Doctors & Lawyers for Kids A Medical- Legal Partnership

Becky Carothers, MD

Andrea Hunt, JD

July 12, 2013

• Describe the medical-legal partnership

movement nationwide and in Louisville.

• Relate how preventive legal care can

improve patients’ health and well-being.

• Identify social determinants of health with

a legal remedy.

• Introduce the referral process and how to

involve your patients.

Objectives

e

Timmy

• Toddler with a burn on hand from

touching an open oven

• Burn treated in ED

• His sister, Olivia,

returned with a

burn 6 weeks later

• CPS contacted

Barry Zuckerman, MD

Medical-Legal Partnership

Medical-Legal Partnership

• A preventive healthcare delivery model

• Improves health and well-being of

vulnerable populations

• Addresses unmet legal needs

• Removes legal barriers that impede

health

Michael

Traditional Approach

Mold/Pests

Asthma

Call landlord

Frustration, withholding rent

Eviction notice.

Legal Aid?

Substandard Housing Homelessness Overcrowding

MLP Approach

Mold/Pests

Asthma

Medical-Legal

Intervention

No mold/pests

Asthma well-managed

Why a Medical-Legal

Partnership? • Healthcare teams have early access to

vulnerable populations

• Build on trust in healthcare professionals

• Reduce barriers to legal services

• Channel limited legal resources

• Comprehensive services in ambulatory

practices

Retkin, Randye, et al. “Medical Legal Partnerships: A Key Strategy for Mitigating the Negative

Health Impacts of the Recession.” The Health Lawyer, Vol. 22 No. 1, (Oct. 2009).

Sandel, Megan et al. “Medical-Legal Partnerships: Transforming Primary Care By Addressing

The Legal Needs Of Vulnerable Populations.” Health Affairs, Vol. 29. No. 9 (Sept. 2010).

Asthma

• Retrospective review

• 12 adults with moderate to severe asthma

receiving a medical-legal intervention

• 22 ED visits and 11 admissions to 2 ED visits

and 1 admission (91% reduction)

• All patients had reductions in the dose

and/or number of medications

• During post-intervention, 11 (91%) patients

• dropped ≥2 classes in asthma severity.

– O’Sullivan, et al. (2012). Environmental Improvements Brought by the Legal Interventions in the

Homes of Poorly-Controlled Inner-city Adult Asthmatic Patients: A Proof-of-Concept Study.

Journal of Asthma, 49(9), 911-917.

Cancer

• Women with cervical cancer

– 75% patients showed a reduction in stress

– 30% increase in treatment adherence

– 25% patients had greater ease in keeping

appointments

– Captured ~ $923,188 of previously denied

benefit claims

Rodabaugh, K. J., Hammond, M., Myszka, D., & Sandel, M. (2010). A medical-legal partnership as

a component of a palliative care model Journal of Palliative Medicine, 13(1), 15-18.

•

– Fleishman SB, Retkin R, Brandfield J, Braun V. The attorney as the newest member of the

cancer treatment team. J Clin Oncol. 2006 May 1;24(13):2123-6

–

Resident Education

• Residents in clinics with social/legal

resources were more likely to:

– Ask patients about their social history and

situation with housing and public benefits.

– More confident regarding their personal

knowledge of social determinants of health

and screened for them more frequently.

– More confident about public benefits.

– O'Toole JK, Burkhardt MC, Solan LG, Vaughn L, Klein MD. Resident confidence addressing

social history: is it influenced by availability of social and legal resources? Clin Pediatr (Phila).

2012 Jul;51(7):625-31.

Return on Investment

• MLP of Southern Illinois

– 319% return on the original investment of

$116,250 between 2007 - 2009.

– Helped relieve $4 million in patients' health

care debt

– Claiming $2 million in additional Social

Security benefits for patients.

• Teufel, J. A. & Werner, D. & Goffinet, D. & Thorne, W. & Brown, S. L. & Gettinger, L. (2012). Rural

Medical-Legal Partnership and Advocacy: A Three-Year Follow-up Study. Journal of Health Care for

the Poor and Underserved 23(2), 705-714. The Johns Hopkins University Press.

Nationwide Successes

• 275 hospitals and health centers

• 54,000 clients receive legal assistance yearly

* 9,163 healthcare providers trained

* 2,696 residents trained

* $37.7 million recovered for patient-

clients by MLPs

* 2011 National Center MLP survey

Medical-Legal Partnership

1993 Boston Medical Center

2005 National Center for Medical-

Legal Partnership

2010 Doctors & Lawyers For Kids

Children & Youth Project

Legal Aid Society

• Up to 200% of

poverty level

• Divorces, DVOs, life

planning documents,

foreclosures,

evictions, &

other civil legal

needs

4,000

served

6,000

Turned

away

Source: Legal Services Corporation, Documenting the Justice Gap in America: The Current Unmet Civil Legal Needs of Low-Income Americans (September 2009).

Legal Aid:

Supply & Demand

Medical-Legal Interventions

Individual representation

Changing healthcare and legal institutions

Policy changes and

“impact litigation”

Advocating for Patients

Collaborative Approach

• Cincinnati

Children’s Hospital

• 4 patients referred

in a 6-week period

• Poor-quality

housing cluster

identified

Beck A.F., Klein M.D., Schaffzin J.K., Tallent V., gillam M., Kahn R.S. Identifying and

Treating a Substandard Housing Cluster Using a Medical-Legal Partnership. Pediatrics

130:5, 11/2012 pp. 831-836.

