MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.

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Q2 Please describe your company or organizations overall goals and mission.

Founded in 1987, Seedco is a national non–profit that advances economic opportunity for people, communities and businesses in need.

We achieve our mission through two core program portfolios:

• Workforce development: Using our long–term career case management model, we help individuals with barriers to employment obtain, retain and advance in jobs.
• Work and family support: Seedco helps low–income families successfully enroll in benefits and assistance programs and move towards self–sufficiency. Seedco´s proprietary EarnBenefits Online (EBO) software is central to this work.

Seedco serves many different communities, from rural farmland to urban centers, across five states: Tennessee, Maryland, New York, Georgia and Connecticut.

Seedco operates as both a direct services provider and an intermediary organization, helping community–based organizations expand outreach and secure funding.

Seedco is an affiliate of the Acacia Network, the leading Latino integrated care nonprofit in the nation, which offers the community, from children to seniors, a pathway to behavioral and primary healthcare, housing, and empowerment. Acacia´s behavioral health services care for people with substance and/or mental illness within a comprehensive set of 31 programs including detoxification and short term rehabilitation, adult, youth, and women and children residential treatment, ambulatory treatment including 3 large medication assisted treatment programs (MAT), mental health outpatient and strength based day treatment, community residences, and supportive housing. Acacia´s 6 Federally Qualified Health Centers incorporate MAT, and other behavioral health interventions, and Acacia´s Medicaid Certified Health Home ensures care coordination for over 1,500 people.

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Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

Innovation Overview:

Seedco and Acacia Network are implementing an innovative approach to address Social Determinants of Health (SDH) by integrating Seedco´s proprietary EarnBenefits Online (EBO) software into Acacia´s health, behavioral health and housing programs serving low– income New York City residents. Seedco and Acacia have received funding from two Performing Provider Systems´ (PPS) Innovation Funds through DSRIP: Bronx Partners for Healthy Communities ($249,728 award made in late 2017) and OneCity Health ($699,450 award made in June 2018) to implement this innovation.

EBO is a web–based software tool which includes rapid and accurate benefit eligibility determination, application assistance, case management and reporting functionality. EBO is a caseworker–facing technology which allows the worker to: 1) Discuss more than 20 benefits with a client in one sitting; 2) Input client information; 3) Determine eligibility for multiple benefits; 4) Populate application forms; and 5) Help clients submit them to the relevant government agency. Nationally, since 2005, EBO has helped more than 200,000 households across the country access over $300 million in income–enhancing benefits.

Through this partnership, Seedco is helping Acacia clients to enroll in public benefits, including Medicaid, SNAP (food stamps), tax credits, heating/energy assistance, free cell phones, and prescription drug coverage. Spanish–speaking EarnBenefits Screeners conduct outreach, screen clients, assist with applications, follow up with clients to document receipt of benefits, and troubleshoot problems clients encounter while applying for benefits, such as gathering documentation. Funding through DSRIP has also allowed Seedco to provide EBO licenses and training for Acacia staff (e.g. Care Coordinators, Entitlement Specialists) to use EBO in their programs, drawing on their experience, trust, and cultural competency. The goal is to ultimately integrate EBO into Acacia´s existing care teams.

The program has launched at Acacia´s Federally Qualified Health Centers (FQHCs), and we are planning to expand to Acacia´s behavioral health programs, homeless shelters and substance abuse programs. Outcomes will be connected to DSRIP targets of reducing ER visits and unnecessary hospitalizations while increasing preventive care and medication adherence.

Relevance to the Medicaid population:

Imagine a patient with a chronic health condition being discharged to an apartment where the heat has been turned off and the pantry is bare. Her paycheck only covers her prescription drugs or child care bills – not both. She is eligible for Medicaid but doesn´t know how to enroll. She can´t make ends meet, her health fails, and she lands back in the ER, still with no insurance.

Dozens of government programs are designed to address these very basic needs: food, warmth, shelter, income. But while they are entitled to these resources, too many low–income New Yorkers lack the awareness or ability to enroll. Instead, they remain caught in a vicious cycle of instability that directly impacts their health outcomes.

