Come behind the scenes for a view into how Aunt Bertha's team is connecting all people in need and the programs that serve them (with dignity and ease).
This month, a new study called the #RealCollege Survey published alarming statistics about the social well-being of California community college students. The study estimated that around 20% of California community college students have experienced homelessness in the last year, 60% have experienced recent housing insecurity, and 50% have experienced food insecurity (1). The #RealCollege Survey was completed on community college campuses across California in the fall of 2016 and 2018. It’s worth noting that college students experiencing poverty, homelessness, and food/housing insecurity is not unique to California as educational institutions across the country face these issues.
According to StandUp for Kids, a nonprofit organization that serves homeless youth, the rising costs of housing and stagnant wages across the country (2) have made it increasingly challenging for families to support their college-age children pursuing higher education. Parents may find themselves unable to help their children at all or at least struggle to pay for both tuition and housing, leaving students to make their own accommodations. Some students may not even have the support of parents, such as students who were raised in foster care. The #RealCollege survey noted that these students experienced homelessness at a higher rate than children of parents with either a bachelor’s degree or higher education (1).
While college campuses have been reporting student homelessness growing in recent years, the recent publication is one of the first to study the problem with a student survey. Over 40,000 students participated in the survey conducted by the Hope Center for College, Community, and Justice at Temple University’s College of Education in Philadelphia. Key observations are highlighted below:
Actual homelessness rates among students are likely higher.
Only six percent of students labeled themselves as homeless, while the other thirteen percent were only classified as homeless after stating where they lived (shelters, hotels, couchsurfing, etc).
This indicates the likelihood that other surveys that estimate rates of homelessness through self disclosure are understating the true values.
Sixty percent of California community college students have experienced housing insecurity in the last year.
Housing insecurity encompasses a category of experiences ranging from difficulty or inability to pay rent to having to move frequently.
Students may need to move frequently for a variety of reasons, such as living in areas which feel unsafe or being forced out of a living situation due to the space being over-capacity.
Fifty percent of California community college students have experienced food insecurity in the past month.
Food insecurity is defined as limited access to adequate supplies of nutritious food or the inability to access food via socially acceptable means.
Removing non-academic barriers to student success.
Homelessness on college campuses is a growing problem across the country. Students who are experiencing homelessness, housing insecurity, or food insecurity face risks not only to their well-being, but also to their education. Many students experiencing these challenges are not able to graduate due to the greater mental burden of securing access to life essentials such as food or housing. To help these students succeed, we need to become aware of their presence on campuses across the country and take action to help them connect with resources to support their social needs.
Many institutions of higher education are already partnering with Aunt Bertha to address the social needs of students. With our platform, they can help students and their families remove non-academic barriers to student success. Through an assessment, staff can identify and refer students to community resources which are often provided on campus. Aunt Bertha enables institutions of higher education to connect the dots between the campus and the community, gaining a deeper understanding of the impact those connections have on a student’s success in the process. Our higher education partners include forward thinking institutions such as Ivy Tech Community College, St. Edward’s University, University of South Florida, and NC Community Colleges to name just a few.
We also partner with nonprofit organizations serving homeless populations, such as StandUp for Kids. Many of our nonprofit partners place a search engine powered by Aunt Bertha, with their own branding, onto their websites so that the communities they serve can search for social assistance on their own. You can check out an example of Aunt Bertha’s configurable search engine here!
References
Goldrick-Rab, Sara, et al. California Community Colleges #RealCollege Survey. The Hope Center, 1 Mar. 2019, Christine Baker-Smith.
The footprint left in the wake of natural disasters in the United States in 2018.
Natural disasters have effects which are both immediate and long-term, deeply affecting the areas in which these emergencies occur. The immediate effects are obvious, bringing to mind the image of a family stranded on the roof of their flooded home or that of a wildfire casting up a cloud of dark smoke. The long-term effects can be just as devastating, though, as natural disasters can force communities to rebuild everything from homes to social networks. Fortunately, there are many people, programs, and organizations that are generous with their time and resources to help people impacted by disasters in affected areas.
This heat map shows searches for free & reduced cost services on a disaster relief organization’s branded website, powered by Aunt Bertha. Search trends on this platform show areas of concentrated need, with the map showing search density as a spectrum of color moving from purple (low concentration of searches) to blue (medium concentration) to green (high concentration).
The heat map shows areas of highest search concentration over several areas of the US which were impacted by natural disasters in the past year:
Central California
The 2018 wildfire season was one of the most deadly and devastating seasons on record, with Central California experiencing widespread disaster from fires.
The high search density for social care resources in Central California aligns with areas which were most impacted by wildfires in 2018, likely as a result of communities recovering from fires.
Southern California
The 2018 wildfire season was devastating to Southern California as fires encroached on the densely populated areas surrounding Los Angeles.
The high search density for social care resources in Southern California is clustered in the region outside of Los Angeles, which was heavily impacted by wildfires in 2018.
A digital fire tracker created by the San Francisco Chronicle (1).
Florida Panhandle & Central Georgia
In 2018, the Florida Panhandle experienced one of the strongest storms ever to strike the US when Michael landed as a Category 4 hurricane.
Damages were estimated in the millions and assistance groups anticipated it would take months to even determine the full scope of the damages.
The high search density for social care resources in the Florida Panhandle and Central Georgia can be found in the region that was devastated by Hurricane Michael.
Hurricane Michael baring down on FL and GA (2).
Carolinas
Hurricane Florence caused unprecedented damage in the Carolinas and the East Coast as a slow-moving, moisture-heavy storm.
There is a high density of searches over the Carolinas, where Hurricane Florence stalled and dumped up to 30 inches of rain in some regions.
Interestingly, there is a medium density of searches across Virginia, West Virginia, and Ohio following the path of Hurricane Florence before it turned east to New England.
A map showing Hurricane Florence’s devastating path across the East Coast.
Camden Coalition, founded by Dr. Jeffrey Brenner in 2002, is an organization of hospitals, providers, and advocates that collaborate to deliver healthcare to the most vulnerable people in their community. They are one of 32 organizations selected to participate in the Accountable Health Communities (AHC) initiative through the Centers for Medicare and Medicaid Services (CMS). This initiative aims to bridge the critical gap between clinical and community service providers by addressing health-related social care needs, aligning well with the missions of both Camden Coalition and Aunt Bertha. In 2018, Aunt Bertha and Camden Coalition collaborated to build assessment workflows to enable Camden’s success in the AHC Model.
Aunt Bertha has features built to meet AHC requirements, including integrated screening, navigation, goal tracking and reporting. Let’s dive into more detail on how some of these tools help meet AHC requirements.
Needs Assessments
1. AHC-eligible beneficiaries are able to complete a web-based assessment to identify social care risks and needs.
2. Camden staff help eligible AHC beneficiaries complete or administer the screening.
3. Needs identified through the assessment are then used to recommend social care resources as well as an action plan.
4. Results from the assessment can be reviewed at any time and goals can be updated and tracked over time.
Referrals
1. Referrals are tracked through the Aunt Bertha platform and allow updates to be made in real time.
2. The Seeker, staff, or the Community Based Organization can “close the loop” to indicate if the community member was able to get help.
Navigation
1. Camden Coalition and Aunt Bertha collaborated closely on designing the workflows to ensure a smooth process for both staff and community members.
2. The navigation tools represent a central location from which individual member profiles can be reviewed and updated.
3. Staff manage goals, needs, referrals, assessment results, contact information, and more.
Reporting
1. Aunt Bertha offers a detailed reporting suite and has the capability to create CMS-required reports, which was essential for the Camden Coalition AHC project.
2. AHC specifications require a weekly data submission and Aunt Bertha regularly runs and maintains these reports, which are then submitted to CMS by Camden Coalition to meet the demonstration project goals.
3. Since the Camden project launched in 2018, over 3,700 assessments have been submitted. Recently, the frequency of completed submissions has grown to over 1,000 completed submissions each month.
4. Camden Coalition is an impactful example of an innovative team using our tools to demonstrate new ways to support community health and wellness. Through thoughtful collaboration, our teams developed tools, workflows, and a community-facing experience that keeps the Seeker at the center.
The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. The project described was supported by Funding Opportunity Number CMS CMS-1P1-17-001 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.
In honor of Professional Social Workers month in March, we thank the nearly 700,000 Social Workers in America who selflessly connect people in need to resources in their community. We applaud organizations like the National Association of Social Workers (NASW) that’s started a dialogue on boosting the pay of Social Workers, which continues to lag behind other highly trained, helping professions.
Credit: National Association of Social Workers (NASW)
Earlier this month, the Department of Health and Human Services (HHS) announced a new initiative termed Medicare ET3, or Emergency Triage, Treat, and Transport (ET3) Model.1 Although the program will largely serve Medicare beneficiaries, it has the potential to create a long-term impact on how Americans think about transportation, cost savings, and health.
