Thursday, September 4, 2014

Moving the Mountain with a Bulldozer instead of a Spoon: How Medical-Legal Partnership can do Primary Prevention for Populations through Policy Solutions

By Megan Sandel, Medical Director, NCMLP

Each aspect of the medical-legal partnership approach is in some way an act of prevention.  Any time someone has better access to healthy food, safe housing or quality education, they are more likely to have better health outcomes.  But how and when they get access to those basic needs play a big role in their health.

In health care, we approach prevention in three ways: tertiary, secondary and primary prevention. We can help someone manage the symptoms of an existing long-term disease to try and promote the best quality of life possible once they are already sick (tertiary).  We can provide care to help stop the progression or onset of a disease for which they have high risk factors (secondary).  Or we can do something to protect them from ever getting ill in the first place, such as administer a vaccination (primary).  Health care tries to do all three, but primary prevention has hands down the best health outcomes and promotes the best quality of life.  It is also the least expensive for the health care system.  And the more primary prevention we do, the less tertiary and secondary prevention is needed.  I often think about tertiary prevention as like moving the mountain with a spoon; the disease course is pretty set and you can only make small differences.  Primary prevention is like moving the mountain with a bulldozer and there are cascades of benefits for people.

Think about medical-legal partnership in the housing context.  Helping a family who is already homeless get into safe housing is important and absolutely critical to preventing the progression of health problems, but many of the adverse health effects from being homeless may have already started.  However, ensuring that housing subsidies are protected and equally enforced throughout a community so that families do not become homeless in the first place is a vaccination.  This inoculation is cheaper from a health care perspective as well as from a legal aid perspective.

We make a big deal at the National Center for Medical-Legal Partnership about encouraging medical-legal partnerships to move as upstream as possible, to focus on using the direct representation cases they do as “legal hotspotting” to detect and treat laws and policies that affect the health of entire communities, rather than putting all their time and resources into individual cases.  This is not because the direct legal assistance for patients is not important work or because it does not have powerful health outcomes for individual patients.  It is an important form of prevention.  But is it the best kind of prevention we have to offer?  How do we go from the spoon to the bull dozer to move the mountain of social and legal determinants impacting the health of patients?  Policy work.  It increases a medical-legal partnership’s capacity and the number of people it can reach.  Most important, targeting the policies that make people sick has a better chance of preventing the disease and not just treating the symptoms as they develop.

Wednesday, July 23, 2014

Lessons in Not Reinventing the Wheel: What MLP Can Learn from Other Integrated Care Models

By Maggie Eisen*

As someone who recently helped start a medical-legal partnership (MLP) in Philadelphia, I have found that there are important lessons to be learned about integrating services, not just from other MLPs, but from our healthcare partners themselves who already embrace other models of interprofessional, collaborative care.  After working my way through Phase I of the 2014 MLP Toolkit, I wanted to offer two additional pieces of advice to anyone starting an MLP:
  • Mine a potential health care partner’s internal landscape and history for examples of service integration, whether successful or not.  Indeed, advice and technical assistance from the National Center for Medical-Legal Partnership (NCMLP) and from other MLPs will be essential to your planning and implementation processes.  However, it’s critical to dedicate equal attention to unpacking the history and experiences of the place where you plan to integrate legal advocates and learn all you can from their past attempts at service integration.  As Phase I of the MLP Toolkit mentions on page 6, “Addressing psychosocial and care coordination needs have been increasingly accepted as critical to improving health, and both social workers and patient navigators have been integrated into the healthcare team at most healthcare institutions.”  Leveraging these types of experiences, lessons learned, and best practices will likely streamline your integration process, making it more efficient and effective.  They have lessons to teach MLPs, and an individual healthcare institution’s personal history with these types of projects may inform their willingness to partner with legal services.
  • Explore websites and publications authored by thought leaders from organizations in parallel movements like Collaborative Family Healthcare Association (CFHA), which was established around the same time as the first medical-legal partnership at Boston Medical Center.  Just as NCMLP espouses the importance of fostering relationships across disciplines to “build a better healthcare team,” CFHA “envisions seamless collaboration between psychosocial, biomedical, nursing, and other healthcare providers, and views patient, family, community, and provider systems as equal participants in the healthcare process.”  To get started, I recommend reading a recent blog post on interprofessional integration processes by Dan Marlowe, PhD, LMFT on CFHA’s website.
Medical-legal partnership and all other “strains” of integrated care delivery should not be considered as ends in themselves; rather, they are iterative processes, deeply dependent on thoughtful cultivation of trusting, equitable relationships.  These critical relationships should be made horizontally and vertically, within and across organizations and movements, as we strive together to achieve the healthcare Triple Aim.  And making use of existing infrastructure and familiar operational procedures is a strategic way for MLP practitioners to anticipate and answer institutional resistance to integrating legal advocates.

