Monday, April 21, 2014

The Legal Aid Community Needs its Own Affordable Care Act

By Ellen Lawton, Co-Principal Investigator, National Center for Medical-Legal Partnership

Whether you agree with the specific strategies of the Affordable Care Act (ACA) or not, it is a call to action for the healthcare community.  It acknowledges that health has not always been at the center of how healthcare approaches either its service delivery or its business model.  The ACA prioritizes prevention and asks the healthcare community to re-examine every aspect of how it trains professionals, partners with communities and delivers care.  It sounds to me like the kind of call to arms that the legal community needs.

I have written before about the invisibility of civil legal aid, and that the powerhouse skillset of lawyers can be a secret weapon to promote health.  But to reach its potential as a force for good, the civil legal aid community needs to rethink its approach to the civil legal aid crisis in America.  As we have learned in the recent healthcare debate, more funds without reform is not necessarily the answer.  Is the civil legal aid community radically underfunded given its potential and importance to ensure fairness for people and communities and systems?  Absolutely.  But have we examined our professional priorities and delivery systems to synchronize with a 21st century approach to problem-solving?  Uh – no, we haven’t.

Like the healthcare sector’s struggle to move patients from expensive emergency room visits to better, cheaper upstream care, it’s time for the civil legal aid community to think about prevention strategies for the people and communities it serves.  The civil legal aid office that allocates its scarce, sacred resources to the hardy individuals and families who make it through the intake process is missing the opportunity to align its service provision upstream in a community setting, using public health data to reach more vulnerable people before their legal problems turns into legal crises. 

This requires a wholesale shift of the conception of legal work and how it is valued internally in the civil legal aid community.  Litigation, like its healthcare equivalent, surgery, will always have a place in the armament of legal tools.  But like the healthcare system overhaul that has brought thousands of patient navigators and community health workers front and center into the healthcare team, it is time for the civil legal aid community to re-conceptualize the roles of those attorneys and paralegals on the front-lines, so that they can  prevent, rather than react to, civil legal problems.  It’s not going to be easy.  Look how hard the healthcare profession has worked – and is still working – to build the army of primary care physicians and nurse practitioners funded under the ACA to take care of the millions of Americans who will now have access to primary care.

Which brings me to funding.  How can chronically underfunded legal aid agencies besieged with demand take a deep breath and realign their work towards prevention?  Many are treading water, jockeying for scarce funds while continuing to churn out a myriad of critical advocacy successes against the odds.  A realignment of this scale requires investment.  When dozens of families are in court every day facing eviction, it takes a leap of faith – not to mention leadership and the support of funding partners – to reallocate those resources to a “primary care” legal team further upstream, tasked with preventing those families from ever reaching the courthouse.  Some legal aid agencies are bravely innovating preventive strategies.  But they need help to scale them, and they need the commitment of their peers and allies in the legal community.  Indeed, to move toward prevention, we in the civil legal aid community need our own version of the ACA.  We need the incentive to change, and we need the resources to develop the roadmap for change.  Because when the civil legal aid community succeeds at becoming visible, we will need a better strategy to meet the sea of civil legal needs that we know is out there.

We won’t get it all right the first time.  But the lesson we in the legal community need to take from our healthcare partners and the ACA is that business as usual is not going to cut it.

Friday, March 28, 2014

Lessons from the Field Part III: Involve the Whole Care Team

In honor of the launch of the new Medical-Legal Partnership Toolkit, we asked longtime MLP practitioners to write blog posts answering the question, ""If you were starting your MLP for the first time today, what would you do differently?"  This post is the third in that series.

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By The Community Advocacy Program Team (Cleveland, OH)*
Jaime Garay, LISW, Social Worker, The MetroHealth System
E. Harry Walker, MD, Exec. Dir. of Primary Care & Patient Care Unit, The MetroHealth System
Megan L. Sprecher, JD, Senior Attorney, The Legal Aid Society of Cleveland


A couple years after our medical-legal partnership started in pediatrics, we expanded to serve formerly incarcerated people with chronic health conditions at MetroHealth Broadway Health Center.  When we expanded to the ReEntry population, we knew that we would be serving a vulnerable population with special needs.  What we wish had known then was to involve the whole care team sooner.

Mr. Smith**, one of our first ReEntry patient-clients, had diagnoses of depression with psychosis and anxiety.  Despite a clear need for both treatment and medication, he had not seen a psychiatrist since leaving prison 2 months before.  Mr. Smith did not have insurance, and did not know where to turn for treatment.

