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					The Child Health Advocacy Program
  (A Medical-Legal Partnership For Children)




                 Kimberly Emery, J.D.
           Assistant Dean of Pro Bono & Public Interest
              University of Virginia School of Law


               Diane Pappas, M.D., J.D.
            Associate Professor of Clinical Pediatrics
                  Director of Child Advocacy
            University of Virginia Children’s Hospital


               Christianne Queiroz, J.D.
             Legal Aid Justice Center, Charlottesville
     What is a Medical–Legal
          Partnership?
It is a collaboration between lawyers and
health care professionals which is designed
to provide legal advocacy in the clinical
setting to improve health outcomes.
           Goals of the MLPC
• Educate medical staff about programs and laws
  that can impact health.
• Help low-income families access resources to
  improve the health of themselves and their
  families.
• Provide holistic, preventative and cooperative
  client services.
• Encourage creative problem solving to serve
  patient and client needs more effectively through
  interdisciplinary cooperation.
     A Successful Partnership
• Developed at Boston Medical Center
  in 1993
• National network of programs
  created
  – 80 sites currently operational
  – Many more in the planning phase
A Good Idea . . .
Replication of MLPC Programs, 1993-2007
                                   *




   * 6 additional partnership sites in active development
Distribution of MLPCs Across The Country
             In Virginia . . .
• First partnership formed in Charlottesville,
  2004
  – UVA Department of Pediatrics
  – UVA School of Law
  – Legal Aid Justice Center
          Charlottesville CHAP . . .

• CHAP began accepting referrals 10/04
• Volunteer staff and law students on-site at
  the medical center since 2/06
• Full time program attorney hired 1/07; on-
  site several times weekly
Charlottesville CHAP . . .
              In Virginia . . .
• There are 5 MLPC programs now at work!
  –   Charlottesville
  –   Richmond
  –   Lynchburg
  –   Suffolk
  –   INOVA Fairfax (in development)
Essential Components of a Medical-
         Legal Partnership
• Physician Champion
   – Works in the clinical area to be served and acts as the liaison
     between medical and legal system
   – Help navigate healthcare bureaucracy
   – Key to a successful collaboration
• Legal Staff in the clinical setting
• Cross Training
   – Health care providers are trained to identify legal issues that can
     affect child and family health and to make appropriate referrals to
     the program.
   – Legal providers learn how the health care system works and the
     demands that medical professionals struggle to balance.
• Systemic Advocacy
   – Policy and the needs of the patient population.
Why the Medical–Legal Partnership
       Works for Families
• Ongoing contact with their child’s physician – at
  least 10 times during the first two years of life
• Families trust their child’s physician and the
  physician’s office is a safe place.
• Families already often share intimate details with
  their child’s physician about issues that can affect
  their child’s health (marital discord, pending
  divorce, visitation issues, eviction, job loss, school
  problems, housing conditions, etc.).
Why the Medical–Legal Partnership
       Works for Families
• Families are stretched thin trying to provide for basic needs
  (food, housing, medical care, education).
• Families must navigate complex systems (WIC, Medicaid,
  education, TANF, public housing).
• Available legal resources may be unknown or effectually
  inaccessible because of transportation difficulties or
  competing responsibilities in order to provide for the
  family’s subsistence.
• By identifying needs and providing stream-lined access to
  legal services in the clinical setting, problems are
  addressed earlier when positive solutions are more likely
  and less costly, thus improving family health, well-being,
  and stability.
The “System” Families Must
         Navigate
                     Family
                      Law       Child
         Education
                              Protection