ET3 is a program which increases the flexibility for how ambulance care teams can choose to respond to emergency calls. In the existing model, ambulance care teams are directed to transport the patient to the nearest hospital ER. Under the ET3 model, these teams respond to an emergency call but have the option to take any of the following actions:
Treat the patient onsite;
Treat the patient with a provider through a telemedicine service;
Transport the patient to a nearby primary care provider; or
Transport the patient to the nearest hospital ER.
The initiative also sets aside funding to assist 911 dispatch services with setting up a medical triage line which can serve anyone who calls in. Together, these processes lend the new initiative its three Ts: Triage, Treat, and Transport.
For now, the ET3 model is simply an initiative by The Centers for Medicare & Medicaid Services (CMS). While it’s limited in timeline and scope (with a five year performance period serving a specific population) the most important takeaway from this initiative is what it means for US healthcare as a whole. The model aims to reduce healthcare costs by increasing the flexibility of responses to emergency calls, improving transportation options for immediate care, and encouraging medical triage. In doing so, the initiative highlights the importance of these factors for the future of healthcare.
Transportation is a social determinant which can significantly impact a patient’s ability to get the care they need.2 To date, though, this need has not been largely acknowledged by the US healthcare system. The launch of this initiative by CMS signals that this may soon be changing. Approximately 40% of health spending in the US is funded by Medicare and Medicaid programs3, representing more than a trillion dollars. This gives CMS significant buying power and influence in the US healthcare space, meaning other payers may take note and go down the same path.
For example, some commercial health insurance companies have begun to offer transportation to healthcare appointments as a value-add for members, although this is hardly a widespread practice. One plan will offer a scheduled car service, while another offers a transportation escort for those who may need assistance to travel to medical appointments. Additionally, several new companies are popping up to partner with rideshare services to help get patients to their appointments.
While these innovative efforts are beginning to address transport barriers to healthcare access in select markets, they are still fragmented and inconsistent in their availability across the country. That’s why it’s important to pay attention to the new ET3 model announced by CMS. While the model will largely serve Medicare beneficiaries, the significant purchasing power and influence of CMS hopefully signals a shift towards addressing the social domain of transportation for all people in need.
References
Emergency Triage, Treat, and Transport (ET3) Model. (n.d.). Retrieved from https://innovation.cms.gov/initiatives/et3/
Syed, S., Gerber, B., & Sharp, L. (n.d.). Traveling Towards Disease: Transportation Barriers to … Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265215/
National Health Expenditures 2017 Highlights. (n.d.). Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf
Aggregated searches for housing assistance on auntbertha.com in the past 365 days.
Until recently, homelessness in Los Angeles was concentrated—for the most part—in Skid Row, a downtown district just a few blocks south of City Hall. Starting about five years ago, though, a sharp rise in homelessness in Los Angeles meant that LA’s homeless population could no longer be confined to four square miles.
This heat map shows searches for housing assistance on Aunt Bertha’s public platform at https://www.auntbertha.com/ across Los Angeles and Orange Counties. Search trends on our free platform are a proxy for where people are falling behind in a community and what their most critical needs are. The search density spectrum moves from purple (low concentration of searches) to blue (medium concentration) to green (high concentration).
Twenty years ago, it’s likely that this map would have been a smaller sea of purple with one prominent, green dot overlaid on Downtown Los Angeles. Today, we see housing searches spread far and wide across both counties, with high search density in areas that have not been traditionally associated with homelessness.
We saw the highest volume of housing related searches in Santa Monica, which has experienced a growing number of homeless individuals living in its beaches and parks. The cities of Malibu and Pacific Palisades, previously isolated enclaves of affluence, have witnessed a migration of the homeless population northward along its beaches. (The other hotspot north of Santa Monica reflects the famous 90210 ZIP Code often entered by users exploring our platform for the first time).
It’s much easier for someone to become homeless in Los Angeles compared to other cities, due to the worrisome combination of skyrocketing rents and lack of affordable housing. The housing mix in Los Angeles, with its low ratio of multifamily housing to single family homes, has exacerbated both factors.
It’s worth noting that we observed substantial search volume by people in need for housing assistance in regions without a visible homeless population, such as Pasadena and the San Fernando Valley. Our data on search patterns can be useful for pinpointing communities where people may be at risk for homelessness in the near future, based on real-time spikes in housing assistance searches. Our data was consistent with the notion that the rising number of Los Angeles natives experiencing homelessness for the first time (a 16 percent increase between 2017 and 2018 according to Bloomberg) may have been foreshadowed by the high search density samples on Aunt Bertha’s platform.
An innovative way that health clinics, government agencies, and Community Based Organizations have helped to tackle homelessness is to identify at-risk clients as part of their intake process. Questions such as the following can be incorporated into intake applications:
Do you have any overdue utility or housing bills?
In the last three years, how many times have you been without steady housing?
How long has it been since you’ve had a steady place to live?
Are you worried about losing your housing in the future?
Do you have a proof of address, such as a signed lease or utility bill in your name?
A client who meets criteria would then be assisted by a social services navigator who would refer them to resources in the community for help with their situation.
For example, a health system with clinics in the San Fernando Valley may monitor housing assistance searches in real-time to determine whether additional care coordination is needed at those locations. Such interventions benefit healthcare organizations as social risk factors such as housing insecurity often interfere with a patient’s health. Screening questions may help identify relationships such as patients coming in for stress-related illness who also cannot keep up with rising rents. A screening questionnaire would identify such at-risk patients and direct them towards help to pay for housing before further detriment to their well being.
Here at Aunt Bertha, we invest significantly in our Data Operations team. It’s the largest department in the company, with over 20 members, and it’s still growing! Data team members are Seeker-focused, meaning they research and enter programs with the Seeker in mind, continually asking if the data being entered will help them more easily find and connect with the services they need.
This deep knowledge of the system and dedication to our mission have made it possible for data team members to transition and make an impact in other roles within the company. All of these team members have one thing in common—a belief in making a change for the better.
Here are some of their stories…
Nazanin Garcia, Data Quality Specialist Supervisor
Nazanin began her career at Aunt Bertha as a Part-Time Data Quality Specialist and after a year transitioned into a supervisor role and currently serves as the Data Quality Specialist Supervisor. Before joining Aunt Bertha she worked as a Customer Service Representative for State Farm, where she gained perspective on the importance of planning for the future. After seeing an Aunt Bertha job posting, reading about Aunt Bertha’s mission and Erine’s future vision for accessing social services, Nazanin was drawn to apply. She wanted to learn new things while serving the mission of the organization.
She came in as a blank canvas, eager to learn, and the more she learned, the more she loved being at Aunt Bertha. She’s been inspired by the people, the passion, the mission, and the culture. Being at Aunt Bertha has helped Nazanin with personal growth as well. She has been able to create a career path for herself with the guidance of her managers. She is constantly learning how to be a better leader and implement the steps needed to further her career.
Jeremy Owens, Data Quality Specialist & Reporting Analyst Intern
Jeremy began his career at Aunt Bertha as a Data Quality Intern and now uses his expertise as a Data Quality Specialist and as a Reporting Analyst Intern on the Product team. Before working at Aunt Bertha, Jeremy worked as a cashier and parking lot attendant for the University of Texas while attending school there. (During his time in that job, he met former UT quarterback Vince Young several times while working UT football games!) Jeremy was originally drawn to Aunt Bertha for its mission and its role in the social services industry. He knew from his grandmother’s experience, struggling to get help in the past how incredibly difficult it can be to navigate the system. He was excited for the opportunity to help people in need and make a difference for people who are going through difficult times. In Jeremy’s words, a job where you’re helping people day in and day out is a pretty sweet gig.
Aunt Bertha has grown quite a bit since Jeremy started but he still feels it is a tight-knit group of people committed to helping others. His favorite part about working at Aunt Bertha is knowing he is making a positive impact on the lives of people. Aunt Bertha has helped Jeremy grow as an employee. He recognizes the effort that goes into giving people opportunities to step up to new responsibilities and develop themselves. Management has been supportive and their desire to develop employees within the company is visible on a daily basis. Recently, Jeremy was recognized as one of Aunt Bertha’s most valuable employees in 2018!
Erica Rodriguez, Community Engagement Coordinator
Erica started at Aunt Bertha as a Data Quality Specialist and now uses her expertise as a Community Engagement Coordinator. Before joining Aunt Bertha, Erica served as an Administrative Assistant. She was drawn to Aunt Bertha because of its mission. Knowing the organization started because of Erine Gray’s personal experience was incredibly impactful to her.
Her favorite part about working at Aunt Bertha is knowing she’s not just working for a faceless company. She’s inspired by the fact that every department within the company is working collectively to meet people where they are and to serve them with dignity and ease. Aunt Bertha has taught Erica to advocate for herself professionally and has helped her become more adaptable and team-oriented.
