Medical-Financial Partnerships: Cross-Sector Collaborations Between Medical and Financial Services to Improve Health

Abstract

Financial stress is the root cause of many adverse health outcomes among poor and low-income children and their families, yet few clinical interventions have been developed to improve health by directly addressing patient and family finances. Medical-Financial Partnerships (MFPs) are novel cross-sector collaborations in which health care systems and financial service organizations work collaboratively to improve health by reducing patient financial stress, primarily in low-income communities. Financial services provided by MFPs include individually tailored financial coaching, free tax preparation, budgeting, debt reduction, savings support, and job assistance, among others. MFPs have been shown to improve finances and, in the few existing studies available, health outcomes. We describe the rationale for MFPs and examine eight established MFPs providing financial services under 1 of 3 models: full-scope on-site service partnerships; targeted on-site service partnerships; and partnerships facilitating referral to off-site financial services. The services MFPs provide complement clinical social risk screening and navigation programs by preventing or repairing common financial problems that would otherwise lead to poverty-related social needs, such as food and housing insecurity. We identify common themes, as well as unique strengths and solutions to a variety of implementation challenges MFPs commonly encounter. Given that the financial circumstances and health outcomes of socially marginalized patients and families are closely linked, MFPs represent a promising and feasible cross-sector service delivery approach and a new model for upstream health care to promote synergistic financial well-being and health improvement.

Introduction

Evidence from population-based studies consistently shows that poverty and related social determinants of health account for a much greater proportion of health risk than does access to medical care.¹ The “toxic stress” of poverty is linked to higher rates of obesity, smoking, chronic health conditions such as diabetes, poor overall health status, and premature mortality beginning in childhood and continuing over the life course.^2,3 Not only does financial stress increase the risk of chronic illness the medical system ultimately absorbs, it also limits the effectiveness of medical disease management when a quarter of adults report cost-related medical nonadherence.⁴ Indeed, with approximately 20% of Americans living with medical debt and over half of bankruptcies attributable in some part to iatrogenic financial hardship, there is a need to actively address patient finances as an integral part of medical care.⁵ Accordingly, health experts and organizations have identified financial stress as a key clinical risk factor for poor health outcomes⁶ and professional organizations in pediatrics and family medicine recommend all families be screened for financial insecurity so poverty-related social needs can be addressed as part of routine health care visits.^7,8

As evidence grows showing financial factors are strong drivers of health outcomes, new models of care integrating financial and clinical interventions make sense, especially considering that successful delivery of clinical and financial services for low-income communities both require trust and shared decision-making to overcome complex individual and structural challenges. While many health care delivery systems employ social workers, hospital financial counselors, health insurance eligibility workers, and patient billing staff to address patients’ financial concerns narrowly related to medical care, some have taken a step further to develop partnerships with financial service organizations inside and outside clinical settings to reduce financial stress more broadly as a health promotion strategy. These novel clinical programs have been termed Medical-Financial Partnerships (MFPs), defined as collaborations between medical clinics, hospitals, or health systems and financial service organizations designed to improve patients’ financial well-being as a health intervention.

No prior literature has summarized the evidence linking common individual-level financial service interventions and health outcomes, nor have MFP models based on this evidence supporting health-wealth interventions been described previously. We aim to 1) summarize existing evidence on the health impact of financial services interventions from both the medical and non-medical literature and 2) describe existing MFPs and a framework for these innovative health care delivery models.

Literature Review & Case Series Approach

We conducted a review of evidence from peer-reviewed academic literature, grey literature, program evidence briefs, and white papers to compile information on health and financial impacts of financial services. The search strategy began with querying Pubmed, JSTOR, and Google Scholar using combinations of standardized search terms, including general terms (“financial”, “financial stress”, “financial services”, “financial capability”, “economic stress”, “health”, “outcomes”) and terms for specific financial metrics and services (“employment”, “debt”, “assets”, “savings”, “credit”, “financial coaching”, “child savings accounts”, “earned income tax credit”). The authors also identified publications on the impact of financial interventions from key identified studies in the literature, and reference sections from these publications were scoured for further citations of interest. References kept and reported in the review describe adult and child health outcomes (irrespective of effect size) of financial interventions or programs typically deployed by public or nonprofit organizations to improve the financial well-being of low-income individuals and families.

For the MFP case series, we interviewed staff members and leaders at established MFPs known to the authors. Leaders of these MFPs included clinicians and financial services professionals. Interviews were conducted over the phone in English using a semi-structured format. Questions asked are listed in the Appendix. All interviews were recorded, transcribed, and analyzed for themes by two authors (OB, AS). Summaries of all information derived from the interviews were sent to the key informants to verify validity. Categories of MFP care models were conceptualized based on the interview results. The sections below summarize our findings from the evidence review and key informant interviews.

