Health, Education & Legal assistance Project: A Medical-Legal Partnership Chester County Committee on Birth Disparities

March 13, 2014

Agenda ´ Background of Medical-Legal Partnerships (MLP) ´ MLP connection to health and maternal child

health ´ Health, Education & Legal assistance Project: A

Medical-Legal Partnership (HELP: MLP), Chester, PA

´ Delaware Medical-Legal Partnership Pilot Project, Community Legal Aid Society, Inc. (CLASI), Wilmington, DE

´ Public health and policy implications of MLP ´ Questions

Where we work, live, and play…

…determines our health status.

What is Medical-Legal Partnership? MLP is a healthcare delivery model that integrates legal assistance as a vital component of patient care. MLP’s 3 key activities transform the delivery of health and legal services and improve health and well-being for America’s most vulnerable

Unmet Legal Need •  Fewer than 1 in 5 low-income persons receive assistance with an

unmet civil legal need.

•  Low-income households experience on average between 1 and 3 unmet civil legal needs per year.

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

MLP Connection to Health

•  Improved physical environment

•  Increased access to health care

•  Increased access to basic necessities

•  Decreased stress

•  Increased access to educational services

MLP Connection to Maternal Child Health •  Healthy Start MLPs improve

overall health by reducing RISK factors and increasing PROTECTIVE factors through legal intervention & advocacy

•  Risk factors include: •  Stress •  Poor environment •  Poverty

•  Protective factors include: •  Increasing access to care •  Increasing education •  Reuniting families •  Coordinating care

Anxiety and Stress ´ Anxiety and Stress during pregnancy have been linked with

poor birth outcomes. ´  Dole, N., Savitz, D., Hertz-Picciotto, I., Siega-Riz, A., McMahon, M., Buekens, P. (2003).

Maternal stress and preterm birth. Am J Epidemiol, 157(1): 14-24

´  Wainstock, T., Anteby, E., Glasser, S., Shoham-Vardi, I., Lerner-Geva, L. (2013). The association between prenatal maternal objective stress, perceived stress, preterm birth, and low birthweight. J Maternal-Fetal and Neonatal Medicine, 26, 10, 973-977

´  Hedegaard, M., Henriksen, T., Secher, N., et al. (1996). Do stressful life events affect duration of gestation and risk of preterm delivery? Epidemiol, 7, 339-345.

´  Lobel, M., Dunkel-Schetter, C., Scrimshaw, S. (1992). Prenatal maternal stress and prematurity: a prospective study of socioeconomically disadvantaged women. Health Psychol, 11, 32-40.

´ MLP services are a method to reduce anxiety and stress for expectant mothers with low socioeconomic means experiencing legal and social stressors (housing issues, immigration status, etc.).

Health, Education & Legal assistance Project: A Medical-Legal Partnership (HELP: MLP) A collaboration between Widener University School of Law, Crozer-Keystone Healthy Start and Crozer-Keystone Nurse-Family Partnership.

Chester, Pennsylvania

HELP: MLP Project Goals •  Overall Goal: Eliminate disparities in perinatal health

•  Project Aims:

•  Identify the unmet legal needs of program participants.

•  Train staff to identify and address unmet legal needs of program participants.

•  Increase staff capacity to better serve participants.

•  Provide direct legal services to participants to improve overall health and well-being.

•  Educate multi-disciplinary students of the value of public service and the ways in which legal advocacy can help vulnerable populations.

HELP: MLP at CKHS Organizational Chart

Directors: Daniel Atkins, Esq.

Joanne Craig, M.S.

HS Case Manager Supervisor:

Donovan Pratt, MSW, LSW

NFP Supervisor: Amy Martin, R.N.

Healthy Start Case Managers and

NFP Nurses

Healthy Start Care Coordination Team

Attorneys: Laura Handel, Esq.

Megan Mahle, Esq. Jordan Mickman, Esq.

Students: Law, Public Health,

Psychology, Social Work, Nursing, Spanish

Public Health Law Specialists:

Shannon Mace, JD, MPH

Shloka Joshi, JD

HELP: MLP Referral Process •  Education: Healthy Start/NFP case

managers and staff receive trainings about potential legal issues of participants

•  Screening: Healthy Start/NFP case managers/nurses use an integrated legal needs screening tool to identify unmet legal needs of participants

•  Referral: When an unmet legal need is identified the participant is referred to HELP: MLP staff attorneys

•  Action: Attorney contacts the participant within 24 hours to begin addressing the problem

•  Follow-Up: Evaluation staff contact participant for follow up interview after obtaining informed consent

Education

Screening

Referral Action

Follow-Up

I-HELP Legal Screening Tool

•  Developed by the National Center for Medical-Legal Partnership

•  Integrated into Healthy Start Participant Profile electronic case record

•  Identifies common legal issues that impact health and well-being

I Income Supports

H Housing & Utilities

E Education

L Legal (immigration) Status

P Personal & Family Stability

Evaluation Methods •  Public health faculty from Thomas Jefferson

University led evaluation methods.

