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Journal of Legal Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ulgm20
The MLP Vital Sign: Assessing and Managing Legal Needs in the Healthcare Setting a
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Megan Sandel MD MPH , Emily Suther MA , Carrie Brown MD , c
Marissa Wise MD & Mark Hansen MPH
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The National Center for Medical-Legal Partnership
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University of Arkansas for Medical Sciences
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Icahn School of Medicine at Mount Sinai Published online: 26 Mar 2014.
Click for updates To cite this article: Megan Sandel MD MPH , Emily Suther MA , Carrie Brown MD , Marissa Wise MD & Mark Hansen MPH (2014) The MLP Vital Sign: Assessing and Managing Legal Needs in the Healthcare Setting, Journal of Legal Medicine, 35:1, 41-56, DOI: 10.1080/01947648.2014.884431 To link to this article: http://dx.doi.org/10.1080/01947648.2014.884431
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Journal of Legal Medicine, 35:41–56 C 2014 American College of Legal Medicine Copyright 0194-7648 print / 1521-057X online DOI: 10.1080/01947648.2014.884431
THE MLP VITAL SIGN: ASSESSING AND MANAGING LEGAL NEEDS IN THE HEALTHCARE SETTING Megan Sandel, MD, MPH, Emily Suther, MA, Carrie Brown, MD, Marissa Wise, MD, and Mark Hansen, MPH*
INTRODUCTION Social conditions have a powerful impact on the overall health and well-being of patients. In 2012, the United States Census reported that more than 46 million people were living in poverty, including more than 16 million children under the age of 18.1 Many social determinants of health (SDHs) are manifested as material hardships. There is evidence that demonstrates how these hardships, such as inadequate housing,2 food insecurity,3 educational disruption, and utility shut-offs,4—which are very common among impoverished families—can negatively impact health. Notably, studies have shown that children living in poverty have chronic asthma rates that are twice those of
* Megan
Sandel is an Associate Professor of Pediatrics at Boston University School of Medicine and Public Health. She is also the Medical Director at the National Center for Medical-Legal Partnership. Emily Suther is a Research Assistant for the National Center for Medical-Legal Partnership. Carrie Brown is an Assistant Professor of Pediatrics at the University of Arkansas for Medical Sciences. Marissa Wise is a physician at the Icahn School of Medicine at Mount Sinai. Mark Hansen is a Senior Evaluation Consultant at the The National Center for Medical-Legal Partnership. Please direct correspondence to Megan Sandel at [email protected]. 1 Income, Poverty and Health Insurance in the United States: 2011, U.S. DEP’T OF COMMERCE, http://www. census.gov/prod/2012pubs/p60–243.pdf (last visited Oct. 10, 2013). 2 See Diana Becker Cutts et al., US Housing Insecurity and the Health of Very Young Children, 101 J. AM. PUB. HEALTH 1508 (2011), http://www.childrenshealthwatch.org/upload/resource/ushousing andchildhealth ajph dc aug11.pdf. 3 See John T. Cook et al., Are Food Insecurity’s Health Impacts Underestimated in the U.S. Population? Marginal Food Security Also Predicts Adverse Health Outcomes in Young U.S. Children and Mothers, 4 ADVANCES IN NUTRITION 51 (2013). 4 See Deborah A. Frank et al., Cumulative Hardship and Wellness of Low-Income, Young Children: Multisite Surveillance Study, 125 PEDIATRICS e1115 (2010), http://pediatrics.aappublications.org/content/ 125/5/e1115.full.pdf.
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their higher-income peers.5 Furthermore, families living in inadequate home environments face greater rates of infestations and mold, which have been shown to exacerbate chronic asthma.6 Given that the exposure to these material hardships is common and that such exposure is detrimental to health, it is important to understand the spectrum of these underlying issues. Though some of these can be simple resource needs, some of these are, in fact, legal issues, and the remedies for these lie in the laws and regulations that govern whether people receive the benefits that can address hardships, such as the Supplemental Nutrition Assistance Program (SNAP)7 to address food insecurity, or protections under the law, such as enforcement of housing codes for children with asthma living with mold or pests. Healthcare providers have long monitored health and well-being through a handful of informative indicators—so-called “vital signs.” Our argument here is that information concerning exposure to various material hardships or adverse conditions is just as relevant to evaluating the health of patients as are the traditional vital signs. Screening for these hardships and their legal underpinnings will need to become the new health vital sign if healthcare is going to effectively address the SDHs. Screening then will need to lead to action, and healthcare sites will have to have the right professionals as part of the healthcare team to address the issues identified. There can be many reasons why information about social conditions and hardships are not considered in most current healthcare practices, and why a medical-legal partnership (MLP) vital sign has not already become integrated into practice. One reason is that, sometimes, social hardships are not considered to be related to health and well-being, though this might be a less common belief given the emerging understanding of SDHs. A more important reason, however, might be that healthcare providers generally do not have the tools or resources necessary to respond to the hardships that their patients are facing. In this case, having the right professionals as part of the healthcare team to address patients’ social concerns and unmet needs will become just as important as checking patients’ blood pressure.8 MLP is a
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M. Weitzman, Racial, Social, and Environmental Risks for Childhood Asthma, 144 AM. J. DISEASES CHILD. 1189 (1990). 6 David L. Rosenstreich et al., The Role of Cockroach Allergy and Exposure to Cockroach Allergen in Causing Morbidity Among Inner-City Children with Asthma, 336 NEW ENG. J. MED. 1356 (1997), http://www.nejm.org/doi/pdf/10.1056/NEJM199705083361904. 7 SNAP: FOOD AND NUTRITION SERVICE, http://www.fns.usda.gov/snap (last visited Oct. 11, 2013). 8 Health Care’s Blind Side: The Overlooked Connection Between Social Needs and Good Health, THE ROBERT WOOD JOHNSON FOUND. (2011), http://www.rwjf.org/content/dam/farm/reports/surveys and polls/2011/rwjf71795.
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healthcare model to address legal needs as part of care and could become the new vital sign of healthcare.9
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I. HOW HARDSHIPS IMPACT HEALTH Food insecurity plays an important role in overall health. According to a 2013 study of more than 41,000 caregiver-child pairs, 14.9% of families live in marginally food-secure households, and 23.3% of families live in food-insecure households.10 Both marginal food security and food insecurity were associated with higher rates of child fair/poor health status and hospitalizations, as well as higher rates of caregiver depressive symptoms.11 According to Children’s Healthwatch data, even children at very low levels of inadequate access to healthy foods suffer negative health and developmental effects. Children under age three who grow up in homes that are marginally food secure are at higher risk for negative health outcomes than are children in households that are food secure.12 The children in food-insecure households are at higher risk for developmental delays, and are more likely to: lack stable housing, live in homes with inadequate heating or cooling, have caregivers who are experiencing depressive symptoms, and be in fair or poor health.13 Energy hardships also can impact the health of families negatively. As the cost of energy increases, and as the demand for heating and cooling increases as the temperature rises in the summer and falls in the winter, families often have difficulty paying for the energy that they need. Frequently, families have to make a choice when it comes to paying the bills, and they often resort to alternative energy sources. These include using a kitchen oven to heat their home or relying on candles for lighting. These actions can put families at risk of carbon monoxide exposure and burns. Despite the existence of Low Income Home Energy Assistance Program (LIHEAP), a federal program that provides assistance with utilities, few families actually
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Megan Sandel, Creating the Social Determinants of Health Vital Sign: Are We Ready, MEDICAL-LEGAL PARTNERSHIP BLOG (July 26, 2013), http://medical-legalpartnership.blogspot.com/2013/07/creatingsocial-determinants-of-health.html; see Ellen M. Lawton, Medical-Legal Partnerships: From Surgery to Prevention?, MANAGEMENT INFO. EXCHANGE J. 37 (2007), http://www.washingtonmlp.org/documents/ 439011Medical-Legal%20Partnerships%20-%20From%20Surgery%20to%20Prevention.pdf. 10 See Cook et al., supra note 3. 11 Id. at 58. 12 John T. Cook et al., Even Very Low Levels of Food Insecurity Found to Harm Children’s Health, CHILDREN’S HEALTHWATCH 1 (May 2009), http://www.childrenshealthwatch.org/upload/ resource/chwbrief FI.pdf. 13 Id.
