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GHHI Sites

Where We Work

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If you need additional assistance, call GHHI at (410)-534-6447 or email


Marin County, CA

Marin County became an established GHHI site in 2017 through execution of a GHHI Compact (partnership agreement) among the County of Marin, Community Action Marin, City of Sausalito, MCE, Marin Center for Independent Living, Marin City Community Development Corporation, Marin Housing Authority, and Strategic Energy Innovations. MCE leads GHHI Marin County unit production through implementation of residential energy efficiency and healthy homes programs.

Highlights / Accomplishments

Contra Costa County, CA

  • Overview: A cross-sector partnership to develop an asthma home visiting program with in-home asthma trigger assessment and remediation. GHHI provided technical assistance to develop the program service model and secure short and long-term funding.
  • Partners: Contra Costa Health Services, Contra Costa Health Plan, MCE, Association for Energy Affordability, Contra Costa Department of Conservation and Development
  • Highlights/accomplishments: In process of securing pilot funding


Denver, CO

Denver became an established GHHI site in 2011 through a Compact signing (partnership agreement) among Adams County Community Development, City of Denver, County of Denver, American Lung Association in Colorado, AmeriCorps, Audubon Colorado, Boulder County Health Department, Brothers Redevelopment, Center for Resource Conservation, City of Fort Collins, Colorado Department of Public Health and Environment, Colorado Division of Housing, Colorado Energy Office, Colorado Office of Policy & Initiatives, Colorado Renewable Energy Society, Colorado State University, Community Faith in Action, Denver Housing Authority, Denver Indian Center, Denver Public Schools, Denver Urban Renewal Authority, Denver Water, Denver Works, Denver’s Road Home, EarthForce, EnergyLogic, Energy Outreach Colorado, Extreme Community Makeover, FRESC, GB3 Energy Solutions, Greenprint Denver, Groundwork Denver, Habitat Metro Denver, iCAST, Impact Colorado, Mi Casa Resource Center, Mile High United Way, Mile High Youth Corps, National Association of State Community Services Program, National Environmental Health Association, National Jewish Health, Northeast Denver Housing Center, Our Savior’s Lutheran Church, Parks & Rec Mile High Million, Rebuilding Together Denver, Recharge Colorado, Revision International, RTD-Denver, Trans World Realty, University of Colorado at Denver Health Sciences Center, Veterans Green Jobs, Visiting Nurses Association and Xcel Energy.

Highlights / Accomplishments


Connecticut Department of Public Health

A cross-sector partnership to develop an asthma home visiting program with in-home asthma trigger assessment and remediation. GHHI provided technical assistance to advocate for sustainable funding from State Medicaid.


  • Connecticut River Area Health District
  • Connecticut Department of Public Health Putting on AIRS
  • Middlesex Hospital

Highlights / Accomplishments

  • Serving approximately 50 patients per year

Connecticut Green Bank

A cross-sector partnership to develop a comprehensive healthy homes model to reduce health/safety hazards and improve energy efficiency for Connecticut households at greatest risk of hospitalization for asthma or fall-related injuries. GHHI provided technical assistance to 1) conduct an initial asset/gap analysis, 2) hold workshop with service delivery partners to develop a coordinated model, and 3) estimate the impact of the program on Connecticut Medicaid expenditures through analysis of three years of Medicaid and CHIP data.


  • Connecticut Green Bank
  • Connecticut Department of Public Health

Highlights / Accomplishments

  • Analysis of State Medicaid data estimated that the program could pay for itself within three years.

New Haven, CT

New Haven became an established GHHI site in 2011 through execution of a GHHI Compact (partnership agreement) among the Annie E. Casey Foundation, City of New Haven Department of Environmental Health, City of New Haven Livable City Initiative, City of New Haven Office of Sustainability, Community Action Agency of New Haven, Community Foundation for Greater New Haven, Greater New Haven Community Loan Fund, Neighborhood Housing Services of New Haven, New Haven Health Department, The United Illuminating Company – Connecticut Efficient Healthy Homes Initiative, and Yale-New Haven Regional Lead Treatment Center.

Highlights / Accomplishments


Atlanta, GA

Atlanta became an established GHHI site in 2011 through a Compact signing (partnership commitment) driven by the City of Atlanta, Annie E. Casey Foundation, Center for Working Families, and other agencies including the Centers for Disease Control and Prevention, Children’s Healthcare of Atlanta, Community Foundation of Greater Atlanta, Fulton County Health Department, Georgia Department of Human Services, Georgia Environmental Finance Authority, Georgia Piedmont Technical College, Morehouse School of Medicine, Pittsburg Community Improvement Association, Southeast Energy Assistance, Southside Medical Center, Sustainable Atlanta, Sustainable Neighborhood Development Strategies, U.S. EPA (Region IV), U.S. Department of HHS (Region IV), and U.S. Department of HUD (Region IV).

Highlights / Accomplishments


Chicago, IL

Chicago became an established GHHI site in 2012 through a Compact signing (partnership agreement) among Bethel New Life, Bickerdike Community Development Corporation, City of Chicago, Chicago Housing Authority, Chicago Metropolitan Agency for Planning, Claretian Associates, Community and Economic Development Association of Cook County, Delta Institute, Heartland Alliance, Historic Chicago Bungalow Association, Lead Safe Illinois, Loyola University Chicago, Mayer Brown, Metropolitan Tenants Organization, Polk Bros. Foundation, Safer Pest Control Project, Smart Policy Works, The Field Museum, The Joyce Foundation, and the University of Illinois at Chicago. In 2017 Loyola University of Chicago became one of the first five of the Inaugural GHHI Lead Catalytic Grant Awardees. GHHI is also supporting development and implementation of a pilot project for asthma interventions with Elevate Energy and AMITA Health (formerly Presence Health).

Highlights / Accomplishments

Chicago, IL: AMITA Health

GHHI worked with AMITA Health (formerly Presence Health) and Elevate Energy to assess the feasibility of Pay for Success financing to scale asthma home visiting and repair services. The project focused on the Saints Mary and Elizabeth Medical Center on Chicago’s West Side.

Highlights / Accomplishments

  • The team completed a feasibility study and secured grant funding to pilot coordinated services between AMITA and Elevate Energy teams to serve high-utilizing asthma patients. The team successfully delivered services to 20 families laid the foundation for a second pilot based out of a second AMITA Health hospital. The team also successfully engaged a local Medicaid payer to access claims data and perform return-on-investment analysis.

Chicago, IL: ComEd

A cross-sector partnership to test a coordinated service delivery model with a hospital system (AMITA) and a utility’s energy-efficiency program implementer, Elevate Energy.


  • AMITA St. Francis Hospital
  • Elevate Energy
  • Sinai Urban Health Institute
  • ComEd

Highlights / Accomplishments

  1. Used $100,000 grant from ComEd, coupled with local grant funding for home visits, to fund both health/safety and energy-efficiency measures for patients with asthma


South Bend, IN: Memorial Hospital

In 2019, GHHI provided technical assistance to support development of a coordinated home-based asthma program implemented by the Memorial Hospital of South Bend and Near Northwest Neighborhood, Inc. The focus of GHHI’s technical assistance was on data and evaluation planning; operational planning; and cost-benefit analysis.


