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Jeffrey Colvin, MD, JDJeffrey Colvin, MD, JDSection of Pediatric Hospital Section of Pediatric Hospital
MedicineMedicineChildren’s Mercy HospitalChildren’s Mercy Hospital
June 12, 2010June 12, 2010
Allies Not Adversaries:Partnering with Attorneys to Improve Patient Health
Allies Not Adversaries:Partnering with Attorneys to Improve Patient Health
DisclosuresDisclosures
I have no current financial interest or I have no current financial interest or direct affiliation with any commercial direct affiliation with any commercial
organizations or products that may be organizations or products that may be referenced in this presentation.referenced in this presentation.
OutlineOutline
1.1. Introduction to medical legal partnershipsIntroduction to medical legal partnerships
2.2. Areas where an attorney can improve Areas where an attorney can improve patient healthpatient health
3.3. The nuts and bolts of one medical legal The nuts and bolts of one medical legal partnership: Children’s Mercy Hospitalpartnership: Children’s Mercy Hospital
4.4. Keys to starting a medical legal partnershipKeys to starting a medical legal partnership
5.5. SummarySummary
Clinical VignetteClinical Vignette A 6 year old male is admitted for status A 6 year old male is admitted for status
asthmaticus for the third time in four asthmaticus for the third time in four months. His maintenance inhaled steroids months. His maintenance inhaled steroids have been steadily increased despite full have been steadily increased despite full adherence. Their apartment has mold due to adherence. Their apartment has mold due to a leaking roof. She has brought this concern a leaking roof. She has brought this concern to the attention of the landlord multiple to the attention of the landlord multiple times, but no action has been taken. The times, but no action has been taken. The patient has previously skin tested positive to patient has previously skin tested positive to molds. The mother states that the family can molds. The mother states that the family can not afford to move and but if they did move not afford to move and but if they did move “someone else would walk into the problems “someone else would walk into the problems we’re leaving.”we’re leaving.”
Clinical VignetteClinical Vignette
What would be the most appropriate What would be the most appropriate action to take?action to take?a.a. Shrug your shouldersShrug your shoulders
b.b. Hope that your pager goes off so that you Hope that your pager goes off so that you can leave the roomcan leave the room
c.c. Write a letter to the landlord who will first Write a letter to the landlord who will first laugh and then ignore the letterlaugh and then ignore the letter
d.d. Refer the patient to a public interest Refer the patient to a public interest attorneyattorney
The History of Medical Legal Partnerships
The History of Medical Legal Partnerships
* Over a dozen programs in active development
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Med
ical-
Leg
al P
art
ners
hip
s *
The History of Medical Legal Partnerships
2. How can an attorney help?
2. How can an attorney help?
Housing Conditions & Child Health
Housing Conditions & Child Health
Asthma: mice, mold, Asthma: mice, mold, cockroaches, poor cockroaches, poor ventilation, ventilation, “homemade” “homemade” heatersheaters
Lead poisoning: Lead poisoning: lead paintlead paint
Burns: exposed Burns: exposed wires & heaterswires & heaters
Falls from WindowsFalls from WindowsRosenstreich, NEJM 1997; Fuller-Thompson, Rev Enviro Health 2000.
Homelessness & Child Health
Homelessness & Child Health
Poor Overall Health: 13% v 4%Poor Overall Health: 13% v 4% Any Health problem: 2.5Any Health problem: 2.5 Severe Health problem: 3xSevere Health problem: 3x Multiple Health problems: 6xMultiple Health problems: 6x Asthma: 6xAsthma: 6x Immunization Delay: 2-3x Immunization Delay: 2-3x Poor Dentition: 10xPoor Dentition: 10x Developmental Delay: 54% Developmental Delay: 54%
failed Denver (compared to failed Denver (compared to 16% of housed poor)16% of housed poor)
Depression: 46-57% exceed Depression: 46-57% exceed Children’s Depression Children’s Depression Inventory evaluation pointInventory evaluation point
Wood, Pediatrics 1990; McLean, Arch Peds Adol Med 2004.
“Heat or Eat”“Heat or Eat”
Association of Wt/Ht Association of Wt/Ht <5% in <3yo’s in 3 <5% in <3yo’s in 3 months following winter months following winter months (8.8% v 6.6%)months (8.8% v 6.6%)
Most associated with Most associated with families having families having difficulty paying heating difficulty paying heating utilities & food utilities & food insecurityinsecurity
Poor Children had 10% Poor Children had 10% fewer caloriesfewer calories
LIHEAP prevented this LIHEAP prevented this effecteffect
Bhattacharya, Am J Pub Health 2003; Frank, Pediatrics 2006.
