Bar Journal - Spring 2007
Improving the Health of Children in Poverty Through Legal Advocacy
By: Anne Phillips and Attorney Cheryl Driscoll
Families living in poverty require special intervention to ensure that their needs are met and that children are able to grow and develop.1 Sometimes that intervention can occur entirely within the health care system, and a pediatrician is able to advocate for the kinds of changes needed to positively impact the health of a child. However children, especially those living in poverty, often face social and economic problems that have a great impact on their health and development, but that fall outside the influence of even the most advocacy-minded pediatrician. Sub-standard housing, lack of health insurance, denial of needed income or nutritional benefits, domestic violence, lack of access to special education services, and immigration issues all can negatively impact child health and threaten family stability in a profound way.2 While there are laws on the books to ensure that the poor have access to needed services, government bureaucracies, school officials and landlords often treat the poor unfairly. Poor families and their pediatricians don’t have the time or skills to negotiate with these institutions or individuals. However, legal services lawyers do have those skills.
Health care providers and public-interest attorneys working together can remove social and environmental barriers that directly impact child health, growth and development and affect the prevention and treatment of illness among children living in poverty. Recognizing the great benefit of a medical-legal partnership, New Hampshire Legal Assistance (NHLA) has teamed up with Child Health Services (CHS) to create the New Hampshire Health Law Collaborative (NHHLC)—a program designed to combine the skills of pediatricians who serve poor children in Manchester, New Hampshire with those of attorneys who can help solve civil legal issues that impact child health.
The NHHLC is modeled on the Medical Legal Partnership for Children (MLPC) in Boston. Formerly the Family Advocacy Program, the MLPC was established in 1993 by Boston Medical Center’s pediatric department. The MLPC is nationally recognized, and has been replicated in over 45 other sites across the country, including five in New England.3 Here in New Hampshire the project brings together two partners with a long history of serving the most poor and vulnerable citizens of the state, NHLA and CHS. CHS is a community-based clinic located in Manchester that provides integrated health care, social services and nutrition services to poor children and their families. Recognized locally and nationally as a leader in child health advocacy, CHS provides a medical home delivering specialized care that is adapted to the physical and psychosocial needs of low-income children. NHLA is a statewide legal services organization dedicated to providing legal services to underserved clients who face legal problems that affect their daily survival and most basic needs. NHLA advocates work to preserve clients’ housing, protect their subsistence income, obtain access to health care—assistance that helps clients provide food and clothing for their families and maintain their safety, independence and dignity.
Together, these two agencies have been implementing a pilot project in Manchester that places an NHLA attorney onsite at CHS and integrates that attorney into the multidisciplinary team that provides care to CHS clients. While modeled after existing programs, the NHHLC is unique in that it has been developed entirely in a community-based health setting—other replication sites around the country have been largely affiliated with hospitals.
The NHHLC has three major objectives:
1.) To improve health outcomes for individual clients by providing direct legal assistance to children and families.
2.) To address systemic social and environmental barriers to children’s health and well being through advocating for the institution of laws and/or policies that will improve the health of large groups of children.
3.) To provide a framework of medical-legal collaboration that NH Legal Assistance can use to expand legal advocacy services to other underserved populations in New Hampshire.
As of April 30, 2007, the project has opened a total of 246 cases since the project was launched in August 2005. The majority are family law, housing, benefits, domestic violence and special education cases. Examples include:
• Advocating for educational supports and services for a child with cerebral palsy;
• Defending a young couple and their nine-month old child against an illegal eviction action;
• Maintaining Social Security benefits for two young disabled children.
All of the families served by CHS are living in poverty, and many of the parents of the children served by the agency have often lived their entire lives struggling against barriers that keep them exactly where they are. Marginalized and isolated, they are not likely to feel capable of demanding special education services from a school system they could not negotiate themselves, or stand up to a landlord who is wrongly evicting them or keeping a security deposit when they move. Indeed, many feel resigned to accepting whatever happens, and do not understand that they may have rights that deserve to be defended. The strength of this program draws on the highly developed and trusting relationship that CHS establishes with it clients—clients who might otherwise not feel comfortable or capable of approaching NHLA or any other law firm on their own. Through the visits that families make to CHS for medical visits for their children or to access the other support services the agency provides, the staff is able to learn about significant family problems. Some are crises that require immediate action and intervention. However, most are not, and the focus of the project is on early intervention and prevention of situations that will have a negative impact on child health and overall family stability.
