Michael K. Hole

Redesigning Health Care Practices to Address Childhood Poverty

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Determinants of Health and Pediatric Primary Care Practices

More than 20% of children nationally live in poverty. Pediatric primary care practices are critical points-of-contact for these patients and their families. Practices must consider risks that are rooted in poverty as they determine how to best deliver family-centered care and move toward action on the social determinants of health. The Practice-Level Care Delivery Subgroup of the Academic Pediatric Association’s Task Force on Poverty has developed a roadmap for pediatric providers and practices to use as they adopt clinical practice redesign strategies aimed at mitigating poverty’s negative impact on child health and well-being. The present article describes how care structures and processes can be altered in ways that align with the needs of families living in poverty. Attention is paid to both facilitators of and barriers to successful redesign strategies. We also illustrate how such a roadmap can be adapted by practices depending on the degree of patient need and the availability of practice resources devoted to intervening on the social determinants of health. In addition, ways in which practices can advocate for families in their communities and nationally are identified. Finally, given the relative dearth of evidence for many poverty-focused interventions in primary care, areas that would benefit from more in-depth study are considered. Such a focus is especially relevant as practices consider how they can best help families mitigate the impact of poverty-related risks in ways that promote long-term health and well-being for children.

Improving Access to Evidence-Based Antipoverty Government Programs in the United States: A Novel Primary Care Initiative

The US government acknowledges the struggle of lowincome, working families raising children by providing the Earned Income Tax Credit (EITC), a program repeatedly shown to improve child health but largely overlooked by the pediatrics community. During the 2016 tax season, we developed a program called “StreetCred” (http: //www.mystreetcred.org) to help families access the EITC while visiting their pediatricians in primary care clinics. The EITC is the largest and most effective incomebased antipoverty tool in the United States and offers more than

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66 billion in annual tax benefits. The program encourages and rewards work because a taxpayer’s EITC grows with each additional dollar of earnings until reaching the maximum household wage income. In 2015, a taxpayer could receive more than

Mediastinal Kaposiform Hemangioendothelioma and Kasabach-Merritt Phenomenon in a Patient with no Skin Changes and a Normal Chest CT

6000 based on income, marital status, and number of dependent children, and in 2013, 31.8 million persons, including 13.2 million children, were lifted from poverty or made less poor by the EITC and Child Tax Credit.1 The EITC has been linked to improved infant birth weight, lower premature birth rates, less maternal stress, higher employment rates of single mothers, improved kindergarten through grade 12 school performance, higher graduation rates, and increased future earnings.2 Despite these triumphs, however, the EITC’s impact is dampened by 2 challenges. First, an estimated 20% of families eligible for the EITC do not receive the credit yearly because they lack awareness of the benefit, misunderstand their eligibility, or have a difficult time accessing free tax-preparation services because of time and transportation constraints.3 Second, low-income families already strapped for funds are losing nearly

Free Tax Services in Pediatric Clinics

2 billion of tax credit annually to the for-profit tax-filing industry (eg, H&R Block, Jackson Hewitt, and Liberty Tax Service), which often focuses marketing efforts on communities with high populations of low earners eligible for sizeable EITC refunds and charges excessive amounts for help filing taxes.4 We hypothesize these 2 challenges could be addressed to lower the risk of poor development and adverse health outcomes for children in the United States. The American Academy of Pediatrics named “Poverty and Child Health” a strategic priority, an effort involving coordination between health care sites and community assistance agencies5 to curb poverty’s potential negative impact on children’s brains, learning, health, and future workplace productivity; poverty costs the US economy more than

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500 billion annually from lower workplace productivity and higher health care costs.6 Expansion of existing referral services addressing the social determinants of health, such as the Medical Legal Partnership and Health Leads, is important because medicines do little for homelessness, hunger, and lowpaying jobs. However, more innovations bringing services to patients and their families are needed, particularly because time is scarce for working, poor families and obtaining basic resources from public assistance programs often means overcoming barriers such as navigating public transportation, waiting in long lines, filling out confusing forms, and persistent self-advocacy. Recognizing these challenges, we started StreetCred, an innovative program embedded in the pediatric primary care clinic at Boston Medical Center. StreetCred provided tax-filing services during routine health care visits, often by taking advantage of clinic wait times. StreetCred volunteers and staff called families with upcoming pediatrician appointments to (1) remind families of their appointment, (2) offer free tax preparation during their appointment, and (3) tell families what tax-related documents to bring to their appointment. When a family arrived to the clinic, StreetCred volunteers collected the family’s documents and began the tax return while the family waited on and saw their pediatrician. Most tax returns were completed in approximately 20 minutes. After seeing the physician, the family returned to review, sign, and submit their tax return alongside StreetCred staff. During the 2016 tax season, StreetCred’s pilot program provided free tax preparation to 186 families and, ultimately, returned more than

Kala-azar in a Brazilian child.

400 000 to lowincome working families, including several Boston Medical Center employees. Set-up and implementation costs totaled less than

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20 000, mostly in staff salary expenses; thus, for every

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1 we spent, we returned