Anthonee Esparza, Associate Business Analyst
Anthonee began his career at Aunt Bertha as a Data Quality Specialist and now uses his expertise as an Associate Business Analyst. Anthonee connected to Aunt Bertha because of our mission. His favorite part about working at Aunt Bertha is knowing that the platform is helping make people’s lives easier by providing support to those who may not have any. He enjoys working with others who believe in the same mission.
Aunt Bertha has helped Anthonee learn a wide variety of skills, both technical and inter-personal. The knowledge and experience that he gained during his time at Aunt Bertha shapes Anthonee’s career now and his future endeavors.
Keith Young, Production Support Engineer
Keith began his career at Aunt Bertha as a Data Quality Specialist and now uses his expertise as a Production Support Engineer. Before working at Aunt Bertha, Keith was a Field Assistant for a soil scientist at the University of Texas Bureau of Economic Geology. While reading through job listing after job listing, he was struck by Aunt Bertha’s posting because of the mission. He was excited to be part of a company that provides a valuable platform that gives people tools to mitigate and overcome real hardships. Aunt Bertha has helped Keith in his career development by providing a collaborative and supportive environment with endless learning opportunities.
The Data Operations team has been instrumental in our company’s growth. A big challenge when growing a company is finding great people. At Aunt Bertha, however, we have a pool of amazing folks right here that we look to promote first.
Each day in America, 40 million people don’t know where their next meal will come from (Feeding America). Families and individuals across the country are struggling to find and buy healthy food, and the struggle is often worsened for people with specific health needs, like diabetes, or other factors like income, race, or even location. In fact, 23 million Americans live in food deserts, more than a mile away from a supermarket (United States Department of Agriculture).
In Austin’s Travis County, these factors mean that 15% of the population is food insecure, including 21% of all children in the county, according to Austin’s Office of Sustainability.
This past week, the Aunt Bertha Data team took a morning off from researching social services to do our part to help people in our community by volunteering at a food pantry run by the Austin City Health Department. Nearly 100 families came to get food– a combination of fresh produce and bread. The Health Department also offered on-site screening services for participants, including blood pressure, blood sugar, and cholesterol.
At the food pantry, we saw families with young children, seniors, single adults, and generally a very diverse population. Any of the participants could have been my neighbors, my family, or anybody I could meet in the street. There are thousands of food pantries across the country, serving unique populations in need of some extra help. Just on Aunt Bertha, we list more than 9,000 food pantries spanning across the country, and we are constantly adding more. This means that every day in America, tens of thousands of people are visiting food pantries so they can feed themselves and their families, and I am so happy that we are able to connect people in need with food in their community.
During the event, after the bread and dessert items were long gone, Wegot a chance to talk about health and hunger with the staff from Austin Public Health’s Blackland Neighborhood center. They visit the Turner Roberts Recreation Center every month to provide needed groceries to the community. The staff was able to give us some insight into what the Austin City Public Health department is seeing in our communities.
One of the health department’s main focuses is related to special health needs, like diabetes. In food deserts especially, healthy food can be hard to find, and even more difficult if someone needs a specialized diet. They tackle health and hunger holistically, providing food, specialized healthcare, and even financial assistance to improve the city’s health outcomes. This comprehensive approach is needed to ensure the cycle of hunger ends. Someone with diabetes, for instance, might be able to access food or afford some food, but they might not have the knowledge or funds available to access the types of food they need in order to stay healthy in the long term.
The Austin City Health Department provides social services such as food assistance, bus passes, counseling, health screenings, pregnancy tests, flu shots, and much more in six neighborhood centers across the city. The city also has satellite locations in more isolated communities, especially low-income areas and food deserts, where they provide food to community members in need.
If you’re interested in volunteering to provide Fresh Food For Families at Turner Roberts Recreation Center, register here on the United Way Austin website. For more information about the work the Blackland Neighborhood Center is doing, visit them here.
As we’ve written about previously in Part One of this series, one of the most significant changes in healthcare reimbursement was CMS’ (Centers for Medicare and Medicaid Services) promise to start reimbursing Medicare Advantage plans for non-medical benefits beginning in 2020. Previously, supplemental benefits reimbursed by CMS for chronically ill beneficiaries had to be health-related services but they expanded that definition in the CHRONIC Care Act, passed back in April 2018, by stating that covered services “may not be limited to being primarily health related benefits.” Now referring to these supplemental benefits as Special Supplemental Benefits for the Chronically Ill (SSBCI), CMS recently provided more clarification in January 2019. Some of the main takeaways:
Permanent home modifications aren’t going to be reimbursed but food-related benefits will be; and
CMS is encouraging Medicare Advantage Plans and Community Based Organizations (CBOs) to work closely with another to address social determinants of health.
Defining Non-Medical Benefits
While CMS previously released additional information around uniformity rules and qualifying conditions related to SSBCI (which we summarized in Part Two of our series), health plans and industry experts have been waiting for further clarification on what’s actually considered a non-medical related benefit.
Some speculated that home modifications might end up being covered, but the document states that the non-medical benefits “may not include capital or structural improvements to the home of the enrollee that could potentially increase property value (e.g., permanent ramps, and widening hallways or doorways)…”. Although this leaves out reimbursement for major structural projects, this means that there is still some room for non-permanent solutions, such as temporary ramps or assistance with moving furnishings.
The document also includes several examples of what will be allowed for reimbursement, including the following:
Transportation for non-medical needs;
Home-delivered meals (beyond just post-discharge from a hospital visit); and
Food and produce.
It will be interesting to see how “food and produce” will be billed for, how these goods will be provided, and how they will be reimbursed.
While all of this information provides some clarification, questions still remain around other items and services, such as air conditioners, pest control, and mold removal. Where will CMS land on reimbursing for these services?
New Partners: Health Plans and Community-Based Organizations
In addition to clarification around benefits, the document also briefly discusses the potential role Community Based Organizations (CBOs) may take in the new reimbursement landscape. Coordinated care Medicare Advantage (MA) plans (HMOs, POSs, PPOs, SNPs) are already obligated to “coordinate MA benefits with community and social services generally available in the area served by the MA plan.”1 In addition to care coordination, CMS outlines two other ways in which these types of plans can partner with CBOs:
Plans can contract with CBOs to provide these new supplemental benefits; and
CBOs can help the plan determine if a member meets eligibility requirements for supplemental benefits.
The continued push for health care plans and CBOs to work closely together is just more evidence of CMS’ growing interest in tackling social determinants of health.
CMS also states that Medicare Advantage plans must make sure they have rigorous and objective criteria for determining eligibility for SSBCI. They must also “maintain detailed documentation” to ensure that all patients are screened equally. Since CBOs will be able to help them with eligibility, they will have to think of ways to ensure that screening and documentation follow these requirements.
The Impact
One consequence of the allowances set forth by CMS is that the relationship between the health plan, healthcare provider, and CBOs becomes extremely important. If done right, this systemic approach to social determinants will mean that more people will get the social services they need outside of the doctor’s office, with support from both their health plan and their community.
Note: CMS is currently taking comments on the Proposals and Draft Letter through March 1, 2019. You can find more information here.
As a Program Manager, you’ve been through this scenario more times than you can count…
Your organization receives a referral or a request for services and your instinct is to immediately reach out to see how you can help the person being referred. However, you don’t have enough information to determine if the person needing help is actually eligible for your organization’s services!
Skip the frustrating, time-consuming back & forth with our new, fully customizable Screener.
This screening form is associated with your program listing and lets you gauge the eligibility of applicants as referrals to your organization are initiated.
We built the Screener to help Community Based Organizations listed on Aunt Bertha’s closed loop referral platform accomplish a few goals:
Spend less time qualifying people by asking the right questions, right away
Provide a next step to folks who may be screened as ineligible
Display a customized list of alternative resources or directions to ineligible applicants
View impact through free analytic reporting, including your applicants’ submissions, status, and answer details
Aunt Bertha’s Screener includes:
Over 80 standard questions to select from
The ability to create and customize your own questions
A ‘Qualified Applicants View’ so your organization can stay focused on just those applicants you’re actively working with
And much more!
Aunt Bertha’s Screener is a completely free feature—all you have to do to activate it is claim your program listing and then edit your program’s contact settings!
If you’d like an in-depth tour of the tool to learn how you can put it to work for your organization, click here to schedule a demonstration with an Aunt Bertha team member!
At Aunt Bertha, every single organization, community program, and user holds a very special place in our heart and, more importantly, in our network! Without this network, we could not connect people needing help (Seekers) with the programs that serve them. In the success story below, we highlight the partnership between UMass Memorial Health Care and Reliant Medical Group (UMass Reliant).
UMass Reliant is a partnership with a unique background that serves Worcester County, MA, an ethnically and linguistically diverse community spread across central Massachusetts. The partnership formed with a vision of improving the health of their communities by bridging the gap between community partners and patients with collaboration across the continuum of care.
