1. MEDICAL-LEGAL PARTNERSHIP AS ANOTHER TOOL TO PREVENT BURNOUT AND COMPASSION FATIGUE PRESENTED BY: KRISTA SELNAU, ESQ. PINE TREE LEGAL ASSISTANCE

2. ROADMAP  1. Acronyms and Terms  2. Overview  3. Case Examples  4. Preventing Burnout through MLP  5. Eligibility  6. “Magic Words”  7. Referral  8. Review  9. Contact

3. ACRONYMS AND TERMS  MLP: medical-legal partnership  SDH: social determinants of health  Health partner: healthcare system partner of a medical-legal partnership  Legal partner: legal aid agency partner of a medical-legal partnership  Health-harming civil legal need: unmet civil legal need harmful to patient health and well-being  Legal care: medical-legal partnership legal assistance provided to patient after referral from healthcare partner  Consult: medical-legal partnership consult for healthcare partner from legal partner

4. OVERVIEW OF THE HEALTHCARE SYSTEM (VETERANS)  Healthcare systems exist to provide healthcare for all individuals  Healthcare systems operate differently based on funding  VA operates the largest healthcare system in the United States and provides care to about 8 million veterans  The VA has about 1,400 care facilities, including 152 VA medical centers, 135 offering nursing home care, 909 ambulatory care facilities and outpatient clinics, 47 residential rehabilitation treatment programs, 108 comprehensive home-care programs, and 232 readjustment counseling centers  Every veteran is not automatically entitled to VA health care  In general, to be eligible for VA health care the veteran must have served the required length of time

5. OVERVIEW OF CIVIL LEGAL AID  Civil legal aid provides necessary legal assistance to low-income individuals free of charge  Civil legal assistance includes: family law, housing and foreclosure, consumer, employment and income maintenance  Nearly 60 million Americans – 1 in 5 – qualify for free civil legal assistance (125% or less FPL); more than 50% are turned away because of lack of resources  Civil legal aid cannot meet the need for services alone  Civil legal aid agencies play a critical role in addressing social determinants of health

6. SOCIAL DETERMINANTS OF HEALTH  Social determinants of health: where we live, learn, work and play  Example: Living in a “food desert” leads to a lack of access to healthy food which can lead to or exacerbate health conditions  Often lead to racial, ethnic, and economic health disparities  Can result in a “revolving door” in which patients are repeatedly hospitalized

7. WHERE THE TWO CONNECT: MEDICAL-LEGAL PARTNERSHIP  Healthcare systems and civil legal aid agencies can work together to address the social determinants of health  A “medical-legal partnership” is generally defined as a partnership that integrates the expertise of healthcare, public health and legal professionals and staff to address and prevent health-harming social and legal needs for patients, clients and populations  There are over 292 health institutions that partner with legal aid agencies throughout the United States to address social determinants of health – that is, the economic and social conditions that influence the health of people and communities  Interdisciplinary collaboration and education to address social determinants of health “upstream”  Every 1 in 6 persons needs legal care

8. HOW CIVIL LEGAL AID HELPS HEALTHCARE ADDRESS THE SOCIAL DETERMINANTS OF HEALTH  EXAMPLE 1:  Tiffany is a single mother with a part-time job. She recently applied for food stamps but was denied. Her daughter has been experiencing an increase in asthma flare-ups recently and Tiffany has had to miss a lot of work to take her daughter to the doctor. She is concerned about missing too many days from work because she needs her job to pay the bills. She moved into a new apartment two months ago. Around the time she moved in was when her daughter began to experience the asthma flare-ups.  Impact on health: 1) being able to afford enough healthy food helps people manage chronic diseases and helps children grow and develop[; 2) consistent employment helps provide money for food and safe housing; 3) a stable, decent, affordable home helps individuals stay healthy and avoid costly emergency room visits  Related social determinant of health: 1) increase the availability of resources to meet basic daily needs; 2) create equal access to the opportunity to work; 3) ensure healthy physical environments  Legal aid intervention: 1) appeal denial of food stamps; 2) enforce workplace rights; 3) improve substandard conditions