Financial Stress is Multidimensional & Many of its Dimensions Affect Health

The effects of poverty on health are well established in the literature, and this relationship follows a consistent gradient up the income ladder. Independent of income, however, there is robust evidence showing that many dimensions of financial status may also influence health outcomes. These include savings, debt, and credit. These financial dimensions are potentially more malleable than income and are the focus of many financial services and organizations.⁹

Wealth and savings, typically defined by net worth (total household assets minus liabilities), represents accumulated financial resources that can buffer financial shocks and reduce financial stress in the face of income fluctuations. Wealth is more unequally distributed population-wide than income and is strongly associated with self-reported health.¹⁰ Individuals who have little to no savings are more likely to smoke, be obese, have type 2 diabetes,¹¹ have hypertension,^12,13 experience psychological distress,^9,14,15 have clinical depression, and live shorter lives¹⁶ relative to those with sufficient financial assets. Decreases in wealth have been linked to increased mortality and poorer physical health, controlling for income.¹⁷ Debt cuts into income and savings, is often predatory in that it can lead to further debt, and can ruin credit. Debt also correlates with negative health outcomes, regardless of income. Individuals with large debts are more likely to be obese^10,17 and have worse self-rated physical and mental health.¹⁸ One study showed extreme debt (i.e. bankruptcy) after receiving a diagnosis of cancer predicted higher mortality.¹⁹ Credit score, a commonly used measure of financial risk and the key to accessing financial resources required for large purchases, has been shown to predict overall health status, psychosocial stress, and cardiovascular disease risk even after adjusting for income and recent financial shocks.^20,21 The range of financial dimensions linked to health offers various opportunities to improve financial stress and health outcomes simultaneously through medical-financial interventions.

Financial Services Improve Client Finances & Health Outcomes

Increasing evidence shows financial stress can be improved through widely-available financial services. The financial services field has evolved considerably over the last two decades with the development of validated client-centered, evidence-based services to help individuals and communities build financial stability. Financial services include free tax preparation (expanding access to the Earned Income Tax Credit, EITC, the largest anti-poverty program in the US), financial coaching (focusing on debt, credit, savings), matched saving accounts such as Child Development Accounts (CDAs), credit counseling, debt consolidation and forgiveness, and employment assistance. These services have been shown to improve family financial stability and reduce the risk of poverty, and a growing literature shows these interventions have positive impacts on health for both adults and children.^22,23

Financial coaching programs are individualized, client-driven using motivational interviewing, and focus on budgeting, credit, debt, and savings to help clients build financial knowledge and change behavior. These programs increase individuals’ financial security and capacity to achieve financial goals, reduce financial stress, manage credit, pay down debt, and increase savings.²⁴ In a two-site randomized trial, financial coaching led to a decrease in debt and financial stress, an increase in savings, and a reduction in medical debt.²⁵ In a separate financial coaching evaluation, most clients felt less stressed about finances, increased their savings and credit scores, and decreased their debt.²⁶ Organizations embedding financial coaching services into existing job training and placement programs also increased individuals’ financial security.²⁷ While the health effects of financial coaching are promising²⁸ and further studies are underway,^23,24 proxy measures of mental health such as worry and stress have shown clear improvements in a randomized trial of financial coaching.²⁶

Credit counseling and programs building credit for communities historically marginalized by financial institutions can help achieve financial stability. For example, Lending Circles, a form of community-based microfinance, help small groups of low-income clients both self-fund and pay out to themselves on a monthly rotating basis, which has a strong positive impact on credit scores. Average credit scores have been shown to increase and average debt decrease by over $1,000 in the largest lending circle study to date.²⁹ Other research has shown increasing credit scores can save a person up to $200,000 over a lifetime and buffer financial shocks. Credit counseling services help repair poor credit, and clients in two studies reported improved overall health status after receiving credit counseling.^30,31

The EITC, a refundable tax credit offered through the Federal tax code and in many states, reduces poverty and incentivizes employment among low-to-moderate-income working individuals, especially those with children. The EITC boosts employment and hours worked, particularly among single mothers.³² Declines in the national child poverty rate since the 1990s have been attributed in part to EITC expansions.^33,34 In 2015, the EITC lifted 6.5 million people from poverty, made an additional 21.2 million less poor, and reduced financial stress for millions of near-poor families. Receipt of EITC is associated with increased self-reported health status among mothers and improvements in child health. The EITC decreases stress, mental health problems, and smoking among low-income mothers.^35,36,37 Quasi-experimental studies found decreases in rates of low birth weight and improved APGAR scores among children of mothers who received the EITC.^36,38 Receiving the EITC has been linked to improvements in other child health outcomes, including hospital admissions for abusive head trauma among young children,³⁹ infant prematurity and mortality,⁴⁰ and measures of overall family well-being, such as maternal employment, child academic performance, and college attendance.^41,42

Matched savings programs allow low-income savers to increase the power of their deposits through dollar-for-dollar matching from nonprofit funders, typically with a monthly deposit minimum requirement and cap on matched dollars. Matched savings programs help build emergency savings, especially when paired with free tax preparation services helping families save their EITC and refund dollars. Other savings vehicles like child development accounts (CDAs) provide tax-protected asset-building accounts focused on building savings for children to use for post-secondary education. Large CDA implementations have shown increases in savings among participants,⁴³ many of whom had never saved for college before.^44,45 In terms of health benefits of CDAs, one large study in which infants throughout Oklahoma were randomized to state-funded CDAs found a positive effect on socio-emotional development of children, especially in low-income families.²³ The study also found CDA receipt reduced standardized maternal depression scale scores, especially for mothers who were low-income, and improved parents’ expectations of educational attainment for their children.⁴⁶

The evidence summarized above broadly supports the conclusion that financial services programs improve finances and health outcomes. MFPs integrate similar financial services into health care delivery to improve patient health outcomes. We provide an overview of existing models for MFPs below, including how they have leveraged the financial services described above to improve patient health outcomes.

