One in six Americans lives in poverty, and research has shown that each of those people — nearly 50 million — has at least one civil legal problem that negatively affects their health.
These people range from children living in substandard housing who need legal help to ensure that housing codes are enforced so they are not breathing mold that can trigger asthma attacks to homeless veterans who need an attorney to help stabilize their housing and income, according to the National Center for Medical-Legal Partnership, housed at George Washington University’s Milken Institute School of Public Health.
Health care providers have reported that three of the top 10 needs of homeless veterans were for legal assistance to prevent housing evictions and help with child support and military discharge issues that impact their income.
The center has identified five main areas where complicated bureaucracies, wrongfully denied benefits and unenforced laws commonly impact health and require legal care. The five areas are: income support and insurance; housing and utilities; employment and education; legal status; and personal and family stability.
It also notes the movement in health care toward more interprofessional education, where two or more professions learn with and about each other in order to improve the quality of patient-centered health care. Significant efforts have been made to teach physicians, nurses, social workers and public-health practitioners together, and the medical-legal partnership (MLP) model brings attorneys to the team.
The model has thus far been adopted by 292 health care institutions in 36 states. In 2007, the American Bar Association passed a resolution in support of the model and established the ABA Medical-Legal Partnership Project. The project’s main goal is to increase the availability of attorneys who provide pro bono services to health care institutions to address legal issues that are detrimental to people’s health. The ABA MLP Project also works with national medical and legal organizations to promote the MLP model through policy and initiatives.
While the model is not new on a national scale, Oregon just recently began initiating its first medical-legal partnership through collaboration between attorneys and law students, Oregon Health & Science University and the coordinated care organization Health Share of Oregon.
“We know there are a lot of things that go on in people’s lives that affect their health that can’t necessarily be solved by physicians or a health care team,” says Rachel Arnold, J.D., Health Share of Oregon’s contracting and provider relations manager.
Serendipity Pulls Partners Together
Laura Russell, a student at Lewis & Clark Law School and president of its Public Interest Law Project, has a background in health policy and decided a year after graduate school that she wanted to become a lawyer to specialize in public health policy. She was not yet familiar with the MLP model, but she did recognize the correlation between people’s health and their legal challenges. Russell began learning about MLP models while working in Chicago.
When she moved to Oregon, Russell met Dr. Ken Gatter, J.D., vice chair of anatomic pathology at OHSU, whose special interest is the interaction of health care and the law. Russell’s boyfriend was completing his medical residency at OHSU and Gatter was his attending physician. As an adjunct professor at Willamette University’s College of Law, Gatter was one of Arnold’s professors. That connection brought Health Share of Oregon to the table.
“It was this serendipitous thing and the partnership has been evolving really well,” says Russell, who began developing the MLP after attending a national conference with Gatter in Seattle in 2014.
Through Oregon’s MLP model, legal professionals train health care teams to identify social and legal needs and refer patients to a legal team, which then provides appropriate legal services. The legal services provided to patients are limited to civil legal services and will not include criminal law issues or issues pertaining to medical malpractice or HIPAA violations, according to Health Share of Oregon.
“These are (services) like income support and Social Security so they don’t have to make choices about whether they are going to eat or buy medication,” Arnold says.
Arnold says the pilot project, which will begin this spring at OHSU’s Richmond Clinic, is twofold. It will test the MLP model with a discrete set of patients at the clinic and the outcomes will be published. In addition to improving patient health, the project aims to reduce the use of health care services, with the goal of lowering the cost of care over a one-year period.
The second piece will allow project partners to collaborate with an array of stakeholders to craft a model that could be used throughout the state. This effort will include developing a vision, strategy and business plan and assessing the needs in various geographic regions, she says.
Gatter, who will lead the outcomes study that will detail the results of the pilot project, says he hopes it will show the MLP model is an effective tool for not only improving people’s physical health, but also the financial sustainability of the state’s health care system. He notes that Oregon’s MLP model is unique because it incorporates a coordinated care organization as a key partner.
“There’s a lot of interest in this. For example, there is interest in pediatrics and having this model outside of OHSU. Most MLPs are limited because people have to start small, but it would be nice to have a model that serves different populations,” Gatter says.
“I think it’s becoming clear to more people that social determinants are a powerful influence on health,” he adds. “Hopefully this will become part of how we teach our residents and medical students as well. They are very aware of it, but this is a great vehicle to help them become more aware of how legal issues can impact people’s health.”
William Penn, assistant director of administration for Legal Aid Services of Oregon, previously worked in the Career & Professional Development Center at Lewis & Clark Law School and organized its pro bono and community service program. Russell talked with him about the MLP model and the feasibility of getting law students involved in its development.
“From the legal side, it’s a good model for identifying problems that are having a sharp affect on people’s lives. From the medical side, it’s beneficial because it helps get to the underlying cause of people’s health issues, which often are not medical issues but legal issues,” Penn points out. “I think another spot where the medical profession is well placed for helping people identify issues that are affecting their health is domestic issues. They are able to spot abuse and start that conversation that may help someone down the line get out or report abuse.”
Penn says this era of health care reform creates a natural platform upon which to discuss new models of care like MLPs.
“It’s one of the things about the Affordable Care Act that people don’t talk about all the time, which is that there are incentives for health care providers to cut down on the recurrence of health issues,” he notes. “There are some people in the medical provider community who have farsighted views, and will see that addressing legal issues is the right way to do it and allow for some funding to get (MLP) projects off the ground.”
Initiative Brings Dormant Concept Back to Life
Melanie Maurice, OHSU’s legal counsel, was part of an Oregon State Bar program several years ago that encouraged attorneys to discuss how they could give back to the legal community and, in particular, the community as a whole. Attorneys participating in the program discussed the idea of a MLP in Oregon, but there wasn’t a strong enough dialogue with the health care field at that point to make it happen, she recalls.
