Allies Not Adversaries: Partnering with Attorneys to Improve Patient Health

Jeffrey Colvin, MD, JDJeffrey Colvin, MD, JDSection of Pediatric Hospital Section of Pediatric Hospital

MedicineMedicineChildren’s Mercy HospitalChildren’s Mercy Hospital

June 12, 2010June 12, 2010

Allies Not Adversaries:Partnering with Attorneys to Improve Patient Health

Disclosures I have no current financial interest or I have no current financial interest or

direct affiliation with any commercial direct affiliation with any commercial organizations or products that may be organizations or products that may be

referenced in this presentation.referenced in this presentation.

Outline1.1. Introduction to medical legal partnershipsIntroduction to medical legal partnerships2.2. Areas where an attorney can improve Areas where an attorney can improve

patient healthpatient health3.3. The nuts and bolts of one medical legal The nuts and bolts of one medical legal

partnership: Children’s Mercy Hospitalpartnership: Children’s Mercy Hospital4.4. Keys to starting a medical legal partnershipKeys to starting a medical legal partnership5.5. SummarySummary

Clinical Vignette A 6 year old male is admitted for status A 6 year old male is admitted for status

asthmaticus for the third time in four asthmaticus for the third time in four months. His maintenance inhaled steroids months. His maintenance inhaled steroids have been steadily increased despite full have been steadily increased despite full adherence. Their apartment has mold due to adherence. Their apartment has mold due to a leaking roof. She has brought this concern a leaking roof. She has brought this concern to the attention of the landlord multiple to the attention of the landlord multiple times, but no action has been taken. The times, but no action has been taken. The patient has previously skin tested positive to patient has previously skin tested positive to molds. The mother states that the family can molds. The mother states that the family can not afford to move and but if they did move not afford to move and but if they did move “someone else would walk into the problems “someone else would walk into the problems we’re leaving.”we’re leaving.”

Clinical Vignette What would be the most appropriate What would be the most appropriate

action to take?action to take?a.a. Shrug your shouldersShrug your shouldersb.b. Hope that your pager goes off so that you Hope that your pager goes off so that you

can leave the roomcan leave the roomc.c. Write a letter to the landlord who will first Write a letter to the landlord who will first

laugh and then ignore the letterlaugh and then ignore the letterd.d. Refer the patient to a public interest attorneyRefer the patient to a public interest attorney

The History of Medical Legal Partnerships

* Over a dozen programs in active development

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The History of Medical Legal Partnerships

2. How can an attorney help?

Housing Conditions & Child Health

Asthma: mice, mold, Asthma: mice, mold, cockroaches, poor cockroaches, poor ventilation, ventilation, “homemade” heaters“homemade” heaters

Lead poisoning: lead Lead poisoning: lead paintpaint

Burns: exposed Burns: exposed wires & heaterswires & heaters

Falls from WindowsFalls from Windows

Rosenstreich, NEJM 1997; Fuller-Thompson, Rev Enviro Health 2000.

Homelessness & Child Health

Poor Overall Health: 13% v 4%Poor Overall Health: 13% v 4% Any Health problem: 2.5Any Health problem: 2.5 Severe Health problem: 3xSevere Health problem: 3x Multiple Health problems: 6xMultiple Health problems: 6x Asthma: 6xAsthma: 6x Immunization Delay: 2-3x Immunization Delay: 2-3x Poor Dentition: 10xPoor Dentition: 10x Developmental Delay: 54% Developmental Delay: 54%

failed Denver (compared to failed Denver (compared to 16% of housed poor)16% of housed poor)

Depression: 46-57% exceed Depression: 46-57% exceed Children’s Depression Children’s Depression Inventory evaluation pointInventory evaluation point

Wood, Pediatrics 1990; McLean, Arch Peds Adol Med 2004.