Medical Financial Partnership Models

Given the evidence showing financial stress shapes health and the emerging literature on health impacts of financial services, health systems have begun to develop clinical programs integrating financial services through Medical Financial Partnerships (MFPs). In addition to the interest among health systems, a handful of studies have found that most low-income parents of pediatric patients want to receive financial services in the clinic setting.^47,48,49 Below, we summarize MFP delivery models based on key informant interviews conducted with leaders from eight MFPs. A summary of each MFP can be found in Table 1 and the Appendix. Themes are presented in Box 1. The MFPs fall within three models: 1) full-scope on-site financial coaching and case management services, 2) targeted on-site financial services, and 3) warm handoff referral to off-site or community-based financial services. Each model presents different challenges, opportunities, and resource needs.

Table 1.

Services provided, structure, population served, funding and outcomes of Medical Financial Partnerships

Medical Financial Partnership	MFP Model Structure	Financial Services	Funding	Staff	Setting	Populations	Outcomes
DotHouse	On Site	Financial Coaching, Free Tax Preparation, & Matched College Savings Program	Foundation grants, public funding, and private donations. Community partners help fund and support services provided.	5 full-time case managers with assistance from the clinic administrative assistant.	Community Health Care Clinic (Dorchester, Massachusetts)	Low income patients of all ages. Primarily non-English speaking	In 2016, 130 patients were triaged and accepted referral to case management for financial health services. Individuals engaged in preventative actions to improve financial health, such as preparing a budget, starting GED courses, becoming banked or accessing food stamps for the first time. In addition, the VITA site served more than 1,000 individuals, helping them claim an average of $2,038 tax refund.
Clarifi and Rising Sun Health Center Partnership	On Site	Financial Coaching	Rose Foundation and Public Health Fund helped fund implementation and evaluation. MFP was implemented in partnership with the National Nurse-led Care Consortium (NNCC).	1 case manager 3 times per week during program evaluation in 2014–16. Currently the case manager is present once a week.	Community Health Care Clinic (Philadelphia, Pennsylvania)	Low income adult patients receiving care at Rising Sun Health Care	Program evaluation included over 300 patients who received services. The MFP helped increase financial literacy and financial capability for the clients served, in addition to reducing financial stress.
Financial Fitness Clinic	On Site	Financial Literacy, Coaching, & Free Tax Preparation	Largely by philanthropic donations from financial institutions using their community reinvestment funds. San Francisco Medical Society Clinical Innovation Award, in addition to The San Francisco General Hospital Foundation.	2 volunteer physicians, 1 part time financial coach & tax site coordinator, 1 volunteer financial advisor, & volunteer tax preparers.	Hospital Wellness Center (San Francisco, California)	Low income patients of all ages receiving care at San Francisco General Hospital and its ambulatory affiliates	Over three quarters of patients said they learned what they had hoped to from the session and were satisfied with the services. The VITA site reached 80 tax filers in its first year and 370 filers in its second year, with an average refund of $1,000 per return.
Financial Futures for Families (FFF)	On Site	Employment Services & Financial Coaching	Intramural grants to support partnerships for primary care coordination and fostering health of urban populations. FFF will be integrated into Health Leads© at the clinic.	3–4 Health Leads© volunteer advocates, & 10 volunteer case managers.	Academic-Based Pediatric Clinic (Baltimore, Maryland)	Low income families of children receiving care at the Johns Hopkins Children’s Center Harriet Lane Clinic	FFF has helped more than 100 caregivers and adolescents with their employment needs. Further outcome data is currently being collected on employment status, financial status, financial stress, and financial efficacy of clients eligible for FFF services, in addition to measures on perception of health and perception of the clinic as a medical home.
StreetCred	On site targeted services	Free Tax Preparation	Mix of foundation grants, private donors, internal grants, and corporate donations. Start-up and implementation costs for the pilot in 2016 totaled less than $20,000.50	2 full-time employees, 4 site coordinators, 40 volunteers, & medical student service learning group. 5 site coordinators and 50 volunteers were added during the 2018 site expansions.	2 Academic Hospital Clinics, 1 Community Health Center, 1 homeless shelter. Several sites being added in 2018 nationally (Boston, Massachusetts)	Low-income patients receiving care at primary care clinics across Boston	More than 750 EITC eligible families have received a total of approximately $1.6 million in tax refunds in the 2016 and 2017 tax seasons. $438,883 was returned to families through the EITC specifically.
St. Michael’s Hospital Income Security Health Promotion (ISHP)	On site targeted services	Financial Literacy, One-on-one case management and assistance in accessing benefits and increasing income security	Supported by the Ontario Ministry of Health and long-term care.	2 full-time income security health promoters who split their time between the 6 health team clinic sites. Additional support from advisory group consisting of a manager, staff physicians, social workers, & community engagement specialist.	Hospital Academic Family Health Team Clinics, interdisciplinary primary care clinics (Toronto, Ontario, Canada)	Low income adult patients	Since December of 2016, 565 referrals were made to the ISHP program and 452 met with an ISHP provider at least once, or are awaiting their first appointment. Outcomes include improving income, reducing expenses, and improving financial literacy.
Local Initiatives Support Corporation (LISC)-ProMedica Financial Opportunity Center (FOC)	Off site	Financial Counseling, Credit Counseling, Job Training, Benefits Screening, & Free Tax Preparation	ProMedica covers much of the staffing costs, along with grants from LISC, United Way, and other nonprofit program funding. The hospital foundation and community benefit provide important support for the FOC along with other efforts to address social determinants.	2 financial coaches, & 1 job coach.	Health-System-Affiliated, Community-Based Financial Opportunity Center. Located in Ebeid (Toledo, Ohio)	Low income patients and community residents, mostly female heads of household	Over 340 individuals received one or more service from the FOC in the last fiscal year, with over 200 engaging in financial counseling and over 180 receiving free tax preparation (worth $313,000 in federal tax returns). The LISC-ProMedica FOC tracks primary outcomes of changes in credit rating, career advancement, income, and financial assets. The average annual income increase per client is roughly $2,500.
Financial Tools & $olutions (FT$) Project	Off site	Financial Coaching Workshops, Microfinance & Emergency Finance	Microfinance grants are funded by EARN and the Mission Asset Fund (MAF). Emergency funds are funded by the California Wellness Foundation Grant.	3 financial coaches, project director, project coordinator, & a project associate.	Clients of Alameda County’s Home Visitation Programs	Low income patients of all ages	Over 120 clients have benefited from the FT$ program. Data is currently being collected and is focused on financial and social outcomes, such as getting banked or joining a lending circle to improve credit.

