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    The doctor — and the financial coach – will see you now

    Recognizing that poverty can drive poor health and even shorten life expectancy, hospitals are offering a range of financial services, from tax preparation to budgeting.

    Stethoscope and big money US dollar

    Shanique Green dreams of owning a house. She wants each of her children — ages 3, 5, and 10 — to have their own bedrooms. Growing up, Green shared a room with two relatives. “There was just not enough space to breathe and be your own person,” says Green, who lives in the Dorchester section of Boston.

    Now, Green is working toward her goal of home ownership with the help of StreetCred, a Boston Medical Center (BMC) program that aims to foster prosperity among the families of pediatric patients. In eight financial literacy sessions, Green and a small group of mothers immersed themselves in strategies like budgeting, saving, and planning for financial emergencies.

    “Before, I just spent my money. I didn’t know where it went,” says the 28-year-old. “Now I have a budget and I stick with it.”

    Green also is excited about the possibility of building the generational wealth her own family could not provide. “My parents were teenagers when they had me. They did their best, but I want to make a real difference for my children,” she says.

    The StreetCred effort that helps Green is part of a nationwide, academic medicine-based movement to reduce the economic strain that often fuels ill health. It involves offering financial counseling, tax preparation, and public benefit enrollment, among other services, right alongside blood pressure checks and medication assessments.

    These programs, called medical financial partnerships (MFPs), help patients — and sometimes hospital staff and community members — navigate a variety of resources that can foster economic stability.

    “Health care has been moving its focus upstream, thinking about social determinants of health,” says Adam Schickedanz, MD, PhD, co-director of an MFP at Harbor-UCLA Medical Center and other Los Angeles sites. “Now people are realizing that if we want to address the root causes underlying social determinants, we need to address patients’ financial situations directly.”

    StreetCred team members provide free tax-prep services at Boston Medical Center.
    StreetCred team members provide free tax-prep services at Boston Medical Center. Each year, the program brings millions of dollars in tax refunds to the community.
    Credit: Boston Medical Center

    Extensive data highlight the connection between wealth and health. In the United States, the richest 1% of men live on average 15 years longer than the poorest 1%, and the richest 1% of women live about 10 years longer than their poorest peers. Among older individuals, those with the least wealth face a threefold risk of disability compared to those with the most. And child poverty — which disproportionately affects families of color — can undermine brain development, emotional well-being, and other health measures.

    This reality has spurred the uptick in MFPs. “Five years ago, there were just a handful of programs in the country,” says Lucy Marcil, MD, MPH, StreetCred co-founder and executive director. “Today there are probably 20, and interest is growing.”

    Most MFPs are in pediatric practices like hers, Marcil adds, largely because of how profoundly financial circumstances can impact a child’s health and subsequent life course.

    “For many of the parents I see in my practice, finances are the biggest issue in their lives,” says Marcil. “I can tell parents to feed their children broccoli and read them a bedtime story, but if they can’t afford food or rent, they have little bandwidth to do either.”

    Making tax prep less taxing

    Several years ago, a parent struggling to find affordable, trustworthy tax preparation asked her BMC pediatrician for help — and thus began StreetCred. Since its 2016 launch, the program has helped over 6,000 families garner more than $14 million in tax refunds.

    Such tax-prep services are at the heart of MFPs. “We want to make sure families are getting the maximum refund and not leaving any money behind,” says George Dalembert, MD, MSHP, director of the MFP at Children’s Hospital of Philadelphia (CHOP).

    In one example, Dalembert points to the earned income tax credit (EITC), a federal bootstrap for lower-income workers. Each year, some 20% of eligible Americans fail to claim their EITC. That’s a shame, experts say, because research links the credit to health benefits like improved nutrition as well as higher educational and employment attainment.

    MFP leaders also want to make sure families get tax prep for free. “Professional services can charge $500. That’s a month’s food for some families,” says Ed Miner, LSW, who leads the tax-prep effort at Nationwide Children’s in Columbus, Ohio.

    Convenience is a priority, too. At Nationwide Children’s, community members can get their taxes done at three clinical sites, two local churches, and a daylong Saturday event at the hospital that has drawn as many as 200 participants.

    “Money is a heavy topic, but people are used to having doctors raise heavy topics.”

    Lucy Marcil, MD
    Boston Medical Center

    Although MFPs share common goals, they take varied approaches to their tax-prep work.

    At BMC, StreetCred employs multiple enrollment methods, including sending a team member into every exam room where a child is younger than 1 to offer the service. Elsewhere, check-in staff screen for need and interest, and many programs enlist providers to recommend enrollment.

    “In many cases, the pediatrician is the person the family trusts the most, so their recommendation carries the greatest weight,” says Marcil. “Money is a heavy topic, but people are used to having doctors raise heavy topics.”

    Often, MFPs partner with community organizations that are part of the federal Volunteer Income Tax Assistance program, which either provide unpaid preparers or train hospital teams to do the work. Most MFPs offer tax preparation right in the clinical space, but some connect patients with community-based services.