*Maggie Eisen is the Director of Medical-Legal-Community Partnership at Philadelphia Legal Assistance.  Their medical-legal partnership works with the Philadelphia Department of Public Health, Ambulatory Health Services Division.

Wednesday, July 9, 2014

The justice availability gap versus justice accessibility gap: A role for medical-legal partnerships

By: James Teufel, MPH, PhD* and Shannon Mace-Heller, MPH, JD**

Protecting and promoting access to justice has been recognized as a significant value in the United States since our nation’s founding.  Historical events including the Gideon decision affirming the right to an attorney in criminal proceedings in 1963 and the passing of the Economic Opportunity Act in 1964 providing federal funding to support civil legal aid services are only a few examples of efforts to protect and expand access to justice for citizens.  However, in the United States, a right to an attorney is only guaranteed in some criminal matters.  To date efforts to establish a civil Gideon standard have not yet come to fruition, resulting in a remarkable disparity between the economically advantaged and disadvantaged population’s availability of and access to justice in civil legal matters.  Medical-legal partnerships have the potential to transform and expand the current legal aid services system in the United States thereby bridging the existing justice gaps.  Moreover, the MLP model is a viable vehicle to reframe the access to justice debate moving from a solely public social justice-based framework to one that engages a wide variety of private and public stakeholders including health care and political systems.

In the United States, there is one private practice attorney for every 217 individuals earning more than 200% of the federal poverty level. However, there is only one legal aid attorney for every 14,229 individuals earning 200% of the federal poverty level or below. The difference in these ratios acts as a conservative marker of a justice availability gap in civil law.  This is an availability disparity of 66 times.  The attorney availability gap can be understood through an analogy using the most populated and least populated states in America: California (over 38 million) and Wyoming (approaching 600 thousand).  If we set the number of attorneys available in each state at 2,690 and kept the population of each state at its naturally occurring level, then we can understand the civil law availability gap experienced by the economically poor in the United States.  The 2,690 attorneys in California would need to serve the needs of over 38 million people, whereas the same number of attorneys in Wyoming would serve a little over half million people’s needs.  Based on the justice availability gap, the economically disadvantaged have the California experience, whereas economically advantaged have the Wyoming experience.  In this hypothetical scenario, the answer to the availability gap would be to move to Wyoming.  The justice availability gap, however, oversimplifies the experience of economically disadvantaged in the United States.  The justice availability gap underestimates the justice access gap.   

The justice access gap includes other important factors.  For example, it is more realistic from a relative poverty perspective that a person would likely need to earn at least 400% of the federal poverty level to have adequate access to private attorneys to address new and ongoing legal care needs.  This adjustment would increase the disparity among those with economic advantages and disadvantages, whereas the justice availability gap was 66 times, the justice access gap has an objective basis of 258 times.  In other words, the ratio of people below 400% poverty to legal aid attorneys is 27578:1, and the ratio of people at or above 400% poverty to private practice attorneys is 107:1. 

Beyond population poverty to attorney ratios, many other factors can impact justice access ratios.  For example, from the perspective of individual financial position, safety net income levels underestimate economic inequalities.  Annual income measures do not account for wealth well.  At least a quarter of American families have no or negligible wealth, and the wealth of the next quarter of Americans has shrunk by about 50% in the last 15 years.  The lack of wealth of many American families could further increase the justice access gap.  Beyond cash and credit availability, other issues such as transportation, no paid time off, and trust in the justice system could also further the access to justice gap.  Additionally, research supports that most economically disadvantaged households have at least one civil legal issue that has gone unmet.  From a Machiavellian perspective, the inequity between the availability and access gaps could be decreased through disinterest in engaging the civil legal system among those experiencing economic disadvantage.  This is similar to the situation that occurs when calculating unemployment rates.  For example, unemployment in the United States is calculated as the number of people unemployed but in the labor force divided by all of those in the workforce (unemployed or employed).  Military personnel, people under age 16, institutionalized individuals, and discouraged workers are not considered part of the workforce and therefore cannot be unemployed.  A discouraged worker is a person who has not sought work in the past 30 days.  If all people stopped seeking work, unemployment would decrease dramatically.  The discouraged worker phenomenon applies to arguments related to the gap between justice availability and justice access.  Perceived legal access problems decrease as people become discouraged by and disengage from the legal system. 

