Aligning Medicaid &TANF for a two-generation impact on behavioral health and economic security Academy Health Annual Research Meeting New Orleans June 26, 2017 Mariana Chilton, PhD, MPH
Research and Program Teams PI: Mariana Chilton, PhD, MPH Professor, Dornsife School of Falguni Patel, MPH Public Health Program Manager Director, Center for Hunger-Free Building Wealth and Health Network Communities Kevin Thomas Co- PI: Sandra Bloom, MD SELF Empowerment Coach Associate Prof, Dornsife School of Building Wealth and Health Network Public Health Founder, Sanctuary Institute Alie Huxta, MSW Co-I: Jerome Dugan, PhD SELF Empowerment Coach Building Wealth and Health Network Assistant Prof, Drexel College of Nursing H.E.A.L. Michael Moody Co-I: Layla Booshehri, PhD Program Coordinator Building Wealth and Health Network Assistant Prof, Drexel College of Nursing H.E.A.L.
Overview • Background – Systems for Action (TANF & Medicaid) – TANF & challenges to economic success – Trauma & trauma-informed practice • The Building Wealth and Health Network – Description of the program – Study design – Preliminary outcomes
Systems for Action (S4A) 1. Assess effects of trauma-informed peer support built into education and training on health and economic security for participants in The Network. 2. Identify cost savings to TANF and Medicaid & make a case for linking these systems. 3. Engage multiple stakeholders to promote a Culture of Health within anti-poverty programming through a strategic public dissemination effort.
Background: #TANFat20 • TANF reaches about 30% of those eligible; this varies by state (from < 10% to > 40%) 1 – PA -> 31% eligible participating and this is declining • Work participation for caregivers w. children < 6yrs = 20hrs; varying/disappointing success 2 – Return to TANF / Churning • Barriers to Work among TANF participants – 33% report work-limiting health condition 3 – 43% report disability 4 – 74% Intimate Partner Violence (Compared to 31% general pop) 5 – High involvement w. criminal justice system 6 1. Pavetti , 2015: TANF continues to weaken as a safety net 4. Loprest & Maag 2009: Disabilities among TANF recipients 2. Ctr Study of Social Policy , 2016: 20 Years of TANF 5. Cheng 2013 : IPV & Welfare Participation 3. Kneipp et al 2011: Public Health Nursing Case Management 6. Bloom et al , 2011: TANF recipients w. barriers to employment
Background: What Do We Really Mean By Trauma? • Toxic Stress (Kids) - Overwhelming relentless stress for young children without adequate support to overcome it - Homelessness / poverty - Adverse Childhood Experiences (abuse, neglect, household dysfunction) - Impact on development • Traumatic Stress (adults) – Internal and external factors insufficient to cope with external threat – Central nervous system overwhelmed – Helplessness
ADVERSE CHILDHOOD EXPERIENCES (ACEs) ADVERSE CHILDHOD EXPERIENENCES 10 questions Category Subcategory Example Question Emotional Abuse Physical Sexual Emotional Abuse Emotional (Did a parent or other adult Neglect in the household...) Physical Often or very often swear Parental at you, insult you, put you Separation down, or humiliate you? OR act in a way that made you Mother Abused Household afraid you might be Mental Illness Instability physically hurt? Substance Abuse Incarceration
ACEs Strong, graded relation to childhood adversity Smoking Attempted suicide COPD Revictimization Heart Disease Teen pregnancy Diabetes Fractures Obesity Promiscuity; STDs Hepatitis Poor self-rated health Alcoholism Violent relationships Trauma- informed Other substance abuse Low educational attainment Depression Poor job performance Two Generation Approach
Background: Trauma - > What’s visible | What’s underneath Behavioral Problems Physical Illness Emotional Dysregulation Financial instability & poor educational outcomes Trauma & Loss Chronic Hyperarousal & Chronic Inflammation Adverse Childhood Experiences Family & Social Dysfunction Historical trauma & social structures based on violence, racism, colonialism, sexism
What is Trauma-Informed practice? • Realizes – Widespread impact on trauma; paths to recovery • Recognizes – Signs & Symptoms trauma in clients, families, staff, and systems • Responds – Fully integrate knowledge about trauma into policies, procedures and practice • Resist – Actively resists “re - traumatization” For more info, go here
Theory-based, trauma- informed, evidence-supported, whole culture approach for creating / changing an organizational culture.
