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Health care legal partnerships

A team-based approach

alter, a patient with uncontrolled diabetes, walks into your exam room. You have been working with Walter over the past 12 months to get his blood sugars and A1C under control. Walter has been homeless for the past three years and without a safe place to store his insulin. Each visit you check his lab values and review his medications, titrating up on his insulin. You refer him to diabetes education. You provide information and handouts on lifestyle changes, including healthy diet and exercise. Yet, despite regular visits, appropriate medications, and a strong patient-provider relationship, there has been little change in Walter’s health. Why? Without stable housing, he has no place to store his medication and insulin. As his provider, it can feel beyond your control; the barriers to Walter’s health are outside of your area of expertise.

Social determinants of health—including access to nutritious and healthy food; a safe and habitable shelter; relationships that are safe and free from violence; and opportunities to pursue education, employment, and a community in which we feel safe­—are increasingly being recognized as significant factors contributing to one’s overall health. To better address the social and economic conditions affecting their patients’ health, physicians at Bethesda Family Medicine Clinic, a primary care residency clinic in St. Paul, are turning to an attorney.

An attorney in the house

Bethesda has partnered with Southern Minnesota Regional Legal Services (SMRLS), a local legal aid provider, to form a health care legal partnership (sometimes referred to as a medical legal partnership) with the goal of addressing patients’ social determinants of health through legal intervention. Founded in 1909, SMRLS attorneys provide free legal services to help low-income individuals and families secure and protect their basic needs, and to maintain freedom from hunger, homelessness, sickness, and abuse. Since July of 2017, a full-time SMRLS attorney has been providing legal services to Bethesda’s patients. Embedded within the clinic, the attorney functions as a member of the care team. Just like a clinical pharmacist, the attorney can be called in to meet in-person with a patient.

At first, the idea of an attorney onsite at a medical clinic may seem both puzzling and daunting. (Many physicians may jump to concerns about malpractice or litigation; others may worry about patient privacy and protection of information.) But the goal of a health care legal partnership is to serve clinic patients. For example, one Bethesda patient was referred to the onsite attorney because she had received a termination notice from public housing. The termination was based on the patient’s failure to follow the management’s housekeeping expectations. However, because of complications during her pregnancy and the subsequent birth, this single mother of three young children was physically unable to do so. With the help of the mother’s provider at Bethesda, the onsite attorney was able to demonstrate that her health condition was directly linked to the reason for the termination, and was able to save the patient’s affordable housing. The attorney also helped the family obtain services to ensure that the mother remained lease-compliant while she continued to heal from her recent childbirth. The attorney’s work, in consultation with the mother’s provider, helped the mother save her housing, allowed her to heal from a difficult pregnancy and birth, and protected the health needs of her young children and newborn baby.

The health care legal partnership attorney has the ability to address many social and economic problems that are beyond a physician’s expertise. Through representation in eviction proceedings, the attorney can help prevent a family from becoming homeless. This means that the family can live in a safe place, attend school regularly, and attend regular preventive visits. The attorney can also help an elderly patient appeal a wrongful reduction in food support. This means that the patient is able to access healthy food, maintain strength, and avoid a disastrous fall at home. Or when the attorney helps a patient fleeing an abusive partner obtain an order of protection, a young woman can sleep soundly at night, attend regular psychotherapy visits, and decrease her number of psychiatric medications. These are just a few examples. The attorney is also available to help children with learning disabilities receive the services they need to succeed in school, or to help refugees apply for citizenship.

There are over 15 health care legal partnerships across the state of Minnesota.

Impact on health outcomes and cost

Partnerships like the one between Bethesda and SMRLS have been shown to improve patient health outcomes, reduce cost, decrease hospital admissions, and improve provider satisfaction. One study through the University of Arizona Alvernon Family Medicine Clinic, published in the Journal of Healthcare for the Poor and Underserved, found that patients noted 30 percent less stress and had a 41 percent increase in well-being following an intervention from the legal services team.

Legal interventions may also be a means to lower rising health care costs. According to the Pennsylvania Healthcare Cost Containment Council, a state agency charged with reducing health care costs, a study showed a 51 percent reduction in per-patient health care costs following a targeted legal intervention with high cost or “super utilizer” patients within Lancaster County, Pennsylvania. Another partnership in New York demonstrated a 90 percent decrease in emergency room visits and hospital admissions for asthma patients following a legal intervention targeting substandard housing, according to a study published in the Journal of Asthma.

Physician wellness and the effects of burnout affect many physicians, but especially those serving low-income populations. A national survey conducted by the National Center for Medical-Legal Partnerships at the George Washington University showed that 38 percent of providers working in a health care legal partnership felt they were “better able to work at the top of their license” because of the presence of the partnership. Eighty-six percent felt that the partnership improved patient outcomes, and 64 percent felt it improved patient compliance with medications and treatment plans.

