A Prescription for Better Health: Medical-Legal Partnerships

Medical-legal partnerships (MLPs) address the social determinants of health that create hardships for vulnerable populations through the integration of free legal services in the healthcare setting. MLPs currently serve patients at nearly 200 hospitals and health centers across the country providing direct legal services to patients, training and education for the healthcare team, and a platform for systemic advocacy. Although MLP models can vary from site to site, all MLPs provide a range of benefits to patients and their families in order to improve their health and well-being.

Members of healthcare team - including doctors, medical residents, nurses, and social workers - are uniquely situated to catch legal issues before a point of crisis. MLPs train healthcare staff to screen and triage potential legal issues that have a negative impact on health such as substandard housing conditions that lead to chronic asthma. After a potential legal problem has been identified, the healthcare provider refers the patient to the MLP lawyer at the hospital or health clinic just as a patient would be referred to a cardiologist for a heart problem. The lawyers can be either a MLP staff attorney or a pro bono attorney.  Depending on the MLP and the patient’s legal needs, the services can range from advice and brief service at a monthly legal clinic to full representation on one or more legal issues including housing, access to utilities, immigration, education, public benefits, education, guardianship, wills and family law.

The MLP Community

The combination of medical providers and lawyers is the ideal team to help low-income families who face legal problems related to their basic needs such as housing and income.  Partners from the health and legal communities include civil legal aid agencies, law schools, pro bono law firms and attorneys, hospitals, health centers, and medical schools. In 2007, the American Bar Association (ABA) passed a resolution in support of MLP. The resolution encourages members of the legal profession to work with the healthcare community and social service organizations to identify and resolve legal issues that have a detrimental effect on health and well-being. After the adoption of the resolution, the ABA created the Medical-Legal Partnerships Pro Bono Support Project (ABA MLP Project).

The primary goal of the ABA MLP Project is to increase the capacity of healthcare institutions to address health-harming legal issues by increasing the availability of volunteer attorneys. Additionally, the Project works with national medical and legal organizations to promote the MLP model through policy and initiatives.  Recent efforts of the Project, along with the assistance from the National Center for Medical-Legal Partnership, resulted in the adoption of policy in support of the MLP model by the American Medical Association (AMA). The AMA resolution encourages physicians to work with lawyers, social workers and nurses to improve the health of their patients. The AMA resolution further states that the AMA should work with physician groups and other stakeholder organizations to educate physicians on MLP and the impact of unmet legal needs on the health of their patients. The passage of the AMA resolution along with the ABA resolution unites the medical and legal professions on their missions to help diminish the obstacles that low-income individuals and families face on a daily basis.

MLP & Pro Bono Partners

Pro bono attorney and law firm involvement has been substantial in the MLP community. According to the MLP Site Survey conducted in January 2010, MLP pro bono partners provided nearly $13 million in in-kind services. To support the growing involvement of MLP pro bono partners, the ABA MLP Project provides information on MLP pro bono model development and implementation through consultations with law firms and MLP sites, conference programming and the Project’s website www.medlegalprobono.org.

MLP pro bono law firms and attorneys provide a range of free services to MLP sites in addition to taking cases upon referral including special technical assistance projects, on-site legal clinics, research projects, trainings, education materials and site coordination. For example, McDermott, Will & Emery LLP recently launched a national project to provide technical assistance on ethics and confidentiality to MLP sites across the network in addition to handling individual special education, immigration and social security cases; Ropes & Gray LLP devoted 6,000 hours to the health clinic at the Dorchester House Multi-Service Center last year and  created a unique infrastructure of leadership groups in five areas of law; and Holland & Knight LLP has led the expansion of services at Northeast Florida Medical-Legal Partnership to act as a model for other programs by facilitating the formation of a steering committee to educate the community, foster collaborations and set goals.  The valuable services provided by these and other pro bono partners enables MLP sites to increase their capacity to serve patients and contribute to larger efforts to change policy.

Systemic Advocacy and MLP

The powerful combination of the medical and legal professions can have an enormous impact on health care policies and practices. By working as a team, MLPs can engage health care providers in systemic advocacy efforts. For example, utility access has been a significant area for systemic advocacy and MLP. When households are faced with utility shut off, too often parents have to decide to “heat or eat.” Children who live in households without heat or light have higher rates of hospitalization, poor general health and developmental delays.  Additionally, children in these households have higher incidents of burn injuries stemming from the use of candles for light and boiled water to heat bath water. These children also have higher rates of carbon monoxide exposure. MLP sites in Hartford, CT and Boston, MA have worked with their partner medical institutions to educate doctors about utility protection and change policy to help patients.

Doctors and staff at Connecticut Children’s Hospital grew concerned with the growing number of families with young children facing utility termination. The pediatric primary care clinic, the pediatric pulmonary clinic and the neonatal intensive care unit turned to the Medical- Legal Partnership Project for Children (MLPP) at the hospital to confront the medical dilemma of releasing a sick infant into a housing environment without heat or lights.  Through the work of MLPP, the issue of utility termination of families with children less than 24 months old has been brought to the attention of the Connecticut legislature. The medical and legal communities have rallied around the issue and formed a strong coalition to introduce a bill during the next legislative session to protect households with children under 24 months old. The effort has also served an educational function for the medical community. As a result of the publicity around the bill, a number of medical providers have asked for training regarding the complexities of utility law and how it affects their patients. Additionally, in evaluating their protocol, the clinic at children's hospital is in the process of re-evaluating their policy for signing the "Medical Protection" form. As a result, the clinic has determined that the physicians will sign a medical protection form for any household with a child under 24 months.

The Medical-Legal Partnership | Boston began an intensive training initiative to raise awareness about access to utilities in the Department of Pediatrics of Boston Medical Center (BMC). The goal of the training was to increase the identification of patients by doctors that are at risk for utility shut-off and refer the patient to MLP | Boston. The initiative was successful, and MLP | Boston created an “energy clinic” in order to provide consultations to staff and patients.  However, Massachusetts required frequent documentation from the doctor of the patients’ eligibility, and the process became an administrative burden for the hospital. In response, MLP | Boston assisted the hospital to create a method using electronic medical records to recertify the patients in an efficient manner.  Furthermore, when the Massachusetts Department of Public Utilities (MDPU) began to reevaluate its regulations regarding utilities shut-off protection, MLP | Boston along with community and national partners documented the negative effects of utility shut-off on health, and proposed strategies based on their experience with BMC. MDPU revised their regulations to included extended protection to households with infants, relaxed the recertification requirements, and authorized nurse practitioners and physician assistants to sign the certification letter.

Conclusion

The benefits provided by MLPs are invaluable. With the help of their lawyer, individuals and families can obtain health benefits, improve housing conditions, and secure other necessary services to help meet their basic needs. Furthermore, communities benefit from the alliances formed by national medical and legal organizations, community partners, and pro bono lawyers. These partnerships provide patients and communities with solutions to the legal issues that burden their health. The result is ability to live a healthier life.