The UMass Reliant project currently serves thousands of people through their platform, and partnership workshops have engaged many community based organizations (CBOs) in their service area, promoting collaboration across the continuum of care with more innovation yet to come. We celebrate their momentum and also emphasize the importance of learning from their key areas of focus:
Design a clear, strategic vision.
Before UMass Reliant discovered Aunt Bertha, their team set the stage for success by laying out a clear vision. They gathered input from their local CBOs and the ultimate goal of the project was shaped by the collaboration and inclusion of their community.
Collaborate in new ways.
Collaboration was a focus across the full span of the project, from vision to execution. The partnership is formed by a collaboration between two distinct health systems—UMass Memorial Health Care and Reliant Medical Group. Two health organizations in the same service area may typically be fierce competitors, yet in this story two such systems have partnered with each other, putting the community first and promoting collaboration across the continuum of care.
Connect and engage with CBOs.
UMass Reliant made a strategic investment by including CBOs in the design of the project and promoting CBO engagement in training, program claiming, and closing the loop on referrals. The partnership has continued to emphasize outreach to CBOs, providing trainings and support to program staff using the platform.
Meet the community where they are.
UMass Reliant recognized the linguistic diversity in their community and the associated need for program information available in many languages. A key requirement for them in selecting the Aunt Bertha Platform was the ability to present information in over 100 languages.
Spread the word.
UMass Reliant emphasizes promoting the communityHELP platform with their community. Most notably, they printed colorful notecards in more than seven languages with information about the platform for staff and CBOs to distribute.
The UMass Reliant partnership and the ultimate product delivered through communityHELP is uniquely powerful thanks to dedication to a strategic vision, collaboration across the project, CBO outreach and buy-in, and promoting the resource in the community. There is still more work to be done, including designing additional incentives for CBOs, regular workshops and trainings, and tailoring programs to specific community needs. We’re excited to follow their progress and network growth!
This map shows the breakout of our 1.6 million users who searched for free and reduced cost services on Aunt Bertha during the first six months of 2018. Because we list programs in every Zip Code across the United States, you can see that searches originated from every part of the country, from urban metros to rural areas. Brighter shaded regions indicate a heavier concentration of searches, such as in the northeast corridor, Central Texas, and Central Florida.
One of the most important metrics for a social services software provider is the number of end users at a given time. The more people there are searching for help in one place, the more high quality resource providers (Community Based Organizations) there are actively monitoring incoming applicants from the platform. This will, in turn, draw even more end users who have a great experience, continuing to build a self-reinforcing network.
Aunt Bertha is, by many factors, the most utilized platform of any resource and referral system in the United States with over 1.6 million Seekers nationwide, and continues to grow at an unprecedented rate. We also host the largest network of Community Based Organizations on our platform. By joining this network made up of an installed user base already sending and receiving high volumes of referrals, you’ll be able to help your community immediately.
Building a network. It’s a familiar term that in practice can lay the foundation of disruptive ventures. Our modern day banking, retail, political, and social networks thrive on the compounding impact of a growing network effect.
I learned about the power of building a network in the urban streets. As a kid growing up outside Boston, MA I suffered from asthma—most of the little league kids had asthma just like me. Not too far from us was one of the largest coal-fired power plants in New England, and, as would later be confirmed years later, one of the dirtiest. Harvard research suggested 159 premature deaths per year attributed to the pollution.
I took action. I pounded the pavements of Charleston, MA and knocked on the doors of homes, small businesses, and local nonprofits to build a network of support to require scrubbers in the plant. The power plant company paid local families thousands of dollars to wash soot off their homes and cars and eventually complied with state scrubber regulation. The experience taught me that a grassroots network of families, businesses, and community organizations creating change could (and did) help these families for generations.
Sometimes, solutions to big problems are less obvious, incremental, and start at the grassroots level.
If we want to improve community health and outcomes, we need to think beyond healthcare. We need to remove barriers to basic needs and increase the affordability of healthcare & security. We need to improve nutrition literacy. We need to expand affordable housing.
Many Community Based Organizations (CBOs) exist to provide free and reduced cost services nationwide. Many are privately funded, some are government programs, and some are payer or healthcare system funded as well. We have a tremendous opportunity to build community organization networks. We can further their impact by improving the eligibility process, appointment management, referral management, capacity management, and more.
With the Centers for Medicare & Medicaid Services demonstrating social determinant frameworks and advocating for removing HIPAA barriers to care coordination, health systems & payers are adopting a social referral model. Healthcare isn’t the only entry point to this network. Local county programs, corrections facilities, and colleges are all entry points that surface personal needs.
I’m excited to see traction across the country in many industries focusing on surfacing needs, providing help, and measuring social support outcomes. This traction will help CBOs maximize their delivery efficiency and even their financial position and power to expand. Electronic Health Record systems are paying attention, with new social care modules and workflows to be released this year and next.
I’m excited that there are healthcare system leaders emerging in this space, such as the Camden Coalition, a unique UMass/Reliant partnership, Atrium Health, Sutter Health, and many others. These organizations are bringing CBOs to their table in large numbers to discuss ways of working together to help more people, surface needs collectively, and empower people to help themselves directly as well.
As we think about wellness, both inside clinical walls and out in the community, we should pay close attention to this emerging network—a social care network of closely aligned Community Based Organizations providing some of the most important services to people in need, with dignity and ease.
The longest government shutdown – 35 days – is coming to a (for now, temporary) halt. However, this has left more than 800,000 federal employees going without their second paychecks since the shutdown started, leaving some unable to pay for basic resources.
Many federal employee are living paycheck to paycheck. A study by the University of Michigan1 on federal and non-federal workers impacted by the 2013 government shutdown showed that the median worker only had enough cash or liquid assets to pay for eight days of average household expenses. The bottom third of the workers studied had on average a $0 balance in their combined savings and checking accounts the day before they received their paycheck.
There have been numerous news stories showing federal employees waiting in lines at food banks, leaning on diaper banks for diapers and wipes, hoping for discounts or extensions from utility companies, and relying on breaks at the gas station. They are struggling to cover their basic needs.
And the effects of the shutdown reach beyond just federal employees, with federal contractors and those seeking services from federally-funded programs feeling the impact as well.
Here at Aunt Bertha, we think that the uptick in searches in the Washington, DC area in recent weeks may be related to the shutdown. Below you can see a significant spike in searches starting in the second and third weeks of January for food resources, diapers, utility bill assistance, and help paying for gas.
Given all of this, we want to make sure federal workers can easily find the resources they need. We’ve added a number of programs specifically related to the shutdown as well as a special page on our site that consolidates many of those programs.
One of the programs listed that’s helping impacted federal workers.
And as always, anybody in need can use our site to search for free!
Our founder, Erine Gray, has been named a TED2019 Senior Fellow, joining a class of innovators from around the world selected for their extraordinary work and contributions to the TED community. A full list of the new TED Fellows and Senior Fellows is available at ted.com/fellows.
Aunt Bertha founder Erine Gray at TEDxHamburg in 2014.
“To be selected with this group of talented artists, journalists and activists is just humbling. I’m in awe of the other fellows in this year’s class, and I hope to be able to contribute as much as I can to the broader TED Fellows community,” said Gray. “I hope by sharing our story, we can continue to highlight American poverty that exists, and work together with other like-minded organizations to help solve some of these very solvable problems.”
Erine is Founder & CEO of Aunt Bertha, a public benefit corporation that connects all people in need and the programs that serve them (with dignity and ease). People in need can find free and reduced cost social services by entering their Zip Code into auntbertha.com. The company was founded in 2010 and now boasts a user base of 1.6 million people, and coverage in every Zip Code across the US. Aunt Bertha employs 60 team members based mostly in Austin, TX.
“We are thrilled to announce the newest class of TED Fellows, who give voice to some of the most exciting ideas we’ve seen in the program’s 10-year history,” said TED Fellows director Shoham Arad. “The Fellows program is committed to using its resources and platform to help scale Fellows’ ideas and impact, and we are so excited to have these Senior Fellows become an even more integral part of our global community.”
Founded in 2009, the TED Fellows program has 472 Fellows from 96 countries, whose talks have been viewed more than 250 million times overall. In its ten-year history, the TED Fellows program has created a powerful, far-reaching network made up of scientists, doctors, activists, artists, entrepreneurs, inventors, journalists and beyond—leading to many meaningful and unexpected collaborations. The TED Fellows has also yielded a wide variety of collaborative projects, including PEEK, the social enterprise that recently raised a $1 billion fund to eradicate preventable blindness in the developing world; BRCK, the technology company that builds mobile WiFi routers that can work anywhere, even in the harshest conditions; and Fine Acts, the international collective bringing together artists and activists to instigate social change.
In the fall of 2010, I started Aunt Bertha. Like many founders, I was Chief Cook and Bottle Washer. I was the only programmer, and the very first data entry person.
