Presentation to 2013 NC Primary Care Conference June 21, 2013

Rebecca Whitaker, MSPH, Director of Health Policy and Governmental AffairsNorth Carolina Community Health Center Association

Madlyn Morreale, JD, MPH, Supervising AttorneyMedical-Legal Partnership Program, Legal Aid of North Carolina

Medical-Legal Partnerships:Addressing Social Determinants of Health to

Improve Patient and Population Health

Agenda

1. Overview of Medical-Legal Partnerships (MLPs)

2. Assessment of Unmet Legal Needs Among Health Center Patients

3. Strategic Decisions for Implementing MLPs

4. Next Steps for Expanding MLPs in NC

5. Questions/Answers

How to Address Social and Environmental Determinants of Poor Health Status?

Health and Well-Being Are Influenced by Individual Factors, Access to Resources, and Broader Legal and Policy Framework

Economic and social opportunities and resources

Living and working conditions in homes and communities

Medical carePersonal behavior

HEALTH

Opportunity for legal & policy

intervention

Opportunity for health care provider intervention

Opportunity for legal & policy

intervention

Adapted from: Braveman, PA, Egerter, SA & Mockenhaupt RE (2011). Broadening the Focus: The Needs to Address the Social Determinants of Health. Am J Prev Med 40(1S1): S4-S18.

Health Care Providers Understand That Patients’ Unmet Social Needs Are Directly Causing Worse Health Outcomes

95% of physicians serving patients in low-income communities believe patients’ social needs are as important to address as their physical health needs

80% of physicians are not confident their ability to address patients’ social needs

76% of physicians wish that the health care system would cover the costs associated with connecting patients to services that meet their social needs

How Can Different “Systems” Work Together on Behalf of Shared Patients and Clients?

What is a Medical-Legal Partnership?

Brings together physicians, nurses, social workers, attorneys, paralegals, and othersTo address the social and environmental determinants of

health, including: Substandard housing conditions; Domestic violence; Food, income, and housing insecurity; Improper denials of Medicaid and other public benefits; and, Failure to provide children with educational services to which they are

entitled

Social Determinants of Health Examples of Legal Remedies

• “Habitability” claims• Fair housing claims• Preventing illegal evictions• Defending clients facing improper termination of

housing subsidy• Mortgage foreclosure assistance, including loan

modifications

Housing stability and conditions

• Appeal of denials of unemployment benefits, income support programs• Supplemental Security Income (SSI)• Work First for Families

• Enforce consumer protection laws

Income instability

Social Determinants of Health Examples of Legal Remedies

• Appeal of eligibility and service denials of Medicaid or NC Health Choice for Children

Inadequate health

coverage

• Appeal of denial of SNAP/ Food StampsFood insecurity

• Domestic violence orders• Health Care Power of Attorney for Minors

Family instability

• Enforcement of special education rights• Challenge improper school disciplinary actions, failure

to provide PEPs

Educational inadequacy

Legal Aid of North Carolina, Inc. Mission and Operations

A statewide, non-profit law firm that provides free legal assistance in civil matters to low-income people in order to ensure equal access to justice and to remove legal barriers to economic opportunity

18 local offices serving all NC counties Statewide, toll-free Help Line

Program AreasHousingDomestic ViolencePublic Benefits Consumer LawEmploymentEducationFamily Law Community Economic Development

Statewide and Regional ProjectsMortgage Foreclosure ProjectDomestic Violence Prevention Initiative and Battered Immigrant ProjectFair Housing ProjectAdvocates for Children’s ServicesFarm Worker UnitSenior Law ProjectLow-income Tax ClinicMedical-Legal Partnership Program

The National MLP Network – Highlights from 2012 Survey Nearly 100 MLPs serving children, the elderly, veterans and patients

with chronic illnesses

Provided services to 54,000 patients/clients

Partnered in 134 hospitals and 143 community health centers

Engaged 38 medical schools, 47 residency programs, 44 law schools

Engaged 102 legal services offices and 60 firms and corporate law departments

Location Medical Partner(s) Legal Partner(s)Asheville, NC Mission Hospitals

Mountain Area Health Education Center Western NC Community Health Services

Pisgah Legal Services

Chapel Hill, NC North Carolina's Children's Hospital, “CATCH” program for complex care patients

Legal Aid of North Carolina, Inc. (Statewide) Pro Bono Program, University of North Carolina

School of LawCharlotte, NC Carolinas HealthCare System, Myers Park -

Pediatrics Legal Aid of North Carolina, Inc. (Charlotte

office) Legal Services of Southern Piedmont, Inc.