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utilize this resource. Children growing up in energy-insecure households are at a higher risk to be: in poor health, at risk of developmental problems, and food insecure.14 Housing is also an important component of health and well-being with respect to both housing environment and affordability. Children’s Healthwatch reports that children in subsidized housing do better than their counterparts who are not living in subsidized housing.15 Children living in subsidized housing are more likely to have enough food and are less likely to be significantly underweight.16 These children are also more likely to be characterized as “well” on health composites.17 Additionally, families in subsidized housing have more money left for other basic needs, such as food.18 Environmental housing conditions also contribute to overall health and well-being in families. Previous studies have shown that deteriorated housing can increase home allergen levels, such as cockroach allergens.19 Exposure to elevated levels of allergens has been shown to be a risk factor for asthma, one of the most prevalent chronic illnesses associated with low-income and minority status. Children with asthma who were also allergic to cockroaches and who were exposed to cockroaches in their home were three times more likely to be hospitalized for asthma.20 Legal needs could be any adverse social conditions with remedies that reside in laws, regulations, or policies.21 For example, a patient might be behind in paying his or her utility bill, which is considered a social need. If the patient’s energy is shut-off, despite there being a legitimate need for the continuation of utility services, such as a disability that requires an electrical device or a medication that requires refrigeration, then the issue becomes legal in nature as there is a legal remedy for the problem.
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See Stephanie Ettinger de Cuba et al., Fuel for Our Future: Impacts of Energy Insecurity on Children’s Health, Nutrition, and Learning, CHILDREN’S SENTINEL NUTRITION ASSESSMENT PROGRAM (Sept. 2007), http://www.childrenshealthwatch.org/wp-content/uploads/fuel for our future 2007.pdf. 15 Elizabeth L. March et al., Rx for Hunger: Affordable Housing, CHILDREN’S HEALTHWATCH (Dec. 2009), http://www.childrenshealthwatch.org/upload/resource/RxforhungerNEW12 09.pdf. 16 Id. 17 Id. 18 Id. 19 Virginia A. Rauh et al., Deteriorated Housing Contributes to High Cockroach Allergen Levels in InnerCity Households, 110 ENVIRON. HEALTH PERSP. 323, 323-27 (Apr. 2002), http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC1241179/pdf/ehp110s-000323.pdf. 20 Rosenstreich et al., supra note 6. 21 See Arvin Garg et al., Screening for Basic Social Needs at a Medical Home for Low-Income Children, 48 CLIN. PED. 32, 34 (Jan. 2009), http://www.washingtonmlp.org/documents/439121Screening% 20for%20Basic%20Social%20Needs%20at%20a%20Medical%20Home[1].pdf.
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TABLE 1. Examples of Legal Needs that Affect Health Using the I-HELP Assessment22 Legal Need Income/Insurance
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Housing
Education/Employment
Legal Status Personal/Family Stability
Examples of Legal Needs Impacting Health - Insurance Access and Benefits - Food Stamps - Disability Benefits - Social Security Benefits - Shelter Access - Access to Housing Subsidies (e.g., Section 8 program) - Sanitary Housing Conditions (e.g., mold, lead) - Foreclosure Prevention - Americans with Disabilities Act Compliance - Utility Access - Americans with Disabilities Act Compliance - Discrimination - Individuals with Disabilities in Education Act Compliance - Immigration (e.g., asylum, Violence Against Women Act) - Criminal Record Issues - Guardianship, Custody, and Divorce - Domestic Violence - Child and Elder Abuse and Neglect - Capacity/Competency - Advanced Directives - Powers of Attorney - Estate Planning
II. HOW HARDSHIPS TRANSLATE TO LEGAL NEEDS Previous studies have consistently demonstrated that22 the majority of low-income families experience some civil legal needs.23 Primarily, these are derived from the most basic human needs, including safe housing, education, access to income support, protection from violence, and access to healthcare. These needs are widely distributed, of long duration, and detrimental to patient health. Both national and state-based legal needs studies suggest that most low-income individuals experience at least two legal needs, most of which are not addressed.24 Given that many laws and regulations govern these rights and benefit programs, hardships often arise after patients are unable to access these benefits and protections. 22
See generally Ch´en Kenyon et al., Revisiting the Social History for Child Health, 120 PEDIATRICS e734, e737 (2007), http://www.pediatricsdigest.mobi/content/120/3/e734.full.pdf. 23 Albert H. Cantril, Agenda for Access: The American People and Civil Justice, AM. BAR ASS’N (May 1996), http://www.nasams.org/DMS/Documents/1029845097.99/agendaforaccess.pdf. 24 Schulman, Ronva, & Bucuvalas, Inc., Massachusetts Legal Needs Survey: Findings from a Survey of Legal Needs of Low-Income Households in Massachusetts, MASS. LEGAL ASSISTANCE CORP. 1, 3 (May 2003), http://lri.lsc.gov/sites/default/files/LRI/pdf/03/030156 malglnds.pdf.
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Studies have also found a significant correlation between legal needs and health.25 Moreover, the hardships associated with poverty include utility shut offs, hunger, safety, and substandard housing, all of which directly influence health. The legal system directly affects how low-income families can have these needs met to ensure the health and well-being of their family. The establishment of legal supports serves to lower these barriers and improve access to care. III. WHY LEGAL NEEDS OFTEN GO UNADDRESSED Because the prevalence of legal needs is so high and the resources are so few, access to legal assistance is often limited, and resources are stretched too thin. In Boston, for example, Greater Boston Legal Services estimates that it turns away three out of every five clients due to a lack of resources.26 National data show that health centers serve more than 22 million patients in the United States, the majority of whom are low-income and are often also ethnic and racial minorities.27 In excess of 70% of health center patients live below the federal poverty level (FPL), and at least 34% are racial minorities.28 Furthermore, while 36% of patients are uninsured, 50% depend on Medicare, Medicaid, or another public insurance option.29 Though the resources offered at health centers try to mitigate the legal issues faced by low-income individuals, they are not equipped to remedy the underlying causes.30 Therefore, it is imperative that legal needs are actively screened for, especially as most patients’ needs go unresolved. Moreover, patients are unsure where to go to access needed legal services. Socioeconomic disparities continue to pervade the realm of healthcare, and previous research has demonstrated that the social circumstances of patients’ lives can directly influence their health.31 For example, families worried about the safety of their home or paying for food are dealing with social issues that might eventually become a legal need with a legal solution. Often, the 25
Nancy E. Adler & Katherine Newman, Socioeconomic Disparities in Health: Pathways and Policies, 21 HEALTH AFF. 60 (Mar. 2006), http://www.sph.umich.edu/sep/downloads/Adler Newman Socioeconomic Disparities in Health.pdf. 26 Legal Needs and Civil Justice: A Survey of Americans, AM. BAR ASS’N (2004), http://www.americanbar. org/content/dam/aba/migrated/legalservices/downloads/sclaid/legalneedstudy.pdf. 27 America’s Health Centers, NAT’L ASS’N COMMUNITY HEALTH CTRS. (2013), http://www.nachc.com/client/ documents/America%27s CHCs 0813.pdf. 28 Id. 29 Id. 30 See Documenting the Justice Gap in America: The Current Unmet Civil Legal Needs of Low-Income Americans, LEGAL SERVS. CORP. (2009), http://www.lsc.gov/sites/default/files/LSC/pdfs/ documenting the justice gap in america 2009.pdf. 31 Michael Marmot et al., Health Inequalities Among British Civil Servants: The Whitehall II Study, 337 LANCET 1387 (1991).