When auntbertha.com first went live, it only served the greater Austin area. Many late nights, I would sit alone in the tiny office I rented near my house and enter relevant programs I found into an Excel spreadsheet. Once I had a list that was big enough to get started, I wrote a basic Python script that could read a file once it was uploaded into a web form, and then I would run another script that put the data into our back-end database.
Erine Gray, Founder & CEO of Aunt Bertha, Photo Credit: Bella Kirchner
In the early days I added those programs myself, and since then every program added to our database was added by a real life human being.
More than eight years later, our company boasts a nationwide user base of over 1.6 million people, 150 customers, and 60 employees. We touch every Zip Code in the US with no fewer than 700 programs in a given county—we treat large cities, small towns, and rural areas equally.
That’s a Lot of Programs!
You’re correct, that is a lot! And we’re proud of the hard work it took to get here. We’re also proud of the fact that we did not cut corners. All of our programs have been entered by real humans, not bots. Some have thought: “My gosh, there’s no way you entered all of those programs, that’s a lot!” Is it really impossible? Let’s do a little math.
There are 260 workdays in a year. If an organization can add, say, 100 new programs in a day, that means that in one year it can add 26,000 programs. In just one year! Aunt Bertha’s been around for 8+ years. Now let’s magnify that a little—we currently have a Data Operations team of 20 people who are constantly entering programs. As you can see, the numbers add up pretty quickly.
Building a Team and a Culture
Once we started to grow our customer base we knew we wanted to grow our Austin-based Data Operations team. We were able to significantly invest in this team since 2016, and we now have around 20 folks who are all based in our Austin office. They’re a smart, fun, diverse group—and they’re the future leaders of our company. This team makes up the largest department in the company and is dedicated to researching information, entering new programs, and responding to changes. They shape the user experience through the programs they vet, the information they distill, and the logical organization of services they tag.
Photo Credit: Bella Kirchner
It would be far easier and cheaper for us to only rely on technology like some of our competitors are doing. But we’ve taken the harder path to build a team made of humans—not robots. We do this for a couple reasons: the quality is far superior, and these entry-level positions provide for us a way to find the next generation of talent to join other parts of our organization.
Growth Opportunities
When we decided to grow our Data Operations team, we wanted to have a way to:
Build and maintain a comprehensive, nationwide database of CBOs;
Provide a flexible work environment for people in Austin; and
Provide growth opportunities for rising stars in other areas of the company.
After several years, we’ve seen entry-level Data Quality Specialists learn the operation and grow to help other teams. Graduates of our Data Operations team are now Software Developers, Reporting Specialists, Business Analysts, and Community Engagement Managers.
A challenge of growing any organization is finding great people. What an excellent way to get to know each other—both for the employees—and the hiring managers. To sum this up, it just makes good business sense to design the organization this way.
Things to Consider
You’re likely reading this blog post because you’re interested in the work we’re doing, and odds are your mission is similar to ours. I share some of our history so you can see how our model and approach are fundamentally different from any software provider in our space. If you’re just beginning to evaluate search and referral platforms for your organization, we can provide some guideposts for you. We know it’s a process that can be mind boggling. There’s a lot of buzz out there right now—and some vendors have an incentive to make it sound more complex than it actually is.
Whether or not you do business with Aunt Bertha, I hope that our learnings from more than eight years of doing this work properly informs your decision in finding the right technology partner for your organization.
Who’s the audience?
One thing to look closely for in a Social Determinants of Health (SDoH) software vendor is whether end users, the people in need of social supports, seem to be their most important audience. This is usually not apparent by what the vendor says, but how they run their business. Decisions they’ve made in regards to their product, pricing model, privacy controls, and what they’re investing resources into can be extremely telling.
It’s important to build tools for Social Workers, Care Coordinators and others to help people in need. However, it’s also just as important to build software that allows people to help themselves. One question to ask a potential vendor:
Can people use your platform without having to log in?
Sometimes people in need aren’t ready for the world to know they’re having a hard time. We see hundreds of thousands of searches every month and people are looking for help for things that they don’t want others to know about. We take that very seriously, and so should the solution you choose. Another question to ask:
Why do you require people in need to log in?
As mentioned earlier, people want to figure out what’s available before they’re ready to identify themselves. We learned this lesson in our very first year of existence. And ever since 2011, logging in is optional on our platform. What we’ve learned is that people will explore anonymously. And when they’d like to connect, they will create an account when they’re ready.
Given that other systems do not work this way, and what we know about our users, it makes me wonder how much volume they are seeing on their platform. I’d suggest asking them how many users they have—a good amount of users is a great proxy for experience.
You may also find that the company you are evaluating bases their pricing on the number of accounts on their system. Not all of these vendors price this way, but some do.
What about 211?
When we first started, we heard about concerns from some 211 call centers that feared that an easy-to-use online search platform like auntbertha.com was a threat to their call center model. We don’t see it that way.
My view is that if people find what they need on auntbertha.com and can do so in the privacy of their own home—what a great thing. And if self-service search on auntbertha.com drives down the number of calls to a 211 call center, that frees up call center staff to do other things that can help people in more meaningful ways—like getting them enrolled in health insurance.
In some cities, this is happening already as United Ways and other organizations are looking for ways to go deeper. For example, instead of telling a caller where the nearest shelter is, agents can help someone fill out an application for an affordable housing program.
“Pay us and we’ll build it!”
If you ever hear this uttered by a potential vendor, take caution. Building a network of participating resource providers and governments is difficult and takes a long time (we’ve been in it longer than anybody). It requires hundreds of organizations to agree to use a software platform. It also requires a large group of people to keep this information current. You may have received proposals from vendors to include a license fee with add-ons like “Network Builders,” or “Consultants.” Simply put, they’re trying to get you to pay for something they already should have invested in.
To keep it clean, and to keep our mission first and foremost, we don’t charge our customers for our data acquisition process and maintenance.
Scraping is Never Okay
Some of our competitors try and take shortcuts by scraping auntbertha.com. We know this because we evaluate our logs and are able to identify these bots as scrapers (see below for an example).
Searches to Utah program listings on auntbertha.com. We experienced malicious scraping activity of our Utah-based records during the evaluation period for a large healthcare system in the state recently.
Scraping is when a computer program pulls valuable content from a website. Scrapers reproduce the unauthorized content under the pretense that it’s original. When our competitors do this, it tells us a lot about what they’re doing. In the example above, we believe that this activity coincided with an in-person demonstration a competitor had with a large health system last fall.
If you are evaluating a vendor and you’re interested in finding out whether or not they may have scraped auntbertha.com in preparation for your demo, please just reach out. We’re happy to share our logs with you. You may not pick us, which is okay, but you may find it helpful to know that the vendor you select strives towards integrity (and doesn’t scrape).
Meet the Team
As you select a partner for your project, I’d encourage you to ask to meet their Data Operations team if possible. If you’re interested in meeting Aunt Bertha’s Data Operations team, come visit Austin as part of your evaluation process. A quick plane trip may be worth it—and also, just so you know, Austin’s a great place to catch some live music and some great food (we won’t tell your boss).
In Conclusion
One of our leading taglines in the early days was that “Aunt Bertha picks up where Uncle Sam leaves off.” This couldn’t be more true today, quite literally. We’ve seen an uptick in our search volumes as a result of the recent government shutdown.
We’re inspired by the work you do in your community, whether it be treating patients, connecting people in need to social supports, running a local nonprofit, providing social services, helping your clients lead healthy lives, and so much more. You make up the backbone of your community and we’d like to support you in any way that we can.
Here’s our favorite quote—we put it in all of our job postings.
Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.
Margaret Mead
We’d be excited to have you join our network, which makes you part of our “small group of committed citizens.”
As healthcare costs continue to rise1, health insurance companies, including The Centers for Medicare and Medicaid Services (CMS), are thinking about ways to incorporate social needs into their reimbursement models. Studies have shown that addressing these needs leads to improved health outcomes which, in turn, lowers the cost it takes to care for patients2. CMS is strongly committed to this idea; according to the Secretary of Health and Human Services, Alex M. Azar II: “Just like how every patient is different in healthcare, every person has unique social service needs—and we are intent on designing models that connect them to the services they need, rather than offering a one-size-fits-all approach.” 3
As we wrote about in Part One of this series, one of the most significant moves towards changing these reimbursement models to include social needs was the passage of The CHRONIC (Creating High-quality Results and Outcomes Necessary to Improve Chronic) Care Act, which specifically affects Medicare Advantage (MA) plans. Previously, supplemental benefits reimbursed by CMS for chronically ill beneficiaries had to be health-related services used to “prevent, cure or diminish an illness or injury.” The CHRONIC Care Act changed that definition to cover services that provide “a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee and may not be limited to being primarily health related benefits.”4 This is a significant move in the industry — reimbursement for non-health (i.e., social needs) services.