  • Memorial Hospital of South Bend
  • Near Northwest Neighborhood, Inc.

Highlights / Accomplishments

  • GHHI and the South Bend partners developed a data management and evaluation guide, a detailed process flow, a budget analysis, and a cost-benefit analysis—all included in a final business plan. Partners also aligned plans with the onboarding process the city of South Bend was undergoing to become an official GHHI site.

Indianapolis, IN: Indiana Joint Asthma Coalition

GHHI worked with the Indiana Joint Asthma Coalition (InJAC), alongside Improving Kids Environment, Riley Hospital for Children, and Indiana Community Health Worker Assocation, to strengthen and build an asthma-specific community health worker (CHW) training for use statewide to implement home visiting services at scale. The project partners brought expertise from across many fields and worked together to build a standardized curriculum that provides asthma education certification to CHWs. This work was timely, as the state just passed a State Plan Amendment that allows Medicaid reimbursement for CHWs performing in-home education for chronic conditions such as asthma.

Highlights / Accomplishments

  • In Fall 2018, project partners held healthy homes and asthma community health worker (CHW) trainings in two counties in Indiana. 23 CHWs passed the asthma certification at the end of the training. Project partners worked with health plans, hospitals, government, and community-based organizations to promote the trainings and recruiting CHWs from multiple healthcare providers and payers. Project partners remarked that this grant has allowed them to interact more with the healthcare community in Indiana than any other opportunity, leading to lasting relationships and partnerships.


Dubuque, IA

Dubuque became an established GHHI site in 2011 through execution of a GHHI Compact (partnership agreement) among the City of Dubuque Department of Housing and Community Development, City of Dubuque Department of Public Health, Community Foundation of Greater Dubuque, Operation New View, and Visiting Nurses Association.

Highlights / Accomplishments

Des Moines: IA Healthy Homes Des Moines

HHDSM and partners worked to mitigate the effects of unhealthy household environments on asthma impaired young children living in substandard housing. With guidance and technical assistance from GHHI, HHDSM created policy and institutional changes to make project interventions more effective, sustainable, and upstream, and enable other Iowa communities to begin environmentally related asthma prevention and mitigation. GHHI also built out a centralized data system to improve efficiencies in care coordination, data collection and performance management which will allow for a rigorous evaluation of the Build Health Challenge HHDSM asthma pilot.


  • Healthy Homes Des Moines, Iowa is the convener of a collaborative effort between three area hospital systems – Mercy Medical Center – Des Moines, UnityPoint Health – Des Moines, and Broadlawns Medical Center, as well as Des Moines Public Schools, Visiting Nurse Services of Iowa, the Polk County Health Department, the Child and Family Policy Center, Polk County Housing Trust Fund, Polk County Public Works, Rebuilding Together Greater Des Moines, Mid-Iowa Health Foundation, and Telligen Community Initiatives

Highlights / Accomplishments


Baton Rouge, LA: LA Department of Health

In 2020, partners in Baton Rouge, LA were awarded GHHI technical assistance as part of the third Business Development cohort funded by the Environmental Protection Agency’s National Initiative for Asthma Reimbursement. In a public-private partnership, the Louisiana Department of Health (LDH) Section of Environmental Epidemiology and Toxicology (SEET), the Louisiana Center for Health Equity, and Louisiana State University Health Sciences Center seek to address disparities in childhood asthma localized in East Baton Rouge Parish through the design and implementation of a comprehensive, home-based asthma intervention.

GHHI worked with partners to identify appropriate local service providers, design actionable work and evaluation plans, and prepare to pilot the intervention. To date, partners have been able to successfully engage State Medicaid and managed care organizations to support project design.


Baltimore, MD

Baltimore, the original GHHI site, began the process to implement a coordinated model for interventions in 2008 when the White House Office of Recovery charged GHHI to lead national efforts to integrate lead hazard control, healthy homes and weatherization and energy efficiency work. This project became the Green & Healthy Homes Initiative, launched nationally in 2011, that addresses the health and energy efficiency needs of a home through a holistic intervention model. Today GHHI partners with the Baltimore City Department of Housing and Community Development and other coordinating agencies to implement the Leading Innovation for a Green and Healthy Tomorrow (LIGHT) Program that screens clients for resources ranging from energy-efficiency/weatherization, home rehabilitation, lead hazard reduction, fall/injury prevention, asthma reduction, healthcare, employment, financial security and more. GHHI Maryland Direct Services perform multiple coordinated interventions to meet the specific needs of clients. Visit the Direct Services page to learn more about GHHI Maryland.

Highlights / Accomplishments

Asthma Pay for Success

GHHI developed a project in partnership with Priority Partners MCO, a Medicaid health plan partially owned by Johns Hopkins, to look at utilizing a pay for success financing model to fund comprehensive in-home asthma interventions including the repair of housing-related triggers like mold and pests. Under this model, outside funders such as philanthropy or impact investors would provide all the upfront funding needed to conduct a comprehensive asthma program at scale, and Priority Partners would only make payments if an evaluation showed that the asthma program lowered their costs. Actuarial analysis was conducted by Milliman of Priority Partners’ members at high risk of asthma utilization such as emergency department visits and hospitalizations. The analysis indicated a good return on investment was possible for providing the services to Priority Partner’s members who had a history of asthma-related emergency department visits or hospitalizations.

Highlights / Accomplishments

  • The asthma Pay for Success project served a model for similar projects developed around the country. With Priority Partners and the State Medicaid office, GHHI was able to identify a mechanism to advance a Pay for Success model in the context of Medicaid managed care regulations. Currently, the project is slated to be part of a proposal to US Treasury for the next round of Social Impact Partnerships to Pay for Results (SIPPRA) awards.


Springfield, MA: Public Health Institute of Western MA

Beginning in June of 2015, GHHI worked with a cohort of healthcare and community-based partners in Springfield, including Baystate Health, Public Health Institute of Western Massachusetts, Revitalize CDC, and City of Springfield, to build and seek reimbursement for an evidence-based comprehensive asthma program. Rated as the #1 asthma capital of the US in 2018, the partners provider a much-needed Healthy Homes Asthma Program for families with asthma.

Highlights / Accomplishments

  • In 2019, the Springfield Healthy Homes Asthma Program, with the help of GHHI, was awarded $750,000 from the Health Policy Commission to provide comprehensive asthma services to 150 patients identified by an accountable care organization (ACO). The goal of this project is to reduce asthma-related hospitalizations and emergency department visits and, if successful, to receive longer-term sustainable financing from the ACO.

