Medical-Legal Partnerships: From Idea to Reality to Changing Pediatric Practice November 3, 2015 Molly Senn-McNally, M.D. Assistant Professor of Pediatrics.

Medical-Legal Partnerships: Medical-Legal Partnerships: From Idea From Idea to Reality to Changing Pediatric Practice to Reality to Changing Pediatric Practice

November 3, 2015November 3, 2015

Molly Senn-McNally, M.D.Molly Senn-McNally, M.D.Assistant Professor of Pediatrics Assistant Professor of Pediatrics Baystate Medical CenterBaystate Medical CenterTufts University School of MedicineTufts University School of Medicine

Jay E. Sicklick, J.D.Jay E. Sicklick, J.D.Clinical Instructor, Department of PediatricsClinical Instructor, Department of PediatricsUniv. of Connecticut School of Medicine Univ. of Connecticut School of Medicine Deputy Director, Center for Children’s AdvocacyDeputy Director, Center for Children’s AdvocacyDirector – Medical-Legal Partnership Project Director – Medical-Legal Partnership Project

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Acknowledgement is made on behalf of the Department that:

There is no commercial support for this Grand Rounds.

Confirmation is also made that today’s lecture and faculty disclosure have been peer reviewed and there are no conflicts of interest.

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Disclosure & Accreditation

Presentation GoalsPresentation Goals

Define poverty and provide an overview of Define poverty and provide an overview of critical social determinants of healthcritical social determinants of health

Introduce Medical Legal Partnerships (MLPs)Introduce Medical Legal Partnerships (MLPs) Examine how MLPs address childhood Examine how MLPs address childhood

adversities that affect healthadversities that affect health Utilize cases to demonstrate MLP Utilize cases to demonstrate MLP

intervention and strategiesintervention and strategies Translate advocacy skills to everyday Translate advocacy skills to everyday

practicepractice

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Two Cases In a DayTwo Cases In a DayWhat Would You DoWhat Would You Do??

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Case #1: Asthma

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Case #1: Asthma 12 year old patient w/asthma Treated in PCP’s office and medically stable Adherent with treatments, but returns to

office frequently with acute attacks Father notes that house is infested with

roaches and is moldy due to leaking water, yet landlord refuses to address complaints

What Would You Do?

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Case #2: Expulsion

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Case #2: Expulsion 7 year old patient whose parent calls PCP

complaining that child has been suspended “again” (third out-of-school suspension in four months)

Now principal stating that child no longer welcome in school, although tutoring at home will be provided until child is “in control”

What Would You Do?

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Knowing the Territory

What is Poverty?What is Poverty?

Definition – US Dept. of Health and Definition – US Dept. of Health and Human Services federal poverty level Human Services federal poverty level (“FPL”)(“FPL”)

Family of three - What’s your guess?Family of three - What’s your guess? $19,130$19,130 $20,090$20,090 $22,616$22,616 $24,854$24,854

ANSWER: $20,090ANSWER: $20,090

mlppSource: Federal Register. 80 FR

3236. Jan. 22, 2015

Poverty QuizPoverty Quiz

What is the child poverty rate in What is the child poverty rate in Massachusetts (children under 18)? Massachusetts (children under 18)? 8%8% 11%11% 14%14% 17%17%

ANSWER: 11%ANSWER: 11%

mlppU.S. Census Bureau American Community Survey 2009-13

Poverty QuizPoverty Quiz

What is the poverty rate for children What is the poverty rate for children under the age of 18 in Springfield under the age of 18 in Springfield (2009-13)? (2009-13)? 13%13% 21%21% 27%27% 44%44%

ANSWER: 44%ANSWER: 44%

mlppU.S. Census Bureau American Community Survey 2009-13

Poverty QuizPoverty Quiz

What was the birthrate/1000 of teen What was the birthrate/1000 of teen mothers, ages 15-17 years, in mothers, ages 15-17 years, in Springfield (2013)? Springfield (2013)? 26.126.1 38.638.6 42.342.3 55.755.7

ANSWER: 42.3ANSWER: 42.3

mlppSource: Mass. Dept. of Public

Health (Dec. 2014)

Poverty QuizPoverty Quiz

What was the birthrate/1000 of teen What was the birthrate/1000 of teen mothers, ages 15-17 years, in mothers, ages 15-17 years, in Longmeadow (2013)? Longmeadow (2013)? 00 44 88 1212

ANSWER: 0ANSWER: 0

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Poverty QuizPoverty Quiz

What is the percentage of eligible What is the percentage of eligible children in Mass who are enrolled in children in Mass who are enrolled in either Medicaid or CHIP?either Medicaid or CHIP? 72.172.1 84.784.7 88.288.2 96.896.8

