Topic 1: Play the Game Spent

http://playspent.org

Associated Dig Deeper Page: http://childpoverty.info/introducti1a

Follow-up Question:

Did you make it to the end of the month?

• Yes
• No

(If yes) How much money did you have left at the end of the month?

_______

The federal poverty level, sometimes called the FPL, is a concept that was developed in the 1960’s to help decide which individuals are eligible for financial support from the government and other supplemental programs.

The FPL is assigned based on the number of individuals supported by that income. In some cases, the government helps families by providing free or reduced-cost health insurance.

Since the passage of the Patient Protection and Affordable Care Act, sometimes referred to as the ACA or Obamacare, the state of California has created an online marketplace called Covered California, where individuals or families that make greater than 100% of the FPL can assess their eligibility for federal assistance in the cost of health insurance premiums. The FPL is used to guide eligibility for this free or low-cost insurance.

Associated Dig Deeper Page: http://www.childpoverty.info/affordable2a/

Follow-up Question:

True or False: The federal poverty level (FPL) is used to guide eligibility for free or
subsidized health insurance offered through Covered California, California’s online health insurance market place.

• True
• False

In 1964, Lyndon B. Johnson declared a “War on Poverty” and in an attempt to measure income inadequacy, a poverty measure was developed based on the work of Mollie Orshanky, an economist who worked for the Social Security Administration at that time.

The federal poverty thresholds were decided based on the total monthly costs of an adequately nutritious meal multiplied by three, as food cost one-third of one’s income at that time. Based on the poverty threshold identified, the federal poverty threshold was created, and updated annually to reflect inflation. This has continued despite food now accounting for only one-tenth of monthly income spending, and higher costs of healthcare, child care, medical expenses, housing, and transportation.

Those with incomes at or below the federal poverty level (FPL) are defined as poor, those with incomes that are two times the FPL are considered low-income or near-poverty, and those with incomes at half of the FPL are described as living in deep-poverty. In the U.S. 44% of children are low-income and 21% are living in poverty.

The government offers entitlement and supplemental programs to help individuals and families with income inadequacy. Some entitlement programs include Medicaid, SNAP, and TANF, and supplemental programs include Head Start, WIC, and the Free School Lunch program. Those in deep poverty are eligible for the most support.

Associated Dig Deeper Page: http://www.childpoverty.info/historyoft3a/

Follow-up Question

True or False: The federal poverty level (FPL) was developed in the 1960’s to assess
income inadequacy, and the original threshold was developed based on a value that was three times the monthly cost of an adequately nutritious diet.

• True
• False

Medicaid is an entitlement program that provides health insurance coverage to millions of low-income Americans, including children, pregnant women, and individuals with disabilities. Entitlement programs are designed to guarantee protection of certain human rights. Medicaid is an entitlement that protects the rights of certain individuals to access the healthcare system by providing health insurance coverage. The eligibility rules vary across states, but in many states, income determines eligibility and those that make below a specific income threshold are eligible to receive Medicaid.

The Children’s Health Insurance Program, or CHIP, is a federal program that is run by each of the states with some funding supported by the federal government. In the state of California, Medicaid is named Medi-Cal, and CHIP funding is combined with Medicaid funding under Medi-Cal. As a result, more children are eligible for health insurance coverage through Medicaid in California than in other states.
Another program that is specific to California is CCS, or California Children’s Services. CCS provides full service healthcare for children with certain chronic illnesses whose families demonstrate a specific level of financial hardship. Under its current design, CCS provides focused health coverage that must be related to a child’s specific diagnosis.

In the state of California, Medi-Cal also offers health insurance coverage to undocumented individuals that are under 19 yeas of age as a result of a bill, SB-75, that was passed to protect the interests of undocumented youth living in California.

Associated Dig Deeper Page: http://www.childpoverty.info/healthcare4a/

Follow-up question:

True or False: In the state of California, CHIP is run separately from Medi-Cal.

