PolicyLab

Almost 25 years ago, a pediatrician at Boston Medical Center saw a young child with asthma who was not responding to treatment, and made an unusual decision. This was a patient the doctor had seen many times before, and each visit always ended the same way. He’d stabilize the boy at the hospital, but then have to send him home to a moldy apartment that the landlord refused to clean even after multiple calls from the doctor himself. This patient was far from an anomaly; his story was an all too common one. But this time, the doctor called a different kind of specialist, a lawyer at a local legal aid agency, and asked, “What can we do?”

That call not only helped the child—the lawyer was able to get the landlord to abide by housing code and abate the mold—but it was also the beginning of what would become the first medical-legal partnership (MLP) in the country, where “lawyers in-residence” work in clinical settings so that health care providers can refer patients with these kinds of problems for immediate help. Today, more than 300 hospitals and health centers have these programs, including 41—or nearly one out of every five—children’s hospitals. The American Academy of Pediatrics (AAP) was an early supporter of this idea, passing a resolution in 2007 that encouraged medical professionals to work more closely with lawyers to improve child health.

Addressing patients’ legal needs

Increasingly, hospitals and health centers use tools like the Accountable Health Communities Screening Tool and PRAPARE to screen patients for a range of social problems that affect health. As a result, patient navigators, social workers, and others have become fixtures on the health care team. Lawyers are additions, not replacements for these team members, adding critical expertise to solve structural barriers to many social problems that are often rooted in laws and policies. Whereas social workers might help a family apply for disability benefits or conduct a housing search, lawyers help families appeal wrongly denied disability benefits, or, like in the story above, force a landlord to make improvements to his property.

Today, more than 300 hospitals and health centers have these MLP programs, including 41—or nearly one out of every five—children’s hospitals.

Lawyers also ensure utilities do not get shut off so medication stays refrigerated and homes stay heated. They work with families and schools to put specialized education plans into place to make sure children get proper support in school. They set up custody and adoption agreements that stabilize children’s lives at home. And they make sure families receive food and cash benefits that help with nutrition, often securing retroactive benefits after a wrongful denial.

From patients to policy

Sometimes, a pattern of referrals of individual patients from health care providers to the legal team speaks to a structural problem. This can catalyze an MLP to engage in systemic advocacy to strengthen laws and care for children. For example, when the families of several kids with asthma were threatened with evictions for using their medically-recommended air conditioners, the MLP at Cincinnati Children’s Hospital traced the problem back to a single landlord who owned 700 units of housing in the community. They helped get the building placed under new ownership and the units updated.

A few years ago at Seattle Children’s Hospital, children on ventilators were being forced to stay in the hospital because there was a shortage of nurses able to care for the children at home, in part because the Medicaid home nurse salary rate was so much lower than salaries for other nursing jobs. On behalf of six patient-families at Seattle Children’s, Northwest Justice Project—the hospital’s MLP legal partner—filed a lawsuit against the state Medicaid director and Health Care Authority, and not only got those kids at-home coverage, but also succeeded in getting the nursing pay rate increased across the state.

In another instance, an increasing number of kids were being admitted to Children’s Healthcare of Atlanta with head trauma. Their MLP team linked these admissions to the fact that the age requirement for booster seats in Georgia was lower than the national average. Their partnership drafted and helped pass a state law raising the booster seat age.

Early evidence suggests lawyers can be good for patients and a hospitals’ bottom line

Initial studies show that receiving legal services as part of care can have important impact on well-being, including patients with chronic illnesses being admitted to the hospital less frequently. Studies also show potential to save health care organizations money by reducing health care spending for high-need, high-use patients, and by getting patients enrolled in health insurance and thus reimbursing clinical services that had been previously denied for payment.

In its 2016 survey of MLP programs, the National Center for Medical-Legal Partnership asked health care organizations to report how often clinicians at their hospital or health center anecdotally reported various benefits of MLP services. Eighty-six percent of respondents reported improved health outcomes for patients, 64 percent reported improved patient compliance with medical treatment, and 38 percent reported an improved ability to perform “at the top of their license.”

We are witnessing an important reckoning in health care: significant research details the ways social factors affect health and how few tangible solutions clinics have to address them. Lawyers—when working closely with social workers and health care providers—are one tangible way to address some of these issues. It's something the AAP knew 10 years ago when, ahead of its time, it became the first professional health association to recognize the role lawyers can play in promoting health. Today, with the future of children's health insurance unknown and the effects of poverty and structural barriers to resources affecting kids in countless ways, children's hospitals have the chance to once again lead the way.

Ellen Lawton, JD, (@ellawton) is the co-director of the National Center for Medical-Legal Partnership at the George Washington University.