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circumstances surrounding legal needs can deteriorate to a point where a legal remedy exists; however, regardless of the degree of severity of the concern, the stress that the patients feel can be overwhelming. Physiological consequences of increased stress include changes in cardiovascular function and have been linked to heart disease.32 Stress can also prompt patients to make unhealthy lifestyle choices, such as smoking, sedentary behavior, and unhealthy eating.33 Legal needs are common and affect multiple social factors and circumstances. At an MLP in Tucson, Arizona, providers referred 104 patients for legal services, and, at the time of intake, 170 discrete legal matters were identified.34 These issues ranged from housing concerns to health insurance coverage to finances. Providers in a pediatric setting at a Baltimore hospital conducted similar research in which parents were surveyed about the legal concerns that they were facing, with employment and education concerns being the most commonly reported issues.35 Legal concerns are important to consider in the patient-care setting, as often they can be ameliorated through social resources and referrals, but, without being appropriate addressed, such concerns could become legal needs that require legal intervention. IV. MEDICAL-LEGAL PARTNERSHIP: A HEALTHCARE MODEL TO ADDRESS LEGAL NEEDS MLP is a healthcare delivery model designed to address legal needs as part of healthcare. MLPs were first developed in 1993.36 Since inception, more than 85 programs have been developed across the country, serving 300 hospitals and clinics.37 MLP is a healthcare delivery model that serves to improve the health and well-being of low-income and other vulnerable populations by addressing unmet legal needs that impede health. Through MLPs, legal professionals, such as legal aid organizations, law school partners, and pro bono communities, are integrated into the healthcare team. Together, the legal and medical teams work in collaboration to provide direct legal assistance to patients, to develop strategy to improve health and legal institutions and 32
Robert M. Carney et al., Reproducibility of Mental Stress-Induced Myocardial Ischemia in the Psychophysiological Investigations of Myocardial Ischemia (PIMI), 60 PSYCHOSOMATIC MED. 64 (1998). 33 Debbie M. Ng & Robert W. Jeffery, Relationships Between Perceived Stress and Health Behaviors in a Sample of Working Adults, 2 HEALTH PSYCHOL. 638 (2003). 34 Ann M. Ryan et al., Pilot Study of Impact of Medical-Legal Partnership Services on Patients’ Perceived Stress and Wellbeing, 23 J. HEALTH CARE POOR & UNDERSERVED 1536, 1540 (2012). 35 Garg et al., supra note 21, at 34. 36 Megan Sandel et al., Medical-Legal Partnerships: Transforming Primary Care by Addressing the Legal Needs of Vulnerable Populations, 19 HEALTH AFF. 1697, 1698 (2010), http://content.healthaffairs.org/ content/29/9/1697.full.pdf. 37 See The Movement, NAT’L CTR. FOR MEDICAL-LEGAL PARTNERSHIP, http://www.medical-legalpartnership. org/movement (last visited Oct. 7, 2013).
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practices, and to change policies that serve to ensure that patients’ legal needs are being met.38
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V. SCREENING FOR LEGAL NEEDS: A PILOT STUDY Many patients may identify that they have hardships, but they may not understand that they have a right to benefits or protections under the law. One study tried to identify whether patients knew they had legal concerns and what assistance was wanted with regard to such concerns. This legal needs assessment study conducted at Boston Medical Center (BMC) surveyed the parents and/or guardians of patients coming to the Pediatric Emergency Department for care in the fall of 2007.39 Families in the waiting area of the clinic were invited to participate in the two-part study, which included a brief self-administered questionnaire and a follow-up telephone interview. In all, 154 individuals completed the questionnaire, and 39 completed the interview. The results paint a cogent and troubling picture about how vulnerable families struggle to meet their basic needs, and, therefore, suffer hardships affording or accessing food, housing, healthcare, education services for their children, and safety. The consequences of having unmet legal needs are varied and often affect the most vital aspects of family life. This study found that, within the previous year, nearly half of the families received a letter threatening a utility shut off from their utility company; moreover, 23% of the families that received such a letter actually experienced a shut off in that time frame. When families have difficulty paying their utility bills, they are often forced to resort to unsafe practices, such as using the stove to heat their home, as 25% of families did in this study. Additionally, more than 36% of families reported that they had to reduce the size of their meals or skipped meals because they did not have enough money for food. Many of these hardships are health-related social problems that can be addressed or resolved through the appropriate resource, to which these patients have the right. This study also demonstrates the persistence and severity of unmet needs that families are facing. Families reported that their issues had been a concern to them for at least six months, demonstrating that unmet needs continue to affect families for extended periods of time, influencing multiple facets of their life. Eight-five percent of families described their concerns as either somewhat “serious” or “very serious,” reflecting that these issues are not 38
See Barry Zuckerman et al., Medical-Legal Partnerships: Transforming Health Care, 372 LANCET 1615 (2008); The Model, NAT’L CTR. FOR MEDICAL-LEGAL PARTNERSHIP, http://www.medical-legalpartnership. org/model (last visited Oct. 7, 2013). 39 Dr. Megan Sandel was the principal investigator on this study. Please contact Dr. Sandel at [email protected] for more information about this study.
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TABLE 2. Reasons Reported for Not Seeking Legal Help for Problem or Concern40
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Why Families Did Not Seek Legal Assistance for Their Concern Do not believe issue to be legal in nature Believe I can handle the issue without legal assistance Cannot afford legal services Do not believe anything can be done Do not know where to go or who can help with the issue
Percentage (n = 33) 79% 79% 67% 55% 52%
minor, and, with the duration of time that they last, these issues can have a huge impact on families and the way that impacted families try to meet their basic needs. One aim of this40 study was to understand why families may be resistant to seeking out legal services for their unmet needs. One part of the survey asked about whether or not they had sought help for their issue. Fifteen percent of those followed-up with by phone reported seeking help from an attorney; half of that 15% sought the help of a free legal service. Nevertheless, most of the families that sought the help of free legal aid services did not receive any assistance. In fact, only one family that sought the help of an attorney actually had the issue addressed. Those families that never sought the help of legal services were asked about the reasons why no legal assistance had been sought, as highlighted in Table 2. These findings suggest that, even though many of these issues have a legal connotation, many families do not believe that their issues can be resolved through legal services, or they are confused about who to contact or worried about the cost. This study highlights the importance of helping patients recognize the legal ramifications of their concerns, as well as arming them with the resources that can help them get their concerns resolved. Another important aim of this study was to determine attitudes and opinions of patients concerning laws, the healthcare system, and community resources. Patients were asked to state their opinion of eight professional groups, and they were given the option to say that they held a positive, neutral, or negative view. They were also asked whether they believed the professional group to be “not at all,” “somewhat,” or “very” helpful to families in the community. Responses were then converted to a three-point scale to derive “favorability” and “helpfulness” scores. Of the eight professional groups, patients indicated that they consider all groups to be both helpful and favorable 40
Original data collected by authors in the Pediatric Emergency Department at Boston Medical Center, Boston, Massachnsctts. Please contact Dr. Sandel at [email protected] for more information about this study.
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with the exception of two. They indicated that they do not believe lawyers to be helpful, giving them a slightly negative helpfulness score. They also indicated that they consider politicians to be unhelpful, with a very negative helpfulness score, and they do not have a favorable opinion of them, giving them a very negative favorability score. This component of the survey highlights the negative impression that these patients hold toward certain professions, and indicates why they may be hesitant to seek out the assistance of a lawyer or legal team. If patients do not feel that they can trust the legal services that may be able to help them, then they will be unlikely to seek out such assistance in the first instance. By integrating legal services into healthcare through MLP, families are not left to recognize that they need legal services, but, rather, the healthcare team helps them identify their legal needs and can address such needs as part of routine care. Depending on the partnering legal entity, eligibility for services can range up to 200% of the FPL and can be restricted to certain citizenship statuses. In the BMC Pediatric Emergency Department study, the majority of respondents were eligible for legal services due to these factors. The barriers to access, however, arose for alternative reasons. Many patients did not believe that their concern was a legal issue or that it could be resolved through legal interventions. Additionally, many were unaware of the services available to them and do not know how to access legal resources. Finally, a major barrier was that respondents did not believe that help would actually resolve their issue, which stemmed from their perception of the resources and services available to them. Another major barrier arises when a family actually tries to seek legal help. In the BMC study, a very small percentage of respondents actually sought out the help of an attorney or free legal services. This problem is perpetuated when the help that families seek is ineffective. Only one of the six families that sought legal services for the concern was actually helped, making it an inefficient system, and an unlikely place for families to turn. Because of the pervasiveness of these issues and the duration of time that they last, the likelihood that these concerns are addressed is very small. While only a few people actually sought out legal help, the majority of families have something that has been concerning them for more than six months. This suggests that many more people could and should be helped by legal assistance but that there is some barrier preventing them from seeking out this help. When legal concerns go unaddressed, there is likely to be some detrimental impact to the family, as evidenced by the number of respondents in the BMC study who had their utility services disconnected, or who had to cut the size of their meals or skip them altogether. This directly influences overall family stability and prevents families from providing the most basic needs to their children.