Durham, NC Lincoln Community Health Center, Pediatrics Department,

Duke Primary Care for Children Duke University Medical Center, Pediatric

clinics

Legal Aid of North Carolina, Inc. (Durham office)

Children's Law Clinic, Duke University School of Law

Greensboro, NC Triad Adult and Pediatric Medicine, HealthServe Community Health Clinic and Guilford Child Health

Legal Aid of North Carolina, Inc. (Greensboro office)

Prospect Hill, NC Piedmont Health Services, Prospect Hill Community Health Center

Legal Aid of North Carolina, Inc. (Durham office)

Winston-Salem, NC Downtown Health Plaza, North Carolina Baptist Hospital

Legal Aid of North Carolina, Inc. (Winston-Salem office)

Winston-Salem, NC Wake Forest University Baptist Medical Center and School of Medicine

Elder Law Clinic, Wake Forest University School of Law

Medical Legal Partnership Sites in North Carolina

What is NCCHCA?

Mission

“To promote and support patient-governed community health care organizations and the populations they serve.”

Vision

“Every North Carolina community will have access to a patient-centered, patient-governed, culturally competent health care home that integrates high quality medical, pharmacy, dental, vision, behavioral health, and enabling services without regard to a person’s ability to pay.”

NCCHCA’s mission, vision and goals have guided interest in addressing social determinants of health and in medical-legal partnerships.

Why NCCHCA Got Involved in MLPs:A Changing Health Care Landscape

Growing emphasis on patient-centered health homes and community centered health homes

Addressing the Triple Aim: Improving the experience of care Improving population healthReducing health care costs

Helping health centers be “providers of choice”

MLPs are a Good Fit for Community Health Centers

Leveraging the social determinants of health is “in the DNA” of community health centers:

Serve predominately low-income, vulnerable populations52% of health center patients are uninsured95% of health center patients have incomes below 200% of the

federal poverty line

Emphasize enabling services to facilitate access to care and to help meet broader socioeconomic needs of patients

The Opportunity: Jim Bernstein Community Health Leadership Fellows Program

Project goals

Conduct a health-related legal needs assessment in NC health centers to bring attention to the health-related legal needs of health center patients and encourage more communities to develop MLPs

Inform MLP program planning and operations

Project Design

Data collected in 5 health centers around the state

Criteria for participation:Diversity in health center location and sizeEmphasis on enabling services staffRange of MLP development

Two needs assessment tools: Pen-and-paper patient survey (available in English & Spanish)Web-based staff survey

Data analysis in Excel & Stata

Patient Survey Results71% of all patient respondents reported experiencing at least one legal or resource need in the past year

Sued or harassed by creditor

Missed paying rent or mortgage

Missed meals - not enough money

Denied Medicaid/Health Choice

Denied SSI/SSDI

Threatened/treated unfairly at work

Denied food stamps/nutrition assistance

Concerns about immigration status

Landlord refused to make repairs

Threatened with eviction

Denied unemployment benefits

Threatened with foreclosure

Trouble receiving child support

Loss of public housing/government assistance

Denied veteran's benefits

Disabled child denied special services

Child suspended >10 days

0% 5% 10% 15% 20% 25% 30% 35%

Summary of Patient Characteristics

Patient characteristicsTotal

(n=334)

Legal/resource need identified (n=236, 71%)

No legal/resource problem identified

(n=98, 29%)

African American 39% 37% 44%

White 45% 46% 43%

Hispanic/Latino 20% 21% 17%

Spanish survey 15% 17% 9%

Self-reported health status

Very good 15% 13% 19%

Good 38% 33% 51%

Fair 29% 31% 23%

Poor 14% 17% 6%

Very poor 4% 5% 1%

At least 1 uninsured adult 69% 73% 60%

At least 1 uninsured child 31% 36% 19%

Patient Data Confirm the Need For MLPs in Health CentersPatients were significantly more likely to report legal or resource

needs if they: Reported fair, poor or very poor health status Had uninsured adults or children in the home Responded to the survey in Spanish

Sickest patients were less likely to have sought help from a lawyer in the past and less likely to know where to go for legal help

Hispanic/Latino patients were less likely to have sought help from a lawyer in the past and less likely to know where to go for legal help

Nearly 80% of patients were very likely or somewhat likely to discuss legal/resource problems with their provider in the future