It is relatively easy to estimate objective availability and access justice gaps.  However, when we include issues of discouragement, the access gap will shrink mathematically.  This must be the case.  Medical-legal partnerships aim to change systems that have historically discouraged participation of vulnerable populations.  Issues of access include subjective experiences of needing and wanting services.  Not unlike accessing healthcare services, a discouraged person may need services but not want services.  The discouraged community effect helps to explain the slow diffusion of innovations within vulnerable populations.  Medical-legal partnerships have the opportunity to not only provide direct services but also change systems, policies, and environments that impact vulnerable populations in the United States.  The benefit and challenge to MLP that change community culture is that they can objectively help to meet access needs.  However, as the innovation of MLP integrates in community culture, MLPs will experience demand that will necessitate scaling of the supply of legal care in order to meet the needs and wants of communities.

*James Teufel, MPH, PhD, Assistant Professor of Public Health and Associate Director of the Institute for Public Health, Mercyhurst University

**Shannon Mace-Heller, MPH, JD, Director, Office of Policy & Planning, Baltimore City Health Department; Public Health Law Specialist, Health, Education and Legal assistance Project: A Medical -Legal Partnership, Chester, PA.

Tuesday, May 27, 2014

Making the Most of Limited Communications Resources

By Kate Marple, Manager for Communications, NCMLP

You want to tell stories.  You want more allies and partners in your community to know about your work.  And you’d especially like to get the attention of groups with funding and stakeholders with the ability to change the policies you’d like changed.  But with so many things to do, how do you find the time and resources to think about communications?

It’s tough.  Medical-legal partnerships aren’t independent 501c3 organizations with an entire staff devoted to their every need.  They are projects that bridge two (three, four, five!) existing organizations of varying sizes.  It’s partly what makes MLPs great; instead of trying to create lots of new infrastructure, they make what already exists in the healthcare and legal communities work better.  The downside is that while many attorneys and healthcare team members participate in MLP activities, each project usually has just one or two people who are eating, sleeping and breathing MLP.  That makes prioritizing communications especially difficult.

There is no easy, quick fix, but there are several things you can do to help expand your limited communications capacity.
  • Enlist help from your legal and healthcare institutions’ communications and development offices.  We talk a lot about how MLPs need buy-in at the institutional level, but that doesn’t just mean from the head of the clinical department or the legal aid executive director.  It means making sure you are on the radar of the folks whose job it is to fundraise for and promote the work of the larger organization.  This can be particularly helpful if you work at a large hospital or with a law school.  These organizations have teams whose job it is to tell stories, find ways to connect projects to the news, and to put together materials.  If they know you, love you and understand how your project benefits the institution, they can be your best friend.
  • Seek out pro bono.  No, not the legal kind.  Some MLPs are part of small community health centers and tiny legal aid offices without communication teams.  Pro bono isn’t just for lawyers.  Check in with communication firms and professionals in your area.  They might be willing to donate or discount a couple of hours of communications help.   Depending on your needs – for help with a graphic design project or pitching a story to the media – a couple of hours may be all you need (at least for one project.)
  • Hire a journalism intern for a semester.  Do you want to tell human stories about the work you do, free of the jargon that permeates the legal and healthcare communities?  Look for a storyteller not entrenched in either community.  A couple of times, we’ve hired a journalism intern for a semester to come in, interview patient-clients and providers, and write up short stories for web and print materials.  You’d be amazed at how different stories sound when they are written by someone with this background.  [Side note: I mentioned this idea at the MLP Summit this year, and I received a dozen requests for a sample intern job description.  I included one at the end of this post.]
  • Get strategic and redefine success.  Programs often think they need more communications product then they actually do.   That’s not an MLP problem; that’s an everyone problem.  Folks start by dreaming about the video they want to film or the 12-panel brochure they want to design.  Really communications is just supposed to be a means by which you get what you really want – the grant, the bill passed, or the increase in program referrals.  Think about communications that way – what are you trying to achieve?  Who is your audience? What do they need to hear and from who? – and you may find that all you really need is a meeting with the right person to tell one well-crafted story.  Depending who you are trying to reach, simpler can be better.  If you’re trying to convince healthcare team members on the ground of the value of linking up with the MLP project, then taking time to email a success story to all your healthcare providers each week will do a lot more good then developing a flashy brochure.  [If you’re interested in thinking through your goals and what you need, I recommend checking out the FREE and easy to use SMART Chart from Spitfire Strategies.]
Besides thinking more strategically, the biggest challenge is often getting started.  Don’t try to do everything; do get in the habit of regularly doing something.