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There are also several expectations of the community and its leaders. It is imperative that the community recognizes the importance of free legal services and that it allocates adequate resources to these services so that such services can provide service to eligible families seeking help. The current system does not support all of these expectations, and, consequently, the patients who are in need face numerous barriers when trying to access legal services and assistance for their most pressing concerns. Social screening tools have been developed to aid providers in helping patients to identify any unmet social needs that may have legal consequences down the line.41 These screening tools are used in practice at many hospitals and MLPs across the country. In some MLP settings, there is a formal screening process where the patient or caregiver completes a screening form at some point during the appointment, which is then given to the provider to help determine whether there are any concerns that may be ameliorated by social or legal resources.42 Many institutions utilize trainings to make their providers aware of the social needs plaguing their patients. The MLP model uses the acronym I-HELP to define the broad range of issues that a legal team in the healthcare setting will address. The acronym includes the following areas of inquiry: income (I), housing and utilities (H), education and employment (E), legal status/immigration (L), and personal safety (P). A study conducted at the Cincinnati Children’s Hospital Medical Center and the Legal Aid Society of Greater Cincinnati looked at training providers to be cognizant of how SDHs affected behavior. 43 The study comprised an intervention group, comprised of 20 pediatric interns beginning their internship in July of 2008, and the control group, comprised of 18 second-year residents.44 The residents in the control group had participated in an intern advocacy course that focused on “obesity, street drugs, poisoning, child abuse, and injury prevention,” but these residents did not have the SDHs curriculum, which the intervention group would receive.45 At the beginning and end of their respective intern years, each group completed a knowledge test survey of attitudes and comfort levels.46 The results showed that the intervention group had significantly better knowledge than the control group in all three of the areas tested: benefits, housing, and education.47 The intervention group also 41
David Keller et al., Development of a Brief Questionnaire to Identify Families in Need of Legal Advocacy to Improve Child Health, 8 AMBULATORY PED. 266, 268 (July 2008); Laura Gottlieb et al., Collecting and Applying Data on Social Determinants of Health in Health Care Settings, 173 JAMA INTERNAL MED. 1017, 1019 (2013). 42 Keller et al., supra note 41, at 266. 43 Melissa D. Klein et al., Training in Social Determinants of Health in Primary Care: Does It Change Resident Behavior?, 11 ACADEMIC PEDS. 387, 388 (Sept. 2011). 44 Id. at 389. 45 Id. 46 Id. 47 Id.
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documented the social history more frequently than the control group, especially issues that were covered during the advocacy course at the beginning of the year. This study highlights the importance of educating providers on the issues most commonly affecting their patients, especially when those issues can have a negative impact on health.
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VI. A CASE STUDY IN LEGAL NEEDS SCREENING At Arkansas Children’s Hospital (ACH), there is a screening process that helps providers identify unmet needs at the start of visits, and it is also designed to follow up on patients who indicate a positive response to a given need. The system is meant to inform providers that a need exists and to equip them with the tools to guide the patient to the appropriate resource. The system does not assign the responsibility of resolution to the provider, but, rather, it informs the provider that the patient could use a referral to a given resource or to the MLP. The screening process at ACH currently begins with patients receiving a screening form that is handed to them at check-in. This form is then brought into the patient room with the family, and the resident reviews it for all concerns. Any positive responses indicated on the form are followed up by the resident with a specific set of questions that pertains to that particular issue. Depending on the nature of the concern, the resident will either hand the family an information sheet about how to access a particular resource, or the resident will make a direct referral to social work or the MLP. If the MLP does get involved in the patient’s case, the provider will receive case status updates periodically. While this is a very effective system, ACH has future plans to make it more seamless and to help provide a more efficient means of referral. Specifically, ACH plans to have a kiosk, where the parent or guardian will answer the questions, instead of on paper. These questions will rotate with each visit, and follow-up questions to positive responses automatically will be asked. The residents will be notified on-screen of any positive responses, and certain positive answers will trigger an automatic page or email to a social worker or lawyer. A. Example of Screening Question Chain for Education The screening question chain is utilized at appointments at ACH. Parents or guardians answer the questions, and affirmative answers trigger certain referrals or follow-up questions from residents. Parents or guardians also have the option, at subsequent appointments, to follow up on these answers with their child’s provider, which helps to ensure that concerns are being addressed.
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FIGURE 1. Example of the Education Screening Chain from Arkansas Children’s Hospital48 (Color figure available online.)
B. Example of Screening Question Chain for Food Another question chain used at ACH screens for food security. Like the education sequence, questions answered affirmatively will trigger certain follow-up questions from residents or a referral to an appropriate resource. C. Current Clinic Screen Format The clinic screen helps to improve the efficacy of this process by indicating where a doctor has requested a social work or MLP referral. Symbols on the screen next to the status codes indicate that the doctor in the room has paged someone for assistance with addressing the patient’s unmet need. Furthermore, the system has a way to page the MLP directly in a similar way that an interpreter or a dietician would be paged. By integrating the MLP into the system, healthcare providers are able to make a referral easily and with little time spent.
48Id.
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FIGURE 2. Food Security Question Chain Used at Arkansas Children’s Hospital49 (Color figure available online.)
VII. A CASE STUDY IN HOW SCREENING FOR LEGAL NEEDS IMPROVES HEALTH OUTCOMES In Lancaster, Pennsylvania, medical49 and legal champions are addressing quality and cost in a high-utilization setting. The Lancaster team uses a 26-point scale to help identify barriers to care. Of the 26 barriers that the team has identified and for which it screens, 12 have been determined to be legal and could have legal solutions. The United States has the highest spending on health and highest total expenditure on health when compared to all other countries.50 In his January 2011 article in The New Yorker entitled “The Hot Spotters,” Atul Gawande highlighted the role of high-utilizer patients on the increasing cost of healthcare.51 These patients cycle in and out of hospitals and emergency departments, despite receiving high-cost medical care. Often, many of the issues plaguing these patients are legal and can be resolved 49
This figure is adapted from the computerized screening questionnaire used at Arkansas Children’s Hospital to show the flow of questions parents or guardians will receive based on affirmative answers they have given. Please contact Dr. Sandel at [email protected] for more information. 50 Health at a Glance 2009, ORG. FOR ECON. CO-OPERATION & DEV. 1, 160 (2009), http://www.oecd.org/ health/health-systems/44117530.pdf. 51 Atul Gawande, The Hot Spotters, NEW YORKER (Jan. 24, 2011), http://www.newyorker.com/reporting/ 2011/01/24/110124fa fact gawande.
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through legal intervention. These patients, however, often face barriers to accessing the resources that could ultimately ameliorate their concerns. Ms. Green52 is an example of a high-utilizer at the Lancaster clinic. Ms. Green is a 45-year-old woman who was referred to the superutilizer team due to her frequent utilization of hospital services. In the year before her referral to the clinic, she had eight emergency room visits, two inpatient visits, and three hospital observation visits for symptoms related to one of her many chronic diseases, including uncontrolled diabetes mellitus, congestive heart failure, hyperlipidemia, and hypertension. The team discovered that Ms. Green had significant financial stressors that impeded her ability to care for herself and cover the cost of dietary foods appropriate for her health. As a consequence of her uncontrolled diabetes, Ms. Green developed retinopathy and neuropathy, which prevented her from maintaining her job at a fast-food restaurant, and she had no other source of income. Ms. Green lived in an apartment with her 16-year-old, pregnant daughter and two-year-old granddaughter. Due to their inability to pay the rent, the family was evicted. At this time, social work was able to secure supportive housing for Ms. Green’s daughter and her children, but Ms. Green had to move in with a family member. These psychosocial stressors led to severe depression, which prevented Ms. Green from taking her medications or getting to medical appointments. With assistance from the physician in coordination with social work, Ms. Green was connected with a bilingual psychotherapist, and she also was assessed for medication needs to address her depression. The patient was referred to the MLP attorney who represented the patient in an appeal of her disability claim. The attorney collaborated with the social worker and physician to create a letter of support to supplement the Social Security claim. Through regular home visits, the social worker was able to keep the attorney updated on changes to Ms. Green’s health status. As well, the attorney was able to advise the medical team on which portions of the disability application were incomplete or underdeveloped so as to provide Social Security with the most accurate picture of the patient’s health functional limitations. Finally, the attorney and social worker were, together, able to meet with the patient to encourage her to attend medical appointments and to stress the importance of getting to all of her appointments. Since being referred to the superutilizer team eight months ago, Ms. Green has not had any inpatient hospitalizations and has had only one emergency room visit.
52
Name has been changed.
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CONCLUSION Exposure to various hardships or adverse social conditions can be detrimental to health. Across the spectrum of these SDHs, many have solutions in the laws and regulations designed to address hardships, such as SNAP. These hardships often become legal needs that can be remedied through MLP. If healthcare is to become serious about improving outcomes so that vulnerable populations can access the resources available to them, it will become important to develop an MLP vital sign and arm the healthcare team with the right professionals to address legal needs.