ANSWER: 96.8ANSWER: 96.8

mlppCMS Monthly Applications June 2015

The Case for Social Determinants

Fundamental Needs for ChildrenFundamental Needs for Children

PeacePeace Shelter Shelter EducationEducation FoodFood IncomeIncome Social JusticeSocial Justice EquityEquity

mlppSource: World Health Org. Ottawa

Charter for Health Promotion (1986)

Springfield Poverty and Unemployment Rates by Race/Ethnicity (2007-11)

Us Census Bureau American Community Surveys 2006-10 (Poverty), 2007-11 (Unemployment)mlpp

Springfield Education Level by Race/Ethnicity, 2006-2010

Source: US Census Bureau American Community Survey 2006-10mlpp

Springfield – Food Security & the Food Desert Problem (2009)

USDA Economic Research Service Food Access Research Atlas 2010mlpp

Springfield Teen Birth Rates by Demographic ID

Mass. Dept. Public Health Birth Dataset 2010

Springfield Asthma Hospitalization Rates, Children 0-14, per 100,000

Mass Dept. Public Health Hospitalization Dataset 2009-11

Social Disparities & Child Health:Social Disparities & Child Health:The Problem PersistsThe Problem Persists

“Children are the poorest segment of society: 22 percent of U.S. children live below the federal poverty level, a prevalence that has persisted since the 1970s. The effects of poverty on children’s health and well-being are well-documented. Poor children have increased infant mortality; more frequent and severe chronic diseases such as asthma; poorer nutrition and growth; less access to quality health care; lower immunization rates; and increased obesity and its complications.” 

mlppAmerican Academy Pediatrics:

May 24, 2013

““Preventive Pediatrics”Preventive Pediatrics”A New Paradigm is BornA New Paradigm is Born

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Preventive PediatricsPreventive Pediatrics

““Double jeopardy” of children in Double jeopardy” of children in povertypoverty More frequently exposed to risks to More frequently exposed to risks to

health and developmenthealth and development Suffer more negative consequences from Suffer more negative consequences from

such exposures than their more such exposures than their more advantaged peersadvantaged peers

Preventive pediatrics model in 1995 Preventive pediatrics model in 1995 was not sufficientwas not sufficient

mlppSource: Zuckerman & Parker, 95

Pediatrics 5 (May 1995)

Preventive PediatricsPreventive Pediatrics

Solution: link needed services within Solution: link needed services within the pediatric officethe pediatric office Legal advocacyLegal advocacy Parenting and child developmentParenting and child development Two-generation approachTwo-generation approach Parental mental healthParental mental health

mlppSource: Zuckerman & Parker, 95

Pediatrics 5 (May 1995)

Legal Advocacy: Why Doctors Legal Advocacy: Why Doctors Really Do Need Lawyers?Really Do Need Lawyers?

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Medical-Legal Partnerships:From Idea to Practice

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Medical-Legal Partnerships:From Idea to Practice

Founded in 1993 at Boston City Hospital (now Boston Medical Center) as the Family Advocacy Project (FAP)

Idea generated from need…

Lawyer as member of pediatric treatment team

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Medical-Legal Partnerships: From Idea to Practice 1993 – Establishment of Boston FAP 2000 – Establishment of Hartford Connecticut’s

Medical-Legal Partnership Project (MLPP) at Conn. Children’s Medical Center (CCMC)

2006 – National Center for MLP founded (Boston), now in DC at GW School of Public Health

2015 In over 292 hospitals/health centers in 36 states Providing legal assistance to over 34,000 individuals

and families Have trained over 15,000 healthcare providers about

the connections between poverty, health, and unmet legal needs

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Medical-Legal Partnerships: From Idea to Practice

Contributed to curricula at 51 law schools, 36 medical schools, and 46 residency programs

MLP nationwide pilot included in first Affordable Care Act bill (and independent MLP for Health Act July 2010)

HRSA recognizes civil legal aid as “enabling service” for health centers

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Medical-Legal Partnerships:National Survey

• 152 hospitals • 136 health

centers• 36 health

schools • 142 legal aid

agencies• 51 law schools• 71 pro bono

partners

mlpp2015 MLP National Site Survey @ www.medical-

legalpartnership.org/mlp-network

Attacking Poverty Collaboratively Attacking Poverty Collaboratively and Collaterallyand Collaterally

September 2, 2015 September 2, 2015 PBS Newshour: PBS Newshour: Why Doctors are Why Doctors are Prescribing Legal Prescribing Legal Aid for Patients Aid for Patients

https://www.youtube.com/watch?v=KKVFHwjWih8

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Doctors and Lawyers in the Clinical Doctors and Lawyers in the Clinical Setting Setting