The NHLA attorney has office space at CHS and spends about half of her time there. During that time, she meets with clients, attends clinical meetings, and provides technical assistance and training to CHS staff. When a CHS medical provider, nutritionist or social worker identifies a possible legal issue affecting child health, the provider refers the case to the NHLA attorney. The NHLA attorney’s involvement may be as simple as providing advice and counsel for the client, or involve full representation. Cases that are outside of NHLA’s areas of expertise are referred to the Pro Bono Program of the New Hampshire Bar Association and to other appropriate organizations. With the family’s permission, the CHS provider and the NHLA attorney collaborate on the client’s problem until the case is resolved, with CHS staff providing necessary medical information, letters and other documentation or information needed to support the attorney’s efforts for the client. The NHLA attorney is viewed by CHS clients as one of the team of specialists available to them.
Training has been an important component of the project and has been an integral part of the program’s success. The focus of the trainings is to assist CHS staff in identifying legal problems early on, before the situation reaches crisis level and requires litigation. While the staff at CHS is very advocacy-minded, it is not always easy for them to discern a legal issue hidden in the complicated situations often presented by the clients. In addition, the CHS staff simply does not have the knowledge to understand when intervention by an attorney could facilitate the solution to a problem. For that reason, NHLA has provided CHS staff with training on a wide range of issues such as local welfare, special education, Children’s Supplemental Security Income (SSI), domestic violence, housing, guardianship, and Temporary Aid to Needy Families (TANF). In the first year, NHLA has provided 20 training sessions to CHS staff. The training is not detailed in nature, but provides staff with information that will help them “issue spot” or recognize a legal issue underlying the child’s or family’s problem. To support this training, NHLA has developed a series of “fact sheets” that serve as summaries of the topics and that staff can use to refer to after the training.
Currently, project staff are in the process of evaluating outcomes through a series of surveys and interviews with both clients who have received services and the health care providers who referred clients. In addition, project staff are participating in the New England Regional Medical Legal Network coordinated by the Boston-based MLPC. Through this collaborative the New Hampshire project will be involved in the development and implementation of a regional evaluation strategy that will determine the most critical outcomes and best practices around the evaluation of the medical-legal collaborative model.
The future of the NHHLC includes two very important goals. First, the project seeks to use the information gained from providing direct services to individual clients to promote systemic change that will affect the health of all children. It is not expected that the project will see the fulfillment of this goal until it is further along in its development. However, NHLA is already using information gathered by CHS to support the enforcement of a consent decree issued in connection with a class action suit NHLA filed seeking to improve the delivery of dental services to children with Medicaid. Based on information provided by CHS staff, the project is also monitoring the delivery of assistance to low-income families in other contexts.
In addition, CHS and NHLA intend to use the statewide presence of NHLA to expand this medical-legal collaborative model to other community-based health care sites across the state, and to use it to improve the health of all New Hampshire’s poor citizens, not just children. To this end, project staff has had initial contact with the North Country Health Consortium and will be providing initial training to staff from Consortium agencies in February 2007. Discussions have also been held with providers in Nashua and Sullivan County.
Medical legal partnerships have been proven to be an effective way to improve child health. NHLA is committed to the NHHLC and its long-term success. With generous support from the Endowment for Health, Jessie B. Cox Charitable Trust, New Hampshire Charitable Foundation and New Hampshire Bar Foundation, NHLA and CHS have been able to make the NHHLC a reality. These organizations are also working with us to develop strategies for long-term sustainability. We welcome all forms of support and involvement from the legal community. For more information contact Cheryl Driscoll at New Hampshire Legal Assistance at firstname.lastname@example.org.
ABOUT THE AUTHORS
Cheryl Driscoll, an attorney and member of the New Hampshire Bar, is Development Director of New Hampshire Legal Assistance and the initial director of the New Hampshire Health Law Collaborative. Anne Phillips, MPH is Director of Special Projects at Child Health Services.
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2. Parker S, Greer S, Zukerman B. Double Jeopardy: The Impact of Poverty on Early Childhood Development. Pediatr Clin North Am. 1988;35:1227-1240.
3. Lawton E, Sandel M, Smith L, Zukerman B. Why Pediatricians Need Lawyers to Keep Children Healthy. Pediatrics 2004;114(1):225.