“There Ought to be a Law Against That”
“There Ought to be a Law Against That”
AffordableHealthyHousing
Public Housing&
Section 8
HousingCode
Landlord-Tenant
Law
“There Ought to be a Law Against That”
“There Ought to be a Law Against That”
AffordableHealthyHousing
Public Housing&
Section 8
HousingCode
Landlord-Tenant
Law
UnlawfulEvictions
UnlawfulConditions
UnlawfulDenial or
Termination
“There Ought to be a Law Against That”
“There Ought to be a Law Against That”
AffordableHealthyHousing
Public Housing&
Section 8
HousingCode
Landlord-Tenant
Law
UnlawfulEvictions
UnlawfulConditions
UnlawfulDenial or
Termination
Attorney Attorney
Attorney
Other Health-Related Legal Issues: Food
Insecurity/Insufficiency
Other Health-Related Legal Issues: Food
Insecurity/InsufficiencyHealth Effects:Health Effects: Fair/Poor Health: 1.7-2.3xFair/Poor Health: 1.7-2.3x Worse Physical and Worse Physical and
Health-Related Quality of Health-Related Quality of Life (p 0.02)Life (p 0.02)
Increased Increased Hospitalizations: 1.3xHospitalizations: 1.3x
Legal Issue:Legal Issue: Unlawful Denials of Unlawful Denials of
TANF, WIC, Food StampsTANF, WIC, Food StampsCasey, Arch Peds Adol Med 2005; Weinrub, Pediatrics 2002; Alaimo, Pediatrics 2001.
Other Health-Related Legal Issues: Insurance & Health
Care Access
Other Health-Related Legal Issues: Insurance & Health
Care Access Health Effect ExamplesHealth Effect Examples
Increases ambulatory health Increases ambulatory health visits & use of a “medical visits & use of a “medical home” byhome” by 20-30%)20-30%)
10% increase in Medicaid 10% increase in Medicaid results in 2.3-3.4% decrease results in 2.3-3.4% decrease in preventable in preventable hospitalizationshospitalizations
Asthma Admission: Asthma Admission: ↓7% after ↓7% after enrollmentenrollment
Legal IssueLegal Issue Unlawful denial or Unlawful denial or
termination of termination of MedicaidMedicaid
Unlawful denial of Unlawful denial of medically necessary medically necessary medications, medications, treatments, equipmenttreatments, equipment
IOM, America’s Uninsured Crisis, 2009 pp. 58-63, 188-95.
Other Examples of Health-Related Legal Issues: Immigration Status
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 Health 3.9% 13.5% 12.2%
No or Discontinuous Insurance (All)
15.3% 34.4% 52.3%
No Usual Source of Care 5.8% 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
Other Examples of Health-Related Legal Issues:
Child Witness to Violence
Other Examples of Health-Related Legal Issues:
Child Witness to Violence
Legal Issue:Legal Issue: Intimate Intimate Partner Partner Violence/Domestic Violence/Domestic ViolenceViolence Orders of ProtectionOrders of Protection Dissolutions/DivorceDissolutions/Divorce
Health Effects:Health Effects: Increased anxiety, Increased anxiety,
aggression, & conduct aggression, & conduct disordersdisorders
Lower self-esteemLower self-esteem Poor school Poor school
performanceperformance
Kerker, Arch Ped Adol Med 2000; Wright, Pediatrics 1997; McCloskey, Child Dev 1995.
Other Examples of Health-Related Legal Issues
Other Examples of Health-Related Legal Issues
DisabilityDisability Unlawful denials of SSIUnlawful denials of SSI Unlawful denial of Medicaid for equipment Unlawful denial of Medicaid for equipment
and servicesand services
Consent for Medical Care, Education, Consent for Medical Care, Education, etcetc GuardianshipsGuardianships Power of AttorneyPower of Attorney
Stress & “The Worry Budget”
Stress & “The Worry Budget”
754 Asthmatic Children
Suboptimal Control37%
Controller Med Underuse48%
Smith, Pediatrics 2008.
Stress & “The Worry Budget”
Stress & “The Worry Budget”
754 Asthmatic Children
Suboptimal Control37%
Controller Med Underuse48%
Associations p<0.05RaceIncomeParent EducationUnemploymentLow ExpectationsCompeting Priorities
Associations p<0.05RaceIncomeParent EducationSingle ParentDiscordant ExpectationsNo Set Time
Smith, Pediatrics 2008.