• True
• False

Entitlements and supplemental programs are benefit programs that are supported by the government to help ensure individuals have adequate income and nutrition for survival. SNAP, which is short for the Supplemental Nutrition Assistance Program, provides recipients with an Electronic Benefits Transfer card, or EBT card, which allows them to purchase approved foods from stores that accept the card. This was referred to as food stamps in the past. In the state of California, SNAP is named CalFresh.

SSI, which stands for Supplemental Security Income, is a cash assistance program that helps to support individuals with specific disabilities by providing additional income.

TANF stands for Temporary Assistance of Needy Families and is another cash assistance program that supports families with children that have inadequate income. In California, TANF is called CalWorks. While the government does fund several entitlement programs that guarantee support for eligible individuals, there are also supplemental programs that provide as much support as they can but cannot guarantee support when funding runs out. WIC is a supplemental program that stands for Women, Infants, and Children and provides supplemental food and nutrition resources to expecting mothers or mothers with children under age 5 that demonstrate certain financial hardships. WIC also provides breastfeeding support to new mothers.

Associated Dig Deeper Page: http://www.childpoverty.info/entitlemen5a/

Follow-up Question:

For each of the state programs listed, please select the name that is used for the program federally:

Social determinants of health, sometimes referred to as SDH or SDOH, is a term used to describe the conditions or circumstances in which people are born, grow-up and age that affect their overall health, health risks, and quality of life.

To more easily explain SDH and the idea that health starts where we live, learn, work, and play, Healthy People 2020 created a “place-based” organizing framework, describing five key domains of social determinants of health. These 5 domains include economic stability, education, social and community context, health and healthcare, and neighborhood and built environment.

1. Economic stability refers to the presence of a stable income, stable access to money to buy food, and stable housing.
2. Education describes language and literacy, as well as educational background, including whether an individual has graduated from high school, or attended college.
3. Social and community context describe social cohesion, the presence of a support network, and civic participation.
4. Health and healthcare refer to health literacy and access to health care.
5. Neighborhood and built environment describe neighborhood crime rates, as well as physical conditions in a neighborhood, such as outdoor spaces to play or stores with healthy foods.

Socio-economic status (SES), though influential in health, is not one of the 5 domains. SES describes a combination of income, education, and occupation.

Associated Dig Deeper Page: http://www.childpoverty.info/socialdete6a/

Follow-up Question:

True or False: Socio-economic status is not considered one of the 5 domains of the social determinants of health.

• True
• False

Health literacy is defined as “the degree to which individuals have the capacity to obtain, understand, and process basic health information and services needed to make appropriate health decisions.” Studies have demonstrated that individuals with low health literacy have poor health status, difficulty communicating with providers, increased rates of hospitalization, poor knowledge of their disease states and medication regimens,  and difficulty with medication adherence. The ability to read medication labels and follow the instructions, fill out insurance forms, and navigate the medical system all require high levels of reading and numerical skills.

Health literacy becomes an increasingly complex issue when language is also a barrier to care. For example, even with the use of a skilled interpreter, families might have difficulty in understanding their health status or health care instructions and plans if complicated language or medical terminology is utilized. As interpreters are not trained to interpret information in a way that addresses issues related to health literacy, this responsibility falls on the communicating provider.

Associated Dig Deeper Page: http://www.childpoverty.info/asthmaanad7a/

Follow-up Question:

True or False: Health literacy is defined as the ability of an individual to read a medication label.

• True
• False

There are many screening tools that have been developed to help assess social determinants of health and address unmet social needs.

One popularly used screening tool for food insecurity is Hager’s two-item screen. This asks parents if they agree with either of the following two statements:

• Within the past 12 months we worried whether our food would run out before we got money to buy more.
• Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.

