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Medical-Legal Partnerships Help Patients Address Barriers to Health

Kim Krisberg , special to AAMCNews
September 27, 2016

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Alise Cool with Dawn Haut at Eskenazi Health Center
From left, Alise Cool, with Neighborhood Christian Legal Clinic and the Eskenazi Health Medical Legal Partnership, and Dawn Haut, MD, MPH, chief physician executive at Eskenazi Health Center.
Eskenazi Health Center

Editor’s Note: Throughout 2015, an AAMCNews series explored how medical schools and teaching hospitals are addressing social determinants of health in their communities through research, clinical care, and education.

A patient is on cardiopulmonary bypass and will die without a heart transplant. Doctors have the medical knowledge and skill to treat the patient, but that is not enough. To save the child’s life, they need the help of a lawyer.

Although a heart transplant was desperately needed, the child did not qualify for the transplant list because of an unstable home situation where appropriate post-transplant care would have been impossible. The scenario—which took place at Children’s Healthcare of Atlanta—illustrates how even the best medical care in the world can be ineffective in the face of seemingly intractable social determinants. Fortunately, the physicians in Atlanta had access to the Health Law Partnership, or HeLP, a powerful collaboration of Children’s Healthcare of Atlanta, Georgia State University College of Law, and the Atlanta Legal Aid Society that began in 2004. An attorney quickly stepped in, securing an emergency legal arrangement that shifted custody from the child’s mother to the grandparents, who were capable of providing postsurgical care. The child got on the transplant list and received a new heart.

“It’s no stretch to say that [medical-legal partnerships] are saving people’s lives,” said Robert Pettignano, MD, MBA, medical director of HeLP and a professor of pediatrics at Emory University School of Medicine.

Today, medical-legal partnerships have been established in 276 health care institutions and 36 states, according to the National Center for Medical-Legal Partnership, which reports that nearly 50 million people in the United States need legal assistance to maintain their health. Medical-legal partnerships are particularly effective at addressing the social and economic determinants of health. For example, such partnerships can force landlords to remedy poor housing conditions that aggravate a patient’s asthma, help patients establish eligibility for Medicaid, secure educational services for children with special needs, or help patients escape domestic violence situations.

“The health care system cannot solve the most intractable problems acting alone as doctors and nurses. We need multidisciplinary efforts that involve everyone.”

Stephen Teach, MD, MPH, Children’s National Health System

These partnerships are the focus of a new AAMC initiative, Accelerating Health Equity, Advancing through Discovery (AHEAD), which is designed to identify, study, and disseminate practices that improve community health and reduce health inequities. Over the next three years, AHEAD and its three grantees will develop and implement metrics to evaluate the impact of medical-legal partnerships on health and health inequities; institutional cost savings, benefits, and efficiencies; and learner outcomes and competencies.

“One of our goals is to raise awareness of actions that providers and health systems can take to address the social determinants of health,” said Philip Alberti, PhD, AAMC senior director for health equity research and policy.

One AHEAD grantee is the Indiana University School of Medicine–Eskenazi Health Medical-Legal Partnership at Eskenazi Health in Indianapolis, one of the country’s largest safety net health systems. Before the program’s launch in 2008, Dawn Haut, MD, MPH, said it never occurred to her that an attorney could affect her patients’ health. However, Haut, coprincipal investigator of the AAMC grant and chief physician executive at Eskenazi Health Center, quickly realized she saw patients nearly every day who could benefit from legal services.

Still, Haut said that while physicians were accustomed to connecting patients with social workers, it took new ways of communicating to identify which patients could benefit from legal services.

“Now, I dig way deeper and ask more questions because I know if I do uncover something, we can do something about it,” said Haut, who is also a faculty member at Indiana University School of Medicine. Medical-legal interventions can be transformative, she noted. For example, more than a year ago, Eskenazi’s medical-legal partnership assisted a patient in escaping her abusive husband, eventually helping her secure a visa designated for victims of crime. Haut recently saw the same patient and her children at the health center. The patient said her new visa status allowed her to get a driver’s license, secure new housing, and go back to school, while her children were excelling academically. The woman credited her family’s new-found wellness to legal services. In this case, legal services not only helped stabilize the family’s home life but also enabled the pursuit of education, which research shows is a key determinant of health throughout the life span.

“It would be very difficult to go back to not having an attorney available,” Haut said. “It’s become the way I practice. It would be like telling me I can’t have a stethoscope.”

AHEAD grantee Healthy Together, a medical-legal partnership in Washington, D.C., between Children’s National Health System and the Children’s Law Center, has been assisting families since 2002.

Stephen Teach, MD, MPH, chair of pediatrics at Children’s National Health System and principal investigator of the grant, said his interest in legal interventions stemmed from his work in asthma, which is linked to environmental and housing conditions often out of the control of patients and their families. Some mothers have shown him videos of mice in their homes, an environmental trigger of asthma symptoms. While a letter from Teach to the landlord would be ignored, correspondence from a lawyer often prompts swift action.

Such anecdotes are plentiful, but medical-legal partnerships remain understudied, and there is “precious little in the way of real, objective data about their effectiveness,” Teach said. Common metrics and better data—goals of the AHEAD initiative—will better equip partnerships to justify their existence and secure sustainable support, Teach added.

“The health care system cannot solve the most intractable problems acting alone as doctors and nurses,” Teach said. “We need multidisciplinary efforts that involve everyone.”

Back in Georgia, at least 50 percent of the 360,000 unique patients who come to Children’s Healthcare of Atlanta each year are eligible for legal services, according to Pettignano. HeLP, which is also an AHEAD grantee, had assisted nearly 3,400 patients as of 2014. As is the case at many teaching hospitals with medical-legal partnerships, medical residents and students have the opportunity to work alongside HeLP and witness the health benefits of legal aid firsthand.

“The best way for us to spread this mission is through the learner,” Pettignano said. “Physicians who have been in practice for decades may be skeptical, but students and residents are more focused on the social determinants of health. They realize this is something they need.”

This article originally appeared in print in the October 2015 issue of the AAMC Reporter.

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