Medical-Legal Partnership

2009-10-25T00:20:00.001-04:00

Chain Reaction, Part I

Two slides into the Health Care Organizations 101 webinar it hit me: for years MLP attorneys have talked with health care staff about a standard advocacy strategy called chain of command.

It works like this: mom complains to lawyer or paralegal about a letter she received from [fill-in the blank – social security, food stamps, housing, welfare, etc] agency. Legal team calls agency worker on mom’s behalf to “push” the system. After a couple of unreturned calls, lawyer calls supervisor to inquire about mom’s case and demand a solution. If supervisor fails to return call, lawyer will continue up the administrative chain of command pressing for explanations, answers, accommodations. This is frequently accompanied by email or letters documenting activities in a range of language from cooperative and unctuous to aggressive and threatening….

Chain-of-command gets results, and it is part of the toolkit for healthcare providers who want to help their patients get what they need in the complicated safety-net of the new millennium. It requires training and empowerment, because doctors don’t naturally buck the system [see Megan Sandel’s May 09 blog entry]. And they need help identifying what the rule is, and what to ask for. But armed with the right tools, there is no more credible advocate than a savvy physician.

Chain Reaction, Part II

Legal aid lawyers love chain-of-command. It is a strategy to help ensure that government agencies adhere to their policies and procedures. Chain-of-command can help nip huge problems – like a lost housing voucher – in the bud, thereby protecting clients from wretched bad luck, incompetence or vindictiveness at the hands of government bureaucrats.

Good administrative chain of command advocacy depends on understanding how bureaucracies operate, where the power centers lie, and how decisions get made and unmade. Some of the legal aid community’s most successful advocates never see the inside of a courtroom or hearing room. They are people who tend relationships in bureaucracies and devise strategies to support their clients using their knowledge of the administrative system.

So why does they prospect of navigating the bureaucratic byways of an academic children’s hospital cause even the most experienced, intrepid legal aid attorney heart palpitations? Is it because the lines of authority don’t carry the same clarity of an administrative agency? Or because we can’t fall back on our more “aggressive” strategies when all else fails and phone calls go unreturned?

Maybe it is something less tangible, and more organic. Lawyers are trained to prize the client relationship above all else. So chain-of-command advocacy with a client purpose is a different (more tolerable?) proposition than having coffee with the assistant general counsel for the hospital with the vague goal of building a relationship over the long-term.

MLP is Pro Pro Bono

2009-10-18T11:47:00.003-04:00

Ellen Lawton, Esq.
Executive Director, National Center for Medical-Legal Partnership

It has been a source of secret professional pride for a long time, but now the word is out: lawyers volunteer their professional services more often than practically all other professional groups. A recent report by the Taproot Foundation, details the mechanisms that the legal profession has used to inculcate law students and lawyers with a deep sense of commitment to pro bono practice. Leadership from the American Bar Association and the American Association of Law Schools has resulted in development of mandatory pro bono requirements, together with the high profile focus on pro bono activities by law firms intent on recruiting talented law students.

This is great news for medical-legal partnership, because we know that the innovation, energy and dynamism of MLP attracts some of the best and brightest lawyers in private practice to leverage the work of legal aid attorneys and their medical partners. The ABA is at the forefront of supporting that work – through the Bar Leader Toolkit for MLP and other web assistance offered through the ABA MLP Pro Bono Support Project, as well as raising visibility of successful pro bono initiatives.

So what do our pro bono partners do for MLP?

If you are Jerry Tichner at McDermott Will & Emery, you offer consultation to sites all over the country about the vicissitudes of HIPPA compliance in the MLP context, and allay concerns about ethics conundrums for programs just starting out.

If you are Chad Priest at Baker Daniel in Indianapolis, you are a community leader who brings together all the MLP stakeholders, matches Baker Daniel resources with community know-how, and motivates a complex, committed team to move the dial on poverty.