Worcester, MA: University of Massachusetts Memorial Medical Center

GHHI worked with UMass Memorial Medical Center (UMMMC) to expand its successful pediatric asthma intervention program aimed at helping high-risk children with asthma improve asthma control and decrease hospitalizations, emergency department (ED) visits, and school absenteeism. After noticing a high number of patients using the UMMMC ED from the region north of Worcester, GHHI worked with the hospital to replicate their evidence-based model in Gardner, Leominster, and Fitchburg in partnership with the Montachusett Opportunity Council (MOC).

Highlights / Accomplishments

  • GHHI worked with MOC to build out a comprehensive asthma program and implement an asthma pilot for 12 families. Three of the homes needed major modifications, all of which were paid for by funding from Weatherization and a local utility, totaling $38,000 in repairs. As a result of this work, MOC received funding from a healthcare payer to provide asthma-related home modifications to families with children that have asthma as part of the Massachusetts Medicaid Flexible Services Program.


Detroit, MI

Detroit was established as a GHHI site in 2011 through execution of a GHHI Compact (partnership agreement) among AmeriCorps Urban Safety Project, Asthma and Allergy Foundation of America—Michigan Chapter (AAFA-MI), Central Detroit Christian Community Development Corporation, Children’s Hospital of Michigan, City of Detroit, CLEARCorps Detroit, Community Development Advocates of Detroit, Detroit Area Green Sector Skills Alliance, Detroit Local Initiatives Support Corporation, Detroit Training Center, Detroiters Working for Environmental Justice (DWEJ), DTE Energy, Eastside Community Network, Ecology Center, EcoWorks Detroit, Focus: HOPE, Green Door Initiative, GS Group LLC, Habitat for Humanity Detroit, Habitat for Humanity of Michigan, Henry Ford Health System Global Health Initiative, Home Builders Association of Southeastern Michigan, ICF International, Institute for Population Health, Jefferson East Inc., Michigan Community Action Agency Association, Michigan Department of Community Health, Michigan Department of Human Services, Michigan Environmental Council, Michigan State Housing Development Authority, Reclaim Detroit, RSM Lead Inspections, Stafford House Inc., The Jewish Fund, The Kresge Foundation, The Skillman Foundation, The Villages Community Development Corporation, U.S. Department of Housing and Urban Development, Vanguard Community Development Corporation, Wayne Children’s Healthcare Access Program, Wayne County Economic Development Growth Engine, Wayne County Prosecutor’s Office, Wayne County Public Health Department, Wayne Metropolitan Community Action Agency, Wayne State University’s Center for Urban Studies, and Young Detroit Builders.

Highlights / Accomplishments

Flint, MI

Flint became an established GHHI site in 2011 through execution of a GHHI Compact (partnership agreement) among Career Alliance, City of Flint, Charles Stewart Mott Foundation, Flint Housing Commission, Genesee County, Genesee County Community Action Resource Department (GCCARD), Genesee County Habitat for Humanity, Genesee County Health Department, Genesee County Land Bank, Greater Flint Health Coalition, Hurley Medical Center, Mott Community College, Priority Children, Reinvest Flint, Ruth Mott Foundation, and University of Michigan – Flint.

Highlights / Accomplishments

Grand Rapids, MI: Spectrum Health

GHHI worked with Spectrum Health and local partners to assess the feasibility of using Pay for Success financing to scale asthma home visiting services in Grand Rapids.


  • Project manager and coordinator: Spectrum Health
  • Payer: Priority Health
  • Community health home visit service provider and backbone organization: Health Net of West Michigan
  • Asthma education home visit service provider: Asthma Network
  • Home assessment and repair service provider: Healthy Homes Coalition of West Michigan

Highlights / Accomplishments

The Pay for Success feasibility project showed potential from a coordinated service delivery model between the service providers, and substantial Medicaid cost savings to Priority Health. This project led to subsequent projects with the team in advancing a Pay for Success project and sustaining asthma home visiting and repair services.

Grand Rapids, MI: Health Net of West Michigan

As a continuation of the Pay for Success (PFS) feasibility study, partners continued to advance the PFS project and tested the model through a pilot.


  • Health Net of West Michigan
  • Healthy Homes Coalition of West Michigan
  • Asthma Network
  • Priority Health

Highlights / Accomplishments

  • The team served 15 families through the pilot project and advance discussions with Priority Health that resulted in direct payment for healthy homes asthma assessments, home visits, and education. While not a PFS project, the contract arrangement enables Priority Health to address housing as a determinant of health under Michigan Medicaid managed care requirements.

Lansing, MI

Lansing became an established GHHI site in 2014 through execution of a GHHI Compact (partnership agreement) among Action of Greater Lansing, Asthma and Allergy Foundation of America – Michigan Chapter, Center for Financial Health, Greater Lansing Housing Coalition, Lansing Board of Water and Light, Michigan Department of Community Health – Childhood Lead Poisoning Prevention and Healthy Homes Program, Michigan Energy Options, Michigan Environmental Council, Mid-Michigan Environmental Action Council, MSU College of Human Medicine, Public Sector Consultants, North Central Integrated Pest Management Center, Rental Property Owners Association of Mid-Michigan, and Sparrow Hospital.

Highlights / Accomplishments

Michigan Department of Health & Human Services: Statewide Lead Fund

GHHI is working with the Michigan Department of Health and Human Services to establish a statewide affordable loan fund to scale lead hazard control. Michigan’s current lead poisoning prevention efforts have resulted in substantial decreases in elevated blood lead levels in the past decade.  However, the state’s highest risk housing, units with lead-based paint and children under age 6, number over 370,000, and thousands of children are still lead poisoned annually. The American Healthy Housing Survey estimates that 1.5 million housing units in Michigan contain lead. A fully capitalized Lead Fund will directly finance tens of thousands of lead hazard control jobs, which would be a transformational increase from the current level of lead hazard control in the state.


  • Michigan Department of Health and Human Services (MDHHS)
  • Michigan Governor’s Office

Highlights / Accomplishments

  • Governor Whitmer’s 2021 budget allocated $2 million to be used as a loan loss reserve. This initial funding will leverage additional philanthropic grants to scale up the loan loss reserve and attract investment capital from impact investors.


Minneapolis, MN: Minnesota Multifamily Affordable Housing Energy Network

Minneapolis, MN: Minnesota Multifamily Affordable Housing Energy Network

Green & Healthy Homes Initiative (GHHI) worked in partnership with members of the Minnesota Multifamily Affordable Housing Energy Network (MMAHEN) to explore and demonstrate the opportunity for healthcare entities to reduce utilization and address social determinants of health by investing in energy efficient retrofits for affordable multifamily housing developments in Minneapolis.


  • Minnesota Housing Finance Agency
  • National Housing Trust
  • Project for Pride in Living
  • Center for Energy and Environment
  • City of Minneapolis

Highlights / Accomplishments

  • GHHI worked with partners to build a cost-benefit model to demonstrate the potential healthcare savings achieved by investing in energy efficiency retrofits for multifamily housing.