Box 1. Central Themes from Interviews with Medical-Financial Partnership Founders.

Rationale

• Universally, the rationale for MFPs was the health system imperative to address social determinants of health in economically marginalized populations and communities

Structure

• Common financial services integrated into health care delivery through MFPs were financial coaching (focused on improving savings and debt), job assistance, free tax preparation, and public benefits referral (i.e. food stamps, WIC, etc.)

• MFP staff varied by program, including a variety of staffing models relying on both paid positions to trained volunteers

• Programs typically operated on small budgets under $50,000 per year

• Data-driven MFPs are common and many MFPs have undertaken evaluations of their impact on the financial needs of patients and their health consequences

Factors Supporting Success

• Strong administration-level support was predictive of staff buy-in and program success

• Adaptability is key to establishing program operations, funding, evaluation, and patient-engagement

• Alignment with existing social needs screening and referral programs was common and helpful for sustainability

• Patient and clinician satisfaction with MFP services was high

MFP Model 1: On-Site Full-Scope Financial Services

Overview:

This type of MFP physically embeds a financial coach or counselor in the clinical space to work with patients or families to address a wide range of financial problems and goals. These services are often the most resource-intensive. On-site MFPs identify patients in need of in-depth financial services through broad screening administered by the clinic for social needs or financial stress, which is followed by clinician referral or warm handoff to financial service professionals. Direct patient recruitment through flyers and word-of-mouth is also common. MFPs of this type, such as DotHouse in Cambridge (Massachusetts), Clarifi at Rising Sun Health Center in Philadelphia, and the Financial Fitness Clinic at San Francisco General Hospital, are staffed by certified financial service professionals, they receive patient referrals from clinicians, and meet with patients/clients longitudinally. A host of financial services are typically available once patients/clients meet with the MFP staff, including basic financial literacy training, budgeting, assistance in maximization of public benefits, expense reduction, savings promotion, debt and/or credit counseling, access to free tax preparation, matched savings programs, and other common financial tools. These services are based on the financial needs and goals of the patients/clients. On-site full-scope MFPs lend themselves to leveraging existing social needs screening and referral infrastructure in clinical settings where this infrastructure has already been built. These MFPs offer a way to ensure that the root causes of poverty-related social needs are addressed, rather than simply screening for social risks.⁵⁰ For example, the Financial Futures for Families (FFF) program, an MFP at the Johns Hopkins University (JHU) Harriet Lane Clinic in Baltimore, builds on a Health Leads social needs help desk staffed by undergraduate volunteers to identify patients and families who could benefit from one-to-one case management focused on employment and financial services. Once identified, patient families meet with specially-trained advocates who have deeper expertise in job skills like resumé and cover letter preparation, job searching, and employment application and enrollment. A partnership between JHU and Humanim, a non-profit organization focusing on human resources and workforce development to connect patients with employment, even provides a pathway to employment within the JHU health system for qualifying patients/clients.

