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From Purse Strings to Heart Strings:  Innovations to Connect the Health & Human Service Delivery

Disruptive Innovations

The United States struggles with a host of complex economic and social issues that have grave implications to the health and wellbeing of our nation. As we grapple with big issues like tax reform, a balanced budget, and overall poverty, helping people meet their most basic needs by investing in effective social service interventions is a promising strategy that truly delivers substantial results by potentially saving billions of dollars in healthcare expenditures. Connecting eligible Americans to benefit programs that cover the costs of food, shelter, heat, and healthcare is not only a moral imperative; it is an effective strategy that addresses the social determinants of health and drastically reduces rising healthcare costs. Benefits Data Trust is at the forefront of connecting vulnerable individuals to the basic services and supports they need to be economically secure and live healthy lives. Our data-informed model uniquely combines person-centered outreach, effective systems change efforts, and cross-sector collaboration in order to design a total health solution; a health & human service delivery system that improves the lives of millions across the country and saves billions of tax dollars in the process. 

46 million Americans cannot afford food, shelter, and medical expenses which results in poor health outcomes for millions. This socio-economic problem has spilled over into a public health crisis. A 2011 Robert Wood Johnson survey indicated, “…85 percent of physicians felt unmet social needs -- such as lack of access to nutritious food, reliable transportation, and adequate housing -- are leading to a worsening of health."1 Individuals struggling with poor health make frequent and expensive visits to urgent care centers, clinics, and hospitals, and emergency departments, yet these institutions have limited staff and resources to connect patients to benefits and social services needed to access the necessary supports to achieve economic stability. In fact, “four in five physicians do not feel confident in their capacity to meet their patients’ social needs, and they believe this impedes their ability to provide quality care.”2 For low-income individuals and families, this has resulted in an unsustainable rise in Medicaid and Medicare spending. 

Programs created to support people in need are underutilized. Millions of individuals fail to get enrolled in benefits and services that help them meet their basic needs, improve their health, and continue on a path to economic stability and financial independence. Applications are confusing, and the health and human services system is fragmented and difficult to navigate. Technology falls short of providing adequate solutions and agency workers are overburdened.  

Low participation rates are further exacerbated as U.S. policymakers debate ways to curb rising healthcare expenditures and threaten drastic cuts to safety net programs that already are underutilized by low-income populations that need them most. It is this multi-faceted problem that BDT seeks to solve; use data to identify individuals who are eligible but not enrolled in critical social supports; work with stakeholders to improve service delivery design to increase access; and continually prove the positive value of creating a person-centered health and human service delivery system that effectively connects low-income individuals to the supports and services they need to be economically secure, healthy, and drastically reduce healthcare costs. 

BDT uniquely tackles this wicked social problem from several angles. We implement direct service programs, and we generate solutions by leveraging data, technology, process, and policy

change in collaboration with government agencies, healthcare organizations, and other key stakeholders. We use available data-sets to identify individuals in need, effectively outreach to them, provide comprehensive person-centered application assistance, and confirm their enrollment in various benefit programs. Our private-sector approach to direct service work allows us to use innovative techniques in every aspect of our programs from the use of cutting edge behavioral economics to elicit high client response rates to developing custom-built integrated technology solutions in order for clients to apply for several social benefits at once. Coupled with our direct service delivery engine, we work with local, state, and federal policymakers to leverage policy and process permissions to break down barriers to access and build a truly person-centered health and human services eco-system.

Currently, there has been a strong national effort underway to align care delivery and identify sustainable interventions that address the Social Determinants of Health (SDOH). This challenge has been a focal point for state agencies, health care providers, and health care payers. Current approaches in the determinants of health space include integrating technology workflows (i.e. Electronic Health Records or EHRs) to large scale population health management systems. The health and human service sector aims to crack the code around effective SDOH integration. BDT provides a unique part of that solution. Our model fills a pervasive gap in the market. While some entities rely solely on an in-person assistance model and others rely solely on a referral based model, BDT’s approach goes further to coordinate access to social service supports. There is real value in educating low-income patients through referrals and in supporting them in-person at the clinical level. However, BDT’s person-centered model serves the low-income population more efficiently by using a data driven strategy to identify those who should be enrolled, conducting multi-channel outreach to successfully connect with them, and support those who prefer phone-based assistance through the entire application process from start-to-finish. We use integrated technologies to provide seamless service delivery for our clients and utilize predictive analytic modeling to accurately segment the population to determine the most effective intervention that works best for them. From low-touch self-service nudging, to medium-touch phone support, to high-touch in-person assistance referrals, BDT supports clients the way that is best suited for them.  

