in the tables above. In the HCP, just 4/27 (15%) of eligible referrals received insulation whereas in the other programmes the proportion of houses insulated was 53% (HHHP) and 63% (OPMP). The reason for comparatively low rates of insulation in the HCP can be explained by the lower need for insulation among the HCP study participants (44% versus 96% in OPMP), participants who needed insulation missing out on a coordinator visit (5/12 in the HCP), and a low rate of referrals to insulation resulting in service provision (4/7 in the HCP). Caution should be taken in interpreting these figures because numbers are few and information on all participants was not complete. The number of health issues and referrals to health providers in the HCP were much lower per household visit compared to other programmes (Table 12). The number of housing and social issues identified and referred were similar compared to other programmes after taking into account the different recording between programmes. In the HHHP, the number of housing and social referrals is under-estimated because this figure does not include insulation as one of the housing referrals because insulation was provided separately to the coordinator visit. In the HHP, the relative number of housing and social referrals per household is overestimated because each housing issue put forward to HNZ (e.g. ventilation, carpeting, heating) was entered as a separate referral; whereas in the HCP it would have been recorded as one referral. The OPMP did not do any health or social referrals to external providers and so this programme was not included in the table. In the HCP study the recorded provision of education was approximately two health topics and two housing or social topics per coordinator visit. Approximately twice as much education on housing and social issues was recorded per coordinator visit for the HCP than the other programmes. As discussed, it is difficult to read too much into the differences between the programmes in the number of health, social and housing issues identified and addressed because of the inconsistencies in the way this data has been entered into the database over time. For example 1-2 years of the earlier data was entered retrospectively and may have inflated the referral numbers by counting the education provided at assessment as a referral. Finally, the demographics of the four programmes differed based on their different designs (Table 13). For example the household members consented in the HCP study were much younger than the other programmes. There was a similar proportion of Māori or Pacific peoples when comparing the database figures alone. The quality of the database figures on ethnicity was limited so the figures for ethnicity are likely to be all under-estimated. A relatively low proportion of HCP participants were home owners (20% in the HCP versus 74% in the HHHP and 79% in the OPMP). In the HHHP this was because the number of home owners was intentionally selected to be high. How did the referrals compare? The following figures provide a way of understanding and comparing the various referrals made from health and social assessments in each of the three of the Hutt Valley housing programmes (Figure 13 and Figure 14). Housing and social referrals are considered separately to the health referrals. When viewing these figures it should be taken into account that insulation referrals are a new feature of the HCP study. Insulation was carried out in a separate arm of the HHHP as part of the programme design. In the HHP housing nurses advocated with HNZ about insulation and other housing improvement interventions. 72

77 The types of referral have changed over time possibly reflecting the changes in services available in the community, changes in actual and perceived needs of clients, and differences in how the participants are selected. For example asthma referrals were an important part of the HCP programme because it selected participants based on being hospitalised with respiratory conditions. In the Counties Manakau HHP (Bullen et al., 2008b) the distribution of referrals were different again. The most common referrals were for budgeting and food parcels, and also to Work and Income to check benefit eligibility. Other types of referrals included enrolling children in early childhood education and ensuring school attendance; registering adults in English language courses; and referring residents with diabetes to neighbourhood support groups. These findings demonstrate a substantial difference in referral types between programmes. Housing Coordinator HCP: common housing and social referrals as a percentage of total programme referrals n=26 Healthy Housing Programme: common housing and social referrals as a percentage of total programme referrals n=

78 Figure 13: Healthy Homes Healthy People Programme: common housing and social referrals as a percentage of total programme referrals n=427 (note insulation and maintenance is in addition to this) Housing coordinator Pilot: common health referrals as a percentage of total programme referrals n=18 Healthy Housing Programme: common health referrals as a percentage of total programme referrals n=

79 Figure 14: Healthy Homes Healthy People Programme: common health referrals as a percentage of total programme referrals n=602 Summary of comparison findings Design and eligibility criteria had a critical impact on the households that were reached and the housing, health and social improvements that were put in place in each of the four different Hutt Valley programmes. The HCP reached a cohort of younger families and less home owners (more private tenants) than the other programmes, but the ethnicity profile was approximately similar. The proportion who did not get coordinator visits (37%) of those enrolled was better than the similar HHHP (53%) but was greater than the HHP and OPMP. Less health referrals were made from the HCP per household than in other programmes but double the amount of education was recorded. Health referrals in the HCP study were more focussed on children s health particularly dental and asthma. The focus of the HCP on housing and social referrals for insulation, budgeting and curtains was similar to the focus of other programmes. The differences of the HCP programme in comparison to other programmes are important to consider in making recommendations going forward. There was a much lower rate of home insulation in the HCP study than in other housing programmes. 75