Jackson, MS

Jackson became an established GHHI site in 2013 through execution of a GHHI Compact (partnership agreement) among Atmos Energy, Bancorp South, BankPlus, City of Jackson, Entergy Mississippi, Habitat for Humanity Mississippi Capital Area, Hope Enterprise Corporation, Jackson Housing Authority, Jackson Medical Mall Foundation, Jackson State University, Midtown Partners Inc., Mississippi Department of Environmental Quality, Mississippi Department of Human Services, Mississippi Home Corporation, Mississippi Housing Partnership, Mississippi Roadmap to Health Equity, Mississippi State Department of Health, Mississippi State University Extension Service, Tougaloo College Central Mississippi Area Health Education Center, University of Southern Mississippi Institute for Disability Studies, Voice of Calvary Ministries, and W.K. Kellogg Foundation. The network has expanded to include Excel By 5 Mississippi, Jackson Association of Neighborhoods, Jackson Hinds Comprehensive Health Center, Springboard to Opportunities, South Central Community Action Agency, United Way of the Capital Area, and University of Mississippi.

Visit the Direct Services page to learn more about GHHI Jackson.

Highlights / Accomplishments

New York

Buffalo, NY

Buffalo became an established GHHI site in 2011 through a Compact signing (partnership agreement) with the Asthma Coalition of Western New York, Center for Employment Opportunities, City of Buffalo, Coalition for a Lead Free Community, Community Foundation for Greater Buffalo, Community Health Foundation of Western and Central New York, Erie 1 BOCES, Erie County Health Department, Erie County Department of Senior Services, Family Environmental Health Resources, Heart of the City Neighborhoods, Home Front Buffalo, Neighborhood Housing Services of South Buffalo, New York State Energy Research and Development Authority, New York State Housing and Community Renewal, Office of the Attorney General of the State of New York, PUSH Buffalo, The Belle Center, University District Community Development Association, Western New York Lead Poisoning Prevention Resource Center, Western New York Public Health Alliance, Westside & Black Rock-Riverside Neighborhood Housing Services, and Women and Children’s Hospital of Buffalo. The Community Foundation for Greater Buffalo housed the first local Outcome Broker to support implementation of the GHHI Model and continues to lead the GHHI collaborative initiative as well as the asthma network.

Highlights / Accomplishments

Buffalo, NY: YourCare Health Plan

GHHI worked with YourCare Health Plan and the Community Foundation for Greater Buffalo to conduct an in-depth analysis and capacity building to determine if an asthma-focused pay for success transaction was feasible. Medicaid claims data was analyzed to determine the return on investment for a comprehensive set of services including remediation of environmental triggers for asthma for high-risk Medicaid members.

Highlights / Accomplishments

  • The project team presented analysis findings to New York State Medicaid, and advocated for the inclusion of specific language in the New York VBP Roadmap or State Medicaid – to – Medicaid managed care organization contracts to allow the managed care organizations to advance innovative funding models like pay for success. Language was added to the New York VBP Roadmap in a 2019 update.

Buffalo, NY: Community Foundation of Greater Buffalo

As an extension of GHHI’s project with YourCare Health Plan, GHHI worked with Community Foundation of Greater Buffalo to bring other stakeholders to the table, including Medicaid Managed Care Organization Independent Health Association (IHA), Millennium Collaborative Care, and John R. Oishei Children’s Hospital. Partners conducted analysis to identify the membership of IHA who could benefit from a comprehensive asthma intervention that included assessment and remediation of asthma triggers. The partners also reviewed State Medicaid efforts around investment in the social determinants of health and increasing value-based payments to align the asthma program with the broader New York Medicaid design. The partners determined that the next step was to pilot out services and conduct preliminary analysis on outcomes. This pilot effort was undertaken by a follow up project with Oishei Children’s Hospital.

Buffalo, NY: Oishei Children’s Hospital

From March 1, 2019 to February 28, 2020, GHHI supported project partners in the City of Buffalo and Erie County, New York through Reimbursement Support Technical Assistance to build and scale an asthma pilot project in 2019 designed to run on sustainable funding secured through a value-based purchasing model, with hopes of expanding it into a full-scale project in 2020. The aim of the technical service offerings for reimbursement structuring was to assist each site to identify any relevant policy and regulatory issues, analyze and select a reimbursement model, support engagement with health plans and Medicaid programs, finalize appropriate data agreements, and finalize reimbursement terms. 


  • John R. Oishei Children’s Hospital (OCH) is leading a strong partnership to implement the Oishei Healthy Kids (OHK) Asthma Pilot Project to improve the lives of children with asthma in Erie County. OCH, in coordination with Independent Health, will identify eligible patients through the pediatric primary care setting (Niagara Street Pediatrics) and their Emergency Department. The asthma home-visiting services are provided by the Buffalo Prenatal Perinatal Network and NHS of South Buffalo and the Community Foundation for Greater Buffalo.

Highlights / Accomplishments

  • OHK Asthma Pilot Project received $74,500 in funding and commenced enrollment in November 2019 and is expected to complete 30 comprehensive asthma interventions for children and their families in the Greater Buffalo Area.

Greater Capital Region, NY

New York Greater Capital Region (Albany, Schenectady, and Troy) became GHHI sites in 2017 through execution of a GHHI Compact (partnership agreement) among the City of Albany, Albany County, Community Foundation for the Greater Capital Region, Albany Community Development Agency, Affordable Housing Partnership, City of Schenectady, Schenectady County Public Health Administration, TAP Inc., MVP Health Care, Community Loan Fund of the Capital Region Inc., Capital Region Land Bank, Troy Rehabilitation and Improvement Program, City of Troy, and Troy Community Land Bank. The partnership has grown to include the Charles L Touhey Foundation, Cornell Cooperative Extension Albany County, Key Bank, Schenectady Foundation, and National Grid. AHP Homeownership Center in Albany serves as the coordinator for the three community-based partnerships in the region.

Highlights / Accomplishments

Greater Capital Region, NY: Affordable Housing Partnership

  • In 2020, partners in the Greater Capital Region, NY, were awarded GHHI technical assistance as part of the third Business Development cohort funded by the Environmental Protection Agency’s National Initiative for Asthma Reimbursement. The Affordable Housing Partnership, Cornell Cooperative Extension – Albany County, the Alliance for Better Health, MVP Healthcare, and the Community Foundation of the Greater Capital Region seek to refine in-home asthma intervention services currently available through the GHHI site to better target and prioritize home repair for asthma patients whose health is negatively impacted by environmental conditions in the home.
  • Partners will work with GHHI through the end of 2020 to: streamline intervention referral and service processes, identify appropriate evaluation metrics and design data collection workstreams, build out a comprehensive business plan for use when seeking reimbursement support from potential funders.

New York City, NY: New York Healthy Homes Collaborative

The New York Healthy Homes Collaborative is a cross-sector partnership of organizations working to scale a comprehensive asthma program for children and adults enrolled in Affinity Health Plan’s Medicaid programs in New York City. Through the innovative combination of Pay for Success (PFS) financing with value-based payment (VBP), partners strive to prove at scale the effectiveness of an asthma program that extends beyond traditional medical services to address families’ needs in the home and community. The program’s main goal is to prevent asthma events, thereby reducing healthcare utilization and costs, increasing school and work attendance, and—most importantly—improving families’ quality of life. The end goal is to establish sustainable healthcare funding for comprehensive asthma programs that improve outcomes and can be scaled and replicated. Proving the viability of this pioneering PFS + VBP model will pave the way for it to be utilized for other issues, potentially unlocking billions for preventive services addressing social determinants of health.


