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
mlpp
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.
mlpp
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
mlpp
Two Cases In a DayTwo Cases In a DayWhat Would You DoWhat Would You Do??
mlpp
Case #1: Asthma
mlpp
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?
mlpp
Case #2: Expulsion
mlpp
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?
mlpp
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
mlpp
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
mlpp
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?
mlpp
Medical-Legal Partnerships:From Idea to Practice
mlpp
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
mlpp
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
mlpp
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
mlpp
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
mlpp
Doctors and Lawyers in the Clinical Doctors and Lawyers in the Clinical Setting Setting
mlpp
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
mlpp
mlpp
Connecticut’s Medical-LegalConnecticut’s Medical-Legal Partnership ProjectPartnership Project
mlpp
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
mlpp
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
mlpp
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
mlpp
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
mlpp
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 …
mlpp
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
mlpp
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
mlpp
mlpp
mlpp
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
mlpp
MYCaW
mlpp
mlpp
mlpp
mlpp
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
mlpp
mlpp
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
mlpp
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
mlpp
mlpp
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)
mlpp
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
mlpp
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)
mlpp
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)
mlpp
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)
mlpp
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.
mlpp
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