80 appendix 4: interview schedules Participant interview schedule Purpose The purpose of this interview is to get feedback on the HCP that was trialled in the Hutt Valley earlier in When participants consented to the HCP study they agreed to be contacted and asked their thoughts about the visit and what has happened since then. The aim of this interview is to get some feedback about the aspects of the project that participants were involved in such as their perspective on the referral process, and whether they were able access to health, social and housing improvement interventions when this was requested and indicated. Invitation script A guide to assist the evaluator when contacting HCP participants to arrange an evaluation interview. The Evaluator will ring HCP Study participants to arrange and confirm a time for the evaluator to visit the household (participants to decide on time and place) to do the interview. Make four call attempts at different times of day, on more than one day, with at least one call in the evening. If ringing a cell phone try texting before calling to say who is calling. A face-to-face interview is preferable however if a client wishes then a telephone interview is an alternative option to maximise the responses. Explain to the householder <Introduce myself> I understand you were involved in a housing coordinator study where a housing nurse _xx came and visited you at home and talked about housing and how it is linked to health. Reason I m ringing: We are doing some interviews to find out how it went for you and see if there were have been any changes since the visit. We want to find out how we can do the programme better. I see you agreed to follow-up about the visit to see how it went. Is it okay if I come and visit you (at your home or somewhere else) and ask you some questions about the coordinator visit? The information you tell us will be kept confidential and will only be used for the purpose of seeing how well the programme went. If you agree, the interview may be recorded. from Māori/Pacific health services at Hutt Hospital has offered to come with me and support. Are you okay for them to join me? The Interview Process The interviewer will: Explain the purpose of the interview and how the findings will be used Summarise the topics to be covered Reassure client re: confidentiality Ask permission to record the interview Provide visual of questions to be asked A story may be written up based on what happened with your household. We will change enough things so people reading it won t know who you are. If a story is written we will give you a call to check back if this is okay with you. To respect the participant s time consider giving a small koha that might reflect the family needs e.g. petrol/supermarket voucher/toothbrush and toothpaste Good practice Allow time to hear the clients background before commencing the interview Be respectful of the people being 76

81 researched in their own setting Allocate 1 hour for each interview with additional time for travel Cultural sensitivity Greet the family in their language: Kia ora, Talofa Lava Be prepared to take shoes off, accept a drink and share about you Consider how you will you develop rapport and the factors that might affect this The interview might need to be conducted in stages. Allow clients to determine the process and come back if required. Consider going accompanied by someone from the family s ethnic group, who may or may not already be known to the family Consider what ethical issues may arise Turn off the recorder if the client wants to talk about a sensitive issue Role as a neutral observer The evaluator is learner, impartiality Let the client talk Avoid leading questions but use probing techniques Quality of data Practice using the topic guide Test the quality of the recording Following the interview, take notes about what you would do next time, tricky questions, how it felt etc. Supports For audio-recording see Carol Cultural guidance see Kuini or Tofa-Suafoli Gush Inform colleague (e.g. Shona) the time you enter house and time you finish and leave Topic guide Are the details we have for you correct? <See attached sheet> Do you own or rent your home? Do you have a community services card? Please use this list to tell me which ethnic group or groups you belong to: New Zealand European; Māori; Samoan; Cook Islands Māori; Tongan; Niuean; Chinese; Indian; Other (such as Dutch, Japanese, Tokelauan), please state... Referral and consent These questions are about how you got connected with the programme. Can you tell me about how you found out about the housing and health programme? Was being in hospital a good time to find out about the programme? Would you rather someone had called after you left hospital? Have you got any suggestions about other ways you would like to find out about the programme? e.g. church, marae, general practice What information was given to you when you signed up/joined the programme? Did you understand the information given to you? Was it explained? Were you comfortable to ask any questions you may have had? What did you expect to happen after you signed up? How was the visit to your home arranged? How easy was it to arrange a time for the visit? What would have made it easier? Were there any problems? Are options outside normal business hours helpful? Was the timing between leaving hospital and the coordinator visit: too soon too long about right? Coordinator visit Can you tell me the coordinator visit? What happened? What were the good aspects? What could be improved? Do you think the visit was too long, too short or about right? 77

