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Medical-Legal Partnerships: From Idea to Reality to Changing Pediatric Practice
November 3, 2015
Molly Senn-McNally, M.D.
Assistant Professor of Pediatrics
Baystate Medical Center
Tufts University School of Medicine
Jay E. Sicklick, J.D.
Clinical Instructor, Department of Pediatrics
Univ. of Connecticut School of Medicine
Deputy Director, Center for Children’s Advocacy
Director – Medical-Legal Partnership Project

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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 Define poverty and provide an overview of critical social determinants of health
 Introduce Medical Legal Partnerships
(MLPs)
 Examine how MLPs address childhood adversities that affect health
 Utilize cases to demonstrate MLP intervention and strategies
 Translate advocacy skills to everyday practice

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Two Cases In a Day
What Would You Do?

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 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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 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

 Definition – US Dept. of Health and
Human Services federal poverty level
(“FPL”)
 Family of three - What’s your guess?
 $19,130
 $20,090
 $22,616
 $24,854
ANSWER: $20,090 mlpp
Source: Federal Register. 80 FR
3236. Jan. 22, 2015

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 What is the child poverty rate in
Massachusetts (children under 18)?
 8%
 11%
 14%
 17%
ANSWER: 11%
U.S. Census Bureau American
Community Survey 2009-13

 What is the poverty rate for children under the age of 18 in Springfield
(2009-13)?
 13%
 21%
 27%
 44%
ANSWER: 44% mlpp
U.S. Census Bureau American
Community Survey 2009-13

 What was the birthrate/1000 of teen mothers, ages 15-17 years, in
Springfield (2013)?
 26.1
 38.6
 42.3
 55.7
ANSWER: 42.3
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Source: Mass. Dept. of Public
Health (Dec. 2014)

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 What was the birthrate/1000 of teen mothers, ages 15-17 years, in
Longmeadow (2013)?
 0
 4
 8
 12
ANSWER: 0

 What is the percentage of eligible children in Mass who are enrolled in either Medicaid or CHIP?
 72.1
 84.7
 88.2
 96.8
ANSWER: 96.8
CMS Monthly Applications June 2015 mlpp

Fundamental Needs for Children
 Peace
 Shelter
 Education
 Food
 Income
 Social Justice
 Equity mlpp
Source: World Health Org. Ottawa
Charter for Health Promotion (1986)

Springfield Poverty and Unemployment
Rates by Race/Ethnicity (2007-11) mlpp
Us Census Bureau American Community Surveys 2006-10
(Poverty), 2007-11 (Unemployment)

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Source: US Census Bureau American
Community Survey 2006-10

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USDA Economic Research Service
Food Access Research Atlas 2010

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:
The 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.” mlpp
American Academy Pediatrics:
May 24, 2013

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“Preventive Pediatrics”
A New Paradigm is Born

 “Double jeopardy” of children in poverty
 More frequently exposed to risks to health and development
 Suffer more negative consequences from such exposures than their more advantaged peers
 Preventive pediatrics model in 1995 was not sufficient mlpp
Source: Zuckerman & Parker, 95
Pediatrics 5 (May 1995)

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 Solution: link needed services within the pediatric office
 Legal advocacy
 Parenting and child development
 Two-generation approach
 Parental mental health
Source: Zuckerman & Parker, 95
Pediatrics 5 (May 1995)

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Legal Advocacy: Why Doctors
Really Do Need Lawyers?

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 mlpp
2015 MLP National Site Survey @ www.medicallegalpartnership.org/mlp-network

Attacking Poverty Collaboratively and Collaterally
 September 2, 2015
PBS Newshour:
Why Doctors are
Prescribing Legal
Aid for Patients
 https://www.youtu
be.com/watch?v=K
KVFHwjWih8 mlpp

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Doctors and Lawyers in the Clinical
Setting
Legal Assistance in the Healthcare
Setting
Health and Legal Institutions Practice
Transformation
Policy Change

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 Clinicians:
 See the patients
 Identify the issues
 Address the needs
 Call in intervention
 Collaborate
 Advocate
 Attorneys
 On-site availability
 Provide consultation
 Provide representation
 Education
 Policy initiatives & systemic reform
 Team partner

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Connecticut’s Medical-Legal
Partnership Project

The Connecticut MLPP: 15 Years of
Multidisciplinary Advocacy
 Three part strategy:
 Direct representation
 Education and Training
 Systemic Advocacy
 Financial Criteria – poverty based program = no fees charged
 Direct Institutional contributions and grants provide funding for program
 Mission – improve health outcomes mlpp

The Connecticut MLPP: 15 Years of
Multidisciplinary Advocacy
 Families Represented = +/- 1,500
 2,500 children
 Consultations = > 8,000
 Trainings = > 1,000
 Residency curricula
 Statewide & National presentations
 Systemic Reform – legislative & policy changes mlpp

The Hartford MLPP: What Have We
Accomplished in 15 Years?
 From one office to five sites
 Publication of nationally recognized book on adolescent health & confidentiality
 Publication of article on Medical-Legal
Partnerships (JLME):
 How Bioethics Can Enrich Medical-Legal
Collaborations mlpp

The Hartford MLPP: What Have We
Accomplished in 15 Years?
 Obtained RWJ grant for IRNAAP
 Full Institutional funding - YNHH
 Systemic Accomplishments:
 Policy change to provide Medicaid coverage for nutritional supplements
 NeuroPsychological testing to students in HPS
(delays up to two years)
 Provision of PT, OT & S&L services to children outside the home in daycare or school aftercare programs
 Mental Health Screening Compliance mlpp

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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 …

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

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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 mlpp

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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 mlpp

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 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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 Environmental Improvements
Brought by the Legal Interventions in the Homes of Poorly Controlled Innercity Adult Asthmatic Patients: A
Proof-of-Concept Study
 Sullivan et al. Journal of Asthma, 2012;
49 (9): 911-917

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 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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 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

 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

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 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)

 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)

 Zuckerman & Parker, Preventive Pediatrics- New Models
of Expanded Health Services, 95 Pediatrics 5 (1995)
 Zuckerman, Sandel, Smith, Lawton, Why Pediatricians
Need Lawyers to Keep Children Healthy, 114 Pediatrics 1
(July 2004)
 Parker, Greer, et al, Double Jeopardy: The Impact of
Poverty on Early Childhood Development. 35 Pediatric
Clin. North Am. (1988)
 Askew, Wise, The Neighborhood: Poverty, Affluence,
Geographic mobility & Violence in Levine, et al,
Developmental-Behavioral Pediatrics (1999).
 Wood, Valdez, et al, Health of Homeless and Housed
Poor Children. 86 Pediatrics (1990) mlpp

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 M. Tebo, Just What the Doctor Ordered. American
Bar Association Journal (2001)
 Ellwood, Ku, Welfare and Immigration Reforms:
Unintended Side Effects for Medicaid. 17 Health
Affairs (1988)
 Marmot, Acting on Evidence to Reduce Inequalities in
Health. 18 Health Affairs 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.

 Connecticut MLPP:
 Attorney Jay Sicklick (860) 570-5327, jsicklick@kidscounsel.org
 Attorney Bonnie Roswig (CCMC) (860) 545-
8581, bonnie.roswig@connecticutchildrens.org
 Attorney Alice Rosenthal (YNHH) (203),
Alice.Rosenthal@YNHH.org
 Center for Children’s Advocacy, www.kidscounsel.org
(860) 570-5327