A lawyer walks into a hospital.
That may sound like the opening joke at a comedy club but if you
really think it is a joke, the joke would be on you. Not all illness is
caused or exacerbated by medical reasons or patient/family
non-compliance, although as physicians that is what we may assume.
Often, patients present with health problems that have a legal
dimension, and the presence of lawyers in the hospital who can assist
with such problems can make a difference in outcomes.
For example, what should we do then when a young patient with
asthma must make repeat visits the emergency department, not because he
doesn't have his medication or his asthma action plan, but because
the apartment he lives in has mold that the landlord refuses to
remediate?
In this real case, a lawyer was able to intervene to secure safe,
healthy housing for the family.
Imagine another case, in which a young girl with insulin-dependent
diabetes is told by school authorities that she must be home schooled
because her school cannot accommodate her need for insulin shots.
Lawyers negotiated the child's continued enrollment in the school
where she was legally entitled to be educated.
Finally, a grandmother became the caretaker of her three
grandchildren after their mother's death. She needed assistance
establishing legal guardianship to be able to obtain medical care for
them. She was assisted by the Health Law Partnership (HeLP), part of the
growing trend across the country to bring together doctors and lawyers
inside the hospital, in an effort to serve those in need.
HeLP wanted
All of these cases were referred to the in-house HeLP attorney by a
social worker or physician who recognized the need for legal
intervention that would assist their patients in receiving services they
needed.
The effect of the problems like these is even more prevalent in
populations that do not have adequate family or societal support, making
them more vulnerable to the socio-economic stressors that impact health.
Instead of medical needs, time and again it is often these social needs
that force families to seek assistance at the hospital or their
physician's office.
Saul Weiner, MD, in the Journal of General Internal Medicine found
that contextual errors are at least as frequent and likely more serious
than medication errors. Contextual errors are errors where the physician
doesn't recognize the impact of the patient's daily life on
the planning of care.(1) He also found that the residents he was
training weren't easily able to detect the unexplained issues that
brought patients to seek medical care.(2)
While recognizing the contextual factors associated with a
patient's medical problem is important, being able to address those
factors depends on the available resources. In 1993, the first
Medical-Legal Partnership for Children (MLPC) was founded by Barry
Zuckerman, MD, to serve as a resource for patient-families at Boston
Medical Center who had legal issues that impeded their ability to get
the care they needed.
Since then, over 180 medical-legal partnerships have formed. In
January 2009, the National Center for Medical-Legal Partnership (NCMLP)
was created to serve as an informational, technical and networking
resource center for existing and emerging medical legal partnerships.
HeLP was the first medical-legal community partnership for children
established in the South, and is part of the NCMLP. HeLP is a recognized
innovator and leader in this national medical-legal partnership trend to
develop what are called "public health legal services."(3)
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HeLP consists of four components:
* Direct legal services
* Educational programming * Advocacy
* Research and evaluation
Shortly after its 2004 inception, HeLP established free legal
services offices at two hospitals--Children's at Egleston and
Children's at Scottish Rite--to serve low-income children and their
families. An additional legal clinic at Georgia State University College
of Law opened in 2007, allowing HeLP to increase its direct services to
underserved families by incorporating law students into the partnership.
In addition to educating law students, the clinic collaborates with
Emory Medical School and Morehouse School of Medicine. Clinic students
work with pediatric residents, attend joint classes with third-year
medical students, and the clinic serves as an elective rotation
placement for fourth-year medical students.
The clinic has been a model interdisciplinary educational program
for training future legal and health professionals to address the
socio-economic needs and legal rights of children and families,
especially those from poor and under-served communities.
In early 2008, HeLP's partners signed an agreement to expand
the project into Children's at Hughes Spalding an inner city
community hospital in downtown Atlanta. The expansion allows HeLP staff
to see client families at the Hughes Spalding campus, which is managed
by Children's and owned by Grady Health System.