We effectively tackle enrollment barriers upstream as well. We work with state agencies to leverage the available state and federal policy options that help streamline the benefits enrollment process for our most vulnerable clients. For instance, we help states utilize The Elderly Simplified Application Project (ESAP) which was established to ease senior access to SNAP. This policy option waives the verification requirements of the application, extends certification periods to 36 months, and can waive the recertification interview for senior-only households depending on the state. We have also helped the State of Pennsylvania utilize a waiver program promoted by the Centers for Medicare and Medicaid Services (CMS) called Fast Track that leverages SNAP enrollment data to streamline enrollment for Medicaid. 

From its inception, BDT has primarily relied on federal and state dollars along with philanthropic funding to support its mission in transforming how individuals in need access essential benefits and services. But because tackling “upstream” social factors such as food insecurity has such a strong return on investment by way of healthcare savings, BDT seeks to develop a total health payment model that allows healthcare entities to address both the clinical and social needs of their low-income beneficiaries. BDT worked with the State of Maryland, Johns Hopkins University, University of Maryland Baltimore County, and the Robert Wood Johnson Foundation to determine the impact SNAP participation had on the healthcare utilization, costs, and outcomes of older adults and found that seniors who were able to access SNAP were 14 percent less likely to be admitted to hospitals3 and 23 percent4 less likely to be admitted to nursing homes. For individuals who were admitted, SNAP enrollment reduced the length of stay in both settings. Based on these findings, health economists from Northwestern University analyzed the healthcare savings associated with greater access to SNAP. Their analysis showed that increased access to SNAP delivered $2,120 per year in healthcare savings for every low-income senior enrolled. With 5.2 million older adults eligible but not enrolled in SNAP, now is the time to invest in order to generate the greatest impact.    

BDT believes that increased social service interventions can serve as an effective national health policy approach provides a strong return on investment. With support from health and human service agencies and Medicaid Managed Care Organizations, we collectively have a worthwhile incentive to effectively assist low-income beneficiaries with benefits enrollment in order to reduce healthcare costs and attain optimal health for millions of Americans. With the United States leading in healthcare spending while lagging in social service spending, there is a critical opportunity to address underlying population health conditions through effective social service interventions. BDT believes that we must leverage robust sources of data from federal and state agencies to quickly identify individuals who are eligible for benefits, invest in building smarter, data-informed government, and serve individuals and families in a person-centered delivery system. Doing so will result in a more effective health and human services eco-system that improves health outcomes, saves tax-payer money and builds stronger communities.

About BDT

Benefits Data Trust is a national not-for-profit social change organization committed to transforming how individuals in need access essential benefits and services. BDT envisions a health and human services system that proactively connects individuals and families in need to all the supports they need to reach economic stability. We believe that when services are well-coordinated across sectors, people will be healthier and more economically secure; the system will be more efficient and cost-effective; and our communities will be stronger. 

To achieve this vision, BDT works closely with partners in federal, state, and local government, as well as the for-profit sector to increase participation in public benefit programs that help cover the cost of food, shelter, and healthcare. BDT also pushes for policy change that makes benefits access more simple, comprehensive, and cost-effective, and engages in cross-sector research to prove the value of safety net services. Since its inception in 2005 BDT has submitted more than 650,000 applications on behalf of low-income clients, resulting in more than seven billion in benefit dollars delivered to families and individuals in need. 

Author bio

Ginger Zielinskie, President & CEO of Benefits Data Trust, leads a diverse and dedicated team committed to transforming how people in need access essential benefits and services. Committed to cross-sector collaboration, Ginger works with states, cities, the private sector, and community based organizations to understand the true outcomes achieved when people are able to meet their basic needs. Fueled by opportunities to better serve low-income families on their pathway to economic stability, financial independence, and better health, Ginger works to liberate and leverage social services data in order to uncover opportunities to make sure that the right people get the right benefits at the right time. As an organizational leader, Ginger is proud to lead an organization that provides a place and space where people want to work, empowers individuals and teams, and remains fiercely committed to solving tough problems. Ginger received an MBA in Social Policy and Management from the Heller School for Social Policy and Management at Brandeis University. 

Works Cited

1 Health Care's Blind Side:  The Overlooked Connection between Social Needs and Good Health.  December, 2011.  (Accessed 9/8/13:  Link)

2 Health Care's Blind Side:  The Overlooked Connection between Social Needs and Good Health.  December, 2011.  (Accessed 9/8/13:  Link)

3 Samuel LJ, Szanton SL, Cahill R, Wolff JL, Ong P, Zielinskie G, Betley C. Does the Supplemental Nutrition Assistance Program Affect Hospital Utilization Among Older Adults? The Case of Maryland. Popul Health Manag. 2017 Jul 6. doi: 10.1089/pop.2017.0055

4 Szanton SL, Samuel LJ, Cahill R, Zielinskie G, Wolff JL, Thorpe RJ Jr, Betley C.Food assistance is associated with decreased nursing home admissions for Maryland's dually eligible older adults. BMC Geriatr. 2017 Jul 24;17(1):162. doi: 10.1186/s12877-017-0553-x