  • GHHI – Project manager and transaction coordinator
  • Affinity Health Plan – Health plan payer
  • AIRnyc – Lead social care and home visiting service provider
  • Association for Energy Affordability – Home remediation service provider
  • NYC Department of Health and Mental Hygiene – Technical advisor
  • Primary Care Development Corporation – Financial intermediary

Highlights / Accomplishments

  • During the project development period, partners planned a coordinated intervention, performed in-depth analysis on Affinity’s claims data to determine the target population and build an economic model, and identified a sustainable payment mechanism to construct a transaction to present to funders with a target launch in 2020.

New York City, NY: LISC

Local Initiatives Support Council (LISC) convened a group of stakeholders in New York City to develop an asthma program that leveraged the strengths of neighborhood-based non-profits in six neighborhoods throughout Brooklyn and Queens. The collaborative included four managed care organizations, two performing provider systems and four community-based organizations.

Highlights / Accomplishments

  • In 2019, GHHI provided technical assistance to the collaborative to advance its goal of having the program be reimbursed through Medicaid funds. GHHI’s technical assistance included guidance on evaluation design, financial modeling, contracting models, and data and privacy.

Suffolk County, NY: Keeping Families Healthy

Keeping Families Healthy (KFH) is an award-winning primary care medical home and asthma program based at Stony Brook Medicine in Suffolk County, NY. The overarching goal of the KFH program is to help “at risk” families achieve self-sufficiency in navigating the health care system and adhering to recommended clinical care.

Highlights / Accomplishments

  • In 2019, under a grant from the EPA, GHHI worked with the KFH leadership to develop a business plan for sustainably financing the program through reimbursement from a Medicaid managed care organization. GHHI’s work with KFH insurance guidance on cost-benefit modeling, evaluation metrics and payment mechanisms.

Syracuse, NY

Syracuse became an established GHHI site in 2016 through execution of a GHHI Compact (partnership agreement) among the City of Syracuse, Onondaga County, City of Syracuse Neighborhood and Business Development, City of Syracuse Office of Community Development, Onondaga County Health Department, Central New York Community Foundation, Health Foundation for Western & Central New York, PEACE Inc., Home HeadQuarters, and CNY Fair Housing. Home HeadQuarters leads site development for GHHI Syracuse and convenes the local partnership network to coordinate housing intervention services.

Highlights / Accomplishments

Utica-Oneida County, NY

  • Overview
  • Partners
  • Highlights/accomplishments

Various Locations: Value-Based Payment (VBP) Trainings

In 2017, GHHI was tapped by New York State Department of Health’s Bureau of Social Determinants of Health and New York Medicaid to provide trainings at six VBP bootcamps held throughout the state. They were a regional learning series created by the Department of Health with the goal to equip VBP contractors and interested parties such as Managed Care Organizations, Providers, Associations, and Community Based Organizations, with the knowledge necessary to implement payment reform. GHHI provided training on addressing health risk factors, part of the sessions around contracting with community based organizations to address the social determinants of health.

In 2019, GHHI provided similar trainings to hundreds of community-based organizations that are seeking to enter into contracts with Managed Care Organizations as part of a series of VBP Forward workshops in Albany, Buffalo, and Syracuse.


Cleveland, OH

Cleveland became an established GHHI site in 2011 through a Compact signing (partnership agreement) among the City of Cleveland, Cleveland Health Department, Cleveland Housing Network, Community Housing Solutions, Cudell Improvement, Cuyahoga County Board of Health, Cuyahoga County Department of Development, Detroit Shoreway Community Development, Environmental Health Watch, Fairfax Renaissance Development Corporation, Healthy Homes Advisory Council of Greater Cleveland, Mt. Pleasant NOW Development Corporation, NHS of Greater Cleveland, Ohio Weatherization Training Center, and Swetland Center Case School of Medicine. The City of Cleveland Division of Neighborhood Services continues to work with community partner organizations to implement the Lead Hazard Control Programs aligned with additional intervention services.

Highlights / Accomplishments

Cincinnati, OH: People Working Cooperatively

People Working Cooperatively (PWC) is a community-based organization based in Cincinnati that serves low-income, elderly, and disabled homeowners. PWC strengthens communities by providing professional, critical home repairs, weatherization, modification, and maintenance services to help residents stay safely in their homes. Since 1975, PWC has provided 250,000 healthy housing services to low-income or disabled individuals across 19 counties in Ohio, Northern Kentucky, and Southeastern Indiana.

Highlights / Accomplishments

  • In 2019, GHHI worked with PWC to explore innovative financing models to fund a novel aging-in-place program that combines group education (Stepping On) with home modifications performed by PWC’s  Whole Home experts. Our hypothesis was that a program that prioritized improved health outcomes, cost-effectiveness, socialization benefits, and operational flexibility had strong potential to be a model that could be sustainably financed and scaled under the architecture of the U.S. healthcare system. Our work lead to a partnership with a leading national health plan to fund and scale the program in Ohio. We also published a paper based on this work exploring sustainable financing options for aging-in-place programs.

Cincinnati, OH: Molina

With funding from the Corporation for National and Community Service, GHHI worked with People Working Cooperatively (PWC) in 2018-2019 to plan and evaluate a pilot for an intervention model designed to improve the health and quality of life for older adults in Cincinnati. The model combined Stepping On, an evidence-based group therapy program, with tailored home modifications provided by PWC’s Whole Home experts. GHHI supported the design and analysis of a qualitative evaluation that led to the publication “Developing Sustainable Financing Models to Scale Aging-in-Place Programs.” That project led to Molina Healthcare contracting with PWC and GHHI to launch a larger pilot to provide the enhanced Stepping On program to Molina’s Medicare Advantage members in Cincinnati. GHHI will design an evaluation that includes not only qualitative data but also quantitative data from Molina’s claims database. GHHI will publish findings on the analysis of the evaluation once complete.


Albany, OR: Community Services Consortium

Community Services Consortium (CSC), Samaritan Health Services and Linn County Health Department utilized business development technical assistance from GHHI to strengthen and expand an established, evidence-based pediatric asthma home visiting intervention throughout the tri-county region –Lincoln, Benton and Linn counties. Partners were previously engaged in the Healthy Homes project for 2+ years, focused on Linn County, where services are provided to help high-risk children with asthma in a collaborative effort to provide in-home health care visits and to develop asthma management plans. As part of GHHI’s EPA Business Development cohort, partners collaborated to improve indoor air quality of homes remediated; decrease asthma-related emergency visits; decrease household school and work asthma-related absences; and obtain a performance-based contract to provide services in the tri-county region of central coastal Oregon.


