Presentation to 2013 NC Primary Care Conference June 21, 2013 Rebecca Whitaker, MSPH, Director of Health Policy and Governmental Affairs North Carolina Community Health Center Association Madlyn Morreale, JD, MPH, Supervising Attorney Medical-Legal Partnership Program, Legal Aid of North Carolina Medical-Legal Partnerships: Addressing Social Determinants of Health to Improve Patient and Population Health

Agenda 1. Overview of Medical-Legal Partnerships (MLPs) 2. Assessment of Unmet Legal Needs Among Health Center Patients 3. Strategic Decisions for Implementing MLPs 4. Next Steps for Expanding MLPs in NC 5. Questions/Answers

How to Address Social and Environmental Determinants of Poor Health Status?

Health and Well-Being Are Influenced by Individual Factors, Access to Resources, and Broader Legal and Policy Framework Economic and social opportunities and resources Living and working conditions in homes and communities Medical care Personal behavior HEALTH Opportunity for legal & policy intervention Opportunity for health care provider intervention Opportunity for legal & policy intervention Adapted from: Braveman, PA, Egerter, SA & Mockenhaupt RE (2011). Broadening the Focus: The Needs to Address the Social Determinants of Health. Am J Prev Med 40(1S1): S4-S18.

Health Care Providers Understand That Patients’ Unmet Social Needs Are Directly Causing Worse Health Outcomes 95% of physicians serving patients in low- income communities believe patients’ social needs are as important to address as their physical health needs 80% of physicians are not confident their ability to address patients’ social needs 76% of physicians wish that the health care system would cover the costs associated with connecting patients to services that meet their social needs

How Can Different “Systems” Work Together on Behalf of Shared Patients and Clients?

What is a Medical-Legal Partnership? Brings together physicians, nurses, social workers, attorneys, paralegals, and others To address the social and environmental determinants of health, i ncluding: Substandard housing conditions; Domestic violence; Food, income, and housing insecurity; Improper denials of Medicaid and other public benefits; and, Failure to provide children with educational services to which they are entitled

Social Determinants of Health  Examples of Legal Remedies “Habitability” claims Fair housing claims Preventing illegal evictions Defending clients facing improper termination of housing subsidy Mortgage foreclosure assistance, including loan modifications Housing stability and conditions Appeal of denials of unemployment benefits, income support programs Supplemental Security Income (SSI) Work First for Families Enforce consumer protection laws Income instability

Social Determinants of Health  Examples of Legal Remedies Appeal of eligibility and service denials of Medicaid or NC Health Choice for Children Inadequate health coverage Appeal of denial of SNAP/ Food Stamps Food insecurity Domestic violence orders Health Care Power of Attorney for Minors Family instability Enforcement of special education rights Challenge improper school disciplinary actions, failure to provide PEPs Educational inadequacy

Legal Aid of North Carolina, Inc. Mission and Operations A statewide, non-profit law firm that provides free legal assistance in civil matters to low-income people in order to ensure equal access to justice and to remove legal barriers to economic opportunity 18 local offices serving all NC counties Statewide, toll-free Help Line Program Areas Housing Domestic Violence Public Benefits Consumer Law Employment Education Family Law Community Economic Development Statewide and Regional Projects Mortgage Foreclosure Project Domestic Violence Prevention Initiative and Battered Immigrant Project Fair Housing Project Advocates for Children’s Services Farm Worker Unit Senior Law Project Low-income Tax Clinic Medical-Legal Partnership Program

The National MLP Network – Highlights from 2012 Survey Nearly 100 MLPs serving children, the elderly, veterans and patients with chronic illnesses Provided services to 54,000 patients/clients Partnered in 134 hospitals and 143 community health centers Engaged 38 medical schools, 47 residency programs, 44 law schools Engaged 102 legal services offices and 60 firms and corporate law departments