The WECARE tool is another tool that families fill out without a provider. This screening tool asks families about

• Education
• Employment
• Daycare needs
• Homelessness
• Food insecurity
• Difficulty in paying bills

The IHELLP tool is a physician administered screening tool thatasks families about

• Income
• Housing
• Education
• Legal Status
• Literacy
• Personal Safety

While there is no gold standard to screen for unmet social needs, providers are encouraged to develop a standard tool or use a previously validated tool that best addresses the needs of their specific patient population. It is important  that providers systematically screen for unmet needs in all families to be most effective in identifying unmet needs.

Look at this week’s dig deeper links to review the screening tools discussed today and for other helpful resources.

Associated Dig Deeper Page: http://www.childpoverty.info/screeningt8a

Follow-up Question

For each of the screening tools, please select the item(s) for which it screens.

The key to high-quality patient care is patient-centered communication characterized by an emphasis on respectful, active, nonjudgmental listening skills, and exploration of social determinants that affect a patient’s health, as well as understanding, desire, and ability to follow through on clinical management plans. It is important to consider the 5 domains of the social determinants of health in addressing the needs of a patient and his or her family, as economic stability, education, social and community context, health and healthcare, and neighborhood and built environment may all influence a patient’s health status. For example, if a patient with poorly controlled asthma continues to have frequent exacerbations, it is important to consider living conditions, including smoke or mold exposure, that may contribute to a patient’s health status, and to address barriers that may exist for medication adherence, including high costs that may prohibit purchase or a lack of understanding of management plan, which may be secondary to language barriers or poor health literacy.

Associated Dig Deeper Page: http://www.childpoverty.info/sdhinpract9a/

Follow-up Question:

Which of the following conditions might result in worsening illness for a patient with asthma?

• Mold
• Smoke exposure
• Inability to afford medications
• Poor health literacy
• All of the above

In obtaining a history from the parent or caretaker of a child who presents with poorly controlled disease, such as asthma, it is important to consider all the ways in which social determinants of health may influence their care. For example, if a family is prescribed medication, but cannot afford that medication, they may not be able to obtain it but might not share this information unless they are asked. If a family is encouraged to seek follow-up but has a lapse in their health insurance, or a brief period in which they are ineligible for Medi-Cal and are awaiting becoming eligible again, they may delay care until they once again have coverage. Alternatively, providers may refuse care until health insurance is in place. Social determinants are important to consider as they are sensitive topics that can easily be overlooked and result in barriers to optimal care.

Associated Dig Deeper Page: http://www.childpoverty.info/anadvocacy10a/

Follow-up Question:

True or False: When caring for a patient, it is important to always consider the ways in which SDH influence health outcomes.

• True
• False

There are many ways in which physicians can help to address social determinants of health during an inpatient admission. For example, screening for smoke exposure among patients that present with a respiratory illness might result in an opportunity to refer to a smoking cessation program and offer nicotine patches or gum to assist with the quitting process. In meeting a patient that does not speak English but expresses interest in learning, a referral can be made to an English class offered through a local library. Social workers and co-workers might help to recommend resources. To address problems related to health literacy, specific communication tools have been developed and demonstrated to be effective in improving patients’ understanding of medication instructions and prescribed treatments. Two highly regarded and well-evaluated communication tools are: the “Teach Back Method” and visual aids/pictorials, such as an asthma action plan and a visual that shows how to use and metered-dose inhaler with a spacer. When using the Teach Back Method, the provider asks the patient to restate in his/her own words the directions that have just been given. This method encourages the clinician to take responsibility for the patient’s understanding of instructions. In this case, Dr. Robinson might have asked: “In order to make sure that I explained this to you well, could you please tell me how you are going to give this medication to Mary?” Not surprisingly, literature has also shown that, when pictorials are combined with written or oral instructions, patient understanding of how to take medications is increased.

Associated Dig Deeper Page: http://www.childpoverty.info/resourcesf11a/

Follow-up Question:

True or False: The teach-back method encourages the clinician to take responsibility for the patient’s understanding of instructions.

• True
• False