Sample MLP Storytelling Internship Description

About us:  We are healthcare and legal professionals who believe that everyone in our community has the right to be healthy, and that for many of our neighbors, health depends on access to basic needs that are in short supply like safe housing and affordable nutritious food.  [Name of MLP] is a partnership between [legal institution name] and [healthcare institution name] that treats the social and legal needs impacting patient health and identifies areas where policy changes can create better health for our whole community.

Intern / Job Description: We are looking for a dynamic storyteller to help us capture stories of how partnership can create better health.  During the [paid/unpaid 3-month] internship, this individual will be responsible for interviewing patient-clients, attorneys and health care providers, obtaining media releases, and writing 7-10 short stories for use in print and web materials.  These stories will be used for different audiences and should try to capture both the impact of MLP on healthcare provider practice and the community impact of policy projects.  Staff will help the intern identify clients and providers for interviews, but the final story product is the responsibility of the intern.

Candidates:  Applicants should be enrolled in a journalism, communications or similar degree program [for which s/he will earn school credit].  S/he must be an excellent writer and storyteller. The selected individual will interview individuals about sensitive subjects, and it is essential that s/he be respectful and culturally sensitive while using ethical story gathering and storytelling practices.   This internship requires someone who is a self-starter with excellent time and project management skills.

Wednesday, May 21, 2014

One Step at a Time: Stories from a Developing Medical-Legal Partnership

By Sarah Hexem, JD, Specialist in Strategic Policy Initiatives, Public Health Management Corporation

“Can I get you anything? Water? Hummus? Let me run out. I can get us some fruit,” offered Hanh, a soft-spoken registered nurse at Rising Sun Health Center.

We arrived early for our meeting, and the staff was wrapping up seeing patients from the morning. The topic of the day was our new medical-legal partnership, and with me were Debby, the Deputy Director of Legal Practice at Community Legal Service (CLS), Kristen, a staff attorney in CLS’s Public Benefits & Welfare Law unit, and Jamie, the Manager for Strategic Policy Initiatives at Public Health Management Corporation (PHMC).

“No, no. We are fine. Please, no rush at all,” we quickly responded. Ten minutes later, Hanh returned with an assortment of fruit for the group. We settled into the glass-walled conference room and I thought how Hanh’s actions reflect the atmosphere as well as the mission of the clinic:  to welcome visitors into a primary care home.

Rising Sun is a nurse-managed federally qualified health center (FQHC) that serves a low-income, widely diverse area of northeast Philadelphia. Over 32 languages are spoken in the community, and many Rising Sun patients live in nearby public housing. Rising Sun is one of five FQHCs operated by PHMC, a public health institute that, with its affiliates, runs a range of public health programs, services, research and evaluation, and policy initiatives on the local, regional, and national level. PHMC believes that advancing public health innovations helps build healthier communities, and Rising Sun has already embraced the patient-centered medical home model.  It recently added a behavior health consultant to its staff of medical assistants, nurses, nurse practitioners, and social workers. In September, a lawyer joins the health care team, officially creating PHMC’s first medical-legal partnership.

However, the journey to CLS-PHMC’s MLP started well before September 2015, and it was filled with intra-organizational conversations and strategy, with fellowship applications and grants, with personal introductions and with a lot of waiting. And there is no shortage of work to do to prepare for the arrival of Lydia, CLS’s new Independence Foundation Fellow who will run the MLP.