LocationMedical Partner(s)Legal Partner(s) Asheville, NC  Mission Hospitals  Mountain Area Health Education Center  Western NC Community Health Services  Pisgah Legal Services Chapel Hill, NC  North Carolina's Children's Hospital, “CATCH” program for complex care patients  Legal Aid of North Carolina, Inc. (Statewide)  Pro Bono Program, University of North Carolina School of Law Charlotte, NC  Carolinas HealthCare System, Myers Park - Pediatrics  Legal Aid of North Carolina, Inc. (Charlotte office)  Legal Services of Southern Piedmont, Inc. Durham, NC  Lincoln Community Health Center, Pediatrics Department,  Duke Primary Care for Children  Duke University Medical Center, Pediatric clinics  Legal Aid of North Carolina, Inc. (Durham office)  Children's Law Clinic, Duke University School of Law Greensboro, NC  Triad Adult and Pediatric Medicine, HealthServe Community Health Clinic and Guilford Child Health  Legal Aid of North Carolina, Inc. (Greensboro office) Prospect Hill, NC  Piedmont Health Services, Prospect Hill Community Health Center  Legal Aid of North Carolina, Inc. (Durham office) Winston-Salem, NC  Downtown Health Plaza, North Carolina Baptist Hospital  Legal Aid of North Carolina, Inc. (Winston- Salem office) Winston-Salem, NC  Wake Forest University Baptist Medical Center and School of Medicine  Elder Law Clinic, Wake Forest University School of Law Medical Legal Partnership Sites in North Carolina

What is NCCHCA? Mission “To promote and support patient-governed community health care organizations and the populations they serve.” Vision “Every North Carolina community will have access to a patient- centered, patient-governed, culturally competent health care home that integrates high quality medical, pharmacy, dental, vision, behavioral health, and enabling services without regard to a person’s ability to pay.” NCCHCA’s mission, vision and goals have guided interest in addressing social determinants of health and in medical-legal partnerships.

Why NCCHCA Got Involved in MLPs: A Changing Health Care Landscape Growing emphasis on patient-centered health homes and community centered health homes Addressing the Triple Aim: Improving the experience of care Improving population health Reducing health care costs Helping health centers be “providers of choice”

MLPs are a Good Fit for Community Health Centers Leveraging the social determinants of health is “in the DNA” of community health centers: Serve predominately low-income, vulnerable populations 52% of health center patients are uninsured 95% of health center patients have incomes below 200% of the federal poverty line Emphasize enabling services to facilitate access to care and to help meet broader socioeconomic needs of patients

The Opportunity: Jim Bernstein Community Health Leadership Fellows Program Project goals Conduct a health-related legal needs assessment in NC health centers to bring attention to the health-related legal needs of health center patients and encourage more communities to develop MLPs Inform MLP program planning and operations

Project Design Data collected in 5 health centers around the state Criteria for participation: Diversity in health center location and size Emphasis on enabling services staff Range of MLP development Two needs assessment tools: Pen-and-paper patient survey (available in English & Spanish) Web-based staff survey Data analysis in Excel & Stata

Patient Survey Results 71% of all patient respondents reported experiencing at least one legal or resource need in the past year

Summary of Patient Characteristics Patient characteristics Total (n=334) Legal/resource need identified (n=236, 71%) No legal/resource problem identified (n=98, 29%) African American39%37%44% White45%46%43% Hispanic/Latino20%21%17% Spanish survey15%17%9% Self-reported health status Very good15%13%19% Good38%33%51% Fair29%31%23% Poor14%17%6% Very poor4%5%1% At least 1 uninsured adult69%73%60% At least 1 uninsured child31%36%19%

Patient Data Confirm the Need For MLPs in Health Centers Patients were significantly more likely to report legal or resource needs if they: Reported fair, poor or very poor health status Had uninsured adults or children in the home Responded to the survey in Spanish Sickest patients were less likely to have sought help from a lawyer in the past and less likely to know where to go for legal help Hispanic/Latino patients were less likely to have sought help from a lawyer in the past and less likely to know where to go for legal help Nearly 80% of patients were very likely or somewhat likely to discuss legal/resource problems with their provider in the future