After a mental health screening, the clinic’s social worker referred him to a psychiatrist for treatment and medication.  He also sent him to our legal team for help securing necessary disability benefits.  Despite considerable efforts, there were delays getting Mr. Smith to the psychiatrist because, like many of our ReEntry patient-clients, he was living in a shelter and had limited access to transportation and a phone. 

While we tried to get Mr. Smith connected with mental health care, our paralegal was helping Mr. Smith apply for Supplemental Security Income (SSI) that would help stabilize his life.  But his SSI claim was denied because of a lack of evidence of his disabilities – disabilities he needed documentation of from the very psychiatrist he was struggling to see.

Eventually, Mr. Smith made it to the psychiatrist, and when she started seeing him regularly, Mr. Smith’s SSI appeal was granted.  He started taking the appropriate medications and his symptoms of psychosis diminished, making caring for his health much easier and more effective.

This case really highlighted for us the great need for mental health care among our patient-clients, and made us realize that, for this population in particular, we need psychiatrists on the MLP team from the start.  We had to pivot and acknowledge a couple of realities: first, our patient-clients were going to need us to better coordinate our interventions.  Second, the people we were serving would need psychiatric services on a tighter time frame. We used that experience to realign our program, advocate for a psychiatrist at the clinic, and recognize where legal interventions can be preventive (e.g. ensuring that Mr. Smith is engaged in treatment and stable) rather than reactive (waiting until a disability denial occurs to go upstream for the cause).

Ultimately, our effectiveness is informed by our experiences with our patient-clients and with each other on the team – and that means we need to constantly pay attention to how we can monitor, pivot and improve – together.  If we were starting over today we would incorporate mental health care from the start.

*The Community Advocacy Program (CAP) in Cleveland is a partnership between The Legal Aid Society of Cleveland and The MetroHealth System.  It started over ten years ago and is one of the oldest MLPs in the country.  Each of the authors has been practicing MLP for more than 5 years.

**The patient-client’s name has been changed to protect his identity.

Wednesday, March 26, 2014

Lessons from the Field Part II: Slow Down, We Move Too Fast

In honor of the launch of the new Medical-Legal Partnership Toolkit, we asked longtime MLP practitioners to write blog posts answering the question, ""If you were starting your MLP for the first time today, what would you do differently?"  This post is the second in that series.

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By Samantha Morton, JD, Executive Director, Medical-Legal Partnership | Boston*

Bringing together creative healthcare practitioners and passionate public interest attorneys to better serve low-income, medically vulnerable people is a no-brainer.  We serve the same people, are seeking to make the world a better, healthier, more just place, and share a hunger to be more effective in executing on our missions.  Getting healthcare and legal folks to the table together has been an important contribution of MLP model – hence the phrase “medical-legal partnership”, right?

But in a local MLP start-up setting, getting these two groups to the table is just the beginning. And too often, our program treated the mutual desire to partner as the end of the analysis, forging ahead with a new initiative without any consensus on key fundamentals such as:
  • What specific need(s) are we trying to address among patient-families?
  • Why do we think an MLP intervention can meet these need(s)? 
  • Who exactly should the MLP team be composed of in order to tackle this challenge?
The excitement of moving forward with terrific, like-minded collaborators simply distracted us from the fact that we didn’t have a basic logic model for the project.

If I had the opportunity to go back in time, I’d take an entirely different approach to the MLP project planning process.  We’d:
  • Spend much more time in the planning phase – many months, possibly years;
  • Focus on defining a need from a range of data sets (clinical outcomes, public health data, health disparities data, focus groups with key stakeholders, etc.);
  • Rigorously connect the dots between the defined need and the proposed MLP intervention; and
  • Evaluate the types of skill sets and team members that would be critical for project success (for example, it may be important to include public health colleagues and/or clinical researchers, or to involve multiple healthcare sites and/or legal community partners).
When we do this kind of project vetting right, some projects will move ahead to implementation and others won’t – and that’s how it should be.

It’s hard to be disciplined about a planning process. I know from experience.  But I’m convinced this is the variable that separates short-lived MLP “pilots” from long-term MLP integrations.  Start with the need, and build from there. Question assumptions, re-evaluate proposed approaches.  Invest more time in planning. This is, after all, a marathon not a race.

It goes without saying that the “secret sauce” of MLP is the structured linkage between a healthcare/public health team and a legal team.  But a partnership should be a means, and not just an end.

*Medical-Legal Partnership | Boston was founded in 1993 and is the oldest MLP in the country.  Samantha Morton has been an MLP practitioner for over 10 years.

