The Civil Legal Aid Toolkit for HRSA-Funded Health Centers: Understanding & Optimizing the Public Interest Legal Community

The Advisory Board Company contributed significant pro bono technical support and expertise to the development of this toolkit. Special thanks to contributing consultant Laura Datz. About this toolkit This presentation is intended to help civil legal aid practitioners highlight the composition, role, limitations, and impact of civil legal aid to their health center partners. This presentation is intended to be used alongside the two-page messaging guide that was downloaded with these slides. Practitioners are welcome to use slides 3-20 in their trainings and presentations. If you have questions about how to use this resource, please contact Ellen Lawton at AcknowledgementsUsing these slides This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under National Training and Technical Assistance Cooperative Agreement number U30CS26936 in the amount of $300,000 with 0% of the total NCA project financed with non-federal sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.

Understanding & Optimizing the Public Interest Legal Community

Understanding the Goals of Civil Legal Aid Remove Economic Barriers to Legal Representation Provide Quality Legal Services Improve Opportunities for Low-Income People Promoting Equal Access to Justice and High-quality Legal Services For Low-income People

Federal and state government Legal community contributions Academia Private foundations and philanthropy Funding Sources Attorneys and non-attorney staff (paralegals) Law school legal clinics Pro bono volunteers Legal Aid Providers Individuals with incomes at or below 125% of the poverty level Clientele An Overview of the Industry

Federally Funded Legal Aid Services Private Pro Bono Resources Academia: Law School Clinic State & Locally Funded Legal Services Funding: $425M Funding: $180M Funding: $600M (estimate) Funding: $75M (estimate) Classifying Civil Legal Aid: By Funding No Unified Delivery System or Funding Source in the U.S.

Key Legal Aid SectorsCase Priorities Scope Federally Funded Legal Aid Services ) Basic needs: housing, income, safety 134 organizations +4,000 attorneys State & Locally Funded Legal Services Basic needs: housing, income, safety, but with a broader range & greater focus on policy 800+ civil legal services offices Private Pro Bono Resources Vary widely; also supports self-help service centers 1,200+ pro bono programs Academia: Law School Clinic Vary widely 200+ law school clinics Leading National Providers of Civil Legal Aid

Board of Directors Deputy Director Executive Director Managing Attorney Staff attorneys Paralegals Dean Legal Clinic Faculty 123 Civil Legal Aid Executives Civil Legal Aid Frontline Staff Law School Pro Bono Programs Law Firms Bar Associations 4 Corporate Law Departments Individual Attorneys Civil Legal Aid: Key Staff Roles Legal Allies for Medical-Legal Partnerships

Legal Aid Provides Otherwise Unaffordable Legal Services The NeedThe Services 1 in 6 live people live in poverty Every low income person has 2-3 unmet civil legal needs that negatively affect their health There is no guarantee to legal services in civil matters Legal aid primarily serves people who live in households with annual incomes at or below 125% of the federal poverty guidelines 65M+ qualified for legal aid in 2013 Legal AidLegal Need Who Needs Civil Legal Aid? Huge Population of Low-Income People With Unmet Civil Legal Needs

Income & Insurance Housing & Energy Americans with Disabilities Act compliance Discrimination Individuals with Disabilities in Education Act compliance Unlawful termination Immigration asylum, Violence Against Women Act) Criminal record issues Guardianship, custody, divorce Domestic violence Child abuse & neglect Advance directives, estate planning Education & Employment Legal StatusPersonal & Family Stability Legal Needs That Impact Health (I-HELP Model) Insurance access & benefits Food stamps Disability benefits Social Security benefits Debt relief Shelter access Access to housing Sanitary housing conditions Utilities access Why Do People Need Civil Legal Aid? Civil Legal Aid Helps People Solve Legal Problems of Every Day Life

Even Compared to Health Care’s Complex Model, Legal Aid is Challenged to Serve Patient presents Patient knows to goes to ED in case of acute medical need ED still not a source for primary care, but a viable last resort Patient is required to be treated regardless of ability to pay With or Without Payment, Treatment providedPatient suffers Patient can self- identify what constitutes medical need, requiring medical attention A Patient’s Path to Emergency Health Care Early intervention improves outcomes, and lowers costs in both settings ! Even When Need is Acute, No Guarantee to Aid No Clear Access Path to Civil Legal Aid, No Right to Representation

No matter how acute the need, there is no entitlement to free legal services in civil legal matters, unlike in criminal legal matters Scarcity of civil legal aid attorneys to support vast need; many turned away Client struggling with issue may or may not understand it is legal in nature (ex: housing issues, benefits, access to education) Even if client recognizes problem requires legal support, there is no one, clear provider of civil legal aid services Early intervention improves outcomes, and lowers costs in both settings ! Even When Need is Acute, No Guarantee to Aid No Clear Access Path to Civil Legal Aid, No Right to Representation A Client’s Path to Civil Legal Aid Client Seeks Legal Aid No Payment, No Requirement to HelpClient Struggles

