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Housekeeping
Prosperity
Now’s mission
is to ensure
everyone in our
country has a
clear path to
financial stability,
wealth and
prosperity.
Our Unique Promise
We open doors to opportunity for those who have been kept
off the path to prosperity.
We help people build wealth by making sure they have
what they need to build a better future.
We enable meaningful mobility through research, policies and
solutions.
The Challenge
``
Liquid Asset Poverty
measures the percentage of
those who lack savings to
cover basic expenses for
three months if job loss, a
medical emergency, or other crisis leads to a loss of
income—$6,150 for a family
of four
Source: 2017 Prosperity Now Scorecard
37%
Welcome
Parker Cohen
Associate Director
Savings & Financial Capability
Prosperity Now
Dr. Adam Schickedanz
Pediatrician & Research Fellow
David Geffen School of Medicine
UCLA
Introductions: The Upstream Lab
Andrew Pinto
Director and Founder
The Upstream Lab
Anne Rucchetto
Research Coordinator
The Upstream Lab
Rose Wang
Research Coordinator
The Upstream Lab
Introductions: Johns Hopkins University
Karl Johnson
Co-founder,
Financial Futures for Families
Johns Hopkins University
Dr. Barry Solomon
Associate Professor of Pediatrics
Johns Hopkins School of Medicine
✓ Welcome and Opening Remarks
✓ Overview of MFPs
✓ Interview with The Upstream Lab
✓ Interview with Johns Hopkins University
✓ Audience Q&A
✓ Wrap Up and Next Steps
Agenda
▪What is a medical financial partnership (MFP)?
▪An MFP is a shared commitment between a healthcare
provider and a financial capability service provider to
improve the health and financial well-being of a population.
While the nature of these partnerships will differ depending
on capacity and other local factors, they will typically
include an assessment of financial needs and the provision
of financial capability services.
MFPs Defined
Income interventions in primary care:
Lessons from The Upstream Lab
Andrew D. Pinto MD CCFP FRCPC MSc, Director
Anne Rucchetto MPH, Research Coordinator
Rose Wang MPH, Research Coordinator
The Upstream Lab, Centre for Urban Health Solutions, Li Ka Shing Knowledge Inst, St. Michael’s Hospital
Exploring the Evidence of Medical Financial Partnerships
14
@upstreamlab
Outline
1. The Upstream Lab
2. Income Security Health Promotion Service
3. Online Financial Benefits Navigator
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
Studies in progress
Income interventions in primary care:
Lessons from The Upstream Lab
Individual level
–Access to adequate income
•Income Security Health Promotion service
•Online Financial Benefits Navigator
•Basic Income pilot
–Access to decent work
–Access to legal services
Organizational level
-Robust SDOH data linked to EMRs to identify health inequities
-E.g. Improve HIV primary care, improve cancer screening, improving care to
transgender patients
Neighbourhood level
–Deploying prevention practitioners in neighbourhoods with SDOH toolkit
–Community organizing in social housing
Population/policy level
–Building an advocacy coalition to influence employment laws during a policy
window
@upstreamlab
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
Income security health promotion service
Income Security Health Promotion
Setting:
Patient Centered Medical Home in downtown Toronto
More than 50,000 patients served at 6 clinic sites
Broad cross-section of the community, with particular focus on serving
marginalized population
30% of patients are living below the poverty line
Objective of the ISHP service:
•To directly improve the income security of individuals, families and the
communities served
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
http://www.stmichaelshospital.com/media/detail.php?source=hospital_news/2014/20140501e_hn
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
http://bmjopen.bmj.com/content/7/8/e014270
Ongoing Evaluation
1. Assessing impact: survey at 1 month
• Method: 5-10 minute telephone survey 1 month following discharge
• Preliminary results
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
Evaluations
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
2. addressInG iNcome securITy in primary carE (IGNITE) RCT
Method: pragmatic randomized control trial with 6 month wait-listed
cross over
Primary outcome: income at 6 months
Secondary outcomes: QoL, community engagement, financial
literacy, food security, health
Evaluations
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
3. Qualitative interviews
Method: In-depth qualitative interviews with patients, health providers,
and Income security health promoters to gain insight on service from
different perspectives.
ONLINE FINANCIAL BENEFITS NAVIGATOR
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
Objectives
• Develop new knowledge
• Evaluate implementation
• Use findings to modify new online tool for future use
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
Methods
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
http://www.stmichaelshospital.com/medi a/detail.php?source=hospital _news/2016/0727
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
“It was helpful learning about
government sites that I could go to for
specific help to ease my life and check
what I need help with; income, health
benefits, training.”
