Strange Bedside Fellows

To some people, the prospect of doctors and lawyers working collaboratively toward patient health is somewhat counter-intuitive.  Yet, to all of the members of a burgeoning movement, known as Medical-Legal Partnership (MLP), the benefits of having not only doctors and lawyers, but also social workers, nurses, and health care administrators working in concert to deliver comprehensive, patient-centered care, are obvious. 

MLP involves integrating attorneys into health care settings that serve low-income individuals and families, to address the socio-economic conditions that influence their health—or, their social determinants of health—that may have legal solutions.  Imagine the following scenario: An asthmatic child whose family brings him to their local community health center for his regularly scheduled primary care visits also visits the emergency department monthly for severe asthma attacks.  Having been trained to identify the social determinants of health, the child’s health care provider asks about the conditions of their home.  The mother describes two known asthma triggers to the pediatrician: a rodent problem and a perpetual leak, which has resulted in mold growth in their apartment.  The mother then tells the doctor that the landlord refuses to remediate the problems despite her multiple requests.  How frustrating it is for the pediatrician to be able to identify problems with solutions that lie beyond the walls of the health center or hospital! 

Fortunately, the health center hosts an MLP where the doctor can make a seamless referral to the on-site attorney.  With a warm handoff, the attorney assists the family either by persuading the landlord to fix the problems or by negotiating with him to break the family’s lease, without losing their Section 8 voucher.  In fact, the scope of medical-legal needs that MLPs seek to address ranges from: insurance and income access; secure housing and utility shutoff prevention; children’s educational advocacy; concerns regarding legal status; in addition to issues with personal safety and family stability.  Indeed, when these conditions are left unaddressed they can lead to medical crises or reduced efficacy of medical treatment and thus, prolonged and unnecessary costs to the health care system. 

In terms of unmet legal needs with health implications, of the 899,817 cases that the federally funded Legal Services Corporation (LSC) programs were able to close in 2011 nationwide, one-third comprised family cases, over one-quarter pertained to housing, and about 12.7% dealt with income maintenance.[1]  This translates to nearly three-quarters of all LSC cases addressing otherwise unmet legal needs that could compromise children’s health and well-being.  Legal aid agencies continue to do the critically important and incredibly challenging work of providing legal assistance to those in greatest need, though dwindling federal and private funding restricts their ability to address the volume of civil legal problems that burden low-income families.  Given this situation, it is not difficult to imagine the number of legal needs that go unmet and the inevitable negative impact many of those unmet needs have on the 15 million children currently living below the poverty line across the U.S.[2]

Over 235 MLPs deliver preventive legal assistance in hospitals and community health centers across the country, from Boston—where the MLP concept was first conceived—to Hawaii.  In fact, several are operating in the Philadelphia region.  Most recently, the Stoneleigh Foundation has made an investment into the creation of a new MLP tailored specifically to the needs of the children and families that Philadelphia’s community health centers serve.  As a Stoneleigh Emerging Leader Fellow, I am coordinating the effort  under the auspices of the Health Federation of Philadelphia (HFP), which serves as a network of community health centers.  In collaboration with the Philadelphia Department of Public Health’s (PDPH) Ambulatory Health Services Division, we are developing an operational plan to pilot a community health center-based MLP.  Additionally, we are thrilled to benefit from the expertise of the Legal Clinic for the Disabled and HELP:MLP, our main consultants, which operate MLPs in other health care settings in the region.

During my fellowship I will be assessing the types and volume of unmet legal needs among health center patients and undertaking a feasibility study to determine how an MLP can be best implemented as a pilot in a community health center.  Additionally, I continually engage with organizations and leaders in the West Philadelphia community surrounding the health center pilot site, as well as with current and potential medical, legal, social services, and philanthropic partners throughout Philadelphia.  Assuming that this project acquires the necessary funding to launch as a pilot MLP, it will be the first time that PDPH has assumed the role of medical partner in an MLP.  Our vision is for the MLP to expand its focus beyond only direct service to demonstrate how it enhances health care delivery as part of the patient-centered medical home through consistent staff trainings on identifying and triaging the legal determinants of health and developing an efficient, replicable internal referral system.  Ultimately, our hope is that the pilot plan will be adapted for implementation at the other PDPH community health centers and Federally Qualified Health Centers in Philadelphia.  Like other MLPs, ours will strive to effect policy change through advocacy efforts at the systems level, supporting policies that would have positive impacts on MLP patient-clients and their communities, such as improving the efficiency and effectiveness of the public benefits system. 

It is important to note that improvements in health care delivery and patient outcomes rely on a true partnership between the traditional health care team and the legal staff who become its newest members.  In fact, such an unconventional relationship becomes logical in light of the Affordable Care Act’s push toward patient-centered, holistic care.


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