The Network Building Wealth and Health Network Member Advisory Board Ongoing Evaluation Social Work Financial Referral Coaching Group Classes & Peer Support Matched Savings Accounts Financial SELF Empowerment (up to $20 per month provided) 12 months 4 months Major Components of Building Wealth and Health Network
Curriculum (16 weeks) Building assets and resiliency Trauma-informed Financial Education peer support 1. Bank Accounts 101 • S.E.L.F. 2. Savings / Reducing Debt – Safety 3. Credit Score – Emotions 4. Tax help – Loss – Future 5. Business planning 6. Planning for an education / home 7. Negotiating with your boss 8. Setting financial goals
Savings Match w/ Credit Union (Shareholders) • $5 per wk • 1:1 match • = ~ $500 per yr
All participants become Network MEMBERS Member Advisory Council (20 members) Provides ongoing feedback on program & dissemination
Outcomes Measured (ACASI) Baseline, 3 month intervals to 12 months 1. Income, Education & Program Participation 2. Financial Wellbeing • Assets, savings patterns 3. Economic Security • Food Insecurity • Housing Insecurity • Energy Insecurity 4. Maternal & Child Health and Development • CES-D (Center for Epidemiologic Studies - Depression) • Self-Rated Health • PEDS ( Parents’ Evaluation of Developmental Status Survey) • Caregiver rated Health See Sun et al (2016) BMC Public Health
Ongoing Recruitment & Survey Participation Network ACASI Survey Completion Cohort Baseline 3-month 6-month 9-month 12-month Cohort 1 (Non-TANF) 31 27 (87%) 24 (77%) 23 (74%) 24 (77%) Cohort 2 (TANF) 67 47 (70%) 33 (49%) 40 (59%) 33 (49%) Cohort 3 (Non-TANF) 28 23 (82%) 18 (64%) 18 (64%) 18 (64%) Cohort 4 (TANF) 37 26 (70%) 21 (57%) 17 (46%) Cohort 5 (TANF) 36 22 (56%) 28 (76%) 17 (46%)* Cohort 6 (Non-TANF) 25 20 (80%) 17 (68%) 8 (32%)* Cohort 7 (TANF) 33 19 (58%) Cohort 8 (TANF) 26 16 (62%) Cohort 9 (Non-TANF) 32 17 (53%) TOTAL 316 217 141 123 75 *indicates follow-up is ongoing; total % changes every day as people cycle in for appointments
Selected Results of Ongoing Evaluation – The Network October 2015-April 2017 80% 73% 71% 71% 70% 67% 67% 70% 62% 62% 60% 53% 49% 47% 50% 46% 42% 40% 28% 30% 18% 20% 10% 0% Household Food Caregiver Health No Depressive Employed* Savings Account* Secure* Excellent/Good+ Symptoms+ * p < .05 ; + p < .10 Baseline (N=126) 6-Month (N=76) 12-Month (N=74)
Phase II Preliminary (Oct ‘15 - Feb ‘17) Household Food Security 80% 73% 70% 68% 64% 62% 62% 60% Percent of Participants 57% 50% 47% 40% 33% 30% Food Secure* 20% Food Secure (4+ ACEs)* 10% *Statistically significant, p<0.05 N=24 N=14 N=13 N=11 0% Baseline 6-month 9-month 12-Month (N=94) (N=48) (N=60) (N=53) N=24 N=11 N=14 N=13
Phase II: Preliminary (Oct ‘15 - Feb ‘17) Caregiver Health 90% 81% 77% 80% 75% 77% 70% 65% Percent of Participants 60% 58% 55% 50% 50% 40% Caregiver Health (p=0.02) 30% Caregiver Health (4+ ACEs) 20% 10% N=24 N=13 N=11 N=14 0% Baseline 6-month 9-month 12-Month (N=94) (N=48) (N=60) (N=53) N=24 N=11 N=14 N=13
Phase II: Preliminary (Oct ‘15 - Feb ‘17 ) Depressive Symptoms 90% 80% 79% 71% 70% Percent of Participants 60% 55% 54% 50% 50% 46% 46% 40% 40% 30% Depression 20% Depression (4+ ACEs) p=0.04 10% N=24 N=13 N=11 N=14 0% Baseline 6-month 9-month 12-Month (N=94) (N=48) (N=60) (N=53) N=24 N=11 N=14 N=13
Phase II: Preliminary (Oct ‘15 - Feb ‘17) Employment 60% 55% 55% 54% 50% Percent of Participants 44% 42% 40% 36% 30% Currently Employed (p<0.0001) 21% 20% 18% Currently Employed (4+ ACEs) (p=0.03) 10% 0% N=11 N=14 N=13 N=24 Baseline 6-month 9-month 12-Month (N=94) (N=48) (N=60) (N=53) N=24 N=11 N=14 N=13
Phase II: Preliminary (Oct ‘15 - Feb ‘17 ) Banking 100% 92% 90% 82% 80% 79% 77% Percent of Participants 71% 70% 70% 70% Checking 65% 64% Account* 63% 60% 63% 55% Checking 50% 50% Account (4+ ACEs)* 40% 40% Savings 30% 29% Account* 28% 20% Savings Account (4+ 10% N=13 ACEs)* N=24 N=14 N=11 0% *Statistically Baseline 6-month 9-month 12-Month significant, (N=94) (N=48) (N=60) (N=53) p<0.05 N=24 N=11 N=14 N=13
Network Member #1 Network Member #2 Network Member #3 Network Member #4
Mariana Chilton, PhD, MPH mmc33@drexexl.edu 267-359-6026 @ thebwhnetwork
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