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Bar News - June 15, 2016

Medical-Legal Partnerships Get Results for Patient-Clients


Candace Cappio Gebhart, a paralegal with New Hampshire Legal Assistance, listens as Rosa Escobar, a social worker at Child Health Services (CHS), talks about the Medical-Legal Partnership at CHS.

Child Health Services in Manchester was treating a family with two children suffering from asthma.

Exposure to the cold could trigger their asthma symptoms, so when the heating system quit in their apartment, and the landlord failed to make the necessary repairs, the family found itself with a medical problem that was being exacerbated by a legal problem.

“They would come here sick,” explains Rosa Escobar, a social worker at Child Health Services (CHS).

When an initial call to the landlord failed to solve the problem, Escobar contacted Candace Cappio Gebhart, a paralegal with New Hampshire Legal Assistance. Cappio Gebhart is one of two paralegals assigned to a new medical-legal partnership program with the Manchester Community Health Center, which includes CHS.

Cappio Gebhart showed the children’s mother how to file a 540-A petition in court, and the landlord was ordered to fix the heat. “Knowledge is power,” she says. “We’re trying to empower these folks.”

Since then, the family has found better housing. Because the children’s asthma affects their school attendance and their mother’s ability to work, decent housing is important not only to their health, but also their financial stability.

Manchester Community Health Center and Amonoosuc Community Health Services in Littleton are two out of seven health centers in the country that have sought and received funding for medical-legal partnerships through the Health Resources and Services Administration (HRSA), part of the US Department of Health and Human Services.

Evidence is growing that these kinds of partnerships can lead to improved patient outcomes, cost savings for health care agencies and greater job satisfaction among providers, by addressing “social determinants of health” – potential obstacles to good health, such as unsafe housing or the improper denial of benefits.

Helen Curry, 68, of Manchester, got help from the medical-legal partnership this year when she and her partner were threatened with eviction after their landlord decided to terminate their lease. “She called in tears; she thought they had to be out on Friday,” Cappio Gebhart recalls. Curry suffers from anxiety, which can lead to other health issues. “Not knowing what was going to happen, whether we had any options, that was making it so much worse,” she says.

Cappio Gebhart helped Curry delay the eviction and put her and her partner in contact with organizations that assisted them in securing better housing.

Kristyn Mueller, a paralegal working with the Amonoosuc Community Health Services in Littleton, understands the intersection between stress and health. Now working with clients who have medical and legal issues, she was a certified nursing assistant before going to school to become a paralegal.

“There are so many people out there who have legal issues who don’t even realize it’s having an impact on their medical diagnoses,” she says. Conditions like high blood pressure or mental health challenges can be made worse by stress, she notes.

Medical-legal partnerships have been established in 292 health care centers in 36 states, according to the National Center for Medical-Legal Partnership, which is affiliated with the Milken Institute School of Public Health at George Washington University.

In New Hampshire, the concept of a medical-legal partnership is not new. The state had a medical-legal project from 2005 to 2011. That effort, despite its popularity, folded due to a lack of funding. Not only had state lawmakers drastically reduced funds for NHLA in 2011, but the recession had also dealt a major blow to the Interest on Lawyer Trust Accounts (IOLTA) program, a major funding source, and remaining grant monies were not enough to keep the project going.

“As successful as it was, we didn’t feel we had the resources to maintain it,” says Cheryl Steinberg, an attorney at NHLA who helped establish the original program and continues to try to line up sustainable funding for this work.

For now, the opportunity to apply for the HRSA funds has opened the door to re-establishing some of these services in New Hampshire.

At the Manchester Community Health Center, the HRSA money allows for two paralegals from NHLA to spend one morning a week at CHS, meeting with patients who are referred to them. The paralegals also educate health center staff, so providers and social workers can ask patients the questions that will help identify the kinds of problems the paralegals can address. Back at NHLA, they spend time following up on cases and consulting with NHLA attorneys.