And if you are Ros Garbose Nasdor at Ropes & Gray, you are dedicated to finding meaningful, relevant roles for deferred associates in struggling legal aid offices, and meeting the challenge of 2009 with a vision for positively impacting the legal aid community.

Thanks to our pro bono partners, one and all – we couldn’t do this without you.

National Pro Bono Celebration Week is October 25-31st. Sponsored by the American Bar Association, it provides an opportunity for local legal associations to collaboratively commemorate the contributions of America's lawyers and to recruit additional volunteers to meet the growing need. Click here for ideas on how your mlp can get involved...

From Deep in the Heart of Primary Care

2009-08-27T10:11:00.001-04:00

Ellen Lawton, Esq.
Executive Director, National Center for Medical-Legal Partnership

The National Association for Community Health Centers held its annual Expo in Chicago this week, and MLP was on the agenda, with a presentation on Health Center Adoption from MLP Boston, Ropes & Gray and Dorchester House Multi-Service Center. R&G partner Michelle Garvin’s presence and presentation moved more than a few workshop participants to pepper us with questions about how to bring MLP services to their health center – from Wichita, Kansas, to Yakima, Washington, to Cook County, Illinois – they immediately saw the value and the potential of the model for their communities.

Our friends in the community health center world have a lot on their plate right now given their central role in the health care transitions that have a foundation in providing primary care for vulnerable populations across the country. It was gratifying to see the Obama administration’s deep support so visible at the conference including speeches by HHS Secretary Sebelius and new head of Medicaid Cindy Mann – as well as a hilarious President Obama impersonator who nailed it.

Whirling from poster session to workshop to plenary, the themes resonated deeply with MLP activities, values and aspirations. Conversations with conference participants – a rainbow hue of health center administrators, board members, physicians, nurses and case managers – inevitably led to comments about social justice, vulnerable populations, and challenges in serving poor communities with dignity and respect. I was reminded again and again of the joy and exhaustion at annual legal aid conferences. Then, on the last night, NACHC members rolled up the carpets and had a crazy dance party. Legal aid and community health centers – separated at birth?

Notes From the Field or "Random Indicators of Market Penetration"

2009-08-07T11:38:00.003-04:00

Ellen Lawton, Esq.
Executive Director, National Center for Medical-Legal Partnership

Sometimes it feels like no matter where I look – my inbox, professional associations, federal agencies, reference calls for former student interns – I see MLP integration.

From the Cinncinati MLP:
One possible indicator of MLP success? At a recent project meeting, the team paralegal started to ask a question -- but before she even finished, the training physician had jumped in to answer. Everyone around the table was clueless about the topic -- and that's when the physician laughed and said "Sorry, we work the same day in the clinic and now I can finish her sentences!"

From Loyola University School of Law:
Loyola University Chicago School of Law invites applications for a clinical position in health law. We are seeking a candidate to start and develop a live client clinic with the Beazley Health Law Institute, one of the foremost health law programs in the U.S. We are open to proposals on a variety of clinical topics including medical-legal partnerships and elder law. All applicants must demonstrate a high level of substantive knowledge, solid practice experience, and a strong desire to teach. Loyola is committed to maintaining a diverse faculty with a wide variety of perspectives and we strongly encourage applications from minorities, women, and persons with disabilities. Interested candidates should submit a cover letter and a resume (writing samples and references are not necessary at this time). Contact: LawCommitteeChair@luc.edu or Prof. Jeffrey L. Kwall, Chair, Committee on Faculty Appointments, Loyola University Chicago School of Law, 25 East Pearson Street, Chicago, IL 60611.

From the Institute of Medicine:
The American Recovery and Reinvestment Act of 2009 called on the Institute of Medicine to recommend a list of 100 priority topics to be the initial focus of a new national investment in comparative effectiveness research. In the second quartile:
Compare the effectiveness of an integrated approach (combining counseling, environmental mitigation, chronic disease management, and legal assistance) with a non-integrated episodic care model in managing asthma in children.