“Heat or Eat” Association of Wt/Ht Association of Wt/Ht

<5% in <3yo’s in 3 <5% in <3yo’s in 3 months following winter months following winter months (8.8% v 6.6%)months (8.8% v 6.6%)

Most associated with Most associated with families having difficulty families having difficulty paying heating utilities paying heating utilities & food insecurity& food insecurity

Poor Children had 10% Poor Children had 10% fewer caloriesfewer calories

LIHEAP prevented this LIHEAP prevented this effecteffect

Bhattacharya, Am J Pub Health 2003; Frank, Pediatrics 2006.

“There Ought to be a Law Against That”

AffordableHealthyHousing

Public Housing&

Section 8

HousingCode

Landlord-Tenant

Law



Public Housing&

Section 8

HousingCode

Landlord-Tenant

Law

UnlawfulEvictions

UnlawfulConditions

UnlawfulDenial or

Termination



Public Housing&

Section 8

HousingCode

Landlord-Tenant

Law

UnlawfulEvictions

UnlawfulConditions

UnlawfulDenial or

Termination

Attorney Attorney

Attorney

Other Health-Related Legal Issues: Food

Insecurity/InsufficiencyHealth Effects:Health Effects: Fair/Poor Health: 1.7-2.3xFair/Poor Health: 1.7-2.3x Worse Physical and Worse Physical and

Health-Related Quality of Health-Related Quality of Life (p 0.02)Life (p 0.02)

Increased Increased Hospitalizations: 1.3xHospitalizations: 1.3x

Legal Issue:Legal Issue: Unlawful Denials of Unlawful Denials of

TANF, WIC, Food StampsTANF, WIC, Food StampsCasey, Arch Peds Adol Med 2005; Weinrub, Pediatrics 2002; Alaimo, Pediatrics 2001.

Other Health-Related Legal Issues: Insurance & Health

Care Access Health Effect ExamplesHealth Effect Examples

Increases ambulatory health Increases ambulatory health visits & use of a “medical visits & use of a “medical home” byhome” by 20-30%)20-30%)

10% increase in Medicaid 10% increase in Medicaid results in 2.3-3.4% decrease results in 2.3-3.4% decrease in preventable in preventable hospitalizationshospitalizations

Asthma Admission: Asthma Admission: ↓7% after ↓7% after enrollmentenrollment

Legal IssueLegal Issue Unlawful denial or Unlawful denial or

termination of termination of MedicaidMedicaid

Unlawful denial of Unlawful denial of medically necessary medically necessary medications, medications, treatments, equipmenttreatments, equipment

IOM, America’s Uninsured Crisis, 2009 pp. 58-63, 188-95.

Other Examples of Health-Related Legal Issues: Immigration Status

HEALTH EFFECTS: Citizen Child,Citizen Parent

Citizen Child,Non-Citizen Parent

Non-Citizen Child,Non-Citizen Parent

Fair/Poor Health 3.9% 13.5% 12.2%

No or Discontinuous Insurance (All)

15.3% 34.4% 52.3%

No Usual Source of Care 5.8% 18.2% 27.9%

Huang, Am J Pub Health 2006

Legal Issues• Counseling regarding rights and access to public benefits• DV/IPV of Immigrants (VAWA)• Family Petitions and Refugee and Asylum Petitions• Counseling re: Deportation Hearings

Other Examples of Health-Related Legal Issues:

Child Witness to Violence Legal Issue:Legal Issue: Intimate Intimate

Partner Partner Violence/Domestic Violence/Domestic ViolenceViolence Orders of ProtectionOrders of Protection Dissolutions/DivorceDissolutions/Divorce

Health Effects:Health Effects: Increased anxiety, Increased anxiety,

aggression, & conduct aggression, & conduct disordersdisorders

Lower self-esteemLower self-esteem Poor school Poor school

performanceperformance

Kerker, Arch Ped Adol Med 2000; Wright, Pediatrics 1997; McCloskey, Child Dev 1995.