    Whatever the structure, MFPs all focus on thoroughly addressing participants’ questions and concerns. At times, that means providing translators or aiding some immigrants who may fear deportation after filing. “We try to be thoughtful when we work with these populations, explaining that the IRS is not an immigration enforcement agency,” says Miner. “We tell them that if they want to one day apply for citizenship, it’s important to show they are law-abiding.”

    Lonnie Perry, a medical resident coordinator who received the service as a CHOP hospital employee, appreciates the in-depth guidance the program provided.

    “Before, taxes were very confusing for me,” partly because the 35-year-old also runs a personal fitness coaching business. “Some places make you feel like you’re a burden to them, but everyone here was very patient,” he says. “I felt like they had my best interests at heart.”

    Mastering money

    Filing tax forms certainly isn’t the only money-related issue lower-income families face. So, many MFPs address various other financial concerns, from finding a job to applying for public benefits.

    The Supplemental Nutrition Assistance Program and other initiatives can help lift a family out of poverty. But numerous obstacles, including difficulty navigating applications, often stymie access to such programs. Many MFPs walk participants through enrollment, and sometimes even build one-stop, user-friendly online enrollment websites. So far, some 900 families have used the portal offered by UCLA’s MFP.

    At CHOP, Dalembert says, parents often appreciate enrolling in Pennsylvania’s Keystone Scholars program, which offers state money for college savings. Such funding is crucial in helping address deep-seated inequities, he adds. “If we are going to achieve the goal of promoting optimal health for all patients, we need to make sure resources are allocated equitably.”

    “Money can be a big cause of depression for people. These programs are about wellness.”

    Shanique Green
    StreetCred participant

    The most robust MFPs also offer in-depth and ongoing financial counseling.

    In addition to individual financial coaching, StreetCred is piloting financial counseling groups. A key goal is creating a safe place to discuss sometimes difficult topics. “We take a trauma-informed approach since many participants may have a history of shame or fear around money,” explains Marcil.

    Green, who joined one such group earlier this year, appreciated the supportive approach, including that the group leader shared her personal experiences. “Money can be a big cause of depression for people. These programs are about wellness,” says Green.

    The financial counseling effort at UCLA — around nine months of coaching during infant checkups plus regular follow-up calls — has been improving both the health and finances of patients. In a study published in February, participants’ monthly household income rose more than $1,700 on average, and enrolled infants were 25% more likely to be up-to-date on their vaccines. Missed medical appointments dropped by half.

    Leaders attribute the success in part to the deep integration of financial services into clinical care. Coaches document their work in patients’ electronic health records, for example, and can pull doctors into sessions, explains Monique Holguin, LCSW, PhD, program co-director.

    “A financial coach often has more contact with families, and they sometimes have information that can be vital to improving a patient’s health,” such as inadequate housing, she says. “We educate residents and talk with faculty so they understand how the financial work dovetails with what they’re doing on their end.”

    Spreading the word

    MFP leaders hope to expand the movement to other institutions and more medical specialties.

    “I’m asked by all kinds of health care institutions about the work we’re doing,” says Miner. “They see an opportunity to impact population health that they hadn’t considered before.”

    At UCLA, the work has already expanded to serve 50 patients in a prenatal clinic, for example. “We want to create a bridge that builds financial resilience as people move from pregnancy into pediatric care,” says Holguin.

    “I’m asked by all kinds of health care institutions about the [financial stability] work we’re doing. They see an opportunity to impact population health that they hadn’t considered before.”

    Ed Miner, LSW
    Nationwide Children’s

    Hospitals hoping to launch an MFP can request guidance from the Medical Tax Collaborative, an initiative based at StreetCred.

    Leaders offer a key recommendation: Start with patients.

    “When we built our program, we made sure to talk with patients to find out what would help meet their goals,” says Dalembert. He also recommends reaching out to local organizations already doing similar work. “It makes sense to leverage their expertise as well as the credibility they have in the community.”

    Of course, the work isn’t feasible without funding. Programs rely on a variety of sources: grants, public funding, donations, and hospital budgets. Miner says he’s grateful that his institution is deeply supportive. “I can say, ‘We need 50 laptops to do taxes on a Saturday,’ and it’s no problem. I don’t have to go run a bake sale.”

    Experts also advise getting physicians on board with recommending the services. Marcil notes that it’s not unusual for doctors to worry that patients don’t want to hear from them about money. In response, she points to research indicating that some 80% of patients appreciate such conversations. “Doctors tend to be data-driven, so that reassures them,” she says.

    Other promotion efforts range from refrigerator magnets to social media campaigns. But one of the most effective methods is word-of-mouth from satisfied participants, say those involved.

    Like other participants who access MFPs as a part of their hospital employment, Perry had no doubts when he signed up for CHOP’s service. “These are people I see almost every day at work. We know each other,” he says. And Perry felt so good about the tax-prep program that he urged friends and family to participate. “Five or six people I know use it now, and I sent an email blast to residents [I work with] to promote it.”

    Meanwhile, CHOP is working to expand its services to more populations and is now developing a financial literacy program specifically for teenagers.

    The notion is that planning ahead and learning crucial skills can have a tremendous impact on adolescents, says Dalembert.

    “We want this to be part of the transition into adulthood,” he says. “If teenagers start saving, even a small amount can balloon over time. That money and those financial skills can really be life-changing.”