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How the Collaboration WorksHow the Collaboration Works

Clinicians:Clinicians: See the patientsSee the patients Identify the issuesIdentify the issues Address the needsAddress the needs Call in interventionCall in intervention Collaborate Collaborate AdvocateAdvocate

AttorneysAttorneys On-site availabilityOn-site availability Provide Provide

consultationconsultation Provide Provide

representationrepresentation EducationEducation Policy initiatives & Policy initiatives &

systemic reform systemic reform Team partner Team partner

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Connecticut’s Medical-LegalConnecticut’s Medical-Legal Partnership ProjectPartnership Project

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The Connecticut MLPP: 15 Years of The Connecticut MLPP: 15 Years of Multidisciplinary AdvocacyMultidisciplinary Advocacy

Three part strategy:Three part strategy: Direct representationDirect representation Education and TrainingEducation and Training Systemic AdvocacySystemic Advocacy

Financial Criteria – poverty based Financial Criteria – poverty based program = no fees chargedprogram = no fees charged

Direct Institutional contributions and Direct Institutional contributions and grants provide funding for programgrants provide funding for program

Mission – improve health outcomesMission – improve health outcomes

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The Connecticut MLPP: 15 Years of The Connecticut MLPP: 15 Years of Multidisciplinary Advocacy Multidisciplinary Advocacy

Families Represented = +/- 1,500Families Represented = +/- 1,500 2,500 children2,500 children

Consultations = > 8,000Consultations = > 8,000 Trainings = > 1,000Trainings = > 1,000

Residency curricula Residency curricula Statewide & National presentations Statewide & National presentations

Systemic Reform – legislative & policy Systemic Reform – legislative & policy changeschanges

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The Hartford MLPP: What Have We The Hartford MLPP: What Have We Accomplished in 15 Years? Accomplished in 15 Years?

From one office to five sitesFrom one office to five sites Publication of nationally recognized Publication of nationally recognized

book on adolescent health & book on adolescent health & confidentiality confidentiality

Publication of article on Medical-Legal Publication of article on Medical-Legal Partnerships (JLME):Partnerships (JLME): How Bioethics Can Enrich Medical-Legal

Collaborations

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The Hartford MLPP: What Have We The Hartford MLPP: What Have We Accomplished in 15 Years? Accomplished in 15 Years?

Obtained RWJ grant for IRNAAPObtained RWJ grant for IRNAAP Full Institutional funding - YNHHFull Institutional funding - YNHH Systemic Accomplishments:Systemic Accomplishments:

Policy change to provide Medicaid coverage for Policy change to provide Medicaid coverage for nutritional supplementsnutritional supplements

NeuroPsychological testing to students in HPS NeuroPsychological testing to students in HPS (delays up to two years)(delays up to two years)

Provision of PT, OT & S&L services to children Provision of PT, OT & S&L services to children outside the home in daycare or school aftercare outside the home in daycare or school aftercare programsprograms

Mental Health Screening Compliance Mental Health Screening Compliance

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MLPP’s “Six Questions”

1. Do you Have Enough Food?2. Are your housing conditions safe/Is your

housing stable?3. Do you have enough money in the house to

pay for basic necessities (food, clothing, shelter, hygiene items)?

4. Have you had any problems with your HUSKY/medical insurance ( eligibility, denials, rejections, bills, etc)

5. Is your child being properly educated?6. Are there any mental health concerns that you

would like to discuss …

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Observational Studies: Focusing on Impact

Three types of studies Financial impact on patients and

partners Patient health and wellbeing Knowledge and training of health

providers

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Cincinnati Children’s Experience – Child HeLP

Doctors and Lawyers Collaborating to HeLP Children – Outcomes from a Successful Partnership Between Professions Klein et al, Journal of Health Care for the

Poor and Underserved 24 (2013): 1063-1073

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Impact on Patient Health and Wellbeing

Pilot Study of Impact of MLP Services on Patients’ Perceived Stress and Wellbeing Ryan et. al, Journal of Health Care for the

Poor and Underserved 23 (2012): 1536-1546

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MYCaW

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Peninsula Family Advocacy Program -Lucile Packard Children’s Hospital

Pilot Study of Medical-Legal Partnership to Address Social and Legal Needs of Patients Weintraub et al. Journal of Health Care

for the Poor and Underserved 21 (2010): 157-168

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Results WCC and imm status: no difference Statistically significant change in avoidance

of health care d/t Worry about cost of health care Did not have health insurance

No difference in numbers of acute care visits, ER visits, or missed school days

Participants were very satisfied with services

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What about medical outcomes?