82 Advice These questions are about some messages about housing and health that the nurses may have given you during the visit. Before the visit, what did you know about the link between housing and the health? Do you remember any things the nurse said about how to make your house healthier? (Prompt: such as about ventilation, mould, insulation, heating, pests) Is there any other advice you remember from the visit? (Prompt: such as about health, budgeting, food or seeking health care early) Possible health messages given: DRY AIR: avoid unflued gas, close doors when cooking/showering, dry clothes outside, cover pots, avoid clutter, pull furniture out from wall, avoid >2 ppr, repair leaks FRESH AIR: daily open window, fans, vent clothes dryer outside, remove bushes away from windows, treat mould, wipe moisture away from surface WARM AIR: lined curtains, close when dark, draught stoppers, board fireplace, heating, insulation HEALTH and SOCIAL: health education, budgeting, advice about food, seeking health care early, avoiding bed sharing Pest control Have you/your whānau or family made any changes since you heard this advice? What changes were made? Are there things that you would like to change but haven t? What would help/enable you make your house healthier? e.g. cost, language, knowledge, transport, priorities, working during day What pamphlets/brochures were given or sent to you? Were they easy to read? Did you find them useful? Referral outcomes These questions are about the referral process after the coordinator visit. For each referral (e.g. Curtain bank, Energy Smart, Kokiri Marae, Super Grans, School Dental, Tu Kotahi Māori Asthma Trust, support letter (landlord/hnz) <see attached sheet>: I have a referral that says Have you had any contact with since the coordinator visit? IF YES: What happened? What changes have been made? When were the changes put in place? Have you noticed any benefit from these changes? What changes are still to be made? IF NO: Are you still interested in being contacted by this provider? Would you like us to follow this up? Is there a preferred way you would like to be contacted? Was the number of referrals too many, too few or about right? If not referred for insulation: Has your house been insulated? (If built before 2000) Housing and Health outcomes Following the visit (+/- insulation) to your home, have you noticed any health improvements among you or your family/whānau? What did you notice? Since the visit (+/- new insulation) to your home, have you (or your family/whānau) needed to visit the doctor or increase their medication due to respiratory complaints? Expectations/satisfaction Has the programme met your expectations? Were there any things that happened that you didn t expect? Has the programme helped you? In what ways? Were there any bad or not so good effects? How do you think this programme could be improved? What should we do differently? Did the programme help your whānau/ 78

83 family s housing needs? health needs? social needs? What would the perfect programme look like, to improve your whānau/family s housing needs? Is there anything else you would like to add? Thank you Would you like to find out about the results of our interviews? We can call, or send you the main findings, which should be out early next year. Interview schedule for participants who did not get a coordinator visit Purpose The purpose of this interview is to get feedback on the HCP that was trialled in the Hutt Valley earlier in When participants consented to the HCP study they agreed to be contacted and asked their thoughts about what has happened since then. The aim of this interview is to get some feedback about the aspects of the project that participants were involved in such as their perspective on the referral process, and whether they were able access to health, social and housing improvement interventions when this was requested and indicated. Invitation script A guide to assist the Housing Coordinator when contacting HCP participants to arrange an evaluation interview The evaluator will ring HCP study consenters to arrange and confirm a time for the interview. A telephone interview is preferable however if a client wishes then a face-to-face interview is an alternative option. The interview may be done immediately after invitation or at a later time if that better suits. Make four call attempts at different times of day, on more than one day, with at least one call in the evening. Explain to the householder Introduction I understand that you agreed to be involved in a housing coordinator study where a housing nurse planned to visit you at home but the visit didn t happen. We want to find out about how the housing study went and I am interested in the reasons why you didn t get the visit. I see that you signed a form saying you would be okay to be followed-up. Is it okay if I ask you some questions over the phone (or at your home if that suits better) about the visit and the housing programme? 79