  • Community Services Consortium (CSC) is a state-designated community action agency that has been serving the communities of Linn, Benton and Lincoln counties for over 40 years. CSC hires, trains, and houses the weatherization staff; performs indoor air quality testing, conducts client and partner training on weatherization and energy conservation, coordinates participation of county health navigators, conducts weatherization and repair work to the homes, submits all required reports, and conducts public relations activities to promote the project. CSC uses federal and state weatherization program funds earmarked for community action agencies to perform the health and safety repairs as well as the weatherization measures.

Samaritan Health Services (SHS) is a not-for-profit regional health system that brings together community hospitals, physician clinics and health insurance plans to serve more than 265,000 residents of Oregon’s Benton, Lincoln and Linn counties. SHS provided care coordination and client referrals by recommending the Healthy Homes program to families of pediatric patients with asthma.

InterCommunity Health Network CCO (IHN-CCO) is the Community Health Plan for Benton, Lincoln and Linn County, Oregon which currently serves more than 50,000 Oregon Health Plan members.

Highlights / Accomplishments

  • SHS provided the funds to purchase asthma kit items which were not allowable expenses for the federal or state weatherization contracts. SHS performs these activities with the support of existing resources.
  • Identified the potential reimbursement pathway of Targeted Case Management Program (TCMS) which allows for case management services furnished to a specific target group of eligible clients under the Medicaid State Plan to gain access to needed medical, social, educational and other services (such as housing and transportation). The TCM services rules are designed to assist the TCM provider organizations, such as CSC, in matching state and federal funds for TCM services defined by Section 1915(g) of the Social Security Act, 42 USC § 1396n(g). The target group is Medicaid eligible children with poorly controlled asthma or a history of environmentally induced respiratory distress, which can result in a life-threatening asthma exacerbation or exacerbation of respiratory distress.
  • Engaged the local Coordinated Care Organization and the potential payer – InterCommunity Health Network CCO to present the business case for the ongoing pilot program


Philadelphia, PA: Health Partners Plans

GHHI worked with local partners to assess the feasibility of Pay for Success financing to scale asthma home visiting services in Philadelphia.


  • Health Partners Plans: Payer
  • St. Christopher’s Hospital for Children: Clinical service provider, asthma education home visiting
  • Philadelphia Department of Public: Service provider for home assessments and integrated pest management

Highlights / Accomplishments

  • The team successfully completed the asthma Pay for Success feasibility study and found that PFS was indeed a viable option for scaling program services.

Philadelphia, PA: Energy Coordinating Agency

Energy Coordinating Agency (ECA) is a provider of energy efficiency and weatherization services and recognizes the importance of the home environment on occupant health, especially asthma. GHHI worked with ECA to build capacity for asthma-specific services in partnership with St. Christopher’s Hospital for Children.

Highlights / Accomplishments

  • ECA and St. Chris developed a joint process flow and referral plan as part of a comprehensive program. The two organizations also completed on-site shadowing sessions in which community health workers and home auditors learned from one another’s expertise.

Philadelphia, PA: National Nurse-Led Care Consortium

The National Nurse-led Care Consortium (NNCC) operates a healthy homes home visiting program called the Safe and Healthy Homes Program (SHHP), funded by the state health department. NNC engaged GHHI to build capacity to address asthma-specific topics that arise for clients in the program. GHHI also worked with NNCC to identify potential sources of sustainable funding beyond the SHHP grant.

Highlights / Accomplishments

  • GHHI helped NNCC develop a comprehensive business plan, which laid out steps to incorporate asthma specific education topics and services under the SHHP program model. NNCC plans to incorporate recommendations and build a track record that will enable them to partner with healthcare payers in the future.

Philadelphia, PA

Philadelphia became a GHHI site in 2012 through execution of a GHHI Compact (partnership agreement) among the City of Philadelphia Office of Housing and Community Development, City of Philadelphia Office of Supportive Housing, Community Legal Services, Habitat for Humanity Philadelphia, Homeowners Association of Greater Philadelphia, Philadelphia Electric Company, Philadelphia Gas Works, Philadelphia Housing and Development Corporation, Philadelphia Housing Authority, Public Citizens for Children and Youth, Rebuilding Together Philadelphia, St. Christopher’s Hospital for Children, Tenant Union Representative Network, and William Penn Foundation.

Highlights / Accomplishments

Pittsburgh, PA

Pittsburgh became a GHHI site in 2017 through execution of a GHHI Compact (partnership agreement) among Allegheny County, City of Pittsburgh, Allegheny County Health Department, ACTION Housing, Allegheny County Economic Development, Conservation Consultants Inc., Habitat for Humanity of Greater Pittsburgh, Homewood Children’s Village, Nazareth Housing Services, The Pittsburgh Project, Rebuilding Together Pittsburgh, The Urban Redevelopment Authority of Pittsburgh, and Women for a Healthy Environment. CCI and Rebuilding Together Pittsburgh serve as the local lead nonprofit partners for this site.

Highlights / Accomplishments

Pittsburgh, PA: UPMC

UPMC, a health system in Pittsburgh, understands the importance of the home environment for members with severe asthma. This understanding led UPMC to engage with GHHI and Alleghany County Health Department (ACHD) to develop an asthma home visiting program for members who have been hospitalized due to asthma. ACHD operates a Safe and Healthy Homes Program (SHHP), grant funded by the state health department, which educates families about health hazards in the home. GHHI worked with UPMC and ACHD to coordinate SHHP services with asthma-focused services already performed by UPMC case management teams.

Highlights / Accomplishments

  • The team developed a process flow, data management plan, and cost-benefit analysis in preparation for a pilot in which UPMC members are referred to ACHD for home visiting and assessment services. Based on pilot outcomes, UPMC may decide to further scale and reimburse for home visiting services once the SHHP grant concludes.

Schuylkill Asthma Project

GHHI is support local partners who are advancing a pilot project that provides a comprehensive asthma program for children and adults with uncontrolled asthma living in five Northern Schuylkill towns- Ashland, Frackville, Girardville, Mahanoy City, and Shenandoah. An asthma program would include guidelines-based care:  home-based asthma education, coordination with medical care providers, home environmental assessment, and remediation of asthma triggers.


  • Regional Housing Legal Services,
  • Schuylkill Community Action
  • Lehigh Valley Health Network
  • MidPenn Legal Services

Rhode Island

Providence, RI

Providence became an established GHHI site in 2011 through execution of a GHHI Compact (partnership agreement) among Amos House, Art Space 220, Blackstone Valley Community Action Program (BVCAP), Brown University’s Center for Environmental Studies, Building Futures at ProvPlan, Capital Good Fund, Childhood Lead Action Project, City of Providence, Clear Corps USA, Community Action Partnership of Providence (CAPP), Community Health Worker Association of RI, Environmental Justice League of Rhode Island, Environment Northwest / Energy Efficiency Management Council, Habitat for Humanity Providence, Local Initiatives Support Corporation Rhode Island, Milenio Latino Institute, National Grid, Neighborhood Health Plan, New Ecology, OIC of Rhode Island Inc., Olneyville Housing Corporation, Optimal Energy, Rhode Island Department of Health, Rhode Island Foundation, Rhode Island Housing, Rhode Island Housing Resources Commission, Rhode Island Office of the Attorney General, Rhode Island Weatherization Assistance Program, RI Kids Count, RI Neighborhood Health Plan, Southside Community Land Trust, St. Joseph’s Hospital, Taco/The While Family Foundation, W. Elmwood Housing, and WEGO Wise.