Environmental Improvements Brought by the Legal Interventions in the Homes of Poorly Controlled Inner-city Adult Asthmatic Patients: A Proof-of-Concept Study Sullivan et al. Journal of Asthma, 2012;

49 (9): 911-917

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Back to the Cases…Case #1: Asthma

Apartment with roaches and mold and an unresponsive landlord

PCP obtains consent from parent to refer to MLPP Provides relevant information to MLPP attorney,

perhaps reviewing chart together (e.g., asthma diagnosis, treatment plan, adherence

to regimen, triggers, frequency/timeline of return to care)

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Back to the Cases…Case #1: Asthma MLPP attorney

Meets with family for intake to obtain detailed history

Conducts investigative home visit (including taking pictures)

Meets with housing inspector Contacts landlord with request to remediate

environmental issues If landlord refuses, reviews options with family,

which includes possibility of taking legal action in court

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Back to the Cases…Case #2: Expulsion

In-home tutoring until child is “in control” of behavior

PCP obtains consent from parent to refer to MLPP Provides relevant information to MLPP attorney,

perhaps reviewing chart together (e.g., disabilities impairing education, academic

supports needed and outcomes of interventions attempted [Special Education], history of suspensions/expulsions)

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Back to the Cases…Case #2: Expulsion

MLPP attorney Meets with family for intake to obtain detailed

history and consent to communicate with school Collects and reviews educational documents

(e.g., evaluation reports, behavior plan, Individualized Education Plan, attendance)

Interviews school staff May invoke support of educational consultant Checks compliance of school provisions for

child’s education AND suggests appropriate remedies (may require legal action)

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New Venue – New Partners: New Ideas?

Multidisciplinary team approach to obesity intervention – legal, medical & social work. Medicaid support Innovative approach (Endocrine, Primary

Care, Behavioral health, MLPP)

Improving primary care access to mental health services – a team approach (Medicaid/Primary Care/MLPP)

ReferencesReferences

Zuckerman & Parker, Zuckerman & Parker, Preventive Pediatrics- New Models Preventive Pediatrics- New Models of Expanded Health Servicesof Expanded Health Services, 95 , 95 PediatricsPediatrics 5 (1995) 5 (1995)

Zuckerman, Sandel, Smith, Lawton, Zuckerman, Sandel, Smith, Lawton, Why Pediatricians Why Pediatricians Need Lawyers to Keep Children HealthyNeed Lawyers to Keep Children Healthy, 114 , 114 PediatricsPediatrics 1 1 (July 2004)(July 2004)

Parker, Greer, et al, Parker, Greer, et al, Double Jeopardy: The Impact of Double Jeopardy: The Impact of Poverty on Early Childhood Development. 35 Poverty on Early Childhood Development. 35 Pediatric Pediatric Clin. North Am.Clin. North Am. (1988) (1988)

Askew, Wise, Askew, Wise, The Neighborhood: Poverty, Affluence, The Neighborhood: Poverty, Affluence, Geographic mobility & Violence Geographic mobility & Violence in Levine, et al, in Levine, et al, Developmental-Behavioral PediatricsDevelopmental-Behavioral Pediatrics (1999). (1999).

Wood, Valdez, et al, Wood, Valdez, et al, Health of Homeless and Housed Health of Homeless and Housed Poor ChildrenPoor Children. 86 . 86 PediatricsPediatrics (1990) (1990)

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ReferencesReferences

M. Tebo, M. Tebo, Just What the Doctor OrderedJust What the Doctor Ordered. . American Bar American Bar Association JournalAssociation Journal (2001) (2001)

Ellwood, Ku, Ellwood, Ku, Welfare and Immigration Reforms: Welfare and Immigration Reforms: Unintended Side Effects for MedicaidUnintended Side Effects for Medicaid. 17 . 17 Health Health AffairsAffairs (1988) (1988)

Marmot, Marmot, Acting on Evidence to Reduce Inequalities in Acting on Evidence to Reduce Inequalities in HealthHealth. 18 . 18 Health AffairsHealth Affairs 3 (1999) 3 (1999)

Amy T. Campbell, Jay Sicklick, Paula Galowitz, Randye Retkin & Stewart B. Fleishman (2010). How Bioethics Can Enrich Medical-Legal Collaborations. Journal of Law, Medicine and Ethics 38 (4):847-862.

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Resources

Connecticut MLPP: Attorney Jay Sicklick (860) 570-5327,

[email protected] Attorney Bonnie Roswig (CCMC) (860) 545-

8581, [email protected]

Attorney Alice Rosenthal (YNHH) (203), [email protected]

Center for Children’s Advocacy, www.kidscounsel.org (860) 570-5327