-Patient
Conclusions
• Putting knowledge into practice
• Improvements needed
• Who’s best to use the tool?
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
SPARK Study
Brings together lessons learned from two areas:
1.Is routine sociodemographic data collection in primary care feasible,
acceptable and useful?
2.If a patient screens positive for poverty, is a modest or robust
intervention most effective?
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
What other research would you recommend participants
read? • Adler, Nancy E., et al. Addressing social determinants of health and
health disparities. Discussion Paper, Vital Directions for Health and
Health Care Series. National Academy of Medicine, Washington,
DC. https://nam. edu/wp-content/uploads/2016/09/addressing-
social-determinantsof-health-and- health-disparities. pdf, 2016.
• Jones, Marcella K., Gary Bloch, and Andrew D. Pinto. "A novel
income security intervention to address poverty in a primary care
setting: a retrospective chart review." BMJ open7.8 (2017):
e014270.
What other research would you recommend participants
read? • Aery, Anjana, et al. "Implementation and impact of an online tool
used in primary care to improve access to financial benefits for
patients: a study protocol." BMJ open 7.10 (2017): e015947
• To, Matthew J., and Malika Sharma. "Training tomorrow's
physician‐advocates." Medical education 49.8 (2015): 752-754.
• Pinto, Andrew D., and Gary Bloch. "Framework for building primary
care capacity to address the social determinants of
health." Canadian Family Physician 63.11 (2017): e476-e482.
What additional research questions would we like to ask?
• How can individual-level interventions lead to system level
changes supported at the policy level?
• How can these interventions foster a sense of mastery, control,
and efficacy for [research participants] who have been deprived
of material resources (among other forms of capital; ex. cultural,
social)
• How might a longitudinal framework support better understanding
of long-term impact on patients/clients/participants?
How can non-profits connect with research projects?
• In Canada, many non-profits conduct their own research (ex. United
Way) and connect with research groups for activities such as program
evaluations
• Shared goals
• Is it sustainable? I.e. one projects versus ongoing partnership?• Dedicated time to learning about each organization’s needs,
mandates, timelines, strengths, constraints, and areas for
improvement.
• Can both parties teach each other something?
• Investigate situational obligations on the part of each organization’s legal requirements
• Ex. community-based research project which produced many
lessons learned
• Negotiating publication status for project with new tool
(balancing agency’s need to report their activities with research lab’s need to report new information in academic journals)
How can non-profits connect with research projects
continued.
• Build on successes and lessons learned
• i.e. ISHP program started and then stopped this time it
appears to be going well which will (hopefully) foster
sustainability
• Online tool: learned about adjusting the tool and making
improvements through ‘Service Design’ research, led by our
non-profit partners
• This proved successful for designing the next iteration of
the tool
What advice do you have for funding?
• Look near and far
• Government (municipal, state-wide, federal), community
organizations, philanthropic organizations, think-tanks,
foundations, various institutions working on the topics being
researched
• Save all your documents for future opportunities
• Maintain relationships with study team members
• Use this as an opportunity to develop networks
• Share expertise and constructive feedback generously
Income interventions in primary care:
Lessons from The Upstream Lab
@upstreamlab
@AndrewDPinto
@upstreamlab
Questions?
Outline
1. Program Setting – Baltimore City and Harriet Lane Clinic
2. Needs Assessment (Quantitative and Qualitative)
3. Program Design
4. Program Implementation
5. Question and Answer
42
Harriet Lane Clinic
• Pediatric primary care clinic of Johns Hopkins Children’s Center in Baltimore
• Medical home to approximately 8,500 infants, children, adolescents and young adults (newborns to 25 years of age)
• 17,000 annual visits
• Patients are predominantly African-American and nearly 90% are eligible for public insurance through Medicaid or the Maryland Children’s Health Insurance Program (M-CHIP)
44
45
Maternal Mental Health Clinic
Developmental Assessments/KKI
Child Mental Health Services
Risk Reduction, PrEP
Youth Fitness Circle
Reach Out & Read& Adolescent
Literacy
Preventive Care
Intensive Primary Care
Chronic Care
Acute Care
Social Work Services
Adolescent Weight Management
Nutritionist & Lactation Specialist
Family-Centered Pediatric
Primary Care
Adolescent Specialty Care
Safety Lane Safety Resource
Center
Health LeadsFamily Help Desk
Financial Futures for Families
Community Advisory Board
Case Management & Adolescent
Transition
Child Life Services
Reproductive Health
Services/Title X Program
Multi-disciplinary Management Team
Cheng TL, Solomon BS. Translating Life Course Theory to clinical practice to address health disparities. Matern Child Health J. 2014 Feb;18(2):389-95.