Tailoring partnerships to serve patients

Each health care legal partnership is different, designed to fit the strengths and needs of both the legal and the health care partner. There are over 15 health care legal partnerships across the state of Minnesota. The first partnership, between Community-University Health Care Center (CUHCC) and Stinson Leonard Street Law Firm, formed in 1993. There are partnerships in a variety of clinical settings, including dental clinics, behavioral health centers, pediatric hospitals, and Federally Qualified Health Centers. Some legal partners include legal aid organizations like SMRLS, but others utilize private law firms whose attorneys provide pro bono services or law students through partnerships with law schools.

Rigorous reports that do not align with clinical and policy needs are not useful.

For SMRLS and Bethesda, strong pre-existing relationships, overlapping missions and visions, and shared target communities provided the basis for the partnership. Bethesda has a strong interdisciplinary team model already, which includes clinical pharmacists, behavioral health professionals, and social workers. This served as a framework for the addition of a legal team member. The Bethesda-SMRLS partnership is located within the clinic, with the legal aid attorney onsite approximately 80 percent of the time. The attorney has her own office adjacent to the exam rooms, allowing patients to be seen as issues are identified during medical visits. When a health-harming legal need is identified, a referral is placed within the electronic medical record, just as it would be for other specialty appointments. Upon conclusion of the legal work, the attorney sends the referring provider a written follow-up that identifies the type of legal intervention taken on behalf of the patient. When not with a patient, the attorney is available for consultations with the providers, and clinic staff regularly stop by to ask questions or discuss potential legal issues. She also works closely with the clinic social worker and care coordinators to identify the appropriate types of intervention.

In the first year, 191 referrals for legal services were placed. Housing was the most common issue addressed, followed by public benefits, family law, insurance coverage, and immigration. Patients have had an overwhelmingly positive response to their interactions with the legal team. One patient shared, “She won the case for me. Now I have low-income housing. It helped me strengthen my mind, my heart.” Physicians also see the positive changes in their patients served by the partnership. “As a provider, I feel empowered to ask about difficult issues because I know there is a team behind me to help me and my patients with answers to social/legal problems,” said one doctor.

Additionally, because Bethesda is the home site for a residency program and hosts family medicine and pharmacy residents, behavioral health fellows, and medical and pharmacy students, education has been a central part of the partnership. The legal team provides monthly conferences to staff and providers on a variety of health-harming legal issues, and learners are given an opportunity to attend housing court with SMRLS attorneys. Bethesda’s provider survey showed a greater than 20 percent increase in providers asking about and addressing family life, housing, income supports, public benefits, and educational needs following the addition of the attorney.

There have been some obstacles to forming and maintaining the partnership, including the need to secure ongoing funding. To ensure that the partnership is working for both organizations and is appropriately responding to the needs of the patients, a group of professionals from SMRLS and Bethesda meets monthly to review referrals, address issues relating to patient privacy and client confidentiality, and work on ways to secure continued funding for the project. Despite these challenges, the presence of a legal aid attorney provides the rest of Bethesda’s care team a viable solution to complex social issues affecting patient health, and this has had a positive impact for both patients and providers.

One success story

Walter is just another patient at Bethesda Clinic. His A1C was too high, he was non-compliant with his insulin regimen, and he was at risk for further complications down the road, such as chronic kidney disease, heart attacks, and foot infections. His provider referred him to the onsite attorney—who discovered he was unlawfully denied affordable housing—and took his case. Now Walter has a stable place to live, store and cook fresh and healthy food, and a better way to manage his diabetes. He’s taking his insulin regularly and his A1C and blood pressure have come down, preventing further hospitalizations. It’s a win for patients, a win for providers, and a win for our health care system.

Kathryn Freeman, MD, is an assistant professor of family medicine and community health at the University of Minnesota St. Joseph’s Family Medicine Residency Program, where she practices full spectrum family medicine with obstetrics.

Meghan Scully, JD, is a supervising attorney at Southern Minnesota Regional Legal Services, Inc., a nonprofit law firm, where she also represents clients in public benefit matters. In addition to the Bethesda Clinic, SMRLS has health care legal partnerships with Children’s Minnesota in St. Paul and Open Door Health Center in Mankato.

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Meghan Scully, JD, is a supervising attorney at Southern Minnesota Regional Legal Services, Inc., a nonprofit law firm, where she also represents clients in public benefit matters. In addition to the Bethesda Clinic, SMRLS has health care legal partnerships with Children’s Minnesota in St. Paul and Open Door Health Center in Mankato.