Journal of Legal Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ulgm20
The MLP Vital Sign: Assessing and Managing Legal Needs in the Healthcare Setting a
a
b
Megan Sandel MD MPH , Emily Suther MA , Carrie Brown MD , c
Marissa Wise MD & Mark Hansen MPH
a
a
The National Center for Medical-Legal Partnership
b
University of Arkansas for Medical Sciences
c
Icahn School of Medicine at Mount Sinai Published online: 26 Mar 2014.
Click for updates To cite this article: Megan Sandel MD MPH , Emily Suther MA , Carrie Brown MD , Marissa Wise MD & Mark Hansen MPH (2014) The MLP Vital Sign: Assessing and Managing Legal Needs in the Healthcare Setting, Journal of Legal Medicine, 35:1, 41-56, DOI: 10.1080/01947648.2014.884431 To link to this article: http://dx.doi.org/10.1080/01947648.2014.884431
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Journal of Legal Medicine, 35:41–56 C 2014 American College of Legal Medicine Copyright 0194-7648 print / 1521-057X online DOI: 10.1080/01947648.2014.884431
THE MLP VITAL SIGN: ASSESSING AND MANAGING LEGAL NEEDS IN THE HEALTHCARE SETTING Megan Sandel, MD, MPH, Emily Suther, MA, Carrie Brown, MD, Marissa Wise, MD, and Mark Hansen, MPH*
INTRODUCTION Social conditions have a powerful impact on the overall health and well-being of patients. In 2012, the United States Census reported that more than 46 million people were living in poverty, including more than 16 million children under the age of 18.1 Many social determinants of health (SDHs) are manifested as material hardships. There is evidence that demonstrates how these hardships, such as inadequate housing,2 food insecurity,3 educational disruption, and utility shut-offs,4—which are very common among impoverished families—can negatively impact health. Notably, studies have shown that children living in poverty have chronic asthma rates that are twice those of
* Megan
Sandel is an Associate Professor of Pediatrics at Boston University School of Medicine and Public Health. She is also the Medical Director at the National Center for Medical-Legal Partnership. Emily Suther is a Research Assistant for the National Center for Medical-Legal Partnership. Carrie Brown is an Assistant Professor of Pediatrics at the University of Arkansas for Medical Sciences. Marissa Wise is a physician at the Icahn School of Medicine at Mount Sinai. Mark Hansen is a Senior Evaluation Consultant at the The National Center for Medical-Legal Partnership. Please direct correspondence to Megan Sandel at [email protected]. 1 Income, Poverty and Health Insurance in the United States: 2011, U.S. DEP’T OF COMMERCE, http://www. census.gov/prod/2012pubs/p60–243.pdf (last visited Oct. 10, 2013). 2 See Diana Becker Cutts et al., US Housing Insecurity and the Health of Very Young Children, 101 J. AM. PUB. HEALTH 1508 (2011), http://www.childrenshealthwatch.org/upload/resource/ushousing andchildhealth ajph dc aug11.pdf. 3 See John T. Cook et al., Are Food Insecurity’s Health Impacts Underestimated in the U.S. Population? Marginal Food Security Also Predicts Adverse Health Outcomes in Young U.S. Children and Mothers, 4 ADVANCES IN NUTRITION 51 (2013). 4 See Deborah A. Frank et al., Cumulative Hardship and Wellness of Low-Income, Young Children: Multisite Surveillance Study, 125 PEDIATRICS e1115 (2010), http://pediatrics.aappublications.org/content/ 125/5/e1115.full.pdf.
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their higher-income peers.5 Furthermore, families living in inadequate home environments face greater rates of infestations and mold, which have been shown to exacerbate chronic asthma.6 Given that the exposure to these material hardships is common and that such exposure is detrimental to health, it is important to understand the spectrum of these underlying issues. Though some of these can be simple resource needs, some of these are, in fact, legal issues, and the remedies for these lie in the laws and regulations that govern whether people receive the benefits that can address hardships, such as the Supplemental Nutrition Assistance Program (SNAP)7 to address food insecurity, or protections under the law, such as enforcement of housing codes for children with asthma living with mold or pests. Healthcare providers have long monitored health and well-being through a handful of informative indicators—so-called “vital signs.” Our argument here is that information concerning exposure to various material hardships or adverse conditions is just as relevant to evaluating the health of patients as are the traditional vital signs. Screening for these hardships and their legal underpinnings will need to become the new health vital sign if healthcare is going to effectively address the SDHs. Screening then will need to lead to action, and healthcare sites will have to have the right professionals as part of the healthcare team to address the issues identified. There can be many reasons why information about social conditions and hardships are not considered in most current healthcare practices, and why a medical-legal partnership (MLP) vital sign has not already become integrated into practice. One reason is that, sometimes, social hardships are not considered to be related to health and well-being, though this might be a less common belief given the emerging understanding of SDHs. A more important reason, however, might be that healthcare providers generally do not have the tools or resources necessary to respond to the hardships that their patients are facing. In this case, having the right professionals as part of the healthcare team to address patients’ social concerns and unmet needs will become just as important as checking patients’ blood pressure.8 MLP is a
5
M. Weitzman, Racial, Social, and Environmental Risks for Childhood Asthma, 144 AM. J. DISEASES CHILD. 1189 (1990). 6 David L. Rosenstreich et al., The Role of Cockroach Allergy and Exposure to Cockroach Allergen in Causing Morbidity Among Inner-City Children with Asthma, 336 NEW ENG. J. MED. 1356 (1997), http://www.nejm.org/doi/pdf/10.1056/NEJM199705083361904. 7 SNAP: FOOD AND NUTRITION SERVICE, http://www.fns.usda.gov/snap (last visited Oct. 11, 2013). 8 Health Care’s Blind Side: The Overlooked Connection Between Social Needs and Good Health, THE ROBERT WOOD JOHNSON FOUND. (2011), http://www.rwjf.org/content/dam/farm/reports/surveys and polls/2011/rwjf71795.
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healthcare model to address legal needs as part of care and could become the new vital sign of healthcare.9
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I. HOW HARDSHIPS IMPACT HEALTH Food insecurity plays an important role in overall health. According to a 2013 study of more than 41,000 caregiver-child pairs, 14.9% of families live in marginally food-secure households, and 23.3% of families live in food-insecure households.10 Both marginal food security and food insecurity were associated with higher rates of child fair/poor health status and hospitalizations, as well as higher rates of caregiver depressive symptoms.11 According to Children’s Healthwatch data, even children at very low levels of inadequate access to healthy foods suffer negative health and developmental effects. Children under age three who grow up in homes that are marginally food secure are at higher risk for negative health outcomes than are children in households that are food secure.12 The children in food-insecure households are at higher risk for developmental delays, and are more likely to: lack stable housing, live in homes with inadequate heating or cooling, have caregivers who are experiencing depressive symptoms, and be in fair or poor health.13 Energy hardships also can impact the health of families negatively. As the cost of energy increases, and as the demand for heating and cooling increases as the temperature rises in the summer and falls in the winter, families often have difficulty paying for the energy that they need. Frequently, families have to make a choice when it comes to paying the bills, and they often resort to alternative energy sources. These include using a kitchen oven to heat their home or relying on candles for lighting. These actions can put families at risk of carbon monoxide exposure and burns. Despite the existence of Low Income Home Energy Assistance Program (LIHEAP), a federal program that provides assistance with utilities, few families actually
9
Megan Sandel, Creating the Social Determinants of Health Vital Sign: Are We Ready, MEDICAL-LEGAL PARTNERSHIP BLOG (July 26, 2013), http://medical-legalpartnership.blogspot.com/2013/07/creatingsocial-determinants-of-health.html; see Ellen M. Lawton, Medical-Legal Partnerships: From Surgery to Prevention?, MANAGEMENT INFO. EXCHANGE J. 37 (2007), http://www.washingtonmlp.org/documents/ 439011Medical-Legal%20Partnerships%20-%20From%20Surgery%20to%20Prevention.pdf. 10 See Cook et al., supra note 3. 11 Id. at 58. 12 John T. Cook et al., Even Very Low Levels of Food Insecurity Found to Harm Children’s Health, CHILDREN’S HEALTHWATCH 1 (May 2009), http://www.childrenshealthwatch.org/upload/ resource/chwbrief FI.pdf. 13 Id.