From St. Louis, MO MLP and Charlottesville, VA MLP:
Two young, intrepid and committed attorneys, Carolyn Pointer and Lucas Caldwell-McMillan, have chased MLP as a career choice. Each has interned or practiced at three MLPs [Ann Arbor, Boston, Worcester and Cleveland in addition to those above], gathering passion, expertise and insight along the way.

Indeed – MLP is popping up all over the place. Time to go on vacation, I say!

Disparities, Determinants & Needs -- Oh My!

2009-07-21T10:18:00.004-04:00

Ellen Lawton, Esq.
Executive Director, National Center for Medical-Legal Partnership

Summer ostensibly brings the opportunity to slow down, reflect a bit, maybe enjoy a popsicle or two....and in an academic setting, churn out some papers. So we have been hard at work with some of our colleagues in the Network developing a range of academic papers describing the MLP model and its components.

Some reflections on that process include the fact that the difference between medical and legal articles is a metaphor for the difference between the professions. My medical colleagues are amused (and sometimes irritated) by lawyers' propensity to explain the world in a gigantic footnote, or dignify a minor point with a lengthy explication. From the legal partners, myself included, we sometimes wish they would pay less attention to the percentages and p values i.e. the numbers, and more attention to defining terms and massaging the message -- i.e. the words.

Which brings us to, as Stephen Colbert would say, "The Word": how do we understand, define and use words that have different meanings depending on your discipline. We have struggled mightily to describe the connection between "social determinants" and unmet legal needs. And who knew that legal needs are distinguishable from legal problems? Here's a classically unhelpful definition courtesy of the ABA in their 1994 Comprehensive Legal Needs Study:

"Legal need"...refers to specific situations members of households were dealing with that raised legal issues -- whether or not they were recognized as 'legal' or taken to some part of the justice system.

Hmm. My medical partners routinely talk about social, psychosocial and material needs, and ask me how those relate to legal needs. I know they do, and I promise to tell you how, but first I am going to step out for a popsicle.....

Collaborative or Partnership -- Let's Call the Whole Thing Off?

2009-07-01T14:41:00.003-04:00

Ellen Lawton, Esq.
Executive Director, National Center for Medical-Legal Partnership

I was reminded recently of a day not so long ago when our team of health care providers, lawyers and researchers sat in a room to focus group our name change, from Family Advocacy Program to Medical-Legal Partnership for Children (now NCMLP and MLP Boston). How we struggled to capture the essence of our shared work in the medical and legal domains. Is this a collaborative or a partnership? What's the difference, anyway? Naturally we headed straight for the dictionary, to wit:

Partnership [from partner noun]: a person who shares or is associated with another in some action or endeavor; sharer; associate...one that is united or associated with another or others in an activity or a sphere of common interest...

and

Collaborate: to work, one with another; cooperate, as on a literary work and to cooperate, usually willingly, with an enemy nation.....

The discussion that ensued centered on the notion or perception that "partnership" conveyed a deeper sense of engagement by the parties, or partners; once this concept alighted with the legal team, we were loathe to let it go. We were eager for the mandate of engagement that we thought the term "partnership" bestowed on our efforts. Sure, there were also those among us who just thought it sounded better. But when the dictionary talks about partners, it offers wonderful images, like either of two people who dance together, and a player on the same side or team as another. And I realize -- that is what we are striving to capture; health care providers and lawyers are players on the same team. Partners.

But no matter what you call each other – partners or collaborators – it’s good to set expectations. Health care providers should give more than just referrals to their legal partners – they need to help develop trainings and engage in evaluation strategies. Lawyers and paralegals need to tailor trainings to the needs and skills of their health care partners and adapt their practices to the clinical setting. Steps like this will make the dance more graceful.