Sometimes, cases are referred elsewhere, such as the NH Bar Association Pro Bono Referral Program’s Domestic Violence Emergency (DOVE) Project, or Catholic Charities, which has some experience dealing with immigration issues. NHLA is working on partnering with the NHBA Pro Bono Program to include volunteer attorneys as part of the legal team assisting patients of the Manchester Community Health Center with civil legal issues. CHS also sought and received help directly from a Manchester law firm for an unusual challenge.

A teenage patient from El Salvador was scheduled for deportation, according to Katy Burchett, director of social services for CHS. The teen had been receiving death threats via text message from a gang he’d left behind. A lawyer was able to use those texts as evidence to federal immigration officials that the young man’s life would be in danger if he returned to El Salvador. He was allowed to stay in the United States, potentially saving his life.

Amonoosuc Community Health Services is using HRSA funds to pay Mueller, the paralegal, to help patients there. Although Amonoosuc’s medical-legal partnership is not directly tied to NHLA, Mueller says she regularly consults with her counterparts there.

“It fits right into the wheelhouse,” says Ed Shanshala, CEO of Amonoosuc, about the medical-legal partnership. “We’ve always been there, conceptually.”

Issues like access to healthy food affect many of the people Amonoosuc treats for diabetes, for example. “If you can’t eat right, you’re in the hospital,” he notes. Access to heat, safe housing, or programs like Meals on Wheels, can have a direct impact on health.

Amonoosuc aims to document the program’s benefits, with the hope that the legal services grant money will eventually become part of the agency’s base grant.

Elsewhere, medical-legal partnerships have been found to provide patient benefits and agency cost savings. A study of the Medical-Legal Partnership of Southern Illinois, which provided services to patients in seven rural counties, found a 319 percent return on investment between 2007 and 2009.

In other studies, improved outcomes were demonstrated in the care of pediatric asthma and patients dealing with sickle cell disease. At least one study found that patients who got help with legal problems also did better at following doctors’ orders when it came to taking their medications. Additional research found that patients report less stress and improved wellbeing, and providers report greater satisfaction with their jobs, in places where legal aid is available to patients.

At Lancaster General Hospital in Pennsylvania, a small pilot study found that addressing patients’ legal issues led to reduced use of the emergency department and reduced costs — a finding touted by the president of the Robert Wood Johnson Foundation in the Journal of the American Medical Association in April.

“In a pilot study of 55 patients, the hospital found that 95 percent of its high-need, high-cost patients had two or more civil legal problems, such as threatened evictions, wrongfully denied disability benefits, or the need for adult guardianship, and that when those problems were addressed both inpatient and emergency department use declined upward of 50 percent, and overall costs, as defined by charges, fell by 45 percent,” wrote Dr. Risa Lavizzo-Mourey.

New Hampshire has yet to undertake a real study of the financial return on investment in medical-legal partnerships, but there is plenty of anecdotal evidence.

Paralegal Vicky Brooks is working with an Arabic-speaking immigrant who was not provided with an interpreter when he applied for Supplemental Security Income for his disabled daughter. When there was a misunderstanding, he was ordered to pay back benefits and became distraught. Sometimes it just takes reminding Social Security of its responsibility to provide proper interpreters, Brooks says. It can go a long way in helping vulnerable populations that have difficulty obtaining advocates.

Steinberg knows the need for legal aid in the health care setting goes beyond the Manchester and Littleton communities, and she says there is interest in expanding the program. As director of NHLA’s senior citizens law project, Steinberg is devoting some of her time to writing grants in hopes of finding broader and more sustainable funding, because the HRSA grants are not expected to permanently support the program. So far, the program has received funding from the NH Bar Foundation, Norwin S. and Elizabeth N. Bean Foundation and Southern Region of the Granite United Way.

Even when patients don’t realize they need legal intervention, legal services can help them become healthier and more productive students and workers – a benefit to the broader community.

“You can make a difference,” says Brooks. “You can help a family for years.”

Sometimes, all it takes is teaching people who are vulnerable about their rights under the law. As Cappio Gebart says, “this is about leveling the playing field.”

Anne Saunders is a freelance writer based in Concord, NH.

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