“When Rachel (Arnold) brought the idea up, it was like a resurrection,” Maurice says. “I think it’s great to be able to identify legal issues that patients may have that impact their health and look for ways to resolve them so their overall health can be improved.”
Maurice, who initially wanted to become a doctor and went to law school to combine both of her professional passions, says her work with OHSU allows her to see firsthand some of the issues patients deal with.
“There are times when I’ll say we can’t really help the patient. They need to talk to their own legal counsel about whatever their issue is, like the need to get guardianship for a patient,” she says. For example, a parent may have a child who is 18 years old and legally responsible for their own decisions. But, if the patient is injured or disabled and unable to make their own decisions, the parent needs a guardianship document to allow medical care to proceed.
“That’s one of the experiences I see the most, and it’s an easy, common example that a MLP could help with,” says Maurice, who got involved in developing Oregon’s MLP model last year and is now helping to develop its business plan and pilot project.
Maurice emphasizes that OHSU medical students and physicians involved in the pilot project will not provide legal advice to any patients at the Richmond Clinic. Rather, the providers who identify clients with legal issues will refer them to an attorney or law student who is participating in the MLP.
Another consideration to be worked out, Penn notes, is the need to make sure there is a consistent ability and sufficient resources to address the legal issues that are identified. The pilot project initially was intended to begin last fall, but the organization of resources and support delayed its implementation.
Arnold says the program ran into roadblocks on the legal side, specifically determining the availability of pro bono services and whether to hire an attorney who could work directly with medical students in the Richmond Clinic.
During a January 2016 interview, Arnold said the MLP team was exploring the possibility of hiring a part-time attorney to supervise and work with the students who will provide intake services at the clinic. It was determined that the position was necessary, and Health Share of Oregon and the Richmond Clinic will supervise and financially support the position, she explained.
In addition, Russell says, a Medical-Legal Partnership of Oregon Advisory Board has been formed as well as two subcommittees, one of which will conduct a needs assessment while the other develops a business model to implement after the pilot project.
“We’ll bring those two subcommittees together to develop a business and funding plan based on what the needs assessment shows,” she says, adding the research study will be conducted in parallel with the pilot project and will help inform the advisory board about how the MLP model should look moving forward and how to sustain it financially.
Russell says that, even before it started, the pilot project at the Richmond Clinic began strengthening the connection with the medical community.
“The interest we’ve seen just from the Richmond Clinic has been really substantial. The medical team is very supportive of this model, which is a little different from other MLPs around the country,” she says, noting outcomes from other MLPs have shown that medical providers are sometimes initially wary of changes in the way they deliver services.
“The leadership team with the Richmond Clinic completely understands how this model helps improve patient care,” according to Russell.
In addition, the MLP team is working with health resiliency specialists to address which attorneys to reach out to as they develop the pro bono team. The resiliency specialists are an essential part of the needs assessment that will continue to inform the legal and medical aspects of the partnership moving forward, Arnold says.
“We want to identify a real, sustainable financial model,” she says. “Many MLPs across the country are grant-funded, and there is a lot of uncertainty in that. We don’t want to be in a position where every year we are worried about funding, so we’re really focused on trying to find out what the sustainability model is.”
The MLP team is focused on devising a system that can connect different areas of the state so that participants have a single point of contact for communication, information and other means of collaboration.
“I think it also gives us a lot more power behind the advocacy piece when we see the need to advocate around particular issues. It’s a stronger voice,” Arnold says.
“What we found out since we’ve begun working on this is that there is actually quite a bit of interest all over the state for MLPs,” she adds, noting several Portland-area health care organizations have expressed excitement about the concept. “The interest is growing and people understand the basics behind the model and the benefits they could reap from it.”
The reaction from the legal community has been strong as well. Along with inquiries from lawyers outside the metro area, attendees at presentations at Lewis & Clark Law School and the Oregon State Bar’s Health Law Section CLE in October 2015 offered positive feedback.
“I can’t even count how many people came up to us after the presentation before the Health Law Section and were really excited about the concept and asked how they could get involved,” Arnold says.
Russell says both attorneys and law students have expressed an interest in getting involved. “The number of people who want to do the legal clerkship side of it is only growing, and we have a lot of support at Lewis & Clark Law School in helping students get involved with us as well as law professors.”
Penn is among several attorneys who serve on the Medical-Legal Partnership of Oregon Advisory Board. His fellow legal colleagues on the advisory board include Cheryl Coon of Swanson, Thomas, Coon & Newton; Libby Davis, associate dean for student affairs at Lewis & Clark Law School; Dawn Jagger, federal policy liaison at the Oregon Health Insurance Marketplace, Oregon Department of Consumer & Business Services; Andrew Schpak, a partner with Barran Liebman; and David Wang, counsel at Vestas American Wind Technology.
“The legal community should want to be involved in general because our system only works when people are adequately represented,” Penn says. “From the housing standpoint, if landlords are allowed to get away with having substandard housing and are able to do it because people aren’t represented or don’t have the knowledge to know they have the right to something better than that, that is something that needs to be addressed.”
“In general, the legal community in Oregon is a generous and caring community,” he says.
And Russell, a driving force behind Oregon’s MLP model, is receiving externship credits to get the project launched. “I’ve been working on this since my first year of law school and I graduate in May, so my goal is to get this off the ground by then,” she says.
ABOUT THE AUTHOR
Melody Finnemore is a Portland-area freelance writer and frequent contributor to the Bulletin. Reach her at firstname.lastname@example.org.
© 2016 Melody Finnemore