Many questions have arisen about how to put this into practice and one of the main concerns health plans have had relates to CMS uniformity requirements for Medicare Advantage plans. These requirements stipulate that beneficiaries residing in the same service area of the MA plan must be offered “a uniform premium, with uniform benefits and level of cost-sharing throughout the plan’s service area, or segment of service area.”5 This has been interpreted to mean that, per plan, whatever is offered to one beneficiary must also be offered to all beneficiaries in the service area. The one-size-fits-all nature of old uniformity requirements was a major hurdle for payers to reimburse services that were not purely medical in nature. The fear was that any beneficiary could claim a need for a social need service, potentially costing the health plan a good deal of money.
However, in April 2018, CMS released clarification around the uniformity rule for Medicare Advantage plans.6 They defined areas for flexibility with the MA uniformity requirements, writing, “We have determined that providing access to services (or specific cost sharing for services or items) that are tied to health status or disease state in a manner that ensures that similarly situated individuals are treated uniformly is consistent with the uniformity requirement in the Medicare Advantage (MA) regulations.” This is a reinterpretation of the rule in that it allows for flexibility specifically related to “health status or disease state.” Starting in 2020, rather than having to offer certain supplemental benefits to ALL members, MA plans can offer them uniformly to the members who meet the specific medical criteria defined by the MA plan.
Insurance companies must design these benefits using “medical criteria that are objective and measurable.”6 Beneficiaries will also be required to be diagnosed with the condition(s) by a plan provider. In order to ensure that the uniformity requirements are fair and do not discriminate, CMS will be reviewing all benefit design plans.
Before the CHRONIC Care Act, this flexibility would have been reserved solely for supplemental medical-related benefits (e.g., tobacco cessation classes for COPD patients, non-emergent transportation for heart failure patients). However, with the passage of the CHRONIC Care Act, those supplemental benefits now include non-medical services. To take advantage of both the new reimbursement models and the reinterpretation of uniformity rules, Medicare Advantage plans should design benefit packages that tie those non-medical benefits to “health status of disease state.” What might this look like?
For asthmatics, provide an air conditioner benefit;
For patients with COPD of other lung diseases, provide a mold removal benefit;
For patients with amputation caused by diabetes, provide a home modification benefit; or
For patients with dementia, provide a home safety benefit.
The list could go on and on. Over time, we predict that insurance plans will start to provide more social need benefits for patients. While there are still plenty of questions that need to be answered, this is an exciting start.
4Willink, A., & DuGoff, E. H. (2018). Integrating medical and nonmedical services – The promise and pitfalls of the CHRONIC care act. New England Journal of Medicine, 378(23), 2153-2155. DOI: 10.1056/NEJMp1803292
Healthcare costs in the United States are the highest in the world and are continuing to rise. On average, the US spends $10,000+ per person on healthcare, 31% higher than the next highest-paying country1. Because of this crisis, insurance companies, as well as Medicare and Medicaid Programs, are moving away from the traditional reimbursement model that pays for volume of services towards one that focuses on value — improving a patient’s health while reducing the cost of care and increasing satisfaction for all participants. The long-standing volume model pays based on number and type of services provided, regardless of patients’ health outcomes, quality of care, or cost to the system. With the new value model, doctors and healthcare organizations have financial incentives to keep patients healthier and control costs, which can be done by providing high-quality care and coordinating better social care. To boil it all down — keep patients healthier and you get paid more.
How Do You Keep Patients Healthier?
For many decades, the healthcare industry has focused on using clinical medical care (e.g., office visits, medications, hospitalizations) to improve the health of their patients. However, research shows that much of a person’s health is actually not determined by clinical healthcare, but by a person’s individual behaviors and social & environmental factors, often referred to as social determinants of health2.
Ignoring and underinvesting in these factors explains to some degree why health indicators in the US lag behind so many other countries3. When you don’t take care of a patient’s basic needs, their overall health suffers. The realization that addressing these factors has major impacts on both health outcomes and the cost of care has led to changes in both care and reimbursement models.
Can Legislation Help?
One of the most significant moves towards changing these reimbursement models was the passage of an act that affects Medicare Advantage plans. These plans are offered by private insurance companies to Medicare-eligible individuals and offer additional benefits beyond traditional Medicare, such as dental, vision, and hearing coverage. The CHRONIC (Creating High-quality Results and Outcomes Necessary to Improve Chronic) Care Act, passed by Congress on February 9, 2018, changes the way these supplemental benefits provided through Medicare Advantage plans are defined4. Previously, supplemental benefits reimbursed by CMS (The Centers for Medicaid & Medicare Services) for chronically ill beneficiaries had to be health-related services used to “prevent, cure or diminish an illness or injury.” The CHRONIC Care Act changes that definition to cover services that provide “a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee and may not be limited to being primarily health related benefits.” 5 This is a significant move in the industry — reimbursement for non-health services.
What Might “Non-Medical” Services Include?
Looking back at the wording, there is a lot of room for interpretation. The act simply states that the service either maintains or improves a patient’s health and does not need to be completely health related. Some examples of these services are:
Home modifications, such as ramps, grab bars, and support stalls;
Air conditioners for asthmatic patients;
Mold removal for emphysema patients;
Pest control for homebound patients;
Food delivery for recently discharged or homebound patients; and
Transportation to medical and social services appointments.
All of these services aim to address the social, environmental, and/or behavioral factors that impact a patient’s health outcomes.
How Can Patients’ Needs be Managed?
As the industry moves towards value (lower costs & better care), health insurance plans and healthcare organizations have realized there is a need for more intensive follow-up, coordination, and care management after the patient leaves the doctor’s office.6 Health plans and providers are hiring nurses and case managers to help coordinate the various elements that are involved in a patient’s care, while keeping an eye on managing costs, in order to lead to better outcomes.7, 8
According to the Bureau of Labor statistics, the number of care managers is expected to increase by 20 percent between 2016 and 2026.9 Currently care managers focus mostly on medical care and services, but as reimbursement models change, these are the workers who will help bridge the gap between medical and non-medical care. In addition to coordinating medical care, they’ll start working with non-profit social service providers, government agencies, and even private vendors that provide services that can be purchased on a members’ behalf. There are going to be challenges in this effort to connect patients to these services and vendors, such as:
How does the healthcare provider (be it nurse, physician, care manager, social worker) know what services are covered?
How do they know what resources are available and how do they vet those resources to ensure they are getting good value (reasonable cost and high quality)?
How do they know the patient has received the service?
How do they bill the insurance company for the service since the service has been provided outside of their care?
The Changing Landscape and the Role of Health Insurance Plans
The CHRONIC Care Act only impacts reimbursement for non-medical services provided by Medicare Advantage plans, but what about the rest of the health insurance industry? Will this trend spill over to private plans? We can see that there is growing interest both from patients and payers in these new types of plans, as evidenced by the rapid growth in Medicare Advantage enrollment, which has continued to increase over the last decade (see chart).10
Why does this uptick in enrollment in Medicare Advantage plans matter in the larger scheme of the health insurance industry and value-based reimbursement? When CMS rolls out new initiatives, the private insurance industry tends to follow. This can be seen in the recent years with the overall adoption of value-based programs by private plans, following CMS’s lead.11 As CMS makes policy changes that allow for reimbursement of non-medical services, private plans are likely to start making similar changes.
When this shift happens, this means that health plans will be at the core of fulfilling non-medical needs to patients, by either acting as the facilitator between patient and service vendor or by reimbursing healthcare organizations to do the same.
Conclusion
The healthcare reimbursement landscape is changing with the realization that addressing social, environmental, and behavioral needs are key to improving health outcomes and lowering healthcare costs. Insurance companies, starting with Medicare Advantage plans, will soon be financially incented to either 1) coordinate the connection between patients and these services directly or 2) reimburse those healthcare organizations that are spending more time with patients to help them get their basic needs met.
This is all based on a bet. The bet is that if people’s basic needs are met, they’ll be healthier. If people are healthier, healthcare providers will make more money because health plans are incentivizing them to go the extra mile. If people are healthier, they’re less likely to strain resources or end up in the hospital, racking up huge medical costs.
If healthcare organizations that are talking to these patients in person every day are going the extra mile to connect with patients on a human level, and to connect patients to social care services too, like food delivery programs, or home modifications, then those healthcare organizations should realize cost savings (or bonuses). If they do realize these savings, they’ll have more money to hire case managers and care coordinators. With more case managers and care coordinators on staff there is a double bottom line effect: they make more money by helping people live healthier lives. A win for the patient and a win for the healthcare organization.
Sound a little utopian? It probably is. But we can strive for Utopia. It’s a lovely place.
3Woolf, S. H., and L. Y. Aron. 2013. The US health disadvantage relative to other high-income countries: Findings from a National Research Council/Institute of Medicine report. Journal of the American Medical Association 309(8):771-772.