84 We want to hear from you and your story and see how we can do it better. The information you tell us will be kept confidential and will only be used for the purpose of evaluation. The interview process The interviewer will Explain the purpose of the interview (as above) Summarise the topics to be covered (as above) Reassure client re: confidentiality (as above) Ask permission to take notes from the interview Cultural sensitivity Greet the family in their language: Kia ora, Talofa Lava Consider how you will you develop rapport and the factors that might affect this The interview might need to be conducted in stages. Allow clients to determine the process and ring back if required. Consider what ethical issues may arise Role as a neutral observer The evaluator is learner, impartiality Let the client talk Avoid leading questions but use probing techniques Quality of data Following the interview take notes about what you would do next time, tricky questions, how it felt etc. Supports Cultural guidance see Kuini or Tofa-Suafoli Gush Topic guide Are the details we have for you correct? <See attached sheet> Do you own or rent your home? Has your house been insulated? Do you have a CSC? Please use this list to tell me which ethnic group or groups you belong to: New Zealand European; Māori; Samoan; Cook Islands Māori; Tongan; Niuean; Chinese; Indian; Other (such as Dutch, Japanese, Tokelauan), please state... Referral and consent These questions are about how you got connected with the programme. Can you tell me about how you found out about the housing and health programme? Was being in hospital a good time to find out? Would you rather someone had called after you left hospital? Have you got any suggestions about others ways you would like to find out about the programme? e.g. church, marae, general practice What information was given to you when you signed up/joined the programme? Did you understand the information given to you? Was it explained? Were you comfortable to ask any questions you may have had? What did you expect to happen after you signed up? What do you know about the link between housing and the health? Did you get a call from the housing coordinator about arranging a coordinator visit? CALL BUT NO VISIT Why do you think the visit didn t happen? What would have made it more likely to have happened? Is there anything else that would make it easier to be involved? Would an appointment time outside business hours have helped? Was the timing between leaving hospital and the call from the housing nurse: too soon too long about right? 80

85 Would you be interested in a home visit for a housing, health and social assessment? Shall I let the housing nurse know and ask her to contact you? NO CALL & NO VISIT I understand you were interested in the programme. The housing nurses tried to make contact and had difficulty getting a hold if you. Perhaps there were some barriers. Do you want to share? Do you know why it may have been difficult to contact you? Is there anything that would make it easier to be involved? Would you be interested in a home visit for a housing, health and social assessment? Shall I let the housing nurse know and ask her to contact you? Improvements How do you think this programme could be improved? What should we do differently? What would the perfect programme look like, to improve your family s/whānau housing needs? Is there anything else you would like to add? Thank you Would you like to find out about the results of our interviews? We can call, or send you the main findings, which should be out early next year. Interview schedule for RPH staff who carried out the Housing Coordinator Pilot Housing coordinator Housing coordinator Public Health Medicine Registrar Purpose The purpose of this interview is to get feedback from those who carried out the HCP trialled at Hutt Hospital earlier in The HCP aimed to link hospitalised patients who had housing related conditions with a home visit providing a housing, health and social assessment. The aim of this interview is to get some information about the processes involved in the HCP study and identify the lessons learned from the perspective of those who carried it out. Operational staff were interviewed to seek information on the development of the referral process; their perspective on how well whānau/ families were able to access interventions as requested and indicated; and to what extent staff collaborated with other housing and health stakeholders. Invitation The interviewer will contact the interviewee to Explain the purpose of the interview Ask permission to interview Arrange a time and place that suits Say that the interview will be recorded The Interview Process The interviewer will Explain the purpose of the interview Summarise the topics to be covered (The interview is about the HCP specifically however some questions may also relate to other aspects of your work) Ask permission to record the interview Good practice The interview might need to be conducted 81