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utilize this resource. Children growing up in energy-insecure households are at a higher risk to be: in poor health, at risk of developmental problems, and food insecure.14 Housing is also an important component of health and well-being with respect to both housing environment and affordability. Children’s Healthwatch reports that children in subsidized housing do better than their counterparts who are not living in subsidized housing.15 Children living in subsidized housing are more likely to have enough food and are less likely to be significantly underweight.16 These children are also more likely to be characterized as “well” on health composites.17 Additionally, families in subsidized housing have more money left for other basic needs, such as food.18 Environmental housing conditions also contribute to overall health and well-being in families. Previous studies have shown that deteriorated housing can increase home allergen levels, such as cockroach allergens.19 Exposure to elevated levels of allergens has been shown to be a risk factor for asthma, one of the most prevalent chronic illnesses associated with low-income and minority status. Children with asthma who were also allergic to cockroaches and who were exposed to cockroaches in their home were three times more likely to be hospitalized for asthma.20 Legal needs could be any adverse social conditions with remedies that reside in laws, regulations, or policies.21 For example, a patient might be behind in paying his or her utility bill, which is considered a social need. If the patient’s energy is shut-off, despite there being a legitimate need for the continuation of utility services, such as a disability that requires an electrical device or a medication that requires refrigeration, then the issue becomes legal in nature as there is a legal remedy for the problem.
14
See Stephanie Ettinger de Cuba et al., Fuel for Our Future: Impacts of Energy Insecurity on Children’s Health, Nutrition, and Learning, CHILDREN’S SENTINEL NUTRITION ASSESSMENT PROGRAM (Sept. 2007), http://www.childrenshealthwatch.org/wp-content/uploads/fuel for our future 2007.pdf. 15 Elizabeth L. March et al., Rx for Hunger: Affordable Housing, CHILDREN’S HEALTHWATCH (Dec. 2009), http://www.childrenshealthwatch.org/upload/resource/RxforhungerNEW12 09.pdf. 16 Id. 17 Id. 18 Id. 19 Virginia A. Rauh et al., Deteriorated Housing Contributes to High Cockroach Allergen Levels in InnerCity Households, 110 ENVIRON. HEALTH PERSP. 323, 323-27 (Apr. 2002), http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC1241179/pdf/ehp110s-000323.pdf. 20 Rosenstreich et al., supra note 6. 21 See Arvin Garg et al., Screening for Basic Social Needs at a Medical Home for Low-Income Children, 48 CLIN. PED. 32, 34 (Jan. 2009), http://www.washingtonmlp.org/documents/439121Screening% 20for%20Basic%20Social%20Needs%20at%20a%20Medical%20Home[1].pdf.
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TABLE 1. Examples of Legal Needs that Affect Health Using the I-HELP Assessment22 Legal Need Income/Insurance
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Housing
Education/Employment
Legal Status Personal/Family Stability
Examples of Legal Needs Impacting Health - Insurance Access and Benefits - Food Stamps - Disability Benefits - Social Security Benefits - Shelter Access - Access to Housing Subsidies (e.g., Section 8 program) - Sanitary Housing Conditions (e.g., mold, lead) - Foreclosure Prevention - Americans with Disabilities Act Compliance - Utility Access - Americans with Disabilities Act Compliance - Discrimination - Individuals with Disabilities in Education Act Compliance - Immigration (e.g., asylum, Violence Against Women Act) - Criminal Record Issues - Guardianship, Custody, and Divorce - Domestic Violence - Child and Elder Abuse and Neglect - Capacity/Competency - Advanced Directives - Powers of Attorney - Estate Planning
II. HOW HARDSHIPS TRANSLATE TO LEGAL NEEDS Previous studies have consistently demonstrated that22 the majority of low-income families experience some civil legal needs.23 Primarily, these are derived from the most basic human needs, including safe housing, education, access to income support, protection from violence, and access to healthcare. These needs are widely distributed, of long duration, and detrimental to patient health. Both national and state-based legal needs studies suggest that most low-income individuals experience at least two legal needs, most of which are not addressed.24 Given that many laws and regulations govern these rights and benefit programs, hardships often arise after patients are unable to access these benefits and protections. 22
See generally Ch´en Kenyon et al., Revisiting the Social History for Child Health, 120 PEDIATRICS e734, e737 (2007), http://www.pediatricsdigest.mobi/content/120/3/e734.full.pdf. 23 Albert H. Cantril, Agenda for Access: The American People and Civil Justice, AM. BAR ASS’N (May 1996), http://www.nasams.org/DMS/Documents/1029845097.99/agendaforaccess.pdf. 24 Schulman, Ronva, & Bucuvalas, Inc., Massachusetts Legal Needs Survey: Findings from a Survey of Legal Needs of Low-Income Households in Massachusetts, MASS. LEGAL ASSISTANCE CORP. 1, 3 (May 2003), http://lri.lsc.gov/sites/default/files/LRI/pdf/03/030156 malglnds.pdf.
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Studies have also found a significant correlation between legal needs and health.25 Moreover, the hardships associated with poverty include utility shut offs, hunger, safety, and substandard housing, all of which directly influence health. The legal system directly affects how low-income families can have these needs met to ensure the health and well-being of their family. The establishment of legal supports serves to lower these barriers and improve access to care. III. WHY LEGAL NEEDS OFTEN GO UNADDRESSED Because the prevalence of legal needs is so high and the resources are so few, access to legal assistance is often limited, and resources are stretched too thin. In Boston, for example, Greater Boston Legal Services estimates that it turns away three out of every five clients due to a lack of resources.26 National data show that health centers serve more than 22 million patients in the United States, the majority of whom are low-income and are often also ethnic and racial minorities.27 In excess of 70% of health center patients live below the federal poverty level (FPL), and at least 34% are racial minorities.28 Furthermore, while 36% of patients are uninsured, 50% depend on Medicare, Medicaid, or another public insurance option.29 Though the resources offered at health centers try to mitigate the legal issues faced by low-income individuals, they are not equipped to remedy the underlying causes.30 Therefore, it is imperative that legal needs are actively screened for, especially as most patients’ needs go unresolved. Moreover, patients are unsure where to go to access needed legal services. Socioeconomic disparities continue to pervade the realm of healthcare, and previous research has demonstrated that the social circumstances of patients’ lives can directly influence their health.31 For example, families worried about the safety of their home or paying for food are dealing with social issues that might eventually become a legal need with a legal solution. Often, the 25
Nancy E. Adler & Katherine Newman, Socioeconomic Disparities in Health: Pathways and Policies, 21 HEALTH AFF. 60 (Mar. 2006), http://www.sph.umich.edu/sep/downloads/Adler Newman Socioeconomic Disparities in Health.pdf. 26 Legal Needs and Civil Justice: A Survey of Americans, AM. BAR ASS’N (2004), http://www.americanbar. org/content/dam/aba/migrated/legalservices/downloads/sclaid/legalneedstudy.pdf. 27 America’s Health Centers, NAT’L ASS’N COMMUNITY HEALTH CTRS. (2013), http://www.nachc.com/client/ documents/America%27s CHCs 0813.pdf. 28 Id. 29 Id. 30 See Documenting the Justice Gap in America: The Current Unmet Civil Legal Needs of Low-Income Americans, LEGAL SERVS. CORP. (2009), http://www.lsc.gov/sites/default/files/LSC/pdfs/ documenting the justice gap in america 2009.pdf. 31 Michael Marmot et al., Health Inequalities Among British Civil Servants: The Whitehall II Study, 337 LANCET 1387 (1991).