Stress & “The Worry Budget”
Stress & “The Worry Budget”
754 Asthmatic Children
Suboptimal Control37%
Controller Med Underuse48%
Associations p<0.05RaceIncomeParent EducationUnemployment
Low ExpectationsCompeting Priorities
Associations p<0.05RaceIncomeParent EducationSingle Parent
Discordant ExpectationsNo Set Time
Smith, Pediatrics 2008.
Stress & “The Worry Budget”
Stress & “The Worry Budget” Competing Priorities, Low Expectations, & Competing Priorities, Low Expectations, &
No Set Medication TimeNo Set Medication Time Competing Priorities: “The Worry Budget”Competing Priorities: “The Worry Budget”
High concern about job, income, paying bills, High concern about job, income, paying bills, home/neighborhood safety, family relationships, home/neighborhood safety, family relationships, parent’s or other family member’s healthparent’s or other family member’s health
Low Expectations: “The Hegemony of Low Low Expectations: “The Hegemony of Low Expectations”Expectations” A reflection of previous asthma experience vs. a A reflection of previous asthma experience vs. a
reflection of general life expectations (?)reflection of general life expectations (?)
No Set Medication TimeNo Set Medication Time Reflection of competing priorities & low expectations (?)Reflection of competing priorities & low expectations (?)
Smith, Pediatrics 2008.
3. The “Nuts & Bolts” of One Medical Legal
Partnership: Children’s Mercy Hospital
3. The “Nuts & Bolts” of One Medical Legal
Partnership: Children’s Mercy Hospital
Medical Legal Partnership at
Children’s Mercy Hospital
Medical Legal Partnership at
Children’s Mercy Hospital Collaboration between Children’s Mercy Collaboration between Children’s Mercy
and Legal Aid of Western Missouri (2007) and Legal Aid of Western Missouri (2007) and Kansas Legal Services (2009)and Kansas Legal Services (2009)
Legal Aid’s “Healthcare Recovery” WorkLegal Aid’s “Healthcare Recovery” Work Funding through healthcare “conversion” Funding through healthcare “conversion”
foundationfoundation Legal Aid has expanded partnerships to two Legal Aid has expanded partnerships to two
additional FQHC and has plans to expand to additional FQHC and has plans to expand to 1-2 more local hospitals1-2 more local hospitals
Annual Number of Referrals
Annual Number of Referrals
0
100
200
300
400
500
600
700
800
4th Qrt 2007 2008 2009 Projected 2010
36
350
508
780
Clinical Vignette, Pt. 2Clinical Vignette, Pt. 2 The mother of your asthmatic patient The mother of your asthmatic patient
would like to be referred to a public would like to be referred to a public interest lawyer. What is the best interest lawyer. What is the best way to connect her to an attorney?way to connect her to an attorney?
a.a. Refer him to the phone book, with Refer him to the phone book, with special emphasis to the back cover.special emphasis to the back cover.
b.b. Call Satan, he’s very familiar with most Call Satan, he’s very familiar with most lawyerslawyers
c.c. Call the hospital’s General Counsel Call the hospital’s General Counsel (they’ll love that!)(they’ll love that!)
d.d. Page the medical-legal partnership.Page the medical-legal partnership.
MD’s
RN’s SW’s
NP’s
Attorney or Paralegal Present in Hospital/Clinic
Legal Intake
Case Handling
ScreeningQuestionnaire
MLP: How It WorksMLP: How It Works
What the Attorney Does: Case Handling
What the Attorney Does: Case Handling
Brief Consultation(21%)
Referral Out (29%)
ExtensiveRepresentation (50%)
MD’s
RN’s SW’s
NP’s
Attorney or Paralegal Present in Hospital/Clinic
Legal Intake
Case Handling
Feedback toMedical Team
1
ScreeningQuestionnaire
MLP: How It WorksMLP: How It Works
MD’s
RN’s SW’s
NP’s
Attorney or Paralegal Present in Hospital/Clinic
Legal Intake
Case Handling
Feedback toMedical Team
1
ScreeningQuestionnaire
2
XMLP: How It WorksMLP: How It Works
MD’s
RN’s SW’s
NP’s
Attorney or Paralegal Present in Hospital/Clinic
Legal Intake
Case Handling
Feedback toMedical Team
1
ScreeningQuestionnaire
2
X 3
MLP: How It WorksMLP: How It Works
MD’s
RN’s SW’s
NP’s
Attorney or Paralegal Present in Hospital/Clinic
Legal Intake
Case Handling
Feedback toMedical Team
1
ScreeningQuestionnaire
2
X 3
4
Issue Spotting&
Lecture Series
MLP: How It WorksMLP: How It Works
MD’s
RN’s SW’s
NP’s
Attorney or Paralegal Present in Hospital/Clinic
Legal Intake
Case Handling
Feedback toMedical Team
1
ScreeningQuestionnaire
2
X 3
4
Issue Spotting&
Lecture Series
5
Pagers &Mimic Referral Process
MLP: How It WorksMLP: How It Works
3. Starting a Medical Legal Partnership
3. Starting a Medical Legal Partnership
What to Think About When Thinking About Starting a
MLP
What to Think About When Thinking About Starting a
MLP1.1. Do you already have one?Do you already have one?