An informal survey of Acacia´s Health Home Care Managers found that 28% of individuals on their caseloads solely receive Medicaid and do not receive other public benefits like SNAP (food stamps), heating assistance or child tax credits. Clients are often frustrated trying to navigate the public benefits system, citing the time spent waiting in various offices and a perception that they "get the run around" from government staff. Most Acacia clients that reside in homeless shelters are eligible for benefits, but many are unable or unwilling to travel from the Bronx to Queens, where the designated benefits center for shelter clients is located.

Speed to market, Feasibility, ROI, Evidence–based Support for Innovation, Scalability:

Public benefits can help make the difference between sustaining a healthy lifestyle and cycling through the hospital. For example, food insecurity is directly associated with myriad chronic conditions that are at the core of DSRIP metrics, including diabetes, heart disease, obesity, depression and complications from pregnancy. Research studies of SNAP (food stamps) have shown that "individuals who had access to food stamps in early childhood have a lower risk of obesity, high blood pressure, heart disease, and diabetes as adults." Studies have shown that SNAP recipients have a lower body mass index (BMI) than non–participants, a higher score for overall dietary quality, lower rates of nutritional deficiency and lower rates of depression.

Many New Yorkers live in homes that are unbearably hot in the summers and bitterly cold in the winters, exacerbating medical conditions and creating unsafe environments. With energy costs rising, some forego filling their prescriptions to keep the heat on. Others risk hypothermia or suffer through extreme heat that drastically raises their risks for stroke and asthma attacks. ER admissions skyrocket during times of extreme weather – but they don´t have to. Designed to help households facing energy burdens, HHS calls the Low–Income Heating and Energy Assistance Program (LIHEAP) "one of the best kept secrets in public health."

When a paycheck doesn´t stretch far enough, families postpone preventive care, diabetics fail to adhere to their diet, mothers ration their child´s prescriptions. Public benefits like the Earned Income Tax Credit (EITC), Temporary Assistance for Needy Families (TANF) and Child Tax Credit put money directly in the pockets of low–income residents, which helps them to maintain economic self–sufficiency and manage their health.

EBO has been designed to identify and address major barriers to enrollment including literacy and education barriers, eligibility misunderstandings, confusing application procedures, and stigma associated with government benefits. EBO materials and benefit applications are translated into Spanish. This innovation can be scaled and implemented extremely rapidly, as Seedco has more than a decade of experience managing EBO and implementing partnerships across the country.

For the Bronx Partners for Healthy Communities Innovation Fund award, Seedco aims to conduct outreach and screenings for 1,300 Bronx residents at a cost of $192 per individual and an average benefit value of $2,307: more than 10 times the per–client cost. We are looking to spread the use of EBO among other PPS members which further enhances the ROI.

Across the country, EBO is used by social service providers, community–based organizations, hospitals and government agencies. The Brookings Institution highlighted the impact of EBO on health outcomes in its study of the partnership between Seedco and Washington Adventist Hospital (WAH) in Maryland, which uses EBO to enroll patients in benefits. Since 2015, more than 300 WAH patient households have been screened using EBO, resulting in more than $631,000 in benefits that support access to food, energy assistance, and healthcare.

The Brookings Institution report found that: "Many WAH patients are not aware of the benefit programs they are eligible for – benefits and services that might stabilize them financially and address other problems that reduce their quality of life and add to their health risks…the partnership is a way of contracting out segments of WAH´s population health spectrum of activities where another organization has more expertise than WAH staff – allowing WAH personnel to continue to practice at the ‘top of their license´."

EBO generates monthly reports on metrics including: Number of households screened/eligible/enrolled in benefits; number referred to providers; dollar value of benefits; breakdown of benefits received. In addition to using EBO in its own programs, Seedco sells licenses to paying subscribers across the country, including a growing number of health care providers. We are optimistic that the impact of EBO on SDH will result in a greater expansion of this program model, which would provide sustainability and growth opportunities.

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