I
H
E
L
L
P
• Income, food income
• Housing conditions, eviction, utilities
• Education placement, early childhood
• Legal – immigration status
• Literacy – parent, health and child
• Personal safety – IPV, neighborhoodKenyon, Sandel, Silverstein, Shakir and Zuckerman, Pediatrics, 2007
SCREENING: IHELP
EXAMPLE: HARRIET LANE CLINIC
Steps:
1) Select a population and setting
2) Select a critical topic
3) Consider how it impacts childhood health and well-being
4) Develop a screening question
5) Identify a resource for positive screens
6) Determine an implementation strategy
7) Consider outcome measures
Needs Assessment: Surveys
METHODS
• Cross sectional survey of 221 caregivers and adolescent patients
• Survey components:
• Demographics and financial status
• Tax behavior and experience with tax credits such as Earned Income Tax Credit (EITC) and Child Tax Credit (CTC)
• Financial self-efficacy, stress and literacy
• If they believe the clinic should have financial programs, and types
50
Needs Assessment: Surveys
RESULTS
• Self-efficacy
• 77% stated that it was hard to stick to spending plan when unexpected expenses arise
• Stress
• 64% feel stressed about finances in general, 57% about monthly expenses
• Literacy
• Low financial literacy (mean 40% correct of 5 questions)
51
Acceptability and types of clinic-based financial services (N=221)
Do you think the clinic should provide financial services? N (%) 150 (68)
Interest in specific services in clinic N (%)
Job training workshops 160 (72)
Financial Education workshop 158 (71)
Resume Building 150 (68)
Computer workspace 145 (65)
Help with Taxes 130 (59)There was no significant difference in desiring services if they were a late adolescent (18-25) or adult 25+ (p = 0.55)
52
Needs Assessment: Surveys
CONCLUSIONS
• There is great financial need: high prevalence (36%) without any household earned income, with high stress, and low self-efficacy and financial literacy
• The majority of participants believe there should be clinic-based services
53
Needs Assessment: Interviews
METHODS
• 18 in-depth qualitative telephone interviews conducted among adolescents and adult caregivers of pediatric patients
• Participants were recruited from those who completed a survey
• Questions focused on patient and caregiver perceived benefits and challenges of integrating employment and financial services into a pediatric primary care clinic serving low-income families
54
55
RESULTS
In the clinic they know us. When you go to your doctor, [they] ask you all these questions, so they know what you're going through. And they can always - the doctor or the nurse - become your advocates. I mean, some people don't want to speak up when they're having issues with jobs and money and all of that. But the doctor could say, "Hey, I have a client here who needs help, so please talk to them”. (Female, age 55)
You are very close so you are free to interact with them and most of the time it's easy to ask, tell, and receive what they tell you because we have some kind of trust with them compared with other outsiders. And also, it could be easier for them to start discussing family issues and how we live and so forth. In the clinic setting, they will be easier to talk to. (Female, age 27)
Needs Assessment: Interviews
Needs Assessment: Interviews
CONCLUSIONS• Adolescents and caregivers expressed difficulty
managing financial stress and many described a sense of hopelessness in escaping the cycle of poverty
• Clinic-based support services were highly acceptable among potential users for the convenience it offers and the established trust and understanding between patients and providers
• Participants preferred one-on-one employment and financial counseling that addressed their specific needs, though they did believe that some topics, like building a resume, could be accomplished in group workshops
56
Needs Assessment: Lessons Learned• It is important to learn about the needs of your
community to determine best services to offer
• challenges of doing in person interviews?