In 2015 services grew to support statewide implementation of the GHHI model. The partnership network has also expanded to include Blue Cross Blue Shield of Rhode Island, HomesRI, Housing Works RI, Integra Community Care Network, LifeSpan, Pawtucket Central Falls Development, Rhode Island Builders Association, RI Coalition for the Homeless, RI Housing Resources Commission, RI Weatherization Assistance Program. Visit the Direct Services page to learn more about GHHI Rhode Island.

Highlights / Accomplishments

Rhode Island Executive Office of Health & Human Services

GHHI conducted a feasibility study for Rhode Island Executive Office of Health & Human Services (EOHHS) to examine the feasibility of using a Pay for Success model to fund comprehensive asthma services for high risk people that are part of Rhode Island Medicaid. Under this model, funding to deliver services would be provided upfront by foundations or impact investors, with Medicaid making payments only if an evaluation showed lowering of Medicaid costs.


  • Actuarial analysis of multi-year Rhode Island Medicaid claims data indicated a high return on investment of a comprehensive asthma program that would include Rhode Island’s award winning Home Asthma Response Program (HARP) as well as home assessments and remediation of environmental asthma triggers. Based on the structure of Rhode Island’s Medicaid program, Medicaid Accountable Entities were determined to be the best fit for this kind of model, leading to additional work GHHI began with Integra Community Care, one of those entities.

Rhode Island: Integra Community Care

GHHI worked with Integra Community Care Network Accountable Entity (Integra) to coordinate clinical and social services to ensure members received both asthma education and home modifications as necessary. As a result of the project, Integra is piloting an asthma home visiting program through St. Joseph’s Hospital in Providence to serve Integra’s members with asthma. The funding for this work will come directly from Integra. GHHI RI is also working with Integra to add home remediation to those services, with a pilot beginning in summer 2020 (also funded by Integra). GHHI also provided healthy homes training to over 20 health and housing practitioners in Providence in November 2019 as well as organized a site visit to a home to demonstrate a comprehensive home assessment.


Memphis-Shelby County, TN

Memphis-Shelby County became an established GHHI site in 2017 through execution of a GHHI Compact (partnership agreement) among Le Bonheur Children’s Hospital, Habitat for Humanity Memphis, Memphis CHiLD, City of Memphis, Shelby County, BLDG Memphis, Memphis & Shelby County Lead-Safe Collaborative, Memphis Area Legal Services, Inc., Memphis Bioworks Foundation, NAACP Memphis Branch, Neighborhood Preservation Inc., Safeways Inc., Shelby County Department of Housing, Shelby County Health Department, Southern Alliance for Clean Energy, Tennessee Housing Development Agency, Tennessee Valley Authority, United Housing Inc., and University of Memphis Cecil C. Humphreys School of Law. The partnership has since expanded to include Frayser CDC, TN Affordable Housing Coalition, TVA, Urban League Memphis & Chattanooga, Black Millennials 4 Flint, Urban League Young Professionals, and Shelby County Office of Sustainability.

Visit the Direct Services page to learn more about GHHI Memphis.

Highlights / Accomplishments

Memphis, TN: Methodist Le Bonheur Hospital CHAMP

Changing High-Risk Asthma in Memphis through Partnership (CHAMP) is a clinic- and community-based asthma program that has operated out of Le Bonheur Children’s Hospital since 2012. CHAMP offers high-need pediatric asthma patients specialty clinical care, home visits from community health workers, and access to a 24/7 nurse call line. Internal and independent evaluations have shown significantly improved health outcomes and reductions in health care cost for patients who receive CHAMP services. GHHI’s project with CHAMP coordinated referral pathways with Habitat for Humanity of Greater Memphis and Memphis CHiLD, a local medical-legal partnership. The team worked together on developing a Pay for Success feasibility project and piloting a full coordinated program model between CHAMP, Habitat home repairs, and legal services. The team also piloted referrals from CHAMP to Habitat for qualifying clients.

Highlights / Accomplishments

  • Partners completed pilot referrals and built relationships with local Medicaid payers in developing a Pay for Success project. Ultimately CHAMP entered discussions with Medicaid MCOs to set up contracts for direct payment for CHAMP services.

Chattanooga, TN: green|spaces

In 2019, Chattanooga, TN was ranked the 21st most challenging city in the country to live with asthma, but the city did not have a comprehensive asthma program for residents. GHHI worked with partners in Chattanooga to successfully build, from scratch, a comprehensive asthma intervention with home visiting, self-management education, environmental home assessments, and healthy home repairs. LifeSpring Community Health provides home-based asthma care, while Electric Power Board (EPB) performs home assessments. green|spaces, a local nonprofit, manages the program.

Highlights / Accomplishments

  • Partners completed a pilot of the city’s first ever comprehensive asthma program, serving 16 families of children with asthma. LifeSpring’s community health workers and EPB’s auditors completed GHHI’s healthy homes training to prepare for service provision. The partners, along with GHHI, presented to TennCare (Tennessee Medicaid) to educate them about the program and discuss potential financing mechanisms.


Austin, TX

Austin became an established GHHI site in 2015 through a Compact signing (partnership commitment) driven by the City of Austin, Austin Energy, Austin Water Utility, Austin Housing Repair Coalition, Austin Area Urban League, Austin Habitat for Humanity, Easter Seals-Central Texas, Interfaith Action of Central Texas, Meals on Wheels & More, and Rebuilding Together Austin. The City of Austin, members of the Austin Housing Repair Coalition, and other agencies work collaboratively to implement the GHHI model for coordinated Housing Interventions.

Highlights / Accomplishments

Houston, TX: Community Health Choice

In 2017-18, GHHI developed a report assessing the feasibility of utilizing value-based payment with Pay for Success financing to scale a comprehensive asthma program for children enrolled in Medicaid programs with Community Health Choice, a Houston-based health plan. After reviewing GHHI’s analysis of feasibility from economic, contracting, and programmatic perspectives, Community Health Choice decided not to pursue development of the innovative model.


  • Community Health Choice
  • Episcopal Health Foundation

Highlights / Accomplishments

Partners performed analyses of the stakeholder landscape, payment mechanism, and the health plan’s Medicaid claims data to estimate potential savings from a comprehensive asthma program. A final feasibility report was created by GHHI for Community Health Choice with recommendations should it pursue development of the model.