Strength in Numbers…State & Regional MLP Coordination

2009-06-11T22:48:00.003-04:00

Kate Marple
National Program Coordinator, National Center for Medical-Legal Partnership

One of the joys of my job is talking with partnerships sites around the country every day about their work – the successes and innovations and the challenges and frustrations that come from interdisciplinary work with vulnerable patient-clients. When we’re in our individual health clinics, legal aid offices and law schools, it’s very easy to feel like we do this work in a vacuum. Maybe no one in a 50 mile radius (or more) does anything like medical-legal partnership – and you’re the only attorney in your office dealing with the questions and issues you come across daily. Your legal aid colleagues may be thinking about the best way to handle eviction defense at housing court, while you’re thinking about the best way for health care workers to reach you. Should I carry a pager? Do we create an online referral system? What about HIPPA? For health care workers, many of your colleagues remain mystified at the difference between a legal clinic and a primary care clinic, and baffled by the subtleties of chain of command advocacy that you are struggling to master.

The good news? There’s a large medical-legal partnership community and it’s growing! You might not be able to walk across the hall to triage a problem, but you can pick up the phone, send an e-mail, or access online resources. Or in some states, you can link up with your regional or statewide medical-legal partnership group.

I just returned from Syracuse where the New York Coalition of Medical-Legal Partnerships held a statewide conference. The Coalition brings together legal and health care workers from NY who either work at an active medical-legal partnership or are developing one. The Coalition meets regularly, but this was the first statewide conference.

Ninety people from all across NY state participated – a testament to the depth of medical-legal partnership work and leadership in the state, including from long-standing partnership sites like LegalHealth and the Syracuse Family Advocacy Program. Sessions were offered on funding, medical champions, starting a partnership, ethics and confidentiality and more – all of which allowed participants to talk about some of the big picture issues facing their partnership and bring tangible ideas back to their own programs.

But most importantly, the conference provided a forum – for partnership site updates, to ask program specific questions and brainstorm with colleagues. It’s a great thing to realize that there are already answers to many of your questions, that your colleagues have been there before. It’s about more than just not reinventing the wheel (although that’s really important); it’s about a sense of community and feeling supported in the work you do. I left the conference with a renewed energy for the work we do – and I know I wasn’t the only one!

Regional groups like the NY Coalition are the perfect mechanism for cross-site evaluation and policy initiatives and are well situated to pursue state bar resolutions and state legislation (NY is working on both).

There are medical-legal partnership statewide and regional collaborations in New York, California, Ohio, Virginia, New England, and the Midwest. Most groups meet in person several times a year, and have listservs for their members to stay in touch in between meetings.

If you live in a state with a regional collaboration, it’s so important to connect with them – to share resources and add your voice to the work being done on the state level. There is strength in numbers…and our numbers are growing.

Medical-Legal Partnerships: NY Professionals Working Together to Improve Health Care was held on Friday, June 5th at the Syracuse University School of Law. The conference was videotaped and will be available on the Syracuse University School of Law website shortly.

Mentorship in Medicine -- How Lawyers Make Me A Better Doctor

2009-06-03T14:27:00.003-04:00

Megan Sandel, MD, MPH
Medical Director, National Center for Medical-Legal Partnership
Assistant Professor of Pediatrics, Boston University School of Medicine

In medicine, mentorship is considered a crucial part of career success. There are many published pieces about what types of mentorship help foster career development -- from topical mentorship in a doctor's area of interest to personal mentorship about work / family balance and a mentor putting their mentee's career development ahead of their own. There is even now discussion of peer to peer mentorship, where people at the same stage of career development help each other plan their career trajectory, grants and publications.

What isn't talked about often is cross disciplinary mentorship. One of the benefits of medical-legal partnership that I have felt is the mentorship the lawyers at our medical-legal partnership have provided to help me be a better advocate.

Advocacy is not inherent in medicine. In fact, it is strongly discouraged at times. As physicians we are trained in a hierarchy. The medical student talks with the intern or resident who may talk to the fellow and then maybe the attending. Bucking the hierarchy is difficult. In the legal world, bucking the hierarchy is the bread and butter of legal practice.