Keys to Success:

All of the on-site, full-service MFPs we interviewed highlighted the critical role of having clinical, financial service, and health system administrative champions to foster the partnership culturally and logistically. Having financial service professionals on-site was seen as an advantage for program efficiency, fidelity of services, ease of data sharing, and opportunity to tailor services to patient and health system needs. Physical space within the clinical offices for the financial service professionals to do their work was also at a premium. Having space on-site significantly reduced barriers to patient/client engagement and retention, factors which often hindered referral-based, off-site MFPs. However, for those on-site full-service MFPs not staffed by volunteers, the costs of securing the financial service professionals’ time on-site to staff the MFP constrained program capacity. Often the staff were hired or contracted on a part-time basis from community-based financial services nonprofit organizations to minimize staffing cost (compared to full-time employees) while maximizing the benefit to health system patients who they exclusively served while on-site. Funding sources were diverse and typical funding portfolios for the on-site MFPs we interviewed included extramural foundation funding, local philanthropy, and intramural research dollars.

MFP Model 2: On-Site Targeted Financial Services

Overview:

The targeted financial services MFP model embeds a specific type of financial service needed by the patient population into the clinic space. Often patients are identified through standardized screening questionnaires during clinical encounters, posted flyers in the clinic, during clinic appointment reminder phone calls, or word of mouth. Patients are provided the opportunity to receive financial services such as income support or tax services before or after clinic visits. This allows patients to maximize their time and receive services while coming to the clinic to see their medical team. An example of such an MFP is StreetCred at Boston Medical Center. The founders of StreetCred identified that many of their patients’ families qualified for the EITC and would benefit from on-site tax preparation assistance. StreetCred partnered with the Boston Tax Help Coalition, an Internal Revenue Service-sponsored Volunteer Income Tax Assistance (VITA) organization, to provide on-site tax preparation during the tax season. Volunteer tax preparers complete the tax returns of patient families while they see their clinic providers, or at a separate time convenient for the family. Patients can then review, sign, and submit their tax return by the end of their clinic visit, saving the patients time and money. St. Michael’s Hospital Income Security Health Promotion (ISHP) in Toronto refer patients likely to benefit from financial coaching and income support to income security health promoters, trained case managers and patient advocates focused on public benefit eligibility and financial issues. Referred patients work closely with health promoters to increase financial literacy and connect to public benefits and income supports for which they qualify. Patients and health promoters meet regularly during clinic appointments, or at times convenient for the patient, until financial goals are met.

Keys to Success:

Partnerships of this type stress the importance of identifying specific needs in patient populations. Both StreetCred and ISHP are currently working to expand the financial services provided to their patient populations. Having financial service professionals on-site was seen as an advantage for program efficiency, a way to maintain the fidelity of services, and an opportunity to continuously tailor services to patient and health system needs. Having space on-site significantly reduced barriers to patient/client engagement. Funding came from a mix of foundation grants, internal hospital grants, and corporate donations. ISHP is a program supported by the Ontario Ministry of Health and long-term care. In order to decrease implementation costs, on-site targeted financial service programs often rely on volunteers in addition to paid employees.

MFP Model 3: Off-Site Financial Service Referral

Overview:

MFPs of this type offer referral to financial services outside of the clinic space to increase financial education and access to anti-poverty services for clients. Financial services programs partner with local health departments and Medicaid providers to offer financial support programs through education workshops and one-on-one meetings to the clients they serve. At the Local Initiatives Support Corporation (LISC)-ProMedica partnership in Toledo, Ohio, patients in the largest Medicaid provider in Ohio (ProMedica) who screen positive for food insecurity or other social needs on a standardized screening questionnaire in the clinic are contacted by the off-site LISC Financial Opportunity Center (FOC) funded by ProMedica’s hospital community benefit grants. Patients are able to meet with financial coaches at the FOC to address personal financial goals with a focus on income support and employment. This partnership also provides a job training program for interested clients. Similarly, the Financial Tools and $olutions (FT$) Project, funded by the Alameda County Public Health Department’s Building Blocks for Health Equity Program, partners home visitation programs with financial education workshops and coaching for patients and families receiving case management. While MFPs of this type are not co-located in the clinical space, they are integrated into agencies addressing financial and social needs in the community.

Keys to Success:

Physician champions have been a mainstay of assuring buy-in for programs of this type. Individualized meeting times and walk-in appointments for clients addressed the challenge of off-clinic-site scheduling and access for some clients. Often financial coaches are hired from the community-based financial services nonprofit organizations to deliver services they would already be providing in their community setting. This minimizes costs and maximizes service delivery. Funding for these programs is mostly through state and municipal grants, nonprofit philanthropic funding, and health system community benefit dollars.

Conclusions and Recommendations

Medical-Financial Partnerships (MFPs) between medical services and financial service organizations have the potential to improve the health and financial well-being of patients and families by tackling common economic root causes of poor health. Health care providers and financial service professionals share the goal of providing education and resources for individuals to improve their quality of life and well-being. Furthermore, health care systems are trusted community hubs whose ability to reach patients in medical and financial need provides an opportunity for clinicians to detect and address financial stress before it adversely affects health.