Houston, TX: United Healthcare

  • Overview
  • Partners
  • Highlights/accomplishments

San Antonio, TX:

San Antonio became an established GHHI site in 2012 through execution of a GHHI Compact (partnership agreement) among the Annie E. Casey Foundation, Bexar County Department of Community Resources, Build San Antonio Green, City Public Service (CPS) – Casa Verde – Weatherization, City of San Antonio, COSA – Metropolitan Health District-Childhood Lead Poisoning Prevention Program, Family Services Association (FSA), HUD’s Office of Healthy Homes and Lead Hazard Control, Merced Housing Texas, Neighborhood Housing Services (NHS), SAHA (Housing Authority), San Antonio Alternative Housing Corporation (SAAHC), San Antonio Housing Trust, San Antonio Independent School District (SAISD), San Antonio Water System (SAWS), The Avenue Baptist Church, and University of Texas Health Science Center. The City of San Antonio Department of Planning & Community Development coordinates the braiding of housing intervention services for GHHI unit production.

Highlights / Accomplishments

San Antonio, TX: San Antonio Metro Health District

With funding from the Environmental Protection Agency’s (EPA) Office of Air and Radiation, GHHI is providing technical assistance to the San Antonio Metropolitan Health District for its new San Antonio Kids BREATHE (SAKB) asthma program. In 2019, GHHI supported development of the SAKB operational model and evaluation plans. In 2020, GHHI is supporting development of a sustainable payment model between Metro Health and Community First Health Plans.


  • San Antonio Metropolitan Health District
  • Community First Health Plans

Highlights / Accomplishments

  • GHHI has supported partners in developing a stakeholder analysis, process flowchart, data management and evaluation guide, and a cost-benefit analysis that were all included in a 2019 business plan with recommendations for sustaining the program. In 2020, GHHI will work with partners to develop an alternative payment model to utilize Medicaid funds to pay for the model.


Salt Lake County, UT

Salt Lake County became an established GHHI site in 2012 through execution of a GHHI Compact (partnership agreement) among Assist Inc., CAP Weatherization, Communidas Unidas, Community Development Corporation of Utah, Intermountain Health Care, NeighborWorks Salt Lake, Salt Lake City, Salt Lake County, Salt Lake Valley Habitat for Humanity, State of Utah Asthma Taskforce, University of Utah Hospital Health Plans Caregiver Program, University of Utah Pediatrics, Utah Clean Energy, Utah Society for Environmental Education, Valley Services, Vorda Landscape Design, West Valley City. Salt Lake County operates GHHI services for partnership development and coordination of housing interventions services for lead and radon hazard control, asthma trigger reduction, efficiency improvements, and injury prevention.

Highlights / Accomplishments

Salt Lake City, UT: Healthy Homes Salt Lake

After completing a study with University of Utah Health Plans (UUHP) and Salt Lake County assessing the feasibility of scaling a comprehensive asthma program through value-based payment and Pay for Success financing (PFS), partners began development of a PFS transaction called Healthy Homes Salt Lake. In early 2018, the project changed course when UUHP decided to pay directly for the program instead of launching a PFS transaction. UUHP is currently funding the program with Salt Lake County for its Medicaid members and seeing positive outcomes.


  • GHHI – Project manager and transaction coordinator
  • University of Utah Health Plans – health plan payer and home visiting service provider
  • Salt Lake County Division of Housing and Community Development – home remediation service provider
  • University of Utah Intensive Outpatient Clinic – Medicaid provider
  • Sorenson Impact Center – Financial advisor

Highlights / Accomplishments

  • Partners developed a feasibility study report; refined a budget and coordinated intervention; implemented three pilot programs that led to significant reductions in acute care utilization and costs; and established a direct payment model that covers home-based services not traditionally covered by Medicaid – one of the first health plan partnerships in the country to do so.


Richmond, VA: Richmond City Health District

Richmond, Virginia has consistently been ranked as one of the most challenging U.S. cities to live in with asthma according to the Asthma and Allergy Foundation of America. The Richmond Childhood Asthma Collaborative (CAC) is a local partnership that has worked to improve asthma outcomes in recent years, and engaged GHHI to help align service delivery models, develop sustainable funding for asthma services, and explore the viability of Pay for Success financing models for comprehensive asthma programs.


  • The CAC is made up of cross-sector organizations including the Richmond City Health District, VCU Health System, Bon Secours Health System, Richmond Public Schools, project:HOMES, and others.

Highlights / Accomplishments

  • GHHI has supported the CAC’s strategy and engagement with managed care organizations to seek sustainable reimbursement for asthma services. Engagement with Virginia’s Medicaid Office (DMAS) and Department of Health has shown great interest and potential for policy-level action that could lead to direct payment of asthma home visiting services. A potential pilot in partnership with DMAS and VDH would pave the way for future reimbursement models for asthma home visiting programs. Discussions with DMAS and VDH are ongoing.

Washington, DC

Washington, DC: Institute for Public Health Innovation

Convened by the Institute for Public Health Innovation, the DC Healthy Housing Collaborative (DCHHC) is made up of a broad range of partners representing government agencies, healthcare, public health, health insurance providers, housing services, legal services, policy advocacy groups, financial institutions, and many others, united in pursuit of policy and systems changes that will lead to healthier housing conditions in Washington, DC. GHHI works with DCHHC to align and coordinate services into a comprehensive healthy homes intervention as well as seek reimbursement for services to improve the health outcomes for children with asthma. IMPACT DC of Children’s National Medical Center identified children with asthma and refers them to Breathe Easy for evidence-based asthma home visiting services as well as Yachad for environmental home assessment and remediation of asthma triggers in the home.   Other partners include the Children’s Law Center and AmeriHealth Caritas DC.


Milwaukee, WI: Children’s Health Alliance of Wisconsin

In Wisconsin, certain age groups, racial and ethnic minorities, geographic regions, and socio-economic groups are disproportionately burdened by asthma. Recent data show significant disparities in asthma burden among blacks, Native Americans, and Hispanics; children under five years; and in the urban southeastern Wisconsin counties of Milwaukee, Racine and Kenosha.

With funding from the Environmental Protection Agency’s (EPA) Office of Air and Radiation, GHHI is providing technical assistance to the Children’s Health Alliance of Wisconsin and the Asthma Care Program (ACP) under the Department of Health Services. In 2020, GHHI is supporting development of a sustainable payment model, evaluation of program outcomes and savings, engagement with Wisconsin Medicaid, and capacity building for existing operations and potential pilot under a new reimbursement model.


  • GHHI – project manager and transaction coordinator
  • Children’s Health Alliance of Wisconsin – project lead
  • Department of Health Services – project lead
  • Children’s Wisconsin – service provider
  • Children’s Community Health Plan – health plan champion

Highlights / Accomplishments

  • Over the last five years, DHS has built an evidence-based, in-home asthma management program, which has leveraged the support of numerous community partners. Using patient self-report and Medicaid data, the ACP has demonstrated improvements in patient satisfaction, health outcomes, and overall cost of care. To build upon this success, DHS and the Alliance have been diligently working to secure reimbursement for these home-based asthma services. This technical assistance opportunity will support our aim to create a sustainable funding source for these asthma services.
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