Evaluating Effectiveness

• Multi-pronged

advocacy

strategy

• Study confirmed

effectiveness of

medical-legal

partnership

Beck A.F., Klein M.D., Schaffzin J.K., Tallent V., Gillam M., Kahn R.S. Identifying and

Treating a Substandard Housing Cluster Using a Medical-Legal Partnership. Pediatrics

130:5, 11/2012 pp. 831-836.

I Income supports: Unfair denial of

benefits

H Housing/Utilities: Unsafe conditions

E Education/Employment: Special needs

L Legal status: Naturalization

P Personal safety and stability: custody for

grandparents

I-HELP

Identifying Legal Needs

• How are you making ends meet?

• Do you have enough food to eat?

• Are you worried about your (child’s) safety?

• Where are you living?

• How is the environment in your home?

• How is your child doing in school?

• Would you like to talk to a social worker or

legal today?

Coordinating Services

• ULP: All Scripts

• KCH: Social Work Dept.

• Attorney’s duty of confidentiality and

attorney-client privilege

• Transitional care to prevent future

admissions

Julia

Income as a Determinant of

Health

Source: P.A. Braveman, et al., “Broadening the Focus: The Need to Address the Social Determinants of Health,” American Journal of Preventive Medicine, 40, no. 1S1 (2011): S6.

Income as a Determinant of

Health

Low Income

Financial Trade-off

Health Impact

Social Risk Index and

Re-Utilization • Relationship between home address

and hospital re-utilization

• Geocoded home addresses

• Social risk index: poverty rates, home

values, graduation rates

• Patients admitted for asthma placed in

one of three geographic risk strata

Beck AF, et al. Geomedicine: area-based socioeconomic measures for assessing risk of

hospital reutilization among children admitted for asthma. Am J Public Health. 2012

Dec;102(12):2308-14.

Re-Utilization Rates

Low Risk Medium Risk High Risk

Beck AF, et al. Geomedicine: area-based socioeconomic measures for

assessing risk of hospital reutilization among children admitted for asthma.

Am J Public Health. 2012 Dec;102(12):2308-14.

• Ms. Sowell video clip with pictures

179 Families Helped

44

66

24

8

37

I H E L P

KCH

General

Pediatrics

Clinics

Sources of Patient-Clients

Sources of Funding Children's Hospital

Foundation

UofL Pediatrics

Glass Slipper Society

Greater Louisville

Medical Society

KY Bar Foundation

KBA Health Law Section

Louisville Bar

Foundation

Ramble by the River

Gheens Foundation

Timmy and Olivia

Summary

• Medical-legal partnership is a new

approach to comprehensive healthcare

• Legal needs can affect patients’ health

• Preventive legal care can improve

patients’ health and well-being

• You can refer your patients to Doctors &

Lawyers for Kids if they may face legal

barriers to their health.

References 1. Beck, A.F., et al. Geomedicine: area-based socioeconomic measures for

assessing risk of hospital reutilization among children admitted for asthma. Am

J Public Health. 2012 Dec;102(12):2308-14.

2. Beck A.F., et al. Identifying and Treating a Substandard Housing Cluster Using

a Medical-Legal Partnership. Pediatrics 130:5, 11/2012 pp. 831-836.

3. Fleishman SB, Retkin R, Brandfield J, Braun V. The attorney as the newest

member of the cancer treatment team. J Clin Oncol. 2006 May 1;24(13):2123-6

4. Knight, 2008. Health Care Recovery Dollars: A Sustainable Strategy for

Medical-Legal Partnerships?

5. Legal Services Corporation, Documenting the Justice Gap in America: The

Current Unmet Civil Legal Needs of Low-Income Americans (Sept. 2009).

6. O’Sullivan, et al. (2012). Environmental Improvements Brought by the Legal

Interventions in the Homes of Poorly-Controlled Inner-city Adult Asthmatic

Patients: A Proof-of-Concept Study. Journal of Asthma, 49(9), 911-917.

References 7. O'Toole JK, Burkhardt MC, Solan LG, Vaughn L, Klein MD. Resident confidence

addressing social history: is it influenced by availability of social and legal

resources? Clin Pediatr (Phila). 2012 Jul;51(7):625-31.

8. P.A. Braveman, et al., “Broadening the Focus: The Need to Address the Social

Determinants of Health,” American Journal of Preventive Medicine, 40, no. 1S1

(2011): S6.

9. Retkin, Randye, et al. “Medical Legal Partnerships: A Key Strategy for

Mitigating the Negative Health Impacts of the Recession.” The Health Lawyer,

Vol. 22 No. 1, (Oct. 2009).

10. Rodabaugh, K. J., Hammond, M., Myszka, D., & Sandel, M. (2010). A medical-

legal partnership as a component of a palliative care model Journal of Palliative

Medicine, 13(1), 15-18.

11. Ryan, A. M. & Kutob, R. M. & Suther, E. & Hansen, M. & Sandel, M.(2012). Pilot

Study of Impact of Medical-Legal Partnership Services on Patients’ Perceived

Stress and Wellbeing. Journal of Health Care for the Poor and Underserved

23(4), 1536-1546.

References

12. Sandel, et al. “Medical-Legal Partnerships: Transforming Primary Care By

Addressing The Legal Needs Of Vulnerable Populations.” Health Affairs, Vol.

29. No. 9 (Sept. 2010).

13.Teufel, J. A. & Werner, D. & Goffinet, D. & Thorne, W. & Brown, S. L. &

Gettinger, L. (2012). Rural Medical-Legal Partnership and Advocacy: A Three-

Year Follow-up Study. Journal of Health Care for the Poor and Underserved

23(2), 705-714. The Johns Hopkins University Press.

14. Zuckerman B, Sandel M, Lawton E, Morton S. Medical-legal partnerships:

transforming health care. Lancet. 2008;372(9650):1615–1617.