• Utilize previously-validated questions (often found in the financial wellness literature)
• Conducting both quantitative and qualitative approaches provide both a general perspective and allows for more in depth assessment
• Interdisciplinary approach—potential collaborators may have already developed relevant tools or have their own questions they feel are important to incorporate
57
Financial Futures for Families (FFF)
• Case managers in clinic are trained to work 1-on-1 with patients and caregivers to help them achieve their financial goals
• Partnership and workshops with workforce empowerment organization Humanim
• Research component will evaluate FFF’s role in increasing employment seeking behaviors and the perception of the clinic as a medical home
• Continuing to connect with other medical-financial partnerships
60
Program Design: Lessons Learned
• Do not redesign the wheel—community organizations have been helping people manage their finances for years, learn from them
• Outreach to community organizations is imperative—becoming aware of the “tools” available for a clinic to work with
• Develop your pitch—many community organizations are not used to working with medical groups and may not understand in detail the important links between financial stability and health
61
Implementation: Lessons Learned
• Constant outreach to all branches of the clinic staff—ensure that everyone who handles patients is aware of the program
• As soon and as often as possible, update clinic staff and community partners on the success/progress of the program
• Routine conversations about gaps in the integration—diagnosing where patients are falling through the cracks or information is not being communicated properly
• Supporting volunteer workforce: weekly meetings, personal investment, constant Q&A to fix “bumps in the road.”
64
Implementation: Results from first 2 months• How many referrals have you tried to contact, but with no
success? (that is, they never reached the "client master list") 8
• How many clients are you currently a primary case manager for? 22
• How many intakes have you completed with a client? 10• How many resumes have created for clients? 10
• How many job applications have you submitted for your clients? 18
• How many of your clients have successfully received a job since you started working with them? 5
• How many total job training programs have your clients applied to? 3
65
Implementation: Lessons Learned
• Merging with Health Leads• Developed, sustainable organization already integrated into
the clinic• Overhead (capital) support• Management support for volunteers• Technical support via access to better case-management
software and resources• “Employment Specialist” position that handles mostly
employment needs, but others also.• Currently 6 “employment specialists” are working with 72 clients.
66
What other research would you recommend participants read? 1. The introduction of non-medical service in medical
environments• Wylie SA, Hassan A, Krull EG, et al. Assessing and referring
adolescents' health-related social problems: Qualitative evaluation of a novel web-based approach. J TelemedTelecare. 2012;18(7):392-398.
• Losonczy LI, Hsieh D, Wang M, et al. The highland health advocates: A preliminary evaluation of a novel programmeaddressing the social needs of emergency department patients. Emerg Med J. 2017; Epub ahead of print.
• Garg, A., Marino, M., Vikani, A. R., & Solomon, B. S. (2012). Addressing families’ unmet social needs within pediatric primary care: the health leads model. Clinical pediatrics, 51(12), 1191-1193.
68
What other research would you recommend participants read? 2. The links between financial wellness on health
• Woolf SH, Aron LY, Dubay L, Simon SM, Zimmerman E, Luk K. How are Income and Wealth Linked to Health and Longevity? April 13, 2015. Washington DC: Urban Institute, 2015. Available at: Available at: http://www.urban.org/research/publication/how-are-income-and-wealth-linked-health-and-longevity.
• Johnson SB, Riley AW, Granger DA, Riis, J. The science of early life toxic stress for pediatric practice and advocacy. Pediatrics. 2013;131(2):319-327.
69
What other research would you recommend participants read? 3. The efficacy of different financial tools:
• Hathaway, I., & Khatiwada, S. (2008). Do financial education programs work?.
• Zhan, Min, Steven G. Anderson, and Jeff Scott. "Financial knowledge of the low-income population: Effects of a financial education program." J. Soc. & Soc. Welfare 33 (2006): 53.
70
What are the gaps in the research that currently exist? • More nuanced understand of the causal relations
between childhood financial stability and long-term health
• The desire (or lack thereof) for financial services within a clinical environment
• Which financial services best comport with clinical structure and medical-related goods and services already being provided
• Populations already being served by the clinic that are in most need of MFP interventions
71
How can non-profits connect with research projects? • Research-oriented clinics can refer patients to non-
profit services, which helps build relationships and knowledge of the kinds of questions either group is interested in
• Researchers can provide the space for non-profits to help design the kinds of questions being asked, during both the needs-assessment and long-term evaluation
72
What was the give and take between the clinical partners and community partners in your project? • The clinic has a dense, consistent population of individuals
that community partners wish to serve. This population already trusts the clinic to be an advocate on their behalf.
• MFP can be seen as an extension of the community partner’s services into a previously unreached population. This added outreach is likely great for their own funding streams.
• In short: clinics provide the population and trusted relationships and community organizations provide the services this population has a desire for.
• Opportunities to market the community partner’s work in the clinic, source for referrals to other programs (financial-related or not) that they may offer
73
What advice do you have for funding these types of initiatives? • As best as possible, avoid absolute dependency on
grants.
• Develop a sound business pitch to community partners—it may be such that they will not request large sums of money to extend their services to a new population.
74
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