We have highlighted eight MFPs from this burgeoning field. Common financial services they integrate into health care delivery are job assistance, free tax preparation, budgeting, debt reduction, savings support, and overall financial coaching. Most were successful through strong administration-level buy-in and staff support, adaptation to overcome health system logistical challenges, and alignment with existing clinical social needs screening and referral programs for sustainability.

More rigorous evaluation is needed to determine the health impact of these partnerships, and evaluations of health utilization and outcome data for MFP patients are underway. Findings from the MFP examples described above help provide insight into how to address the financial needs of patients, as recommended by professional organizations in pediatrics and family medicine.^8,9 Efforts to refine and standardize MFPs are needed to facilitate adoption of evidence-based anti-poverty services within health care systems, especially those serving low-income children and families. The ultimate success of MFPs will depend on the ability of health care to adapt beyond the traditional medical model to directly tackle poverty-related social determinants of health.

What’s New.

Financial stress and health are closely linked. Medical-Financial Partnerships (MFPs) integrate financial services into health care systems to improve health in low-income patients. This overview of health-wealth intervention research and MFPs provides a framework for these innovative cross-sector care models.

APPENDIX

A. Semi-structured interview guide for case reports

Initial questions sent to all participants prior to phone interview:

1. Why did your team/your health care clinic decide to partner with a financial service organization provider? What inspired or motivated you to start?

2. Where is your Medical Financial Partnership program located?

3. What is the setting of your clinic (i.e., pediatrics ambulatory clinic)?

4. Who is the population served by this partnership?

5. What services are provided and what is the frequency of services provided?

6. What is your current staffing model?

7. How many people have you referred to a financial service organization? (Inputs - # referred)

8. How many people have followed through to receive services? (Outputs - # receiving services)

9. What is the structure of your referral system?

10. Is there a system in place to track follow-up? (System of service provision/follow-up)

11. What data is being collected?

12. What are the primary outcomes of the established partnership?

13. How is this work funded? What supports are in place? (Funding/Supports)

14. What challenges have you encountered during this process?

15. What factors, structures, or partners have been the most important for your success (i.e. facilitators)?

Follow up questions addressed during phone interview

1. Program Description

   1. Could you please provide us with a detailed program description?

      1. Please specify the main players in the process as well as the workflow process
2. Administrative/logistical questions

   1. Logistical support: What kind of logistical support do you currently have to coordinate client flow with clinic flow?

      1. What logistical challenges have you encountered? Be specific
   2. Administrative: What is the title of the high-level administrative support/institutional support that allows you to make sure this project remains in place?

      1. Data sharing/tracking health outcomes: What needs to happen in order to get identifiable information from the partner programs in order to track health outcomes and health utilization?
   3. What kind of space do you utilize?

      1. Waiting room? Convening space in the clinic/hospital?
         What kind of space would be ideal for this process?
   4. Finances: If you are willing to disclose, what is your current ballpark budget? What do you think would be the ideal budget to continue to do the work that you are doing?
3. Community/Patients/Moving Forward

   1. How do you define patient trust? How do you build patient trust? Was it already present within the clinic or did you design something to support this?
   2. What are your overall mission and aims?
   3. Can you share a patient story with us?
   4. What is the most interesting thing you have learned along the way?
   5. What would you recommend to other health systems that want to build these partnerships?
   6. What has the feedback been from clinical providers?
   7. What has the feedback been from patients and families?
   8. What are the next steps for your partnership?

B. Medical-Financial Partnership Profiles

DotHouse

Medical-Financial Partnership Description:

Clinical leaders and financial professionals created DotHouse Health at a federally qualified health center in Dorchester, Massachusetts to offer a robust set of financial services to low income patients of all ages as part of their routine clinical care. Through a pre-visit survey, patients answer screening questions about food insecurity, housing instability, and legal issues. Patients who report any of these problems are triaged for financial health by the medical assistant or clinician and linked to financial case managers on site. Case managers develop a care plan, which includes ongoing financial coaching, connecting to public benefits and income supports for which the patients qualify, and follow-up and re-assessment of the patient’s financial issues. Case managers also help connect patients to community partner organizations such as food banks, housing agencies, and a medical-legal partnership. DotHouse also offers on-site Volunteer Income Tax Assistance (VITA, free tax preparation) services during tax season.

Challenges & Solutions:

Many linguistically marginalized families use for-profit tax preparers rather than the VITA onsite at DotHouse due to patient trust and familiarity, so the program is recruiting more volunteers and doing outreach to build community trust.

Next Steps & Innovations:

DotHouse will be one of the six health care provider networks to pilot a Medicaid accountable care organization, global payment reimbursement model that incorporates risk adjustment for housing instability in 2018. This direct reimbursement, contingent on identifying and documenting housing instability, will incentivize improved support and follow-up for the most financially fragile DotHouse MFP patients.