Other Examples of Health-Related Legal Issues

DisabilityDisability Unlawful denials of SSIUnlawful denials of SSI Unlawful denial of Medicaid for equipment Unlawful denial of Medicaid for equipment

and servicesand services

Consent for Medical Care, Education, etcConsent for Medical Care, Education, etc GuardianshipsGuardianships Power of AttorneyPower of Attorney

Stress & “The Worry Budget”

754 Asthmatic Children

Suboptimal Control37%

Controller Med Underuse48%

Smith, Pediatrics 2008.





Associations p<0.05RaceIncomeParent EducationUnemploymentLow ExpectationsCompeting Priorities

Associations p<0.05RaceIncomeParent EducationSingle ParentDiscordant ExpectationsNo Set Time






Associations p<0.05RaceIncomeParent EducationUnemployment

Low ExpectationsCompeting Priorities

Associations p<0.05RaceIncomeParent EducationSingle Parent

Discordant ExpectationsNo Set Time


Stress & “The Worry Budget” Competing Priorities, Low Expectations, & Competing Priorities, Low Expectations, &

No Set Medication TimeNo Set Medication Time Competing Priorities: “The Worry Budget”Competing Priorities: “The Worry Budget”

High concern about job, income, paying bills, High concern about job, income, paying bills, home/neighborhood safety, family relationships, home/neighborhood safety, family relationships, parent’s or other family member’s healthparent’s or other family member’s health

Low Expectations: “The Hegemony of Low Low Expectations: “The Hegemony of Low Expectations”Expectations” A reflection of previous asthma experience vs. a A reflection of previous asthma experience vs. a

reflection of general life expectations (?)reflection of general life expectations (?) No Set Medication TimeNo Set Medication Time

Reflection of competing priorities & low expectations (?)Reflection of competing priorities & low expectations (?)


3. The “Nuts & Bolts” of One Medical Legal

Partnership: Children’s Mercy Hospital

Medical Legal Partnership at

Children’s Mercy Hospital Collaboration between Children’s Mercy Collaboration between Children’s Mercy

and Legal Aid of Western Missouri (2007) and Legal Aid of Western Missouri (2007) and Kansas Legal Services (2009)and Kansas Legal Services (2009)

Legal Aid’s “Healthcare Recovery” WorkLegal Aid’s “Healthcare Recovery” Work Funding through healthcare “conversion” Funding through healthcare “conversion”

foundationfoundation Legal Aid has expanded partnerships to two Legal Aid has expanded partnerships to two

additional FQHC and has plans to expand to additional FQHC and has plans to expand to 1-2 more local hospitals1-2 more local hospitals

Annual Number of Referrals

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4th Qrt 2007 2008 2009 Projected 2010

36

350508

780

Clinical Vignette, Pt. 2 The mother of your asthmatic patient The mother of your asthmatic patient

would like to be referred to a public would like to be referred to a public interest lawyer. What is the best way interest lawyer. What is the best way to connect her to an attorney?to connect her to an attorney?

a.a. Refer him to the phone book, with special Refer him to the phone book, with special emphasis to the back cover.emphasis to the back cover.

b.b. Call Satan, he’s very familiar with most Call Satan, he’s very familiar with most lawyerslawyers

c.c. Call the hospital’s General Counsel Call the hospital’s General Counsel (they’ll love that!)(they’ll love that!)

d.d. Page the medical-legal partnership.Page the medical-legal partnership.

MD’s

RN’s SW’s

NP’s

Attorney or Paralegal Present in Hospital/Clinic

Legal Intake

Case Handling

ScreeningQuestionnaire

MLP: How It Works

What the Attorney Does: Case Handling

Brief Consultation(21%)Referral Out (29%)

ExtensiveRepresentation (50%)