Monday, March 24, 2014

Lessons from the Field Part I: Make the Business Case for MLP from Day One

In honor of the launch of the new Medical-Legal Partnership Toolkit, we asked longtime MLP practitioners to write blog posts answering the question, ""If you were starting your MLP for the first time today, what would you do differently?"  This post is the first in that series.
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By Randye Retkin, JD, Founder and Director, LegalHealth*
 
Nearly 14 years ago, LegalHealth started with $20,000 in seed money and a hunch that legal services delivered in a healthcare setting would improve quality of life, and possibly health outcomes. 

If I were starting LegalHealth today, I would immediately articulate the business case to potential hospital partners.  Making the business case legitimizes your program by positioning your work as something of  value and when you make the monetary asks that reflect the true cost of your services healthcare providers will not be surprised.

Both the business case and the ‘ask’ will be aided by incorporating an evaluation component from the start. We have spent years catching up to the anecdotal information we had. When LegalHealth started, there were no plans for a formal evaluation built into our program.  If starting today I would bring in research professionals from the outset. MLP attorneys are not trained to properly carry out this role.  Evaluation of the legal work and our clients’ outcomes is linked to our success as a program and as a model. If a formal evaluation component was not feasible, I would dedicate resources to truly follow up with clients once the legal work was over.  Much can be learned from what happened in their lives once our work was completed.

There are so many arguments to be made for why this model, especially with the new health care landscape is a win, win, win for all (clients, healthcare providers and institutions) and the list keeps growing. If starting over, I would begin each conversation with a health care partner on how they cannot afford not to have a MLP.

*LegalHealth is the largest and one of the oldest medical-legal partnerships in the United States, serving 20 hospitals in the New York City area.  Randye Retkin has been an MLP practioner for nearly 14 years.

Thursday, January 2, 2014

Training the 21st century health professional to take the social determinants of health vital sign

By Megan Sandel, MD, MPH, Medical Director, NCMLP

For one week in December, a group of Boston University medical students ate only food they could buy for $1.40 per meal, spending roughly $30 for the week.  (Read full story.)  Why would medical students do this?  Because with the November cuts to the Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps), $1.40 per meal is how much 47 million patients often spend to feed themselves and their families.  This exercise was a small chance for students to understand the challenges of the patients they are likely to see over and over again as doctors, to recognize the tradeoffs people make for basic needs and the stress and poor health poverty causes.

I have written that it is time to create a Social Determinants of Health Vital Sign that will help us detect and treat the nutrition and housing problems that are making people in poverty sick.  But one idea that has haunted me since first writing about this is how we will train our future healthcare workforce to use this vital sign appropriately.  We can’t ask every medical student to eat like their patients or live in similar housing conditions, but we can help them better understand, detect and treat these issues by building it into their standard training.

More and more, medical training is focused on the “competencies” every doctor is expected to execute, and in turn, whether medical students and residents are ready to perform “Entrustable Practice Activities” (EPAs) – the undertakings that “link competencies to clinical practice.”  In Pediatrics, it tests whether a resident can care for a newborn baby, in Family Medicine whether a resident can manage a person at risk for a heart attack or stroke.  When medical students and residents are evaluated, competencies and EPAs drive the definitions of what it means to be a physician and the key skills physicians need to keep both individual patients and populations healthy.

In an Academic Pediatrics article, Dr. Melissa Klein, Dr. Dan Schumacher and I argue that medical students and residents should be able and required to assess and intervene in social conditions, from hunger to inadequate housing, as a viable part of any treatment plan.  In the supplement, we lay out vignettes illustrating the differences in competencies from a totally rote uninformed pediatric resident in level one to a fully engaged community networked physician in level five.  If we include the assessment and management of social determinants of health (SDH) as an Entrustable Practice Activity with the same emphasis as we do any other preventative or chronic disease evaluation and management, then we will create physicians ready to use the SDH vital sign to its full effect.

The Robert Wood Johnson Foundation has re-convened the Commission to Build a Healthier America and will be releasing its recommendations next Monday in a live webcast.  (Click here to register.)  During the webcast, they will focus on three key areas including encouraging “health professionals and health care institutions to expand their focus from treating illness to helping people live healthy lives.”  I am hopeful they will call out training all health professions – from medicine, nursing, social work, public health and law through medical-legal partnerships – into moving from health care to health, as a key step towards realizing a healthier America.

Thursday, December 12, 2013

Nurse-led medical-legal partnership: Natural partners at a necessary time

By Tine Hansen-Turton, Chief Executive Officer of the National Nursing Centers Consortium*

Almost 50 years ago, the first nurse-managed health center (NMHC) opened to expand care and resources for rural and medically underserved patients.  The driving idea behind NMHCs was to provide communities facing the most need with access to high quality, affordable health care in a holistic, patient-centered setting.

