Medical-Legal Partnership in Action
Monday, August 17, 2015
Resolving the Social Conditions of Health by Embedding Civil Legal Aid Lawyers in the Health Center
Ellen Lawton, The National Center for Medical-Legal Partnership
Annette Quayle, Seattle Children's Hospital
Dr. Brian Johnston, Harborview Hospital
Sharena Hagins, The National Center for Medical-Legal Partnership
Editor’s note: Medical-Legal Partnership will be presenting on this topic at our Fall Primary Care Conference in October
Attorney Scott Crain and Chief of Pediatrics Brian Johnston meet with a family at the Washington Medical-Legal Partnership. Credit: Bill Stickney
“Sunny” is a teenager with complex health needs requiring 16 hours of home nursing care every day. Without warning, her mother received notice that Sunny’s home care would be significantly reduced, even though her health had not improved. In a panic, Sunny’s mother contacted the girl’s primary care physician at Odessa Brown Children’s Clinic (OBCC), who referred the family to the Medical-Legal Partnership (MLP) clinic, where lawyers work as a regular part of the health care team. The MLP team appealed the case and won, stabilizing Sunny’s home care. Sunny was unable to move by herself, and her single mother was her only family caregiver. Without MLP’s intervention, Sunny would have had to be hospitalized.
Sunny’s nurse at OBCC was clear about the impact: “The nursing care at home allowed providers at OBCC to work with a healthcare professional, providing care over the phone, preventing ED visits and hospital stays and instead bringing the child to OBCC or taking care of the health issue at home.”
The successful resolution of Sunny’s case relied on the consistent training and consultation practice between the clinical and legal teams. It also set the stage for a policy discussion with the state agency that administers home nursing services to ensure no other families were affected like Sunny’s.
A lawyer as part of the health care team? It's not as strange as it sounds. Many of the social conditions that impede health, such as housing, education, employment, food and insurance, can be traced to laws unfairly applied or under-enforced, often leading to the improper denial of services and benefits designed to help vulnerable people. There are eight thousand civil legal aid lawyers in the U.S., and much of their work is directly related to improving health. They ensure access to food, health benefits and insurance for their clients. By fighting for better housing conditions and preventing evictions, they help create healthier physical environments. They help keep families safe and stable by establishing guardianships. In Seattle, for example, the Northwest Justice Project is the leading civil legal aid provider in the region, bolstered by resources from law schools, pro bono volunteers and other agencies. But the resources are thin, and the need is great. National data say that every low-income person has between two and five unmet legal needs.
Considering that landscape of high demand and low resources, the medical-legal partnership approach leverages existing community resources to better coordinate services and interventions that address the social determinants of health. In 2015, nearly 280 hospitals and health centers have partnered with civil legal aid agencies to screen for and remedy the social problems that affect the health of vulnerable people and communities. Many more are in the planning stages. In late 2014, HRSA recognized civil legal aid as an enabling service and awarded the National Center for Medical-Legal Partnership a National Cooperative Agreement to provide training and technical assistance to the health center field seeking to partner with the civil legal aid community.
The impact of medical-legal partnership is multifaceted, from small pilot studies that demonstrate health impacts, to studies that highlight the efficiency and financial impact of embedding civil legal aid services. For example, since 2003, Community Legal Aid and UMass Memorial Medical Center have had a medical-legal partnership in which pediatric primary care staff connect patients with civil legal aid services. In 2014, the partners began using the program as a vehicle specifically to address housing conditions that can trigger asthma attacks.
A July Health Affairs blog details how the small pilot program had attorneys training community health workers to screen families for housing-related civil legal problems—in particular for substandard housing conditions and threats of eviction—during home visits. The community health workers then provided asthma management education and a healthy home assessment, addressing both medication management and housing conditions simultaneously. The community health workers were able to initiate code enforcement actions and refer families who needed legal counsel in addressing housing conditions to the medical–legal partnership attorney.
The pilot served 30 children and gave community health workers, UMass Memorial providers, and civil legal aid partners an opportunity to build strong relationships and hone service delivery from referral mechanisms to case feedback loops. After the pilot concluded, the partners received a grant from the Massachusetts Prevention and Wellness Trust Fund, scaling the asthma home visit project from a single neighborhood intervention to a city-wide approach.
The grant project brought in new partners, including the City of Worcester Division of Public Health and Worcester’s two federally qualified community health centers — Edward M. Kennedy Community Health Center and Family Health Center of Worcester. Together, these centers provide a medical home to many of the low-income asthmatic children in Worcester. The target population of the new grant is the approximately 700 low-income children in Worcester who are listed on the asthma registries of participating clinical sites.
Health centers are natural partners for civil legal aid agencies; they share a community-based mission and frequently have overlapping patients/clients. Given the healthcare transformation at hand and the growing demand for interventions that target social determinants, the National Center for Medical-Legal Partnership is pleased to join NWRPCA in October with colleagues from the Washington Medical-Legal Partnership to explain what a medical-legal partnership looks like in practice and how to build one from the ground up.
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