•  Program Participants: •  Collected data through telephone interviews 3-4 weeks

after cases closed and review of case notes

•  Measured: satisfaction, stress, health, and self-efficacy

•  At time data was collected 21 participants had closed cases; 13 completed follow up interviews

•  Staff: •  Conducted pre and post tests during trainings and follow

up interviews at end of grant period

•  Measured: satisfaction, knowledge and beliefs

Project Results (Sept. 2010-May 2013) •  Over 300 Healthy Start

Program Participants & their family members received services

•  187 Legal cases were addressed

•  151 Case consultations occurred with CKHS case managers & staff

•  38 Students from multiple disciplines educated

•  34 Trainings were conducted for CKHS staff & community partners

More than

300 Individuals

Helped

187 Legal issues addressed

151 Case

Consults

34 Trainings conducted with CKHS

38 Students

educated at WUSL

Legal Issues Resolved (5/12 -6/13)

50%

14%

10%

6%

4% 6% 10%

Public Benefits

Disability benefits

Housing

Utilities

Custody

Consumer issues

Other N=70

Impact on Client Stress (6/12-5/13)

Client Average Overall Level of Stress

8.7

3.6

0 1 2 3 4 5 6 7 8 9

10

Prior to Services

After services

Client Average Overall Level of Stress

Average Level of Stress for Clients with Public Benefit Matters

8.3

1.375 0

1

2

3

4

5

6

7

8

9

Prior to Services

After services

Client Average Overall Level of Stress

N=13 N=8

Client Quotations

•  I didn't know I could even get help like that. I didn't know where to turn. It made a big difference and I'm very grateful. She still keeps in contact with me.

•  Having a lawyer really changes everything. Being able to say, "my lawyer will call you" gets results. I now know that if anything happens I can call my lawyer, Laura.

•  Laura was a big help, she has been beyond a blessing. I didn’t have a state ID or any other documents because of my personal problems and she was able to help me apply for benefits anyway.

•  The issue she worked on I was working on for more than a year. No one knows how hard it was. She just stepped in and in a month everything was done.

Impact on CKHS Staff

•  MLP integration has resulted in: •  Increased knowledge

•  Increased capacity to serve clients

•  Increased advocacy capacity

•  Decreased stress

•  Increased ability to identify and refer legal needs

Staff Quotations •  “We wouldn’t be able to operate on our own without the

trainings and the support of the attorneys. The training is continuous; there is always something new. When that change comes, the attorneys understand and teach us.

•  ”The increased knowledge base of the staff has benefited clients. The staff can serve more clients, due to the increased capacity of staff.”

•  “One of the outcomes of the MLP is that it has “allowed the case managers to have the time to do what they need to do really well.” Clients can be “all consuming” and being more efficient in resolving issues and referring complex cases to the attorneys has allowed them to address additional clients’ concerns since they are not “weighed down with just one person.”

Delaware MLP Pilot Project A Collaboration between the Delaware Division of Public Health, Community Legal Aid Society, Inc. (CLASI), Brandywine Women’s Health Associates and Westside Family Healthcare

Wilmington, Delaware

About Pilot Project ´ Healthy Women Healthy Babies Sites:

´ Brandywine Women’s Health Associates

´ Westside Family Healthcare

´ Enrollees: ´ Expectant Mothers Experiencing Legal and Social Stressors

´ Methods: ´ Needs Assessment

´ Enrollees Identified

´ Complete SF-36/PSS (R1)

´ Receive Services

´ Complete SF-36/PSS at Follow-Up (R2)

´ SF-36/PSS Dates: April 1, 2013 - September 6, 2013.