Today, we face an urgent need to expand where patients receive care.  As we alternate between inspiration and frustration with healthcare reform, one fact remains clear: starting in 2014, many more people will have health insurance and they will be looking for healthcare.  And it may be time to look once more to nurses and the more than 250 NMHCs in the U.S. to meet the need.

Last week, MSNBC’s Geoffrey Cowley suggested NMHCs could be an antidote to the primary care shortage problem we are facing.  Cowley’s argument drew on research addressing projected shortages in primary care, cost savings associated with maximizing nurse practitioner scope of practice, and, most recently, innovative modeling by the RAND Corporation. He also pointed to research establishing that nurses provide high quality care and reiterated the Institute of Medicine’s recommendation that “nurses [be able] to practice to the full extent of their education, training, and competence.”

But health reform is about more than ensuring people have a place to receive care; it’s about ensuring high quality, preventive care.  That won’t happen unless the environmental, physical, and social factors beyond the biomedical model that affect patient and population health are addressed.  The health of our patients is connected to safe and healthy homes, enough of the right healthy foods and access to benefits and supports that keep patients insured.  I am consistently amazed by the innovative approaches our member clinics take to address the needs of patients, such as building community anti-violence programs, providing pre- and post-natal care to women in their homes, and integrating behavioral health and nutrition specialists to ensure that patient care centers on the patient.

More and more at NMHCs, we see the health needs of our patients as being connected to laws, programs and systems that are difficult to navigate and enforce – whether that means ensuring sanitary codes are enforced in apartments or that patients with disabilities are receiving Social Security benefits.  In other words, so many of the things affecting where our patients live, work and play are civil legal needs, and addressing these legal needs can have real benefits for our patients’ health.  When I talk with our members at NMHCs about integrating civil legal care into the healthcare services provided in our clinics, it seems like the natural next step.

The Kresge Foundation agrees.  Recognizing the potential impact of supporting nurse-led medical-legal partnerships (MLP), they recently funded a three-year pilot program focused on demonstrating and disseminating the MLP model to the National Nursing Centers Consortium’s 250 NMHC members. The project’s first phase is already underway at Abbottsford Falls Health Center in Philadelphia, an NMHC that started an MLP in 2008 with a legal fellow from the Legal Clinic for the Disabled.

We can’t anticipate every change that will result from health reform, but we know NMHCs will be called on to provide care to an increasing number of Americans, and it is important to us that we continue to innovate and build partnerships that will provide the highest quality, holistic care we can.  Nurse-led MLPs is one way to do it.

*The National Nursing Centers Consortium is a 501(c)(3) nonprofit dedicating to advancing nurse-led health care through policy, consultation, programs and applied research to reduce health disparities and meet people’s primary care and wellness needs.

Tuesday, November 26, 2013

Innovative Curriculum to Train Residents in Screening and Addressing the Social Determinants of Health

By: Melissa Klein, MD, Associate Professor, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and Alicia Alcamo, Pediatric Resident, Cincinnati Children’s Hospital Medical Center

Learning to provide appropriate medical care in a variety of clinical settings is a challenging pursuit for medical residents.  It becomes even more complex when these residents are asked to develop skills to recognize and intervene on behalf of social determinants of health (SDH).  Yet doctors are frequently charged with providing care to patients from underserved communities and those patients’ health is directly connected to social factors.

Residents need dedicated training to learn how to screen for these challenging social issues such as food insecurity, unhealthy housing, domestic violence, school expulsions, access to health insurance, and transportation.  Residents also need resources and support to help address these problems once they are identified. With SDH emerging as a new morbidity, the ability to skillfully address both medical and social needs is critical to improving health outcomes in this patient population.

Success in recognizing and intervening on SDH hinges on the combination of resident knowledge, skill and resource availability.  Dr. Jennifer O’Toole et.al previously demonstrated that residents in continuity clinics with a medical-legal partnership – where lawyers were part of the training team and available to treat identified legal needs – were more confident in their knowledge of SDH issues, screened more frequently, and spent more time obtaining the social history.  However, detection rates of social issues still trailed prevalence rates.

To improve resident communication in screening for the SDH, we created an interactive video curriculum to review the SDH, understand their impact on child health, develop appropriate screening techniques and review resources available both in clinic and the community.  Training topics include food insecurity, public benefits, housing conditions, maternal depression and domestic violence.

Residents who were trained using this curriculum in Cincinnati reported higher levels of confidence in their ability to screen SDH.  Post-training, screening rates increased for all issues, most significantly for domestic violence and maternal depression and there was an increased rate of referrals to our medical-legal partnership.

The full curriculum is available on the American Association of Medical Colleges’ MedEdPortal.