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circumstances surrounding legal needs can deteriorate to a point where a legal remedy exists; however, regardless of the degree of severity of the concern, the stress that the patients feel can be overwhelming. Physiological consequences of increased stress include changes in cardiovascular function and have been linked to heart disease.32 Stress can also prompt patients to make unhealthy lifestyle choices, such as smoking, sedentary behavior, and unhealthy eating.33 Legal needs are common and affect multiple social factors and circumstances. At an MLP in Tucson, Arizona, providers referred 104 patients for legal services, and, at the time of intake, 170 discrete legal matters were identified.34 These issues ranged from housing concerns to health insurance coverage to finances. Providers in a pediatric setting at a Baltimore hospital conducted similar research in which parents were surveyed about the legal concerns that they were facing, with employment and education concerns being the most commonly reported issues.35 Legal concerns are important to consider in the patient-care setting, as often they can be ameliorated through social resources and referrals, but, without being appropriate addressed, such concerns could become legal needs that require legal intervention. IV. MEDICAL-LEGAL PARTNERSHIP: A HEALTHCARE MODEL TO ADDRESS LEGAL NEEDS MLP is a healthcare delivery model designed to address legal needs as part of healthcare. MLPs were first developed in 1993.36 Since inception, more than 85 programs have been developed across the country, serving 300 hospitals and clinics.37 MLP is a healthcare delivery model that serves to improve the health and well-being of low-income and other vulnerable populations by addressing unmet legal needs that impede health. Through MLPs, legal professionals, such as legal aid organizations, law school partners, and pro bono communities, are integrated into the healthcare team. Together, the legal and medical teams work in collaboration to provide direct legal assistance to patients, to develop strategy to improve health and legal institutions and 32
Robert M. Carney et al., Reproducibility of Mental Stress-Induced Myocardial Ischemia in the Psychophysiological Investigations of Myocardial Ischemia (PIMI), 60 PSYCHOSOMATIC MED. 64 (1998). 33 Debbie M. Ng & Robert W. Jeffery, Relationships Between Perceived Stress and Health Behaviors in a Sample of Working Adults, 2 HEALTH PSYCHOL. 638 (2003). 34 Ann M. Ryan et al., Pilot Study of Impact of Medical-Legal Partnership Services on Patients’ Perceived Stress and Wellbeing, 23 J. HEALTH CARE POOR & UNDERSERVED 1536, 1540 (2012). 35 Garg et al., supra note 21, at 34. 36 Megan Sandel et al., Medical-Legal Partnerships: Transforming Primary Care by Addressing the Legal Needs of Vulnerable Populations, 19 HEALTH AFF. 1697, 1698 (2010), http://content.healthaffairs.org/ content/29/9/1697.full.pdf. 37 See The Movement, NAT’L CTR. FOR MEDICAL-LEGAL PARTNERSHIP, http://www.medical-legalpartnership. org/movement (last visited Oct. 7, 2013).
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practices, and to change policies that serve to ensure that patients’ legal needs are being met.38
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V. SCREENING FOR LEGAL NEEDS: A PILOT STUDY Many patients may identify that they have hardships, but they may not understand that they have a right to benefits or protections under the law. One study tried to identify whether patients knew they had legal concerns and what assistance was wanted with regard to such concerns. This legal needs assessment study conducted at Boston Medical Center (BMC) surveyed the parents and/or guardians of patients coming to the Pediatric Emergency Department for care in the fall of 2007.39 Families in the waiting area of the clinic were invited to participate in the two-part study, which included a brief self-administered questionnaire and a follow-up telephone interview. In all, 154 individuals completed the questionnaire, and 39 completed the interview. The results paint a cogent and troubling picture about how vulnerable families struggle to meet their basic needs, and, therefore, suffer hardships affording or accessing food, housing, healthcare, education services for their children, and safety. The consequences of having unmet legal needs are varied and often affect the most vital aspects of family life. This study found that, within the previous year, nearly half of the families received a letter threatening a utility shut off from their utility company; moreover, 23% of the families that received such a letter actually experienced a shut off in that time frame. When families have difficulty paying their utility bills, they are often forced to resort to unsafe practices, such as using the stove to heat their home, as 25% of families did in this study. Additionally, more than 36% of families reported that they had to reduce the size of their meals or skipped meals because they did not have enough money for food. Many of these hardships are health-related social problems that can be addressed or resolved through the appropriate resource, to which these patients have the right. This study also demonstrates the persistence and severity of unmet needs that families are facing. Families reported that their issues had been a concern to them for at least six months, demonstrating that unmet needs continue to affect families for extended periods of time, influencing multiple facets of their life. Eight-five percent of families described their concerns as either somewhat “serious” or “very serious,” reflecting that these issues are not 38
See Barry Zuckerman et al., Medical-Legal Partnerships: Transforming Health Care, 372 LANCET 1615 (2008); The Model, NAT’L CTR. FOR MEDICAL-LEGAL PARTNERSHIP, http://www.medical-legalpartnership. org/model (last visited Oct. 7, 2013). 39 Dr. Megan Sandel was the principal investigator on this study. Please contact Dr. Sandel at [email protected] for more information about this study.
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TABLE 2. Reasons Reported for Not Seeking Legal Help for Problem or Concern40
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Why Families Did Not Seek Legal Assistance for Their Concern Do not believe issue to be legal in nature Believe I can handle the issue without legal assistance Cannot afford legal services Do not believe anything can be done Do not know where to go or who can help with the issue
Percentage (n = 33) 79% 79% 67% 55% 52%
minor, and, with the duration of time that they last, these issues can have a huge impact on families and the way that impacted families try to meet their basic needs. One aim of this40 study was to understand why families may be resistant to seeking out legal services for their unmet needs. One part of the survey asked about whether or not they had sought help for their issue. Fifteen percent of those followed-up with by phone reported seeking help from an attorney; half of that 15% sought the help of a free legal service. Nevertheless, most of the families that sought the help of free legal aid services did not receive any assistance. In fact, only one family that sought the help of an attorney actually had the issue addressed. Those families that never sought the help of legal services were asked about the reasons why no legal assistance had been sought, as highlighted in Table 2. These findings suggest that, even though many of these issues have a legal connotation, many families do not believe that their issues can be resolved through legal services, or they are confused about who to contact or worried about the cost. This study highlights the importance of helping patients recognize the legal ramifications of their concerns, as well as arming them with the resources that can help them get their concerns resolved. Another important aim of this study was to determine attitudes and opinions of patients concerning laws, the healthcare system, and community resources. Patients were asked to state their opinion of eight professional groups, and they were given the option to say that they held a positive, neutral, or negative view. They were also asked whether they believed the professional group to be “not at all,” “somewhat,” or “very” helpful to families in the community. Responses were then converted to a three-point scale to derive “favorability” and “helpfulness” scores. Of the eight professional groups, patients indicated that they consider all groups to be both helpful and favorable 40
Original data collected by authors in the Pediatric Emergency Department at Boston Medical Center, Boston, Massachnsctts. Please contact Dr. Sandel at [email protected] for more information about this study.
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with the exception of two. They indicated that they do not believe lawyers to be helpful, giving them a slightly negative helpfulness score. They also indicated that they consider politicians to be unhelpful, with a very negative helpfulness score, and they do not have a favorable opinion of them, giving them a very negative favorability score. This component of the survey highlights the negative impression that these patients hold toward certain professions, and indicates why they may be hesitant to seek out the assistance of a lawyer or legal team. If patients do not feel that they can trust the legal services that may be able to help them, then they will be unlikely to seek out such assistance in the first instance. By integrating legal services into healthcare through MLP, families are not left to recognize that they need legal services, but, rather, the healthcare team helps them identify their legal needs and can address such needs as part of routine care. Depending on the partnering legal entity, eligibility for services can range up to 200% of the FPL and can be restricted to certain citizenship statuses. In the BMC Pediatric Emergency Department study, the majority of respondents were eligible for legal services due to these factors. The barriers to access, however, arose for alternative reasons. Many patients did not believe that their concern was a legal issue or that it could be resolved through legal interventions. Additionally, many were unaware of the services available to them and do not know how to access legal resources. Finally, a major barrier was that respondents did not believe that help would actually resolve their issue, which stemmed from their perception of the resources and services available to them. Another major barrier arises when a family actually tries to seek legal help. In the BMC study, a very small percentage of respondents actually sought out the help of an attorney or free legal services. This problem is perpetuated when the help that families seek is ineffective. Only one of the six families that sought legal services for the concern was actually helped, making it an inefficient system, and an unlikely place for families to turn. Because of the pervasiveness of these issues and the duration of time that they last, the likelihood that these concerns are addressed is very small. While only a few people actually sought out legal help, the majority of families have something that has been concerning them for more than six months. This suggests that many more people could and should be helped by legal assistance but that there is some barrier preventing them from seeking out this help. When legal concerns go unaddressed, there is likely to be some detrimental impact to the family, as evidenced by the number of respondents in the BMC study who had their utility services disconnected, or who had to cut the size of their meals or skip them altogether. This directly influences overall family stability and prevents families from providing the most basic needs to their children.