The purpose of this meeting was to share the Strengths/Weakness, Opportunities/Threats (“SWOT”) assessments that each partner completed (also known as Step 5 of The Medical-Legal Partnership Toolkit: Phase One, Laying the Groundwork.)  As part of the planning process, both the legal and healthcare teams spent several hours after work evaluating what they had to contribute to our MLP, which aspects of the partnership would be strongest, where vulnerabilities existed, and where more work needed to be done. 

The most important part of this exercise and our meeting was that both groups shared the information openly and honestly with each other.  We highlighted the top three strengths/opportunities and top three weaknesses/threats of each organization. The exercise was incredibly encouraging. It did not take long for weaknesses to turn into opportunities and for strengths to trigger new ideas. For example, the clinical leadership at Rising Sun is transitioning in the next few months, a situation with the potential to cause disruption, inconsistency, and uncertainty. Yet, the transition is revealing a strength: multiple levels of healthcare engagement. Rising Sun’s outgoing director, by this point well-versed in the MLP model, joined the meeting because she was so committed to seeing the project continue. Across from her sat the interim clinical director, who jumped in with both feet to learn about how MLP works and support the project. Back at the PHMC corporate, Dinetta, the Deputy Director for the PHMC clinic network, called me to find how out she could be helpful going forward.

The response from the PHMC healthcare team was both reassuring and informative. We realized that sustainable healthcare buy-in should occur on multiple levels. MLPs need not depend on any one person when organizations full engage in the model. Moreover, cultivating champions at all levels can bring different perspectives and skills to the project. As the potential threat revealed PHMC’s commitment to and belief in the model, it also inspired ideas regarding other stakeholders to engage and how to leverage Rising Sun’s transition to further integrate the MLP. And from there, over grapes and strawberries, we brainstormed our next steps with newfound transparency that sent a message: now we are on the same team.

Friday, May 16, 2014

How MLP stocks the Pharmacy for Social Determinants of Health Interventions

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

Early in my residency, a young girl was hospitalized in the intensive care unit for a severe asthma attack.  The family had just gotten a cat, even though the daughter was severely allergic, because they had found a mouse in her bed.  Her parents were faced with an awful choice: live with the mice that were making their daughter sick, or get a cat that was just as harmful to her health.  As her physician, I knew none of the medicines I could give her would help her breathe well in her home. The prescription I wanted to write was for healthy housing.

A physician wanting to write prescriptions to address social or legal problems is hardly a new phenomenon. In 1967, Dr. Jack Geiger, one of the founders of the Community Health Center movement, famously wrote prescriptions for food for his patients at the community health center he founded in Mississippi. He used his pharmacy budget to pay local grocery stores to fill them because, as he said, “The last time I checked my textbooks, the specific therapy for malnutrition was, in fact, food.”

It sounds simple enough.  If a house is making you sick, move.  If you take a medicine that requires refrigeration to be effective, keep it cold.  And if managing your diabetes depends on a healthy diet, eat more fresh foods.  But the reality is that those are not options for many patients like the family I saw in the intensive care unit.  There is not enough affordable housing, and a housing search cannot find what does not exist.  We cannot help a family keep their lights on if there are not protections in place to guarantee access to electricity as a medical necessity.  If what patients need to be healthy is safer housing, better food and consistent utilities, how are we going to stock that dwindling pharmacy?

We need medical-legal partnerships (MLP) – healthcare and legal professionals working together to understand the shortages in individual communities and create policy level changes that stock the pharmacy. We need Health Impact Assessments that will support additional investments in housing voucher programs, and we need attorneys with policy expertise to take that research and advocate for policies informed by healthcare research.  We need healthcare to “hotspot” where sick patients live, and we need lawyers to enforce laws and sanitary codes to improve the conditions of existing affordable housing units.  In Cincinnati, an MLP recently helped get 19 low-income housing developments rehabbed and put under new management.  That is stocking the housing pharmacy.