Being involved in medical-legal partnership has helped me grow in my career as an advocate. When I talk about medical-legal partnership impacting housing, many doctors I interact with say "It's too difficult". My reaction is "You haven't put the right members of the team together, and you need a lawyer" or "If you get an answer that you do not like, you need to bump it up when you are right."

Successful careers in advocacy are crucial to the future of medicine. Having lawyers mentor doctors in medical-legal partnership to train them and sustain them in advocacy is more and more going to be norm, and I look forward to finding ways to make it happen.

You Can't Tell the Players Without a Scorecard

2009-05-26T23:13:00.002-04:00

Ellen Lawton, Esq.
Executive Director, National Center for Medical-Legal Partnership

Medical-legal partnership teams spend a lot of time thinking about what kind of data to collect -- from patients, from each other, and from the records.

MLP research and evaluation activities constitute a rapidly expanding landscape that challenge academics and practitioners by refusing to yield simple solutions to simple questions. I guess things just aren't that simple when you try to meld two distinct disciplines, namely law and medicine. Three, if you count public health.

So when I detect a simple truth amid all the murky conversations about data, I want to shout it from the rooftop. I will settle for writing it here, and it is this: legal aid intake forms ought to require client information about their health care providers as part of every intake -- and not just for the MLP cases. Legal aid attorneys should understand where their clients get -- or should get -- primary and specialty care, and get to know the local hospitals or health centers that serve clients. This is going to have an impact whether your practice is SSI, housing or consumer law -- since each of those areas might send you scurrying for medical records or a physician's letter.

If every legal aid office collected data on where their clients get health care, they would know immediately who their medical counterparts are in the community. In some cases, it might help raise legal aid's profile as a community responder in synch with health care providers. Sure, there are legal aid offices that are watchdogs of the health care community. But the greater number -- many folks across the legal aid community in the US -- draw a blank when I ask if they know exactly where their clients get health care. And that's too bad, because our medical counterparts -- MLP and non-MLP alike -- deserve to know what a tremendous amount of amazing, quality advocacy is happening just down the street, on behalf of their patients. It's our job to tell them, loud and clear!

Doctorly Love – What More Could a Lawyer Ask For?

2009-05-17T18:08:00.003-04:00

Pamela Tames, Esq.
Director of Training, National Center for Medical-Legal Partnership

As my medical colleague Dr. Steve Blatt (Syracuse Family Advocacy Program) explained the cultural differences between doctors and lawyers and how he overcomes them, the all-legal audience at the Equal Justice Conference sat enrapt in his talk.

He was the only health care provider in the room. His stories about cultural exchanges were filled with humor and wit. It was then that I promised myself I would always invite a medical colleague to present with me at conferences.

For sometime, this has been my practice at local presentations, on-site at the hospital and community health centers. But this was the first time I had invited a medical colleague from another medical-legal partnership site to join our panel of lawyers at a national legal meeting. He ended by saying that he loves lawyers and can't imagine practicing without them. Doctorly love – What more could a lawyer ask for?

The Equal Justice Conference was held May 14-16, 2009 in Orlando, Florida, and is hosted by the American Bar Association and the National Legal Aid & Defender Association.

The Knee-Bone's Connected to the...Shin-Bone?

2009-05-13T17:01:00.003-04:00

Ellen Lawton, Esq.
Executive Director, National Center for Medical-Legal Partnership

The question arrives at our door almost daily, usually over e-mail, and usually from the lawyers, but sometimes from the health care partners. "Do the lawyers have to be on-site at the health center to be a medical-legal partnership?"

My first instinct is always to say a resounding YES -- that is the whole point of medical-legal partnership -- bringing legal assistance into the health care setting.

But then I qualify that resounding yes with some classic legal parlance: it depends. Depends on how successful you want to be.