9. HOW CIVIL LEGAL AID HELPS HEALTHCARE ADDRESS THE SOCIAL DETERMINANTS OF HEALTH  EXAMPLE 2:  Ryan received a denial letter for SSI in the mail two days ago. He doesn’t understand why because his doctors have told him he is disabled and can’t work and he receives VA disability. He hasn’t been able to pay his rent for the past several months and his landlord told him he is taking him to court to evict him. Ryan has fallen behind on his federal student loan payments. He has been unemployed since he was diagnosed with cancer four months ago.  Impact on health: 1) increasing someone’s income means s/he makes fewer trade-offs between affording food and health care, including medications; 2) a stable, decent, affordable home helps individuals avoid costly emergency room visits related to homelessness; 3) consistent housing helps people follow their medical treatment plans  Related social determinant of health: 1) increase the availability of resources to meet daily basic needs; 2) ensure healthy physical environments  Legal aid intervention: 1) appeal denial of benefits; 2) prevent eviction; 3) enforce discharge of federal student loan debt

10. HOW CIVIL LEGAL AID HELPS HEALTHCARE ADDRESS THE SOCIAL DETERMINANTS OF HEALTH  EXAMPLE 3:  John lost his job last year and hasn’t been able to make his court-ordered child support payments. He never modified the child support order. Yesterday he received a letter in the mail telling him he owes $6,000 in arrears and his license is suspended. He also goes to Togus once a week for therapy.  Impact on health?  Related social determinants of health?  Legal aid intervention?

11. HOW CIVIL LEGAL AID HELPS HEALTHCARE ADDRESS THE SOCIAL DETERMINANTS OF HEALTH  EXAMPLE 3:  Impact on health: 1) ensuring access to a drivers license helps make consistent employment and medical care compliance possible; 2) increasing someone’s income means fewer trade-offs between affording food, health care, and a home

12. HOW CIVIL LEGAL AID HELPS HEALTHCARE ADDRESS THE SOCIAL DETERMINANTS OF HEALTH  EXAMPLE 3:  Related social determinant of health: 1) increase the availability of resources to meet daily basic needs; 2) create equal access to the opportunity to work

13. HOW CIVIL LEGAL AID HELPS HEALTHCARE ADDRESS THE SOCIAL DETERMINANTS OF HEALTH  EXAMPLE 3:  Legal aid intervention: 1) Resolve license suspension and modify underlying child support order based on old income information

14. MEDICAL-LEGAL PARTNERSHIP AS ANOTHER TOOL IN THE TOOLBOX  Medical-legal partnerships allow us to practice at the top of our fields with the largest impact  Frees up clinician time from writing “legal” advocacy letters to landlord to attempt to stave off eviction  Assists lawyers with complex disability claims requiring medical letters of support and records  Both examples above would be less successful without collaboration from their health/legal partner  Clinicians focus on medicine/social work and lawyers focus on legal work  Utilize medical-legal partnership as a tool in the toolbox to prevent clinician burnout  Interdisciplinary training to issue spot for legal issues  Referral system to pass legal issues to legal partner  Communication and collaboration to learn from health/legal partner

15. BASIC ELIGIBILITY  Patient must be a veteran receiving healthcare at VA Togus Primary Care or Mental Health  Civil legal needs only; no criminal cases  Must have a health nexus (health-harming civil legal need)  Income guidelines apply only to extended representation cases (200% or below FPL)

16. HEALTH-HARMING CIVIL LEGAL NEEDS  Medical-legal partnership provides legal assistance for civil legal needs only:  Housing  Income and benefits  Employment  Education  Consumer  Family law  VA benefits  *Discharge upgrades

17. “MAGIC WORDS”  Magic words to look listen for that trigger a medical-legal partnership referral:  Eviction  Mold  Problems with my license  Denied for… (government benefits, food stamps, VA benefits)  Losing my home  Can’t pay all my bills  Concerned about my safety  Behind on payments (rent, credit cards)

18. REFERRAL TO MEDICAL-LEGAL PARTNERSHIP  Call Krista at Pine Tree Legal Assistance (207) 400-3251 or email at kselnau@ptla.org to schedule an appointment (veteran or clinician may call) kselnau@ptla.org  Walk-In hours as available: Mondays and Thursdays 8:30-1pm, Room 202 Building 206  May 2016: referral screener form available  Summer 2016: legal training series

19. REVIEW: MEDICAL-LEGAL PARTNERSHIP  Healthcare systems and civil legal aid agencies can work together to address the social determinants of health  A “medical-legal partnership” is generally defined as a partnership that integrates the expertise of healthcare, public health and legal professionals and staff to address and prevent health-harming social and legal needs for patients, clients and populations  Interdisciplinary collaboration and education to address social determinants of health “upstream”  Every 1 in 6 persons needs legal care

20. CONTACT INFORMATION Krista Selnau, Staff Attorney Veterans Medical-Legal Partnership Pine Tree Legal Assistance kselnau@ptla.org (207) 400-3251