Doctors and nurses regularly take vital signs – heart beat, blood pressure – because we know this information is important to understanding the scope of problems, even when we do not have perfect solutions, to drive innovation for treatments.   I have called for the need to develop a social determinants of health vital sign, one where we consistently and regularly screen patients for housing, hunger and utility vulnerability.  This is critical both to helping patients and to understanding communities and population health. The question is whether we are ready to address these hardships and their extraordinary impact on health as part of the formulary in American healthcare.  I think we are, but we cannot do it unless we think about what is available in the pharmacy, and invest appropriately in upstream solutions like medical-legal partnership that actually create more of the resources for housing, food and utilities that patients need.

Thursday, April 24, 2014

Making the Invisible Visible: Finding New Ways to Talk About Legal Care

By Kate Marple, Manager for Communications, NCMLP

Last week, I heard Dr. Kerry Rodabaugh, an oncologist in Nebraska, tell the story of a woman who cancelled her critical cancer surgery because she was about to be evicted from her apartment and couldn't face being homeless in a post-operative condition.  The healthcare team had a lawyer on board who discovered the eviction was erroneous and unlawful.  The attorney prevented the eviction, the woman had her surgery and now she is in remission.  Think how differently that story would have ended if the healthcare team hadn't thought to ask why she was canceling her surgery, or if they hadn't had a legal partner down the hall.

These stories underscore just how much legal problems impact health. So why doesn't healthcare prioritize legal care as an intervention?  It's because the value of legal care to patient health remains invisible, and when we think about how legal aid has traditionally conveyed its mission and the impact of its services, it's not hard to see why.

Pick up almost any legal aid document – an annual report, a donor appeal – and you'll encounter descriptions of systems, work that is measured in cases closed, and step-by-step “stories” of how lawyers appealed wrongly denied benefits.  What is missing?  The human impact of legal services and their broader benefit to our communities.

The legal community in most states produce what are called "Access to Justice Reports" to describe the changes needed to improve access to legal services.  Below is a word cloud that I generated from the most recent Illinois State Access to Justice report. 

The words that dominate this cloud are process words like "commission," "court," "judge," "committee," and "circuit."  No one looking at the word cloud or the report it comes from would gain any understanding of why civil legal aid attorneys do their work or how communities benefit from those services.  Healthcare institutions and providers certainly couldn't look to this messaging and see any correlation to health.  [This word cloud is not an isolated example.  I generated dozens more from legal aid annual reports and donor appeals, from national organizations and ones in local cities.  They all came out shockingly similar.] 

The healthcare community is much more effective at describing its community impact.  Many large healthcare institutions produce "Community Health Needs Assessments (CHNA)” to articulate their value to their local communities.  Indeed, under the Affordable Care Act, these reports will be required.  Check out the word cloud below that I generated from Seattle Children's Hospital's most recent CHNA

Here you see words like "health," "communities," "homelessness," "housing," "literacy," "education," "families," and "prevention."  When you look at this cloud or read the document it comes from, you get a real sense of how the hospital views its role in the community.

According to the most recent annual report of the Legal Services Corporation (the federal funder of civil legal aid), legal aid attorneys spent 72% of their time and resources last year on: (1) family law cases related to domestic violence, custody and adoption; (2) housing cases to prevent evictions and improve substandard housing conditions; and (3) disability, food, cash and veteran benefit cases to help people maintain their income.  That work is not only important to the well-being of our communities, it's important to the health of our communities.  But it is almost always talked about in terms that no one understands – cases closed, regulations, appeals, awards attained – and framed through a mission of justice that just doesn't resonate outside the legal aid community.

That exact same work could be framed through a social determinants of health lens.  If it was, we'd see that civil legal aid attorneys spend 72% of their time and resources helping ensure people in our communities: (1) are safe; (2) live in healthy physical environments; and (3) have the resources necessary to meet their daily needs.

Stop for a second and imagine legal aid reports and campaigns that talked about being partners in building healthier communities.  Imagine legal aid reports that abandoned telling us how benefits are appealed and how many cases were closed, and started telling us how many people in our community were safe, lived in healthy homes and had insurance to see a doctor when they needed one, and how all those things transformed whole communities.  I believe it would change the entire conversation about the role and impact of civil legal aid.  I couldn’t agree more that legal aid is unseen and undervalued in this country, especially by key allies in the public health and healthcare sectors, but let’s be honest – to change that perception, we have to start with how legal aid conveys its own value.