1. Jeffrey Colvin, MD, JD Section of Pediatric Hospital Medicine Children’s Mercy Hospital June 12, 2010 Allies Not Adversaries: Partnering with Attorneys to Improve Patient Health

2. Disclosures I have no current financial interest or direct affiliation with any commercial organizations or products that may be referenced in this presentation. I have no current financial interest or direct affiliation with any commercial organizations or products that may be referenced in this presentation.

3. Outline 1.Introduction to medical legal partnerships 2.Areas where an attorney can improve patient health 3.The nuts and bolts of one medical legal partnership: Children’s Mercy Hospital 4.Keys to starting a medical legal partnership 5.Summary

4. Clinical Vignette A 6 year old male is admitted for status asthmaticus for the third time in four months. His maintenance inhaled steroids have been steadily increased despite full adherence. Their apartment has mold due to a leaking roof. She has brought this concern to the attention of the landlord multiple times, but no action has been taken. The patient has previously skin tested positive to molds. The mother states that the family can not afford to move and but if they did move “someone else would walk into the problems we’re leaving.” A 6 year old male is admitted for status asthmaticus for the third time in four months. His maintenance inhaled steroids have been steadily increased despite full adherence. Their apartment has mold due to a leaking roof. She has brought this concern to the attention of the landlord multiple times, but no action has been taken. The patient has previously skin tested positive to molds. The mother states that the family can not afford to move and but if they did move “someone else would walk into the problems we’re leaving.”

5. Clinical Vignette What would be the most appropriate action to take? What would be the most appropriate action to take? a. Shrug your shoulders b. Hope that your pager goes off so that you can leave the room c. Write a letter to the landlord who will first laugh and then ignore the letter d. Refer the patient to a public interest attorney

6. The History of Medical Legal Partnerships

7. * Over a dozen programs in active development * The History of Medical Legal Partnerships

11. 2. How can an attorney help?

12. Housing Conditions & Child Health  Asthma: mice, mold, cockroaches, poor ventilation, “homemade” heaters  Lead poisoning: lead paint  Burns: exposed wires & heaters  Falls from Windows Rosenstreich, NEJM 1997; Fuller-Thompson, Rev Enviro Health 2000.

13. Homelessness & Child Health  Poor Overall Health: 13% v 4%  Any Health problem: 2.5  Severe Health problem: 3x  Multiple Health problems: 6x  Asthma: 6x  Immunization Delay: 2-3x  Poor Dentition: 10x  Developmental Delay: 54% failed Denver (compared to 16% of housed poor)  Depression: 46-57% exceed Children’s Depression Inventory evaluation point Wood, Pediatrics 1990; McLean, Arch Peds Adol Med 2004.

14. “Heat or Eat”  Association of Wt/Ht <5% in <3yo’s in 3 months following winter months (8.8% v 6.6%)  Most associated with families having difficulty paying heating utilities & food insecurity  Poor Children had 10% fewer calories  LIHEAP prevented this effect Bhattacharya, Am J Pub Health 2003; Frank, Pediatrics 2006.

15. “There Ought to be a Law Against That” Affordable Healthy Housing Public Housing & Section 8 Housing Code Landlord- Tenant Law

16. “There Ought to be a Law Against That” Affordable Healthy Housing Public Housing & Section 8 Housing Code Landlord- Tenant Law Unlawful Evictions Unlawful Conditions Unlawful Denial or Termination

17. “There Ought to be a Law Against That” Affordable Healthy Housing Public Housing & Section 8 Housing Code Landlord- Tenant Law Unlawful Evictions Unlawful Conditions Unlawful Denial or Termination Attorney

18. Other Health-Related Legal Issues: Food Insecurity/Insufficiency Health Effects:  Fair/Poor Health: 1.7-2.3x  Worse Physical and Health-Related Quality of Life (p 0.02)  Increased Hospitalizations: 1.3x Legal Issue:  Unlawful Denials of TANF, WIC, Food Stamps Casey, Arch Peds Adol Med 2005; Weinrub, Pediatrics 2002; Alaimo, Pediatrics 2001.

19. Other Health-Related Legal Issues: Insurance & Health Care Access  Health Effect Examples  Increases ambulatory health visits & use of a “medical home” by 20-30%)  10% increase in Medicaid results in 2.3-3.4% decrease in preventable hospitalizations  Asthma Admission: ↓7% after enrollment  Legal Issue  Unlawful denial or termination of Medicaid  Unlawful denial of medically necessary medications, treatments, equipment IOM, America’s Uninsured Crisis, 2009 pp. 58-63, 188-95.

20. 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 Health3.9%13.5%12.2% No or Discontinuous Insurance (All) 15.3%34.4%52.3% No Usual Source of Care5.8%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

21. Other Examples of Health-Related Legal Issues: Child Witness to Violence  Legal Issue: Intimate Partner Violence/Domestic Violence  Orders of Protection  Dissolutions/Divorce  Health Effects:  Increased anxiety, aggression, & conduct disorders  Lower self-esteem  Poor school performance Kerker, Arch Ped Adol Med 2000; Wright, Pediatrics 1997; McCloskey, Child Dev 1995.

22. Other Examples of Health-Related Legal Issues  Disability  Unlawful denials of SSI  Unlawful denial of Medicaid for equipment and services  Consent for Medical Care, Education, etc  Guardianships  Power of Attorney

23. Stress & “The Worry Budget” 754 Asthmatic Children Suboptimal Control 37% Controller Med Underuse 48% Smith, Pediatrics 2008.