5Willink, A., & DuGoff, E. H. (2018). Integrating medical and nonmedical services – The promise and pitfalls of the CHRONIC care act. New England Journal of Medicine, 378(23), 2153-2155. DOI: 10.1056/NEJMp1803292
We always begin team meetings at Aunt Bertha with our mission statement — “To connect all people in need and the programs that serve them (with dignity and ease).” As part of that mission, we strive to build products that help Community Based Organizations (providers of socials services) streamline their processes, work together, and most importantly, save time so they can better meet the needs of the people they serve.
We consistently hear from Program Administrators that they lack insight into their colleagues’ schedules and consequently double (or triple) book intake appointments. This leaves professionals at these organizations overworked and the people they help, confused. We believe there is a better way.
The Appointment Scheduling tool offers a way for claimed Community Based Organizations (CBOs) listed on Aunt Bertha to easily create, schedule, and manage appointments with people in need of services as a key step in their intake process. Managing appointments can be stressful (on both sides), time consuming, and expensive. Our tool is free and simple to use.
CBOs will save time, resources, and can:
benefit from a full history of their touch points with a person in need, including appointments, all on one platform;
easily show availability for appointments at all program locations;
book appointments on behalf of people in need, or allow them to book for themselves;
schedule appointments for colleagues;
save calendar invites to colleagues’ work calendars
People In need get the dignity of an immediate response and can:
easily see when and where their appointment is;
see what documents or identification they’ll need to bring to their appointment;
get reminders via email or text message so they never miss an important appointment.
Interested in adding appointment scheduling to your program listings on Aunt Bertha?We’re so glad! Just click below and our team will set you up.Reminder: Appointment Scheduling is a completely free feature — all you have to do is claim your program listing.
Caritas of Austin, a nonprofit organization focused on ending homelessness in Austin TX, works tirelessly to deliver hot lunches to people in need. Starting at 9:00am each morning, a dedicated team of volunteers works under the guidance of Jennifer Mattson (Head Chef) and Brandon Harrison (Food Services Assistant), endearingly referred to as “Sous Chef” by Jennifer. They prep the Community Kitchen to serve over 250 meals daily. For the past year and a half, Mattson and Harrison have built a well oiled machine that serves hot, nutritious meals to anyone who walks through their doors (Monday thru Friday, 11:00am-12:30pm). That’s right — anyone.
For all you planners out there, prepare to have your minds blown. The menu for each meal is determined by donations received at Caritas of Austin; yet, each morning, Mattson and Harrison walk into the kitchen unsure of what donations have come in the night before. That means their lunches (prepared for over 300 people) are planned, created, and prepped in a matter of hours. How’s that for thinking on your toes?
Last month, the Aunt Bertha team had the privilege of volunteering at the Caritas of Austin Community Kitchen for a day, and were humbled and in awe of the team’s dedication and fine-tuned process. Alongside Mattson, Harrison, and a handful of long time volunteers, we served entrees, salad, fresh fruit, hot rolls, and washed dishes. Every single person that walked through the door was served — a standard that Mattson and Harrison strive for every day.
Caritas of Austin’s oft-mispronounced name (pronounced “CARE – it – ahs”) means love or charity in Latin. Although their first priority is working with people to establish stable housing, many don’t realize they offer comprehensive wrap-around services including: food services (enter, Community Kitchen), education classes, job placement, and veterans assistance.
According to the Ending Community Homelessness Coalition, 2,036 persons were homeless in Austin as of January 2017 — an 11% increase from 2015. That’s why these services are needed now more than ever in the Greater Austin community.
If you’re in the Austin area and are interested in volunteering with Caritas of Austin, please sign up on their website.
To find other community kitchens or meals in your area, please go to Aunt Bertha and select the “Food” category to search for programs serving your zip code.
By Meredith Englehart, Community Engagement Manager
One of our mottos here at Aunt Bertha is a quote by Margaret Mead:
“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”
In that spirit and in honor of the New Year, we’re highlighting six of our direct service providers’ powerful missions and showcasing how they were there for their communities in 2017. These are the people whose work fuels ours, and we hope their stories inspire you as we begin 2018 with this special series.
“Most people don’t realize that horses are effective therapy animals beyond therapeutic riding, and are not aware of the vast differences between therapeutic riding and equine assisted psychotherapy.” —Emily Williams, Project Horse Empowerment Center (Purcellville, VA)
Project Horse Empowerment Center connects people in need of renewed hope and confidence with rehabilitated rescue horses, through innovative experiential learning programs and therapy services. The organization is dedicated to improving the quality of life for both horses and humans, creating a unique community of mutual healing and benefit.
It all started with a rescue horse named Reeses. Reeses used to be a competitive athlete but her career ended with a dangerous fall. For reasons unknown to Project Horse, Reeses did not receive proper medical care and rehabilitation, leaving her physically disabled and no longer able to be ridden. Reeses was then sent to a breeding farm to be a broodmare, but when that didn’t produce results, she was deemed useless, turned out into a field, and forgotten.
Reeses was frightened and in very poor condition when the organization’s founder and Executive Director, Darcy Woessner, stumbled upon her. Reeses was not in sale condition and would never again be a riding horse, which left her in a dangerous situation. Woessner simply could not leave the horse there, so she purchased Reeses for a small price and began the slow rehabilitation process.
Reeses soon revealed an extraordinary ability to connect deeply with others, especially children and women. It quickly became apparent that, although Reeses could no longer be ridden, she had so much to offer through her quiet wisdom and nurturing support. Since no other programs existed where non-rideable horses could share their skills to help people, Reeses and Darcy founded Project Horse — a place where non-riding horses and humans needing support partner to find hope and mutual healing.
Over the past decade, Reeses and her herd have rescued, supported, and helped over 1,000 individuals of all ages and a wide variety of challenges.
“We recently moved to a new location that is more accessible, so we have been expanding our programming to include groups for veterans, the elderly, programs through Loudoun County Parks and Recreation, as well as servicing a growing number of individual therapy clients,” according to Williams.
A highlight for the organization in 2017? Being only one of eighteen nonprofits in the United States to receive a grant from VetsAid Foundation. With the grant from VetsAid and a matching corporate sponsorship from Lockheed Martin, Project Horse was able to launch their Warrior HerdTM initiative.
Warrior HerdTM is a free monthly program that focuses on strengthening connections between veterans and their families and enhancing resiliency. Warrior HerdTM offers workshops for couples, individuals, and families. During the summer of 2018, Project Horse will host a Warrior HerdTM Family Day for all members of the military (active, inactive, veterans, reservists) and their families. They will also host a week-long summer camp for children who have lost a parent in combat.
Project Horse has seen demand for individual therapy services nearly double this past year.
One of our mottos here at Aunt Bertha is a quote by Margaret Mead:
“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”
In that spirit and in honor of the New Year, we’re highlighting six of our direct service providers’ powerful missions and showcasing how they were there for their communities in 2017. These are the people whose work fuels ours, and we hope their stories inspire you as we begin 2018 with this special series.
“Most Americans are one to two paychecks from living on the street. It can happen to anyone.” —Roz Palmer, The Kitchen (Springfield, MO)
On any given night in 2017, 554,000 people were homeless in the United States. That’s just shy of the entire population of Springfield, MO, where The Kitchen’s mission is to prevent and end homelessness in the communities they serve by providing housing and stabilizing services with dignity and compassion.
“We’re trying to let people know that they are worthy of the help. Youth, or those living on the street sometimes don’t feel they’re worth the services, so our biggest challenge is just getting them in the door. We want people to know we work with everyone — from infants to the elderly. If you’re homeless, we work with you. We have youth programs, programs for at-risk and homeless veterans, programs for the chronically homeless, families, and the working poor,” said Palmer.
In 2017, The Kitchen housed more than 600 individuals. A third of those individuals were children under the age of 18.
One of those people was Belinda. Belinda was a registered Medical Assistant, but due to a brain injury, she was placed on leave from her job. Her Family & Medical Leave (FMLA) ran out, but Belinda still wasn’t cleared to work. After going through her savings, Belinda had to decide between her medication and a stable home. The Kitchen was able to provide Belinda a place to stay while helping her navigate through and apply for, disability benefits. She has since exited the program and is living on her own in one of The Kitchen’s affordable housing communities.
“We have a Housing First philosophy. We want to place someone in a home, then figure out the factors that may be leading to their homelessness. For some it may mean education, for some, sobriety. Our goal is that by the time they exit, they can do whatever “it” is on their own.”
One of our mottos here at Aunt Bertha is a quote by Margaret Mead:
“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”
In that spirit and in honor of the New Year, we’re highlighting six of our direct service providers’ powerful missions and showcasing how they were there for their communities in 2017. These are the people whose work fuels ours, and we hope their stories inspire you as we begin 2018 with this special series.