Description of Tools Used ´ Short Form 36 (SF-36)

´ Physical Functioning: Moderate Activities, Walking

´ Role-Physical: Physically Performing Activities

´ Bodily Pain: Pain in Performing Activities

´ General Health: Perception of Health

´ Vitality: Pep/Life, Energy, Tiredness

´ Social Functioning: Social Time and Extent

´ Role-Emotional: Emotional in Performing Activities

´ Mental Health: Nervous, Peaceful, Happy

´ Perceived Stress Scale (PSS-4)

Results ´ 39 Referrals, 26 Enrollees

Completed R1

´ 11 Enrollees Completed R1 and R2 Surveys

´ Age:

´ Average: 29 Years

´ Minimum: 21 Years

´ Maximum: 37 Years

´ Race/Ethnicity: ´ Hispanics: 7

´ White non-Hispanics: 2

´ Black non-Hispanics: 2

´ Days Between R1 and R2 Surveys:

´ Average: 78 Days

´ Minimum: 26 Days

´ Maximum: 144 Days

Results

´ Physical Health Scales

´  Physical Functioning: Xbar = 8.64, p = 0.12

´  Role-Physical: Xbar = 27.27, p = 0.01

´  Bodily Pain: Xbar = 14.09, p = 0.15

´  General Health: Xbar = -1.36, p = 0.81

´ Mental Health Scales

´  Vitality: Xbar = 16.36, p = 0.04

´  Social Functioning: Xbar = 17.05, p = 0.06

´  Role-Emotional: Xbar = 6.06, p = 0.56

´  Mental Health: Xbar = 10.91, p = 0.08

Results

- Δ No Δ + Δ

Physical Functioning 3 2 6

Role-Physical 0 4 7

Bodily Pain 2 3 6

General Health 7 0 4

Vitality 2 0 9

Social Functioning 1 3 7

Role-Emotional 2 4 5

Mental Health 2 3 6

Perceived Stress 3 2 5

Case Examples ´  Valentina was experiencing pregnancy-related discrimination at work - she

was not allowed to take snack breaks - and had a significant fear of deportation due to not having legal immigration status.

´  Maria was fired by her employer/landlord due to her pregnancy. Due to her termination, not only was she no longer bringing home income, her employer/landlord ceased offering her reduced rent.

´  Camila requested Medical-Legal Partnership Project assistance because she had overdue bills in collections. Camila did not know the status of these bills and wished to learn their status. She was also fearful of their potential impact on her immigration status in the future.

´  Tamira’s son was awarded temporary SSI benefits. Tamira was fearful of spending the checks for risk of incurring an overpayment. Thus, she was not able to spend the income she needed to support her family without significant anxiety.

´  Nicole, several months pregnant, discovered when she moved into a house, that there was mold in the basement, a leak from the bathroom into the room below, and the landlord was entering the house without proper notice, among many other problems.

Limitations/Challenges ´ Non-Responsive Clients è Small Cohort (n = 11)

´ Multiple Attempts to Contact: Calls, Letters by Culturally/Linguistically Appropriate Staff

´ Why:

´ No Incentive After Services Provided

´ Changes in Clients’ Address/Phone

´ After Delivery

´ Poverty

´ Relatively Short Project Period ´ Longer Time for Certain Services (e.g., Immigration)

´ Lack of Control Group

´ Broad Range of Legal Problems – Link to Health

´ Funding Limits Scope of Service and Program

Public Health & Policy Implications of MLP

´ Improved public health outcomes through: ´ Addressing issues

“upstream” through systemic advocacy efforts

´ Reducing maternal stress and anxiety

´ Increasing provider advocacy capacity and decreasing provider stress

´ Affordable Care Act provisions: ´ Patient Centered Medical

Home, Health Home, and Accountable Care Organization models

´ Community Health Needs Assessment (CHNA) obligations

´ Movement toward bundled-payment model incentivizing outcomes

MLP Potential within Healthcare Systems ´ Demonstrated return on investment (ROI)

´ Potential for reduced ER visits and reduced hospitalizations

´ Potential for increased compliance

´ Increased access to health insurance coverage

´ Achievement of mandates and incentives set forth by the ACA ´ E.g. CHNAs; PCMH; quality improvement, etc.

Contact information

Daniel Atkins, Esq. Project Director HELP: MLP Adjunct Professor, Widener University School of Law c/o Crozer-Keystone Healthy Start 2600 W. Ninth Street Chester, PA 19013 Email: da.helplmp@gmail.com Mobile phone: (484) 557-0171 Web: www.helpmlp.org

Publications, Presentations, and Distinctions ´ One of three MLPs in country funded by HRSA to serve

Healthy Start programs.

´ Present at national conferences, including National Center for Medical-Legal Partnership, American Public Health Association, CityMatch, and National Healthy Start Association.

´ Published articles on MLP in Journal of Legal Medicine, Delaware Medical Journal.

´ Selected to serve as lead facilitator (one of four in country) by NCMLP on quality and sustainability.

´ Three staff attorneys are specially trained and experienced in poverty and health law.

Thank you! Questions?