In concert with the expansion of the capabilities of HeLP, client
services have grown steadily over the years of operation from initial
intake of 23 clients to 325 for the state fiscal year 2009 (Table 1).
Direct Legal Services
The mission of HeLP is to:
* Provide a comprehensive set of public health legal services to
address the full spectrum of socioeconomic and environmental factors
affecting low-income children's health.
* Promote the interdisciplinary education of health care and legal
professionals to work as a team to improve the health of children,
especially those from under-served and vulnerable communities.
Within that mission are four goals:
1. The first goal is to improve health outcomes for low-income
children through the establishment of onsite public health legal
services offices at Children's three hospital campuses.
2 The second is to foster knowledge, understanding, and a
cooperative spirit between the health care and legal professions to
promote children's health through interdisciplinary educational
programs, including in-service education for health care professionals
at Children's and student education for law students and graduate
professional students. The HeLP Legal Services Clinic at Georgia State
University's College of Law as well as externships and practicum
placements train future lawyers and health care professionals to work
together to improve children's health.
3. The third goal is to improve low-income children's access
to health care and the conditions that affect their health through a
program of legal and policy advocacy, including advocacy at the
legislative, policymaking, and government agency levels.
4. Finally, HeLP wants to serve as a model demonstration program
for interdisciplinary community collaborations that seek to promote the
public's health.
HeLP serves the patients and families of Children's Healthcare
of Atlanta with an income at or below 200 percent of the federal poverty
level. Approximately 53 percent of all patients at Children's
Healthcare of Atlanta meet eligibility criteria of HeLP.
HeLP handles those cases that pose legal or other issues beyond the
scope of practice of the social worker and physician (Table 2). Through
in-kind support from Children's, there is an office at each of the
three campuses with a lawyer who has primary responsibility for that
individual campus and its patients/families.
What is it HeLP does not do? The partnership does not handle any
case placing the patients or their families in an adversarial position
to the hospital, any case placing the parents in adversarial position to
the child, and most importantly to the physicians and the hospital
administration, medical malpractice.
Education
The educational component of HeLP focuses on legal, policy and
ethical issues that affect the child's health. It provides
interdisciplinary education through in-service education and training of
both medical and non-medical professionals, including doctors, lawyers,
nurses, social workers, medical students and medical residents.
HeLP also includes an in-house, live client, legal services clinic
providing clinical education to students at Georgia State
University's College of Law and to other professional and graduate
students.
The clinic provides a supportive learning environment for law
students to develop practical lawyering skills in substantive legal
fields related to the health and well-being of low-income children and
their families.
Cases referred to HeLP for legal representation that arc
appropriate for student learning and interaction are assigned to law
students enrolled in the clinic. The students obtain course credit for
participating in the clinic. Students develop skills such as
interviewing, counseling, negotiation, legal research, writing,
drafting, and case management.
Advocacy
In the long-term, helping individual patients is not the only
solution to address the socio-economic determinants of health. Thus, in
addition to providing legal services, HeLP advocates for systemic change
that addresses the barriers that impede access to vital services and
sources of unmet basic needs.
As part of its overall program, HeLP seeks to address the legal,
policy, and social issues that adversely affect the health of low-income
children and their families. These issues are sometimes discovered as
part of a pattern of recurring individual cases in the public health
legal services practice.
The attorneys at HeLP address broader legal problems in several
ways. They negotiate with government agencies about appropriate
implementation of policies and regulations, and work with the Georgia
General Assembly to develop legislative solutions.
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Research and evaluation
HeLP has Institutional Review Board approval to gather data,
including health care outcomes (Table 3). Research data collected from
parent participants, from participants in the educational programs, from
physicians involved in utilizing the services and from the lawyers
providing the services are used to evaluate the quality and
effectiveness of the program.
An annual report is published, and the executive summaries are
available on the HeLP website. (4) The report is produced by an
independent health services research consultant hired by HeLP to
undertake data collection and analysis throughout the year.