86 in stages. Allow interviewees to determine the process and come back if required. Turn off the recorder if the interviewee wants to talk about a sensitive issue Let the interviewee talk The evaluator is learner, impartiality Avoid leading questions but use probing techniques Consider what ethical issues may arise Topic guide PERSONAL How would you describe your role at RPH? How long have (did) you been doing (do) this? What was your role in the Housing Coordinator Pilot Study? REFERRALS IN How were eligible patients identified and referred to the programme? What was the role of clinical staff? What was your role? How much time did you spend on identifying eligible patients? e.g. each day, for each person who was eligible How much time did you spend consenting patients? Which wards/services did the patients come from? How did you develop contacts with these services? Were there advantages/disadvantages of working with particular wards? How did the referral process develop over time? What worked well? What would improve the referral process? Eligibility How were the eligibility criteria developed? How easy were the eligibility criteria to apply in practice? ELIGIBILITY CRITERIA: Housing related hospital admissions including bronchiolitis, asthma, pneumonia, Rheumatic Fever Age group 0-4yo or 5+ yo with Māori or Pacific ethnicity Community services card eligibility Non-HNZ property Audience Who was the intended target group of the HCP programme? How well, would you say, was the target group reached? What could be done to better reach the intended families/whānau? COORDINATOR VISITS - particularly for Nic/ Shirley Appointments What methods did you use to get in touch with families to arrange a coordinator visit? What were the greatest barriers to arranging a coordinator visit? What would it require to address these barriers? Coordinator visit What worked well about the visits? How much time did the visits normally take? What were the most relevant aspects of the housing, health and social assessment? How did you decide which questions to ask, in the housing, health and social assessment? What were the most common tips and advice you gave? Is there anything that could be done to improve the coordinator visits? REFERRALS OUT - particularly for Nic/Shirley Referral process What was the process for referring to 3rd party providers? 82

87 How did you decide which referrals to offer a household? In what instances did you refer for insulation? How much time did you spend making referrals and following-up? Access What aspects of the programme best helped families access 3rd party services? Did you have enough information to advise households how long they could expect to wait before they were contacted by 3rd party providers? Do you know of any barriers that prevented access to 3rd party services? How could access to 3rd party services be improved? (by you, by families or by providers) In your perspective, what worked well in the housing HCP programme? What are the weaknesses and issues that need to be addressed? Did the HCP have any unintended effects? What would the perfect programme look like to address family housing needs? Is there anything else you would like to add? Thank you COLLABORATION What communication did you have with hospital staff? How did this develop during the HCP study? Does this level of collaboration meet your needs? What would improve your working relationship with hospital staff? What communication did you have with 3rd party providers? - Nic/Shirley Did this develop during the HCP study? Are you satisfied with the information you get back after families are referred? Was there any way of knowing whether 3rd party providers received a referral and acted on it? What would improve your working relationship with 3rd party providers? SATISFACTION What is your opinion on extending the HCP? (i.e. inviting patients for a home visit to link households with housing, health and social services) What will determine whether it is a sustainable programme? What are the risks? 83

88 Focus group schedule to interview RPH staff 3rd December 2013 Purpose The purpose of this interview is to get RPH staff feedback about lessons from HCP that was trialled in the Hutt Valley earlier in The aim of the focus group is to explore the ideas and common understanding of RPH staff about the HCP particularly in regards to the design of the programme, the development of the hospital referral process and collaboration with other organisations. Process The interviewer will Arrange a suitable time and place for the focus group Welcome participants Explain the purpose of the focus group: evaluating the HCP study Frame the focus group interview as an opportunity for participants to be intentional, thoughtful and exploring. People will have different perspectives, there are not right and wrong answers I am interested in all views however they may or may not differ Summarise the topics to be covered Explain the interview will be recorded and notes taken Provide guidance in relation to participating in a focus group interview one person to speak at a time treat everyone s ideas with respect Ask the first question Contribute to field notes The assistant will take notes during the focus group to capture information on Any changes in the list of questions Participant characteristics Descriptive phrases or words used by participants as they discussed the key question Themes in the responses to the key questions Description of participant enthusiasm Consistency between participant comments and their reported behaviours Body language Overall mood of discussion Topic guide Introduction: Let s start by introducing ourselves for the record. Say your name and your role in the Housing Coordinator Pilot Study. BACKGROUND AND CONTEXT How would you describe the problem that this HCP aimed to address? Housing, or health and social services as well Aim and purpose of the programme How did the HCP address this problem/s? What are the key aspects of the programme? What is the role of the nurse s assessment? How did the idea to link hospital patients with housing services develop? What resources were required? In your opinion, what would indicate that the HCP had been a success? REFERRAL PROCESS How well did the process of referrals to the HCP work? What would improve the referral process? How were the eligibility criteria selected? How well did they work? ELIGIBILITY CRITERIA: (put on board) Housing related hospital admissions including bronchiolitis, asthma, pneumonia, Rheumatic Fever Age group 0-4yo or 5+ yo with Māori or 84