MD’s

RN’s SW’s

NP’s


Legal Intake

Case Handling

Feedback toMedical Team

1


MLP: How It Works

MD’s

RN’s SW’s

NP’s


Legal Intake

Case Handling


1


2

XMLP: How It Works

MD’s

RN’s SW’s

NP’s


Legal Intake

Case Handling


1


2

X 3

MLP: How It Works

MD’s

RN’s SW’s

NP’s


Legal Intake

Case Handling


1


2

X 3

4Issue Spotting

&Lecture Series

MLP: How It Works

MD’s

RN’s SW’s

NP’s


Legal Intake

Case Handling


1


2

X 3

4Issue Spotting

&Lecture Series

5Pagers &Mimic Referral Process

MLP: How It Works

3. Starting a Medical Legal Partnership

What to Think About When Thinking About Starting a

MLP1.1. Do you already have one?Do you already have one?

Number of Healthcare Sites

with an MLP___________________________

0

1

2-4

5-9

10+

Medical Legal Partnerships


MLP1.1. Do you already have one?Do you already have one?2.2. How to find lawyers to How to find lawyers to

collaborate with?collaborate with? Legal AidLegal Aid Law School ClinicsLaw School Clinics Hire attorneysHire attorneys Private law firm pro bono workPrivate law firm pro bono work



collaborate with?collaborate with?3.3. Open the flood gates?Open the flood gates?

One clinicOne clinic Outpatient onlyOutpatient only One legal area versus all legal One legal area versus all legal

areasareas



collaborate with?collaborate with?3.3. Open the flood gates?Open the flood gates?4.4. Screening versus ReferralsScreening versus Referrals


MLP1.1. Do you already have one?Do you already have one?2.2. How to find lawyers to collaborate How to find lawyers to collaborate

with?with?3.3. Open the flood gates?Open the flood gates?4.4. Screening versus ReferralsScreening versus Referrals5.5. Funding: foundations, bar Funding: foundations, bar

associations, pro bono associations, pro bono assistance, healthcare recoveryassistance, healthcare recovery

Funding Sources for Medical Legal Partnerships

Legal (20%)

Healthcare (21%)

Government (9%)

CommunityFoundations (33%)Other (17%)

N=53, Total Cash Funding=$8,092,500

Other Keys to Success Strong legal partnerStrong legal partner Patience and Buy-In Patience and Buy-In Recognizing every specialty’s unique Recognizing every specialty’s unique

legal interestlegal interest Making Your Medical Legal Partnership Making Your Medical Legal Partnership

Scholarly: research, resident educationScholarly: research, resident education Start with legal issues suggested by Start with legal issues suggested by

the hospitalthe hospital

Steps to Start a MLP1.1. Find a MLP in your hospital or city or Find a MLP in your hospital or city or

contact local Legal Aidcontact local Legal Aid2.2. Approach your Administration: Selling Approach your Administration: Selling

PointsPoints• Unmet Need: Improved patient care & Unmet Need: Improved patient care &

satisfactionsatisfaction• Potential health recovery dollarsPotential health recovery dollars• No association with malpractice No association with malpractice

(medical or legal)(medical or legal)

Steps to Start a MLP3.3. Determine scope: legal issues Determine scope: legal issues

& medical settings based on & medical settings based on capacity & interestcapacity & interest

4.4. Seek funding: start with local Seek funding: start with local foundationsfoundations

5.5. Teach attorneys to adapt to the Teach attorneys to adapt to the culture and practices of culture and practices of medicinemedicine

6.6. Educate, educate, educateEducate, educate, educate

Ask me to help you with Ask me to help you with contacts.contacts.

Summary1.1. By collaborating with attorneys, we By collaborating with attorneys, we

can improve the health of our can improve the health of our patients.patients.

2.2. For medical-legal partnerships to be For medical-legal partnerships to be successful, attorneys need to be successful, attorneys need to be seen as the “new consultant” and a seen as the “new consultant” and a part of the medical team.part of the medical team.

3.3. Several options exist for starting Several options exist for starting and structuring a medical-legal and structuring a medical-legal partnership.partnership.

Thank You.Questions?

Documents

Allies Not Adversaries: Partnering with Attorneys to Improve Patient Health