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There are also several expectations of the community and its leaders. It is imperative that the community recognizes the importance of free legal services and that it allocates adequate resources to these services so that such services can provide service to eligible families seeking help. The current system does not support all of these expectations, and, consequently, the patients who are in need face numerous barriers when trying to access legal services and assistance for their most pressing concerns. Social screening tools have been developed to aid providers in helping patients to identify any unmet social needs that may have legal consequences down the line.41 These screening tools are used in practice at many hospitals and MLPs across the country. In some MLP settings, there is a formal screening process where the patient or caregiver completes a screening form at some point during the appointment, which is then given to the provider to help determine whether there are any concerns that may be ameliorated by social or legal resources.42 Many institutions utilize trainings to make their providers aware of the social needs plaguing their patients. The MLP model uses the acronym I-HELP to define the broad range of issues that a legal team in the healthcare setting will address. The acronym includes the following areas of inquiry: income (I), housing and utilities (H), education and employment (E), legal status/immigration (L), and personal safety (P). A study conducted at the Cincinnati Children’s Hospital Medical Center and the Legal Aid Society of Greater Cincinnati looked at training providers to be cognizant of how SDHs affected behavior. 43 The study comprised an intervention group, comprised of 20 pediatric interns beginning their internship in July of 2008, and the control group, comprised of 18 second-year residents.44 The residents in the control group had participated in an intern advocacy course that focused on “obesity, street drugs, poisoning, child abuse, and injury prevention,” but these residents did not have the SDHs curriculum, which the intervention group would receive.45 At the beginning and end of their respective intern years, each group completed a knowledge test survey of attitudes and comfort levels.46 The results showed that the intervention group had significantly better knowledge than the control group in all three of the areas tested: benefits, housing, and education.47 The intervention group also 41
David Keller et al., Development of a Brief Questionnaire to Identify Families in Need of Legal Advocacy to Improve Child Health, 8 AMBULATORY PED. 266, 268 (July 2008); Laura Gottlieb et al., Collecting and Applying Data on Social Determinants of Health in Health Care Settings, 173 JAMA INTERNAL MED. 1017, 1019 (2013). 42 Keller et al., supra note 41, at 266. 43 Melissa D. Klein et al., Training in Social Determinants of Health in Primary Care: Does It Change Resident Behavior?, 11 ACADEMIC PEDS. 387, 388 (Sept. 2011). 44 Id. at 389. 45 Id. 46 Id. 47 Id.
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documented the social history more frequently than the control group, especially issues that were covered during the advocacy course at the beginning of the year. This study highlights the importance of educating providers on the issues most commonly affecting their patients, especially when those issues can have a negative impact on health.
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VI. A CASE STUDY IN LEGAL NEEDS SCREENING At Arkansas Children’s Hospital (ACH), there is a screening process that helps providers identify unmet needs at the start of visits, and it is also designed to follow up on patients who indicate a positive response to a given need. The system is meant to inform providers that a need exists and to equip them with the tools to guide the patient to the appropriate resource. The system does not assign the responsibility of resolution to the provider, but, rather, it informs the provider that the patient could use a referral to a given resource or to the MLP. The screening process at ACH currently begins with patients receiving a screening form that is handed to them at check-in. This form is then brought into the patient room with the family, and the resident reviews it for all concerns. Any positive responses indicated on the form are followed up by the resident with a specific set of questions that pertains to that particular issue. Depending on the nature of the concern, the resident will either hand the family an information sheet about how to access a particular resource, or the resident will make a direct referral to social work or the MLP. If the MLP does get involved in the patient’s case, the provider will receive case status updates periodically. While this is a very effective system, ACH has future plans to make it more seamless and to help provide a more efficient means of referral. Specifically, ACH plans to have a kiosk, where the parent or guardian will answer the questions, instead of on paper. These questions will rotate with each visit, and follow-up questions to positive responses automatically will be asked. The residents will be notified on-screen of any positive responses, and certain positive answers will trigger an automatic page or email to a social worker or lawyer. A. Example of Screening Question Chain for Education The screening question chain is utilized at appointments at ACH. Parents or guardians answer the questions, and affirmative answers trigger certain referrals or follow-up questions from residents. Parents or guardians also have the option, at subsequent appointments, to follow up on these answers with their child’s provider, which helps to ensure that concerns are being addressed.
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FIGURE 1. Example of the Education Screening Chain from Arkansas Children’s Hospital48 (Color figure available online.)
B. Example of Screening Question Chain for Food Another question chain used at ACH screens for food security. Like the education sequence, questions answered affirmatively will trigger certain follow-up questions from residents or a referral to an appropriate resource. C. Current Clinic Screen Format The clinic screen helps to improve the efficacy of this process by indicating where a doctor has requested a social work or MLP referral. Symbols on the screen next to the status codes indicate that the doctor in the room has paged someone for assistance with addressing the patient’s unmet need. Furthermore, the system has a way to page the MLP directly in a similar way that an interpreter or a dietician would be paged. By integrating the MLP into the system, healthcare providers are able to make a referral easily and with little time spent.
48Id.
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FIGURE 2. Food Security Question Chain Used at Arkansas Children’s Hospital49 (Color figure available online.)
VII. A CASE STUDY IN HOW SCREENING FOR LEGAL NEEDS IMPROVES HEALTH OUTCOMES In Lancaster, Pennsylvania, medical49 and legal champions are addressing quality and cost in a high-utilization setting. The Lancaster team uses a 26-point scale to help identify barriers to care. Of the 26 barriers that the team has identified and for which it screens, 12 have been determined to be legal and could have legal solutions. The United States has the highest spending on health and highest total expenditure on health when compared to all other countries.50 In his January 2011 article in The New Yorker entitled “The Hot Spotters,” Atul Gawande highlighted the role of high-utilizer patients on the increasing cost of healthcare.51 These patients cycle in and out of hospitals and emergency departments, despite receiving high-cost medical care. Often, many of the issues plaguing these patients are legal and can be resolved 49
This figure is adapted from the computerized screening questionnaire used at Arkansas Children’s Hospital to show the flow of questions parents or guardians will receive based on affirmative answers they have given. Please contact Dr. Sandel at [email protected] for more information. 50 Health at a Glance 2009, ORG. FOR ECON. CO-OPERATION & DEV. 1, 160 (2009), http://www.oecd.org/ health/health-systems/44117530.pdf. 51 Atul Gawande, The Hot Spotters, NEW YORKER (Jan. 24, 2011), http://www.newyorker.com/reporting/ 2011/01/24/110124fa fact gawande.
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through legal intervention. These patients, however, often face barriers to accessing the resources that could ultimately ameliorate their concerns. Ms. Green52 is an example of a high-utilizer at the Lancaster clinic. Ms. Green is a 45-year-old woman who was referred to the superutilizer team due to her frequent utilization of hospital services. In the year before her referral to the clinic, she had eight emergency room visits, two inpatient visits, and three hospital observation visits for symptoms related to one of her many chronic diseases, including uncontrolled diabetes mellitus, congestive heart failure, hyperlipidemia, and hypertension. The team discovered that Ms. Green had significant financial stressors that impeded her ability to care for herself and cover the cost of dietary foods appropriate for her health. As a consequence of her uncontrolled diabetes, Ms. Green developed retinopathy and neuropathy, which prevented her from maintaining her job at a fast-food restaurant, and she had no other source of income. Ms. Green lived in an apartment with her 16-year-old, pregnant daughter and two-year-old granddaughter. Due to their inability to pay the rent, the family was evicted. At this time, social work was able to secure supportive housing for Ms. Green’s daughter and her children, but Ms. Green had to move in with a family member. These psychosocial stressors led to severe depression, which prevented Ms. Green from taking her medications or getting to medical appointments. With assistance from the physician in coordination with social work, Ms. Green was connected with a bilingual psychotherapist, and she also was assessed for medication needs to address her depression. The patient was referred to the MLP attorney who represented the patient in an appeal of her disability claim. The attorney collaborated with the social worker and physician to create a letter of support to supplement the Social Security claim. Through regular home visits, the social worker was able to keep the attorney updated on changes to Ms. Green’s health status. As well, the attorney was able to advise the medical team on which portions of the disability application were incomplete or underdeveloped so as to provide Social Security with the most accurate picture of the patient’s health functional limitations. Finally, the attorney and social worker were, together, able to meet with the patient to encourage her to attend medical appointments and to stress the importance of getting to all of her appointments. Since being referred to the superutilizer team eight months ago, Ms. Green has not had any inpatient hospitalizations and has had only one emergency room visit.
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CONCLUSION Exposure to various hardships or adverse social conditions can be detrimental to health. Across the spectrum of these SDHs, many have solutions in the laws and regulations designed to address hardships, such as SNAP. These hardships often become legal needs that can be remedied through MLP. If healthcare is to become serious about improving outcomes so that vulnerable populations can access the resources available to them, it will become important to develop an MLP vital sign and arm the healthcare team with the right professionals to address legal needs.