24. Stress & “The Worry Budget” 754 Asthmatic Children Suboptimal Control 37% Controller Med Underuse 48% Associations p<0.05 Race Income Parent Education Unemployment Low Expectations Competing Priorities Associations p<0.05 Race Income Parent Education Single Parent Discordant Expectations No Set Time Smith, Pediatrics 2008.

25. Stress & “The Worry Budget” 754 Asthmatic Children Suboptimal Control 37% Controller Med Underuse 48% Associations p<0.05 Race Income Parent Education Unemployment Low Expectations Competing Priorities Associations p<0.05 Race Income Parent Education Single Parent Discordant Expectations No Set Time Smith, Pediatrics 2008.

26. Stress & “The Worry Budget”  Competing Priorities, Low Expectations, & No Set Medication Time  Competing Priorities: “The Worry Budget”  High concern about job, income, paying bills, home/neighborhood safety, family relationships, parent’s or other family member’s health  Low Expectations: “The Hegemony of Low Expectations”  A reflection of previous asthma experience vs. a reflection of general life expectations (?)  No Set Medication Time  Reflection of competing priorities & low expectations (?) Smith, Pediatrics 2008.

27. 3. The “Nuts & Bolts” of One Medical Legal Partnership: Children’s Mercy Hospital

28. Medical Legal Partnership at Children’s Mercy Hospital  Collaboration between Children’s Mercy and Legal Aid of Western Missouri (2007) and Kansas Legal Services (2009)  Legal Aid’s “Healthcare Recovery” Work  Funding through healthcare “conversion” foundation  Legal Aid has expanded partnerships to two additional FQHC and has plans to expand to 1-2 more local hospitals

29. Annual Number of Referrals 36 350 508 780

30. Clinical Vignette, Pt. 2  The mother of your asthmatic patient would like to be referred to a public interest lawyer. What is the best way to connect her to an attorney? a.Refer him to the phone book, with special emphasis to the back cover. b.Call Satan, he’s very familiar with most lawyers c.Call the hospital’s General Counsel (they’ll love that!) d.Page the medical-legal partnership.

31. MD’s RN’sSW’s NP’s Attorney or Paralegal Present in Hospital/Clinic Legal Intake Case Handling Screening Questionnaire MLP: How It Works

32. What the Attorney Does: Case Handling

33. MD’s RN’sSW’s NP’s Attorney or Paralegal Present in Hospital/Clinic Legal Intake Case Handling Feedback to Medical Team 1 Screening Questionnaire MLP: How It Works

34. MD’s RN’sSW’s NP’s Attorney or Paralegal Present in Hospital/Clinic Legal Intake Case Handling Feedback to Medical Team 1 Screening Questionnaire 2 X MLP: How It Works

35. MD’s RN’sSW’s NP’s Attorney or Paralegal Present in Hospital/Clinic Legal Intake Case Handling Feedback to Medical Team 1 Screening Questionnaire 2 X 3 MLP: How It Works

36. MD’s RN’sSW’s NP’s Attorney or Paralegal Present in Hospital/Clinic Legal Intake Case Handling Feedback to Medical Team 1 Screening Questionnaire 2 X 3 4 Issue Spotting & Lecture Series MLP: How It Works

37. MD’s RN’sSW’s NP’s Attorney or Paralegal Present in Hospital/Clinic Legal Intake Case Handling Feedback to Medical Team 1 Screening Questionnaire 2 X 3 4 Issue Spotting & Lecture Series 5 Pagers & Mimic Referral Process MLP: How It Works

38. 3. Starting a Medical Legal Partnership

39. What to Think About When Thinking About Starting a MLP 1.Do you already have one?

40. Number of Healthcare Sites with an MLP ___________________________ 0 1 2-4 5-9 10+ Medical Legal Partnerships

41. What to Think About When Thinking About Starting a MLP 1.Do you already have one? 2.How to find lawyers to collaborate with?  Legal Aid  Law School Clinics  Hire attorneys  Private law firm pro bono work

42. What to Think About When Thinking About Starting a MLP 1.Do you already have one? 2.How to find lawyers to collaborate with? 3.Open the flood gates?  One clinic  Outpatient only  One legal area versus all legal areas

43. What to Think About When Thinking About Starting a MLP 1.Do you already have one? 2.How to find lawyers to collaborate with? 3.Open the flood gates? 4.Screening versus Referrals

44. What to Think About When Thinking About Starting a MLP 1.Do you already have one? 2.How to find lawyers to collaborate with? 3.Open the flood gates? 4.Screening versus Referrals 5.Funding: foundations, bar associations, pro bono assistance, healthcare recovery

45. Funding Sources for Medical Legal Partnerships N=53, Total Cash Funding=$8,092,500

46. Other Keys to Success  Strong legal partner  Patience and Buy-In  Recognizing every specialty’s unique legal interest  Making Your Medical Legal Partnership Scholarly: research, resident education  Start with legal issues suggested by the hospital

47. Steps to Start a MLP 1.Find a MLP in your hospital or city or contact local Legal Aid 2.Approach your Administration: Selling Points Unmet Need: Improved patient care & satisfactionUnmet Need: Improved patient care & satisfaction Potential health recovery dollarsPotential health recovery dollars No association with malpractice (medical or legal)No association with malpractice (medical or legal)

48. Steps to Start a MLP 3.Determine scope: legal issues & medical settings based on capacity & interest 4.Seek funding: start with local foundations 5.Teach attorneys to adapt to the culture and practices of medicine 6.Educate, educate, educate

49. Ask me to help you with contacts.

50. Summary 1.By collaborating with attorneys, we can improve the health of our patients. 2.For medical-legal partnerships to be successful, attorneys need to be seen as the “new consultant” and a part of the medical team. 3.Several options exist for starting and structuring a medical-legal partnership.

51. Thank You. Questions?