Number of Healthcare Sites
with an MLP___________________________
0
1
2-4
5-9
10+
Medical Legal Partnerships
What to Think About When Thinking About Starting a
MLP
What to Think About When Thinking About Starting a
MLP1.1. Do you already have one?Do you already have one?
2.2. How to find lawyers to How to find lawyers to collaborate with?collaborate with?
Legal AidLegal Aid Law School ClinicsLaw School Clinics Hire attorneysHire attorneys Private law firm pro bono workPrivate law firm pro bono work
What to Think About When Thinking About Starting a
MLP
What to Think About When Thinking About Starting a
MLP1.1. Do you already have one?Do you already have one?
2.2. How to find lawyers to How to find lawyers to collaborate with?collaborate with?
3.3. Open the flood gates?Open the flood gates? One clinicOne clinic Outpatient onlyOutpatient only One legal area versus all legal One legal area versus all legal
areasareas
What to Think About When Thinking About Starting a
MLP
What to Think About When Thinking About Starting a
MLP1.1. Do you already have one?Do you already have one?
2.2. How to find lawyers to How to find lawyers to collaborate with?collaborate with?
3.3. Open the flood gates?Open the flood gates?
4.4. Screening versus ReferralsScreening versus Referrals
What to Think About When Thinking About Starting a
MLP
What to Think About When Thinking About Starting a
MLP1.1. Do you already have one?Do you already have one?
2.2. How to find lawyers to collaborate How to find lawyers to collaborate with?with?
3.3. Open the flood gates?Open the flood gates?
4.4. Screening versus ReferralsScreening versus Referrals
5.5. Funding: foundations, bar Funding: foundations, bar associations, pro bono associations, pro bono assistance, healthcare recoveryassistance, healthcare recovery
Funding Sources for Medical Legal Partnerships
Funding Sources for Medical Legal Partnerships
Legal (20%)
Healthcare (21%)
Government (9%)
CommunityFoundations (33%)
Other (17%)
N=53, Total Cash Funding=$8,092,500
Other Keys to SuccessOther Keys to Success Strong legal partnerStrong legal partner Patience and Buy-In Patience and Buy-In Recognizing every specialty’s unique Recognizing every specialty’s unique
legal interestlegal interest Making Your Medical Legal Making Your Medical Legal
Partnership Scholarly: research, Partnership Scholarly: research, resident educationresident education
Start with legal issues suggested by Start with legal issues suggested by the hospitalthe hospital
Steps to Start a MLPSteps to Start a MLP
1.1. Find a MLP in your hospital or city or Find a MLP in your hospital or city or contact local Legal Aidcontact local Legal Aid
2.2. Approach your Administration: Selling Approach your Administration: Selling PointsPoints
• Unmet Need: Improved patient care & Unmet Need: Improved patient care & satisfactionsatisfaction
• Potential health recovery dollarsPotential health recovery dollars• No association with malpractice No association with malpractice
(medical or legal)(medical or legal)
Steps to Start a MLPSteps to Start a MLP
3.3. Determine scope: legal issues Determine scope: legal issues & medical settings based on & medical settings based on capacity & interestcapacity & interest
4.4. Seek funding: start with local Seek funding: start with local foundationsfoundations
5.5. Teach attorneys to adapt to the Teach attorneys to adapt to the culture and practices of culture and practices of medicinemedicine
6.6. Educate, educate, educateEducate, educate, educate
Ask me to help you with Ask me to help you with contacts.contacts.
Ask me to help you with Ask me to help you with contacts.contacts.
SummarySummary
1.1. By collaborating with attorneys, we By collaborating with attorneys, we can improve the health of our can improve the health of our patients.patients.
2.2. For medical-legal partnerships to be For medical-legal partnerships to be successful, attorneys need to be successful, attorneys need to be seen as the “new consultant” and a seen as the “new consultant” and a part of the medical team.part of the medical team.
3.3. Several options exist for starting Several options exist for starting and structuring a medical-legal and structuring a medical-legal partnership.partnership.
Thank You.Questions?Thank You.Questions?