89 Pacific ethnicity Community services card eligibility Hutt Valley DHB Not HNZ Was the intended target group reached? What were the greatest barriers to this group accessing housing services? Is there anything that could be done to better reach the target group? COLLABORATION How did the HCP affect RPH s relationships with other organisations? Any new relationships? e.g. hospital staff, housing/health/social providers, primary care How could opportunities for working together be improved? SATISFACTION What is your opinion on continuing the HCP programme? (i.e. offering patients a home visit to link their household s with appropriate housing, health and social services) What will determine whether this is sustainable? What are the risks? What were the strengths of the housing HCP programme? What didn t work so well? What could be improved? What would the perfect programme look like that aims to improve housing related health? Is there anything we should have talked about but didn t? Thank you I will disseminate the evaluation report, which should be out February next year. Interview schedule for Hutt Hospital staff Specialty Clinical Nurse Complex Discharge for medical admissions MAPU PSSG, Allied health Head of Respiratory Medicine at Hutt Hospital Paediatrics Nurse & Sagni Prasad Charge Nurse Manager and Associate for Paediatric Patients Purpose The purpose of this interview is to get feedback from Hutt Hospital staff on the HCP that was trialled earlier in The HCP aimed to link hospitalised patients who had housing related conditions with a home visit providing a housing, health and social assessment. The aim of this interview is to get some feedback about the aspects of the project that hospital staff were involved in such as feedback on the referral process from their perspective, and the collaboration with other housing stakeholders. Guide The evaluator will contact hospital staff to arrange and confirm a time for the evaluator to visit them and do the interview (staff to decide on time and place). A face-to-face interview is preferable however if a staff member wishes then a telephone interview is an alternative option to help maximise response. Explain to the staff member We would like to hear about your experience in the HCP particularly about your current practice, the referral process for the HCP, collaboration and your overall opinion about the programme. The information you tell the evaluator is confidential and will only be used for the purpose of evaluation. 85

90 The interview will be recorded and themes will be collated and reported in the evaluation report. Would you like to be interviewed? When is a good time to meet? Where is a good place to meet? Topic guide PERSONAL How would you describe your role in this organisation? How long have you been doing this? What are your personal areas of interest in housing and health? Have you had any training on housing and health? What is your understanding of the link between housing and health? ORGANISATIONAL How do hospital services interact with housing services? Are patients routinely asked questions about housing? What is done for patients who have housing needs identified? Who takes responsibility for this? e.g. social workers Do you know which housing services are referred to? e.g, WINZ, HNZ REFERRAL PROCESS What do you know about the HCP? e.g. what it aims to do What was your role in the housing HCP? Did your role change over time? How much time did you spend on this? What was the referral process for the housing HCP? Did the referral process change over time? Did you personally refer patients to the housing nurses? Yes - how did you decide which patients to refer? e.g. all patients, all patients with certain diagnosis, patients with a community services card, certain ethnic groups What worked well? Is a hospital admission an appropriate time and place for a housing programme referral? If not, where would be more appropriate? e.g. marae, church or GP Was the level of involvement required by clinical staff appropriate? How easy or demanding was it to make a referral to the HCP programme? Was there anything that made it difficult to refer? Did staff have enough time to make referrals to the programme? How could the refer-in process be improved? Are the criteria for inclusion in the housing HCP appropriate? i.e.: Understandable? User friendly? Appropriately to meet housing needs? How could the criteria be improved? Were families/whānau with the greatest housing needs referred to the programme? What could be done to improve the programme s reach to families with housing needs? ELIGIBILITY CRITERIA: Housing related hospital admissions including bronchiolitis, asthma, pneumonia, Rheumatic Fever Age group 0-4yo or 5+ yo with Māori or Pacific ethnicity Community services card eligibility Non-HNZ property COLLABORATION What communication did you have with RPH? How did this develop? Does this level of collaboration meet your needs? Do you get enough information back about what happens after families are referred? SATISFACTION How satisfied were you with the programme? There is potential to extend this housing 86