Clarifi’s Financial Counseling Program at Rising Sun Health Center

Medical-Financial Partnership Description:

The financial literacy non-profit Clarifi, along with the Public Health Management Corporation’s (PHMC) Research & Evaluation Group created an MFP that integrates the financial services provided by Clarifi with health services at the Rising Sun Health Center in Philadelphia, Pennsylvania. Low income adult patients are referred to financial counselors through health center staff and service providers, direct recruitment, posted flyers, and an existing screening form to assess patients’ needs for financial services. One-on-one client-directed appointments with a Clarifi financial counselor are conducted in clinic and are focused on credit score counseling or other financial issues depending on the patient’s need. Phone follow-up on client financial goals occurs every one-to-two months.

Challenges & Solutions:

Challenges around referral volume necessitated flexibility of the clinic staff to explore creative client recruitment strategies. Looking for a partner with sufficient patient volume, staff buy-in, and adaptability in implementation is a key for success.

Next Steps & Innovations:

Clarifi is currently looking for health center partners for the establishment of additional MFPs. They are interested in evaluating health outcome data by focusing on patients with specific health conditions.

The Financial Fitness Clinic

Medical-Financial Partnership Description:

Two physicians (Pediatrics and Family & Community Medicine) at San Francisco General Hospital partnered with a financial coach from a community-based financial services organization to create the Financial Fitness Clinic (FFC) to deliver financial services in the San Francisco safety net. Monthly sessions were held after work hours and consisted of large group financial literacy education and one-to-one financial coaching. Every session began with an assessment of current financial and social needs, allowing patients and FFC providers to identify resources and approaches likely to benefit each patient. The financial literacy component included completing a budget, financial goal setting, and a curriculum surrounding improving savings, debt, and credit. Patients were invited to return until resolution of their financial hardship. In subsequent years, VITA free tax preparation services were offered. Patients were recruited to the FFC through electronic referral from health care providers, word of mouth referrals from providers and other FFC patients, or by walk-in.

Challenges & Solutions:

Retention of patients longitudinally and restrictions on clinical data sharing created barriers to evaluation of the program’s impact on patient finances and health over time. Reminder calls and letters sent from the San Francisco General Department of Pediatrics increased patient retention.

Next Steps & Innovations:

Sustainability of the FFC proved difficult with a small staff. The FFC has been revamped with a narrower scope of services and a focus on tax preparation and financial literacy workshops.

The Financial Futures for Families Program

Medical-Financial Partnership Description:

Pediatricians at the Johns Hopkins Harriet Lane Clinic (HLC) in Baltimore, Maryland founded Financial Futures for Families (FFF) and partnered with Humanim, a non-profit organization focusing on human resources and workforce development to connect patients with employment and financial services. Through this MFP, low income families are provided with one-on-one case management based on their employment and financial goals. Parents of patients are screened for financial risk and employment needs among other social needs using a standardized form while waiting to see their provider. Clinic providers review the form with families, and in the event of a positive screen, refer them to an FFF or Health Leads© volunteer in clinic. Patients can meet with an FFF volunteer at the end of the visit or choose to make an appointment on a separate day. Resume and cover letter preparation, job search, employment application completion, and enrollment in job training are a few of the services offered. The partnership with Humanim allows clients to take advantage of an arrangement which facilitates job placement for clients within the Johns Hopkins University system. Individuals can receive assistance with budgeting and credit union applications for basic financial products like checking and savings accounts. Volunteer case managers follow up with the client at least every two weeks to resolution of their employment needs.

Challenges & Solutions:

Initial challenges included identifying physical space for FFF volunteers within the clinic and developing a streamlined referral process. A large shared work area for FFF and Health Leads© was identified in close proximity to providers and patients. Identifying financial service organizations with goals and vision aligned with the health system required robust partnership building and vetting of services according to FFF goals.

Next Steps & Innovations:

FFF programming was recently integrated into the Health Leads© model at the HLC, which will lead to an expansion of services. FFF volunteers will receive training from both Health Leads© and Humanim to cover a wider scope of financial services, and a small group of Health Leads© advocates will serve as “employment specialists” and staff FFF. The goal of this new structure is to set the foundation for longer-term engagement, improved follow-up with patients and program sustainability.

StreetCred

Medical-Financial Partnership Description:

Pediatricians at Boston Medical Center (BMC) partnered with the Boston Tax Help Coalition, an Internal Revenue Service-sponsored Volunteer Income Tax Assistance (VITA) organization, to embed a VITA site into pediatric primary care clinics and founded StreetCred to expand EITC access among low-income families. Through this MFP, families are offered free tax preparation services. StreetCred’s volunteer tax preparers complete the tax returns of patients’ families while they see their clinical providers or at a time convenient to the family. Families then review, sign, and submit their tax return by the end of their clinic visit, or they may make an appointment to complete their return with volunteer tax preparers at another time. In addition to easing access to EITC benefits for families, the program helps them avoid the charges associated with for-profit tax preparation services, which typically run into the hundreds of dollars. Patients and their families learn about the tax clinic through their medical providers, materials included in their clinic appointment reminder mailings, posted flyers, and word of mouth.

