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

2. About this toolkit
Using these slides
Acknowledgements
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
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.
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.

3. Understanding & Optimizing the Public Interest Legal Community

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

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

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

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

8. Civil Legal Aid: Key Staff Roles
Legal Allies for Medical-Legal Partnerships 1 2 3
Civil Legal Aid Executives
Civil Legal Aid Frontline Staff
Law School
Board of Directors
Deputy Director
Executive Director
Managing Attorney
Staff attorneys
Paralegals
Dean
Legal Clinic Faculty 4
Pro Bono Programs
Law Firms
Bar Associations
Corporate Law Departments
Individual Attorneys

9. Who Needs Civil Legal Aid?
Huge Population of Low-Income People With Unmet Civil Legal Needs
Legal Aid Provides Otherwise Unaffordable Legal Services
The Need
The 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 Aid
Legal Need

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

11. With or Without Payment, Treatment provided
Even When Need is Acute, No Guarantee to Aid
No Clear Access Path to Civil Legal Aid, No Right to Representation
Even Compared to Health Care’s Complex Model,
Legal Aid is Challenged to Serve
A Patient’s Path to Emergency Health Care
Patient suffers
Patient presents
With or Without Payment, Treatment provided
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
Patient can self- identify what constitutes medical need, requiring medical attention !
Early intervention improves outcomes, and lowers costs in both settings

12. No Payment, No Requirement to Help
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 Struggles
Client Seeks Legal Aid
No Payment, No Requirement to Help
Even if client recognizes problem requires legal support, there is no one, clear provider of civil legal aid services
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) !
Early intervention improves outcomes, and lowers costs in both settings

13. >50% 80% 800,000 Need for Legal Services Far Surpasses Resources
Qualifying for legal aid turned away because of limited resources
80%
Legal needs of low and moderate income individuals unmet by current resources
800,000
Low income people whose civil legal aid needs were met by only 8,000 federally funded attorneys

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

15. 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.

16. Patient-Centered Health Care Model Includes an MLP (cont.)
Pilot Medical Legal Partnership Targets High-Need, High-Use Patients
One Patient’s Story Shows Positive Impacts From Program Participation
0 Visits to ED since program
Saved costs for patient and hospital
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
Chronically ill patient heavily utilizes ED
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
Source: “Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”; Health Affairs, April 22, 2015.

17. Patient-Centered Health Care Model Includes an MLP (cont.)
Pilot Medical Legal Partnership Targets High Need, High Use Patients
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%
Source: “Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”; Health Affairs, April 22, 2015.
Source: “Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”; Health Affairs, April 22, 2015.

18. Patient-Centered Health Care Model Includes an MLP (cont.)
Pilot Medical Legal Partnership Targets Health Center Patients
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.
Source: “Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership”; Health Affairs, April 22, 2015.

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

20. Health Care Equivalents of Legal Services
Federal
Legal Aid
State & Local
Private Pro Bono
Resources
Academia: Law
School Clinics
Healthcare equivalent
Federally Qualified Health Centers
Look-alike CHC
Free 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