exploring the evidence of medical financial partnerships

Exploring the Evidence of Medical Financial Partnerships

March 7, 2018

Welcome

Carmen ShorterSenior Manager for Learning Field EngagementProsperity Now

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Housekeeping

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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

Medical Financial Partnerships

▪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

The Upstream Lab

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



@upstreamlab



16@upstreamlab

Studies in progress



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



@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



@upstreamlab



@upstreamlab

http://www.stmichaelshospital.com/media/detail.php?source=hospital_news/2014/20140501e_hn

http://www.stmichaelshospital.com/media/detail.php?source=hospital_news/2014/20140501e_hn



@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



@upstreamlab

Evaluations



@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



@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



@upstreamlab

Objectives

• Develop new knowledge

• Evaluate implementation

• Use findings to modify new online tool for future use



@upstreamlab

Methods



@upstreamlab

http://www.stmichaelshospital.com/medi a/detail.php?source=hospital _news/2016/0727

http://www.stmichaelshospital.com/media/detail.php?source=hospital_news/2016/0727

Key Findings



@upstreamlab



@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?



@upstreamlab



@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?



@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.

https://nam.edu/wp-content/uploads/2016/09/Addressing-Social-Determinants-of-Health-and-Health-Disparities.pdf

http://bmjopen.bmj.com/content/7/8/e014270?utm_source=TrendMD&utm_medium=cpc&utm_campaign=BMJOp_TrendMD-1

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.


http://onlinelibrary.wiley.com/doi/10.1111/medu.12764/full

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



@upstreamlab

[email protected]

@AndrewDPinto

@upstreamlab

Questions?

mailto:[email protected]

Johns Hopkins University

MFP EXAMPLE: FINANCIAL FUTURES FOR FAMILIES

Karl Johnson and Barry Solomon

41

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.

Screening Tools

46

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


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)

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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


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

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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)



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

Funding Opportunities

59

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

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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

Question and Answer

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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.

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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.

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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.

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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

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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

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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.

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Audience Q & A

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exploring the evidence of medical financial partnerships

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