91 programme. Would you be interested in participating again? What do you think worked well in the housing HCP programme? Did the programme have any unintended effects? How do you think the programme could be improved? What would make the programme work for you? What would the perfect programme look like to address the housing needs of whānau/families? Is there anything else you would like to add? Thank you The findings should be out early next year. Would you like to find out about the main evaluation findings? Would you prefer a call, or letter? External providers interview schedule Tu Kotahi Māori Asthma Trust Dental Bee Healthy Earthlink: Hutt Valley Curtain Bank Energy Smart Naku Enei Tamariki NET, Kokiri Marae Super Grans Warm up Capital and Coast The purpose of this interview is to get feedback on the HCP that was trialled in the Hutt Valley earlier in The HCP aimed to link hospitalised patients who had housing related conditions with a home visit for a housing, health and social assessment. The aim of this interview is to identify lessons from the Housing Coordinator Pilot Study; with a particular interest in how well families were able to access health, social and housing improvement interventions. The interview will also describe the collaboration between housing and health providers and RPH staff. Invitation script A guide to assist the evaluator when contacting providers to arrange an evaluation interview The evaluator will ring providers above to arrange and confirm a time to visit and do the interview (provider to decide on time and place). A face-to-face interview is preferable however if a provider wishes then a telephone interview is an alternative option to help maximise response. Explain to the provider I am doing an evaluation of a HCP, which has sent several referrals to your organisation this year. We want to see how we can improve our housing programme, including how referrals are done and how we engage with your organisation. Would you be interested in meeting for an interview? 87

92 The questions would be about your organisation, the referral process, what happens for families once they re referred, your collaboration with RPH, and your overall opinion about the housing HCP. The interview will be recorded and themes will analysed and written up in the evaluation report. The information you provide will be anonymous (not directly linked to your organisation) and will only be used for the purpose of evaluation. Would you like to be interviewed? When is a good time to meet? Where should I meet you? In preparation for interview An was sent to confirm the interview and provide copies of the written referrals for those who were involved in the HCP study. This was accompanied by some preliminary questions. In this way, follow-up could be discussed for these households as an example of what works and what doesn t. The Interview Process The interviewer will Explain the purpose of the interview and how the findings will be used Summarise the topics to be covered Ask permission to record the interview Provide visual of questions to be asked Topic guide YOU & YOUR ORGANISATION How would you describe your role in this organisation? How long have you been doing this? What are your personal areas of interest in housing and health? What is your understanding of the link between housing and health? What is the vision and purpose of your organisation? What services does your organisation deliver? What sort of education does your service provide? How does your organisation interact with hospital and primary care services? GENERAL REFERRALS Referral process How do clients normally find out about or get referred to your organisation? How well does the process of receiving referrals from RPH housing nurses work? Do you have a way of knowing which referrals come from RPH? Are you satisfied with the referrals you received? e.g. detail provided, appropriateness Are the households referred to you from RPH eligible to receive the services you provide? What are the eligibility criteria for the services you provide? What would improve the referral process? Engagement What methods/protocol do you use to contact a household? How many attempts and what kind/s of contact do you use to get in touch with a referred client? Are there barriers to people accessing your services? What are the greatest barriers? e.g. on household side and for the organisation? What would be required to reduce the barriers? Are there other things which would improve access to your services? Timeline How long does it normally take from receiving a referral to providing your service? Do you have a waitlist? What would improve your capacity to act on referrals? Feedback What mechanisms are there for feeding back 88

93 information to the referring agency? Do you routinely feed back outcome information to the RPH housing nurses? Yes - at which stage in the process? No - is this a possibility? PILOT REFERRALS - for each please select the best answer for each row: Referral ID: Was this referral received? Were you able to contact this family? Were they eligible for your service? Were they offered the service? Has the service been delivered? Yes No Unsure Were all aspects of each referral addressed? What was the time between referral and service delivery/conclusion? What follow-up was there for each family? Were there any barriers to access?/ways to improve access? Comment OPINION ABOUT OVERALL PROGRAMME What is your opinion about continuing to respond to referrals from an RPH housing programme? In your perspective, what worked well about the RPH referrals? Did our referrals have any unintended effects on your organisation? How do you think our housing programme could be improved? What could be done to improve access to housing services for families/whānau with housing needs? What would the perfect programme look like to address housing needs? e.g. at RPH Is there anything else you would like to add? Thank you The findings should be out early next year. Would you like to find out about the main evaluation findings? Would you prefer a call, or letter? Have you received referrals before for these households, or are they new to your service? COLLABORATION What communication do you have with RPH? Does this level of collaboration meet your needs? Has the relationship with RPH changed this year? and was this related to the HCP programme? 89

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