Qualifying for legal aid turned away because of limited resources Legal needs of low and moderate income individuals unmet by current resources >50% Low income people whose civil legal aid needs were met by only 8,000 federally funded attorneys 800,000 80% Need for Legal Services Far Surpasses Resources

Self- Representation Formal Representation Self-Help & Community Education: Court-based self-help, workshops, informational websites, downloadable court forms, libraries Self-Help Plus Advice: Paralegals, lay advisors, phone services, advice paired with web-based services Pro Bono Representation From Non-legal Aid Organizations: volunteer attorneys, law students, paralegals Representation From Legal Aid Organizations: attorneys, law students, paralegals Classifying Civil Legal Aid: By Types of Services A Range of Offerings, Not Just Full Representation by an Attorney

Patient-Centered Health Care Model Includes an MLP Pilot Medical Legal Partnership Targets High-Need, High-Use Patients Lancaster General Hospital’s Pilot Program Embeds Attorney in the Health Care Team Social workers Patient- navigators Psychologists Pharmacists Physicians Nurses Attorney Targets highest utilizing patients 95% of high use patients enrolled in program had 2 or more legal needs Source: “Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”; Health Affairs, April 22, 2015.Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”;

Patient-Centered Health Care Model Includes an MLP (cont.) Pilot Medical Legal Partnership Targets High-Need, High-Use Patients Chronically ill patient heavily utilizes ED Through program, patient receives health care with patient navigator and social worker Patient receives legal aid services to enroll in Medicaid and restore SS benefits One Patient’s Story Shows Positive Impacts From Program Participation Patient incurs debt due to co-pays and uncovered services and medications Patient has unmet legal needs : difficulty enrolling in Medicaid, Social Security benefits are being unlawfully garnished 0 Visits to ED since program Saved costs for patient and hospital Source: “Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”; Health Affairs, April 22, 2015.Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”;

Source: “Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”; Health Affairs, April 22, 2015.Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”; Case in Brief: Lancaster General Hospital A 630 bed not-for-profit health system located in Lancaster, Pennsylvania, developed pilot program to address high use, high need patients, that embedded a lawyer within an inter- professional care team Goal of the pilot was to deliver on the patient-centered model of care, and to determine what effect integrating civil legal aid services into the care of high use, high need patients would have on health care costs During the pilot year, 55 patients were enrolled in the program, with 95% of those patients having 2 or more unmet civil legal aid needs, the most prevalent being housing issues and lack of access to public benefits Lawyer provided direct legal services for minor issues, referred more complex issues to external lawyers, and trained other members of the care team to identify and document civil legal aid needs By addressing patients’ civil legal problems, the pilot reduced health care utilization and costs. Results include: decrease in both 30-day and 7-day readmission rates among participating patients, upward of 50% reduction in utilization of inpatient and ED services and overall costs (as defined by charges) dropping by 45% Patient-Centered Health Care Model Includes an MLP (cont.) Pilot Medical Legal Partnership Targets High Need, High Use Patients Source: “Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”; Health Affairs, April 22, 2015.Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”;

Source: “Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”; Health Affairs, April 22, 2015.Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”; Case in Brief: Erie Health Center, Chicago IL A multi-site urban health center on the West side of Chicago developed an MLP to address legal needs for health center patients, working with Loyola Law School and Legal Aid Foundation of Chicago The health center detailed a VISTA volunteer to help the legal team screen, refer and conduct trainings for the providers. The MLP conducts focus groups with staff across all locations to raise awareness about health-harming civil legal needs The law school also helps develop policy strategies for health-harming legal needs that have a population health impact, such as lead poison rates at Chicago Public Housing. Erie Health Center now funds a full-time legal aid attorney on site at the health center, citing it as a key strategy to address patient needs and boost health center team capacity. Patient-Centered Health Care Model Includes an MLP (cont.) Pilot Medical Legal Partnership Targets Health Center Patients

Source: The Advisory Board Company interviews and analysis. Performance Category Accountable Care ImperativesRole of Medical-Legal Partnership Utilization Expense Management Clinical Outcomes Proactively manage chronic illness to avoid low-margin inpatient utilization Reduce inappropriate or duplicative care delivery Manage total cost of care for a defined patient population Target avoidable spending across health system Minimize preventable admissions, readmissions Promote community wellness for at-risk populations Improves at-risk patient management and ongoing wellness, reducing unnecessary hospitalizations Minimizes overall costs by addressing the social determinants driving downstream spending Supports better population health by targeting the environmental risk factors influencing clinical outcomes MLPs Strengthen Value-Based Strategy Partnerships Essential Component of Higher Quality, Lower Cost Care

Federal Legal Aid State & Local Legal Aid Private Pro Bono Resources Academia: Law School Clinics Healthcare equivalent Federally Qualified Health Centers Look-alike CHCFree Clinic Medical student rotation Scope 138 offices 8,000 attys 700+ civil legal aid offices 900+ pro bono programs 125+ law school clinics Funding$600 million$500 million est$180 million est$75 million est Health Care Equivalents of Legal Services