Staff Survey Results

Patients reporting legal or resource problemStaff comfort discussing – Strongly agreeStaff likelihood of screening – Very likely

Sued or harrassed by creditor

Missed meals - not enough money

Denied Medicaid/Health Choice

Threatened with eviction/foreclosure

Denied SSI/SSDI

Threatened/treated unfairly at work

Denied food stamps/nutrition assistance

Concerns about immigration status

Denied unemployment benefits

Trouble receiving child support

Denied veteran's benefits

Disabled child denied special services

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Staff Survey Results

71% of staff said they would screen and refer patients for free legal assistance if their health center had an established referral program

Social workers and outreach workers were most likely to screen and refer patients, followed by clinicians (medical, dental and behavioral health)

Staff with shorter tenures were more comfortable discussing legal or resource needs and were more likely to screen and refer patients

Most common barriers to addressing health-related legal needs:

Key Takeaways

NC health center patients likely to experience legal or resource needs

Sickest patients more likely to have legal or resource needs but less likely to know where to seek help for these issues

Patients are willing to talk with their providers about legal and resource needs

Staff are willing to screen and refer patients for these issues

Why Collaborate?

Opportunity for better outcomes for individual patient/client “Value Added” with health care providers’ and lawyers’ expertise Opportunity for “Preventive Lawyering”

Opportunity to focus on community-level outcomes Use data to target limited resources for important, locally-defined needs “Impact Work”

Opportunities at the institutional level Expand capacity with new partners, resources

Opportunity for “systemic” impact Training of new professionals Multiple disciplinary approach can facilitate sustainability

The Medical-Legal Partnership Model: Core Activities Training to help health care providers screen for health concerns that may have

a legal remedy

Regular, on-site presence of legal staff at medical sites

Legal staff available for “consults” about potential referrals

When a clinician identifies a family with a potential legal problem, offers patient/family opportunity for referral to legal partner

If patient/family consents, clinician fills out a referral form and faxes it to legal partner

Legal partner contacts applicant, screens for eligibility and determines whether legal assistance can be offered

Legal staff and health care providers work collaboratively when needed to achieve goals

Legal partners track MLP referrals and MLP cases, work with medical partners to assess/enhance operations, impact

Recruitment of private bar to enhance capacity

Strategic Decisions for Potential MLP Partners

Who are your potential partners? Medical partners?

Clinics, hospitals, certain groups of providers within those settings? Legal partners?

Legal Aid of NC or other legal services providers?Law Schools?Private Bar?

Other community partners?

Which population(s) are you trying to serve?

What is your capacity? What are your constraints? Staff and other resources Eligibility restrictions Etc.

Strategic Decisions for Potential MLP Partners

Which legal services will be offered? Targeted to particular legal issues, e.g., housing, DV, benefits

appeals? How to handle service gaps?

How will you handle core activities? Training for health care providers Regular presence of legal staff at health care setting Consultations Referral, intake protocols Confidentiality

How to ensure success, sustainability?

Gaining Traction

Work done through Bernstein fellowship has raised visibility of medical-legal partnerships

NCCHCA’s MLP project one of five programs nationally to receive an Innovation Award funded by the Kresge Foundation in “recognition of [an innovative approach] to primary care delivery and other initiatives that promote health and wellness in low-income communities”

Expect NC health centers will want to engage in MLP development for several reasons: Opportunity to generate revenue by helping patients’ secure access to public

health insurance Opportunity to help improve patients’ health status Opportunity to help health centers be “providers of choice” in their

communities

Potential Next Steps for NCCHCA-LANC Collaboration Facilitate strategic development of MLPs in health centers

Identifying and connecting partners Brokering existing resources between partners Developing centralized resources and training for safety-net providers

Consider feasibility of a statewide/regional approach to MLPs in health centers, emphasizing MLPs in rural health centers MLPs most common in urban areas Rural communities more likely to experience persistent poverty and limited

access to services

Collect data and collaborate on a robust evaluation of MLPs in NC CHCs that would measure improvements in health outcomes, as well as the economic impact on CHCs and on clients served

Identify/ secure investment from health centers, private foundations, other funders

Questions?

Rebecca Whitaker, MSPHDirector of Health Policy & Governmental AffairsNCCHCAwhitakerr@ncchca.org919-297-0012

Madlyn Morreale, JD, MPHSupervising Attorney, Medical-Legal Partnership ProgramLegal Aid of NCmadlynm@legalaidnc.org 919-226-5912