Exploring the Evidence of Medical Financial Partnerships March 7, - - PowerPoint PPT Presentation

Exploring the Evidence

• f Medical Financial

Partnerships

March 7, 2018

Welcome

Carmen Shorter

Senior Manager for Learning Field Engagement Prosperity Now

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• ne week

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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

• ff 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

• f 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

• n capacity and other local factors, they will typically

include an assessment of financial needs and the provision

• f 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

Income interventions in primary care: Lessons from The Upstream Lab

@upstreamlab

Income interventions in primary care: Lessons from The Upstream Lab

16

@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

Key Findings

Income interventions in primary care: Lessons from The Upstream Lab

@upstreamlab

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

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

• f material resources (among other forms of capital; ex. cultural,

social)

• How might a longitudinal framework support better understanding
• f 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
• rganizations, 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

upstreamlab@smh.ca @AndrewDPinto @upstreamlab

Questions?

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 Leads Family 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, neighborhood

Kenyon, Sandel, Silverstein, Shakir and Zuckerman, Pediatrics, 2007

SCREENIN

ING: IHELP

EXAMPLE: HARRIET LANECLINIC

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

• f hopelessnessin 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 counselingthat 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

• wn questions they feel are important to incorporate

57

58

Fundin ing Opportunit itie ies

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
• rganizations 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
• rganizations are not used to working with medical

groups and may not understand in detail the important links between financial stability and health

61

62

63

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

Question and Answer

67

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 Telemed

• Telecare. 2012;18(7):392-398.
• Losonczy LI, Hsieh D, Wang M, et al. The highland health

advocates: A preliminary evaluation of a novel programme addressing 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

Audience Q & A

What questions do you have? Share them in the Questions box!

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