Transcript Allies Not Adversaries

Allies Not Adversaries:
Partnering with Attorneys to
Improve Patient Health
Jeffrey Colvin, MD, JD
Section of Pediatric Hospital Medicine
Children’s Mercy Hospital
June 12, 2010
Disclosures
I have no current financial interest or
direct affiliation with any commercial
organizations or products that may be
referenced in this presentation.
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
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.”
Clinical Vignette
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
The History of Medical Legal
Partnerships
The History of Medical Legal
Partnerships
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2009
2008
2007
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Medical-Legal Partnerships
90
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* Over a dozen programs in active development
2. How can an attorney help?
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.
Homelessness & Child Health
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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.
“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.
“There Ought to be a Law Against
That”
Public Housing
&
Section 8
LandlordTenant
Law
Affordable
Healthy
Housing
Housing
Code
“There Ought to be a Law Against
That”
LandlordTenant
Law
Unlawful
Evictions
Public Housing
&
Section 8
Unlawful
Denial or
Termination
Affordable
Healthy
Housing
Housing
Code
Unlawful
Conditions
“There Ought to be a Law Against
That”
Public Housing
&
Section 8
Unlawful
Denial or
Termination
Attorney
Housing
Code
Affordable
Healthy
Housing
LandlordTenant
Law
Attorney
Unlawful
Evictions
Attorney
Unlawful
Conditions
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.
Other Health-Related Legal Issues:
Insurance & Health Care Access
 Health Effect Examples
 Legal Issue
 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
 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.
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%
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
Huang, Am J Pub Health 2006
Other Examples of Health-Related Legal
Issues:
Child Witness to Violence
 Health Effects:
 Legal Issue: Intimate
Partner
 Increased anxiety,
aggression, & conduct
Violence/Domestic
disorders
Violence
 Lower self-esteem
 Poor school
performance
 Orders of Protection
 Dissolutions/Divorce
Kerker, Arch Ped Adol Med 2000; Wright, Pediatrics 1997; McCloskey, Child Dev 1995.
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
Stress & “The Worry Budget”
754 Asthmatic Children
Suboptimal Control
37%
Controller Med Underuse
48%
Smith, Pediatrics 2008.
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.
Stress & “The Worry Budget”
754 Asthmatic
Children
Suboptimal Control
37%
Controller Med Underuse
48%
Associations p<0.05
Associations p<0.05
Race
Income
Parent Education
Unemployment
Race
Income
Parent Education
Single Parent
Low Expectations
Competing Priorities
Discordant Expectations
No Set Time
Smith, Pediatrics 2008.
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.
3. The “Nuts & Bolts” of One
Medical Legal Partnership:
Children’s Mercy Hospital
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
Annual Number of Referrals
780
800
700
508
600
500
350
400
300
200
36
100
0
4th Qrt 2007
2008
2009
Projected 2010
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.
MLP: How It Works
RN’s
Screening
Questionnaire
SW’s
NP’s
MD’s
Attorney or Paralegal
Present in Hospital/Clinic
Legal Intake
Case Handling
What the Attorney Does:
Case Handling
Brief Consultation
(21%)
Referral Out (29%)
Extensive
Representation (50%)
MLP: How It Works
RN’s
Screening
Questionnaire
SW’s
NP’s
MD’s
Attorney or Paralegal
Present in Hospital/Clinic
Legal Intake
Case Handling
1
Feedback to
Medical Team
MLP: How It Works
RN’s
X
2
Screening
Questionnaire
SW’s
MD’s
Attorney or Paralegal
Present in Hospital/Clinic
Legal Intake
Case Handling
NP’s
1
Feedback to
Medical Team
MLP: How It Works
RN’s
X
2
Screening
Questionnaire
3
SW’s
MD’s
Attorney or Paralegal
Present in Hospital/Clinic
Legal Intake
Case Handling
NP’s
1
Feedback to
Medical Team
MLP: How It Works
RN’s
X
2
Screening
Questionnaire
3
SW’s
MD’s
Attorney or Paralegal
Present in Hospital/Clinic
4
Issue Spotting
&
Lecture Series
Legal Intake
Case Handling
NP’s
1
Feedback to
Medical Team
MLP: How It Works
RN’s
X
2
Screening
Questionnaire
3
SW’s
NP’s
MD’s
1
Attorney or Paralegal
Present in Hospital/Clinic
Feedback to
Medical Team
4
Issue Spotting
&
Lecture Series
Legal Intake
5
Pagers &
Mimic Referral Process
Case Handling
3. Starting a Medical Legal
Partnership
What to Think About When
Thinking About Starting a MLP
1. Do you already have one?
Medical Legal Partnerships
Number of
Healthcare Sites
with an MLP
___________________________
0
1
2-4
5-9
10+
What to Think About When Thinking
About Starting a MLP
1. Do you already have one?
2. How to find lawyers to
collaborate with?

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Legal Aid
Law School Clinics
Hire attorneys
Private law firm pro bono work
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?
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One clinic
Outpatient only
One legal area versus all legal
areas
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
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
Funding Sources for Medical Legal
Partnerships
Legal (20%)
Healthcare (21%)
Government (9%)
Community
Foundations (33%)
Other (17%)
N=53, Total Cash Funding=$8,092,500
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
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 &
satisfaction
• Potential health recovery dollars
• No association with malpractice
(medical or legal)
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
Ask me to help you with contacts.
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.
Thank You.
Questions?