There is an annual retreat to review the annual report, assess
performance, address areas of need, and plan strategically for the
upcoming year. HeLP has been supported since it began by a volunteer
advisory council, that is composed of well-known leaders of the legal,
health care, and academic communities of Atlanta and includes medical,
legal, social work, and health research professionals.
Conclusion
Combining the health care expertise of hospital professionals with
the legal expertise of lawyers, the health care team can effectively
address the socio-environmental factors exacerbating poor health, such
as poor housing conditions, food insecurity, poverty, family
instability, and lack of access to appropriate educational resources for
children
The result is a coordinated, interdisciplinary approach that
improves access to care, patient health and well-being, and access to
financial resources for many patients.
In addition, the health care organization may benefit from the
legal interventions by potentially increasing reimbursement when more
patients are approved for Medicaid or Medicare, by obtaining appropriate
supports that may facilitate discharge planning and reduce financial
outliers, and by obtaining necessary benefits that may increase patient
compliance with care.
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References
(1.) Weiner SJ. Contextualizing medical decisions to individualize
care: Lessons from the qualitative sciences. J Gen Intern Med. 2004
March; 19(3): 281-285.
(2.) Weiner SJ, Schwartz A, and others. Evaluating physician
performance at individualizing care: A pilot study tracking contextual
errors in medical decision making. Med Decis Making. 2007; 27: 726-734.
(3.) Schulman DI, Lawton E, Tremblay PR, Retkin R, Sandel M, Public
Health Legal Services: A New and Powerful Vision?, Georgetown Journal on
Poverty Law & Policy Fall 2008 Vol. XVII Number 3.
(4.) www.healthlawpartnership.com
Robert Pettignano, MD, FAAP, FCCM, MBA, is an associate professor
of pediatrics at Emory University School of Medicine, medical champion
at the Health Law Partnership and medical director for campus operations
at Children's Healthcare of Atlanta at Hughes Spalding in Atlanta,
Georgia.
Robert.Pettignano@choa.org
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Sylvia Caley, JD, MBA, RN, is an assistant clinical professor,
director of the Health Law Partnership, and associate director of HeLP
Legal Services Clinic at the Georgia State University College of Law in
Atlanta, Georgia.
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Lisa R. Bliss, JD, is an assistant clinical professor, director and
associate director of HeLP Legal Services Clinic at the Georgia State
University College of Law in Atlanta,
Table 1
State Fiscal Year (SFY) Client intakes
2005 (a) 23
2006 195
2007 240
2008 276
2009 325
Total 1059
(a) Represents intake beginning in January 2005 through June 30, 2005Table 2
Examples of Public Health Legal Services
Consumer Payment of medical bills, debt relief through
bankruptcy
Education Ensuring that chronically sick/disabled
children receive appropriate education
Employment issues Allowing caregivers to take time off from
work to help care for a sick loved one
Family stability Paternity, legitimation, protection from
domestic violence, and child support
Permanency planning and Guardianship; advance directive or a will
consent to care
Housing Unsafe or unsanitary living conditions
affecting health
Utilities issues Threatened shut-offs of utilities
jeopardizing the home environment
Public benefits Eligibility for Medicaid, disability
benefits or eligibility for food stamps to
nutritionTable 3
Outcome Category SFY * 2009 SFY 2008 Annualized SFY 2007
Annualized
Public Benefits $123,017. $101,647. $36,128.
Consumer $258.
Education Benefits $351,650. $147,700.
Employment Benefits $25,740.
Family Stability $1,380. $25,919. $22,968.
Healthcare Coverage $220,630. $1,414,080. ** $70,033.
Housing Issues $66,029. $10,820. $5,400.
Other $27,351. $11,399. $18,100.
Total $816,055. $1,711,565. ** $152,629. ***
* State Fiscal Year = July1-June 30
** Includes coverage of an experimental drug estimated value -
$1.17 million
*** Many benefits obtained/received not captured in data collection