Challenges & Solutions:

Concerns from clinic administrators about the liability associated with sharing financial information and the scope of services provided by VITA volunteers were solved once legal precedent for such partnerships was shared from other VITA sites and it was made clear the VITA electronic tax filing system need not be integrated with any clinical information systems. StreetCred made volunteers’ non-clinical roles clear to administrators, which streamlined and simplified long volunteer onboarding processes.

Next Steps & Innovations:

StreetCred is currently assessing integration of a tax help need question into existing social needs screening workflows in order to identify candidate families and facilitate referral to free tax help. StreetCred is expanding their services to other health care clinics in Boston and nationally for the 2018 tax season. Additionally, StreetCred is expanding its services portfolio by offering incentivized savings programs, financial coaching, childcare connections, and help signing up for health insurance and the Supplemental Nutrition Assistance Program.

St. Michael’s Hospital Income Security Health Promotion (ISHP)

Medical-Financial Partnership Description:

A team including family medicine physicians, case managers, and researchers partnered to implement a patient case management program focused on income support in the primary care clinic setting at St. Michael’s Hospital Family Health Team Clinics in Toronto. Patients identified by physicians through simple standardized screening questions as likely to benefit from financial coaching and income support are referred to the income security health promoters through the clinic electronic medical record. One-to-one client directed appointments with the health promoter are conducted in clinic and are focused on connecting to public benefits and income support for which they qualify, increasing financial literacy, as well as connecting patients to community partner organizations to address concerns around affordable housing and employment. Patients work with health promotors until their financial goals have been met.

Challenges & Solutions:

Initial challenges of relationship building between health promoters and the health care team, as well as with patients were solved by health promoters attending clinic staff meetings and providing guidelines for the health care team that indicated suitable candidacy for the program.

Next Steps & Innovations:

Follow up phone interviews are currently taking place to assess the financial impact of the program. In depth interviews are being conducted with providers and patients who have been served by the program to understand how ISHP has impacted patient’s income security from different perspectives and determine best practices for continued program growth. In addition, a 300-patient randomized controlled study with a waitlist control group will follow both groups for six months to determine whether the ISHP program has an impact on patients’ income. The study will compare the changes in income between the groups in addition to outcomes such as self-reported health, self-reported mental health, housing and food security outcomes, and quality of life.

Alameda County Public Health Department’s Financial Tools and $olutions (FT$) Project

Medical-Financial Partnership Description:

Alameda County Public Health Department’s Building Blocks for Health Equity Program partnered with nine home visitation programs to roll out the Financial Tools and $olutions (FT$) Project. Case managers from the different programs assess interest for FT$ among their clients and refer those interested to financial education workshops. Clients complete a series of three workshops including tax planning, money management, and credit management over a 3-to-6-week period. Workshops occur at the different Alameda County home visitation program sites where clients also receive individual case management regularly. Clients may then opt to continue to participate in more intensive programming through financial resource “pathways” incentivized by micro-finance grants including: a savings program, career and workforce development, small business development, or an emergency fund pathway.

Challenges & Solutions:

Scheduling challenges required flexible and individualized appointment times for working participants. Expectation setting at the beginning of the program addressed client misconceptions that they could access grant money without achieving program goals.

Next Steps & Innovations:

6-and-12-month follow up interviews are currently underway. Physical and mental health measures will be added to these follow up surveys.

LISC-ProMedica Partnership

Medical-Financial Partnership Description:

ProMedica and the Local Initiatives Support Corporation (LISC) partnered to provide financial services to fully staff the community-based Financial Opportunity Center (FOC) of Toledo, Ohio. ProMedica, one of the largest Medicaid providers in Ohio, has referred more than 300 low-income patients to the FOC within the last fiscal year. Referrals from ProMedica’s Community Care Hub are triggered by either repeated positive screens for food insecurity or other social needs identified through standardized clinical screening. Financial coaches from the FOC reach out to patients to schedule visits, perform an intake financial assessment, and identify and address their personal financial goals with a focus on employment and income support. Walk-in services are also available for ProMedica employees. Services and follow-up are driven by patient goals and financial needs. As the largest workforce provider in its area, the job training program at the FOC provides a pipeline of living wage employment within the health system for clients.

Challenges & Solutions:

Breaking down the silos of the two partner organizations has been key to the LISC-ProMedica FOC’s success. One of the most effective strategies has been to hire FOC financial coaches as ProMedica employees who are managed by LISC. Broader provider-to-provider forums and a physician champion group have been successful in building buy-in for this and other programs addressing social determinants of health.

Next Steps & Innovations:

Data sharing agreements between ProMedica and LISC have just begun to allow routine tracking and evaluation of FOC patient/client financial and clinical outcomes in concert. Space is being sought for future FOC financial coaches to be embedded directly into health clinics. ProMedica and LISC have also shared the FOC model with their state Medicaid agency and are exploring “pay for success” metrics that could be used to standardize and measure impact of the program to guide future reimbursement.