Depends on how much the medical partner can integrate the legal partner into their space, consultation practice, training regimen, staffing, screening and triage priorities, electronic medical record tracking and brainstem.

That's right - brainstem. Because MLP is as much about changing the culture of the health care setting -- the social workers, doctors, nurses and administrative staff -- to be advocacy-ready, and legal needs-savvy -- as it is about logging lawyer time in the clinic.

Don't get me wrong -- logging lawyer and paralegal time in the clinic is the key strategy to maximum integration and clinic buy-in, high impact for patients, and efficiency. Call it return on investment. But lots of sites -- both rural and urban -- make the most of their scarce legal staff time on-site by making sure that the front-line health care staff views legal assistance on a par with swabbing cultures and taking blood pressure.

Not every legal partner can score a prime office in the pediatric clinic, just behind the reception area (like, for example, Connecticut's Medical-Legal Partnership Project). And resources will dictate the strategies that you use to increase your footprint in the health setting. But we can all do a better job really integrating our legal partners in the clinical setting, and we can start by asking ourselves a couple of simple questions:

Do the legal partners give the medical partners easy access to a point person for consultation -- with ground rules for how to use the service?
Do the legal partners know the clinic team meeting schedule -- and are they a standing agenda item?
Do the medical partners understand the legal aid referral process -- and recognize the attorney when she walks through the clinic?
Do the legal partners know who the nurse manager is -- and what she does?
Do the medical partners understand the difference between pro bono and legal aid?

We could go on, but you get the point. How well do you really know each other, and each other's systems? Balancing TMI and not enough is tricky -- but if you get it right, it will be smooth(er) sailing. And your patient-clients will get what they need.

Make New Friends, Keep the Old

2009-05-08T11:50:00.011-04:00

Ellen Lawton, Esq.
Executive Director, National Center for Medical-Legal Partnership

Welcome to the MLP Blog, another in a series of National Center efforts to bring MLPs closer together, air ideas and challenges, and provide a voice for the hundreds of MLP practitioners across the country. Over the coming months, we will feature MLP sites in this space, sharing their successes and frustrations directly with you.

Medical-legal partnership is a fast-moving train which seems to gain speed and relevance daily. Just look at any current headline (“Ready or Not – Katrina Victims Lose Temporary Housing”) to find the justification for joining lawyers and health care providers together – to better equip vulnerable populations to get and stay healthy.

Social factors can affect health directly and indirectly as their effects
accumulate across individuals' lifetimes and across generations, leading to
vicious cycles between social factors and health. Although genes and medical
care also are important, social factors probably play a greater role than
either, and interact with both. Fortunately, many social factors can be
influenced by policies and programs. (RWJF Commission to Build a Healthier
America)

Over the next several weeks we will give you a glimpse into the national Network of MLPs, and share some of the vision that is unfurling from Lancaster, PA right through the Midwest to San Jose CA, and beyond. MLPs are putting teeth into the policies and programs that hold the keys to health.

Legal Aid – Primary Care’s New BFF?
As the research on health care and access converges with a change in the White House, we know that primary care for vulnerable populations is poised to get a huge moral and financial boost – and it’s about time. Legal aid lawyers would do well to pay attention to where their clients get their primary health care and not just for the purpose of ensuring that patient rights are protected. Medicaid managed care programs – as funky as they may be – regularly connect low-income individuals and families with a primary care doctor. While academic and community hospitals provide significant care to vulnerable populations, especially in urban areas, it is the network of rural and community health centers (http://www.nachc.org/) that many of America’s poor, rural communities turn to for primary care. They are the legal aid equivalent in the medical world. Those that are federally qualified are required to provide medical services to vulnerable populations that are medically underserved. Front-line health care staff serving low-income patients are committed to the vision of healthy vulnerable populations. And they toil in relative obscurity and pecuniary distress – just like legal aid!

Don’t underestimate the resuscitating quality of a new friendship – especially in this time of deep financial insecurity. We're all in this together.