Staff Survey Results Patients reporting legal or resource problem Staff comfort discussing – Strongly agree Staff likelihood of screening – Very likely

Staff Survey Results 71% of staff said they would screen and refer patients for free legal assistance if their health center had an established referral program Social workers and outreach workers were most likely to screen and refer patients, followed by clinicians (medical, dental and behavioral health) Staff with shorter tenures were more comfortable discussing legal or resource needs and were more likely to screen and refer patients Most common barriers to addressing health-related legal needs:

Key Takeaways NC health center patients likely to experience legal or resource needs Sickest patients more likely to have legal or resource needs but less likely to know where to seek help for these issues Patients are willing to talk with their providers about legal and resource needs Staff are willing to screen and refer patients for these issues

Why Collaborate? Opportunity for better outcomes for individual patient/client “Value Added” with health care providers’ and lawyers’ expertise Opportunity for “Preventive Lawyering” Opportunity to focus on community-level outcomes Use data to target limited resources for important, locally-defined needs “Impact Work” Opportunities at the institutional level Expand capacity with new partners, resources Opportunity for “systemic” impact Training of new professionals Multiple disciplinary approach can facilitate sustainability

The Medical-Legal Partnership Model: Core Activities Training to help health care providers screen for health concerns that may have a legal remedy Regular, on-site presence of legal staff at medical sites Legal staff available for “consults” about potential referrals When a clinician identifies a family with a potential legal problem, offers patient/family opportunity for referral to legal partner If patient/family consents, clinician fills out a referral form and faxes it to legal partner Legal partner contacts applicant, screens for eligibility and determines whether legal assistance can be offered Legal staff and health care providers work collaboratively when needed to achieve goals Legal partners track MLP referrals and MLP cases, work with medical partners to assess/enhance operations, impact Recruitment of private bar to enhance capacity

Strategic Decisions for Potential MLP Partners Who are your potential partners? Medical partners? Clinics, hospitals, certain groups of providers within those settings? Legal partners? Legal Aid of NC or other legal services providers? Law Schools? Private Bar? Other community partners? Which population(s) are you trying to serve? What is your capacity? What are your constraints? Staff and other resources Eligibility restrictions Etc.

Strategic Decisions for Potential MLP Partners Which legal services will be offered? Targeted to particular legal issues, e.g., housing, DV, benefits appeals? How to handle service gaps? How will you handle core activities? Training for health care providers Regular presence of legal staff at health care setting Consultations Referral, intake protocols Confidentiality How to ensure success, sustainability?

Gaining Traction Work done through Bernstein fellowship has raised visibility of medical- legal partnerships NCCHCA’s MLP project one of five programs nationally to receive an Innovation Award funded by the Kresge Foundation in “recognition of [an innovative approach] to primary care delivery and other initiatives that promote health and wellness in low-income communities” Expect NC health centers will want to engage in MLP development for several reasons: Opportunity to generate revenue by helping patients’ secure access to public health insurance Opportunity to help improve patients’ health status Opportunity to help health centers be “providers of choice” in their communities

Potential Next Steps for NCCHCA-LANC Collaboration Facilitate strategic development of MLPs in health centers Identifying and connecting partners Brokering existing resources between partners Developing centralized resources and training for safety-net providers Consider feasibility of a statewide/regional approach to MLPs in health centers, emphasizing MLPs in rural health centers MLPs most common in urban areas Rural communities more likely to experience persistent poverty and limited access to services Collect data and collaborate on a robust evaluation of MLPs in NC CHCs that would measure improvements in health outcomes, as well as the economic impact on CHCs and on clients served Identify/ secure investment from health centers, private foundations, other funders

Questions? Rebecca Whitaker, MSPH Director of Health Policy & Governmental Affairs NCCHCA Madlyn Morreale, JD, MPH Supervising Attorney, Medical-Legal Partnership Program Legal Aid of NC