“The ultimate objective — beyond the measurable goals — is to help participants rebuild their sense of self-worth, dignity, and self-confidence.” —Austin Morreale, NeighborCorps Re-Entry Services (Highland Park, NJ)
Created by the youth pastor at the Reformed Church of Highland Park, NeighborCorps Re-Entry Services’ mission is to work with individuals who are/were incarcerated in Middlesex County Adult Correctional Center (MCACC), helping them successfully transition back to their communities, thereby helping lower the rate of recidivism.
“In addition to the NeighborCorps staff, we utilize volunteers (called Navigators) to work with our participants. They both provide support and guidance to participants and their supportive relatives/friends along their re-entry journey, connecting them with community resources and helping them in the areas of gainful employment, personal development, and social integration,” according to Morreale.
The two biggest challenges NeighborCorps faces in their work: connecting participants to housing and employment. As Morreale explained, “unless a participant has supportive friends or family in the area with whom they can stay, it is incredibly difficult to find housing for participants given the lack of shelters in the area and the long waiting lists for those shelters.”
Additionally, “finding employers who will hire individuals with criminal histories is difficult, and when such an employer is found, securing a livable wage can be challenging. A large percentage of our participants are dependent on public transportation, but often the employers who hire ex-offenders aren’t easily accessible via public transportation. Or, if they are accessible, the participants find the cost of public transportation to their place of employment quickly eats up their hourly wage.”
After adding more staff members in 2017, Morreale said, “I think one of the things I’m proudest of [this year] is the steps we’ve taken on initiatives outside of the relationships with participants.”
One such initiative, a backpack drive for NeighborCorps participants, will extend to all individuals in the jail if successful.
As Morreale explained, “when an individual is released from MCACC, the belongings they had with them when they arrived at the jail are given back to them in a clear plastic bag. If that individual doesn’t have someone picking them up from jail on their release day, then they have to walk along Route 130 with the plastic bag clearly signaling they’ve just left incarceration to anyone who passes them. The backpack drive is a way to remove the stigma of the plastic bag for recently released individuals and hopefully give them a little bit of their dignity back as they take their first steps (literally) in their re-entry journey.”
Educate yourself about criminal justice and re-entry issues and how their effects have an impact that reaches far beyond just the incarcerated individual.
One of our mottos here at Aunt Bertha is a quote by Margaret Mead:
“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”
In that spirit and in honor of the New Year, we’re highlighting six of our direct service providers’ powerful missions and showcasing how they were there for their communities in 2017. These are the people whose work fuels ours, and we hope their stories inspire you as we begin 2018 with this special series.
“Overall, our biggest wins are our client victories — numerous cases where the work of Her Justice, our network of volunteer lawyers, and the resilience of our clients have resulted in positive outcomes and life altering consequences for the women we serve.” —Sharon Rainey, Her Justice (New York City, NY)
In the current political climate, the threat of deportation of undocumented immigrants has spread panic in vulnerable communities. Many immigrants are afraid to reach out for help or engage with the courts or law enforcement. Her Justice stands with women living in poverty in New York City by recruiting and mentoring volunteer lawyers to provide free legal help and by addressing individual and systemic legal barriers. Her Justice fills a unique gap in NYC — providing legal assistance to women living in poverty facing high-stakes legal needs but cannot get help elsewhere.
We serve women in all five boroughs in NYC, with the majority of our clients residing in Queens. Brooklyn is a close second. “More than one out of every four Her Justice clients cannot access the legal system without an interpreter,” said Rainey. Sixty four percent of Her Justice clients are mothers and 80% are survivors of domestic violence.
In 2017, their goal could be summed up simply: Expand access to the legal system in family, matrimonial, and immigration matters for more women living in poverty in NYC. Accomplishing this, however, was no simple task. To reach more women in need, Her Justice ) relaunched their live Legal Help Line; 2) increased outreach into communities to provide information on immigrant rights under the Trump administration; 3) celebrated the one-year anniversary of their Urgent Legal Care Project, where women with high-stakes legal needs received immediate representation; and 4) launched an innovative medical-legal partnership with NYU Langone Hospital to help medical professionals identify victims of intimate partner violence.
All in all, nearly 8,000 women and children living in poverty received free legal help thanks to Her Justice. The organization’s Pro Bono First model, where volunteer attorneys are trained and mentored to provide free legal help in family, matrimonial, and immigration matters to clients efficiently “brings the power of the private bar to serve some of the City’s most vulnerable women and children,” said Rainey.
One of our mottos here at Aunt Bertha is a quote by Margaret Mead:
“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”
In that spirit and in honor of the New Year, we’re highlighting six of our direct service providers’ powerful missions and showcasing how they were there for their communities in 2017. These are the people whose work fuels ours, and we hope their stories inspire you as we begin 2018 with this special series.
“In 2018, we plan to complete over 200 Harvey homes, maybe even more, but we’re still going to continue to repair homes that were not impacted by Harvey, because we have people on our waiting list and we’re not going to let them go. We’re here for the long haul and will continue to take care of the populations we always have and serve the neighbors we always have.” —Christine Holland, Rebuilding Together Houston (Houston, TX)
In late August 2017, Hurricane Harvey devastated Texas’ east coast. In the Houston metropolitan area specifically, widespread flooding damaged property and took lives. Prior to the storm, Rebuilding Together Houston was already providing no-cost home repair to low-income senior citizens, U.S. military veterans, and people with disabilities. They focused predominantly on exteriors of homes to replace siding, ensure doors and windows worked properly, control water leaks, and improve accessibility by adding ramps/railing.
“When Harvey happened, we knew that we needed to widen our lane. Normally, we wouldn’t get involved in repairing a home until it was pretty much put back together and we would work on the outside, but we realized that that just wasn’t going to cut it here,” said Holland.
“It’s been very difficult for anyone impacted by Harvey to begin the process of recovery. For vulnerable populations, even more so. Very quickly, we got together to plan our response. We knew we needed to help our homeowners in a different kind of way, so we started our “Home After Harvey” program. We’re still focusing on the same neighbors that we were before, but now we’re working with contractors and volunteer teams to return the interior of the homes impacted by Harvey to a safe and livable condition.”
The New Orleans affiliate of Rebuilding Together came to Houston following the storm and took several days to teach the Houston staff how to muck and gut and take the house down to the studs. Now though, Rebuilding Together Houston is starting to move into the recovery phase, putting the homes back together. In 2017, the non-profit began recovery work in more than 25 homes, beginning to return them to a safe and livable condition. That number is estimated to be 200 or more in 2018.
When asked what the organization’s biggest “win” in 2017 was, Ms. Holland instantly said, “Neighbors helping neighbors all over this city, and coming from everywhere. There’s been an incredible outpouring of resources, funds, and building materials that gave our organization the confidence to jump in and help right away without worrying how we were going to fund it.”
She added, “There are thousands and thousands of Houstonians who have been impacted by Harvey and it’s going to take us years to get this done. Rebuilding Together Houston expects to be in the thick of this for four or five years. I think what’s going to get harder in the years ahead is the awareness of what’s happening here. Now, people are very engaged. Two years from now, we hope that’s the same story.”
How You Can Help
Volunteer. Skilled volunteers are needed for carpentry, drywall, and painting, but Rebuilding Together Houston staff will also teach skills to anyone who is willing.
One of our mottos here at Aunt Bertha is a quote by Margaret Mead:
“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”
In that spirit and in honor of the New Year, we’re highlighting six of our direct service providers’ powerful missions and showcasing how they were there for their communities in 2017. These are the people whose work fuels ours, and we hope their stories inspire you as we begin 2018 with this special series.
BOSS believes that people affected by crisis have invaluable knowledge and insight about what works to change lives, so we hire from our target population; at least 40% of BOSS staff have personal experience with homelessness, disabilities, substance abuse or criminal justice systems.” —Sonja Fitz, Building Opportunities for Self-Sufficiency (Berkeley, CA)
Building Opportunities for Self-Sufficiency (BOSS)’s mission is to help those who are mentally ill, struggling with substance abuse, formerly incarcerated, or otherwise homeless achieve health and self-sufficiency, and to fight against the root causes of poverty and homelessness.
“We serve the very poor — people with one or more barriers to self-sufficiency, such as former incarceration, mental illness, substance abuse issues, inter-generational poverty, or lack of job skills and/or literacy. There are more people on the streets, more homeless encampments, and little-to-no housing that is affordable on very low incomes. Also, there are hundreds of formerly incarcerated individuals being released to communities in California due to AB 109 and they need help finding jobs and connecting with positive social supports quickly, before they can recidivate,” said Fitz.
One of the ways BOSS tackled these issues in 2017 was by expanding their workforce development program (the Career Training and Employment Center) and partnering with employers who were willing to take a risk on job seekers who needed a second chance. In October, the organization celebrated 50 graduates, all employed full-time.
How You Can Help
Contact your elected officials (especially if you live in California) and tell them that affordable housing for everyone matters to you.