     Housing                        Disability


                   FAMILY
   Resources                        Employment


       Benefits                  Healthcare
                Social  Child
               Services Care
Why the Medical-Legal Partnership
     Works for the Physician
• Physicians are busy and see many patients
  every day…
    7:00 a.m. Hospital Rounds
• See hospital patients
• Review labs and tests
• Make care plan for the
  day
• Document in chart
• Talk with parents and
  staff
• Bill for services
8:00 to ? Office Hours
           • 4-6 patients per hour
           • 25-40 patients per day
           • 10-15 minutes per
             visit
           • Evening and weekend
             hours
           • Lunch (0-30 minutes)
              A “Typical” Well Visit
              in 15 minutes or less!
• Health screening questions (car seat use, safe storage of guns, lead
  risks, anemia risks, sleep patterns, eating habits, elimination patterns,
  toilet training, bedwetting, discipline, smoke exposure, family history,
  dental history, school history, fluoride source, and development)
• Complete physical examination of the patient, which may be a
  wriggling infant, a squirming and independent toddler, or a moody
  adolescent who really doesn’t want to be seen today
• “Wrap up” with a good long, maybe 2-3 minute discussion of our
  findings, a treatment plan, any medications or other necessary
  therapies, and a follow-up plan
• Then, it is on to the next patient and a new set of problems to assess
  and address in 15 minutes or less
• And at some point, everything must be charted in the medical record!
  Busy is an understatement.
       In-Between Patient Visits
• Return patient phone calls
• Review all lab results and
  correspondence from
  consultants
• Provide care coordination
• Write referrals
• Write patient letters
• Write prescription refills
• Complete all charts and
  billing sheets
• Oversee nursing triage
  phone calls
By the end of the day . . .
“On Call”
Why the Medical–Legal Partnership
      Works for Legal Aid
• Most parents bring their children to the doctor
  regularly; providing access in the clinical setting
  increases the likelihood that the family will seek
  and obtain needed legal assistance.
• Problems can be identified and addressed before
  they reach “crisis” mode; this allows legal aid to
  be effective and efficient in its allocation of
  limited resources.
       A Typical Program Referral
• A 10 year old otherwise healthy child comes into
  the clinic with a viral illness; during the course of
  the visit, the physician learns:
   – This is a single mother with two children
   – She worked part-time last year and received Medicaid;
     she has no Medicaid now because she works full-time.
   – The mother’s health is now bad, she has missed a lot of
     work, and has no health insurance; she is unsure if she
     is eligible for Medicaid again.
   – She is having difficulty paying the rent and fears losing
     her home.
   – She receives court-ordered child support, but only gets
     paid about 5 months out of 12 each year.
So, How Do You Get Started?
          Talk to people!!
Talk about bringing lawyers into the clinical setting!
Talk about your program with anyone who will listen!
(Especially, clinic managers, social workers, general
counsel’s office, physician colleagues, volunteer services,
development office, potential donors, chief operating
officer, chair of department, etc.
    What (Who) Do You Need?
• A physician champion (critical first step)
• A legal aid attorney/program
• A social worker in the medical setting
  (ideal)
• A paralegal and development staff
  are also very helpful
                  Find a Doctor
• Find out where poor families receive their medical care in
  your community – is it the hospital ER, a federally
  qualified health clinic, a private practice, the health
  department, or elsewhere?
• Arrange a time to talk with physician(s) about your ideas.
  Hospitals require regular physician meetings; find out if
  you can speak briefly at a staff or department meeting to
  share your ideas and seek out partners. Nurses and social
  workers may be very helpful to get you started.
• Keep trying until you find the right match!
               What Do You Need in a
               Physician Champion?
• Someone with commitment and enthusiasm for the
  project (and time!)
• Someone who can connect the medical and legal
  worlds
• Someone who can talk about your program and
  “spread the word,” especially to medical staff and
  colleagues
• Someone who can help you understand and
  surmount the institutional barriers of the medical
  community
        What Do You Need in a
         Physician Champion?
• Someone who can personalize why this program is
  so important to families in need
• Someone who will collaborate on grant proposals
  and funding opportunities to bring the medical
  perspective and impact clearly to your proposals
• Someone who will be there as a “team member” to
  help with program development every step of the
  way
            What Do You Need in a
            Physician Champion?
• Someone who is willing to change when things are
  not working as expected
• Someone who can help you develop effective
  relationships with hospital development staff and
  other potential funders
• Someone who can “pave the way” through the
  hospital maze and trouble shoot when issues arise
            We Have a Team, Now What?

• Work with your team to develop a mechanism for making
  referrals (pager, in person, fax, phone, email) and other
  details of your program
• Have your team meet with key members of the
  hospital/clinic to start working out the details, including
  clinic director, nursing/support staff, social workers,
  general counsel, etc.
• Work out consent and patient confidentiality issues
  (consider working through hospital volunteer services)
• Once the details are worked out, present at a physician
  staff meeting, medical office meeting, or other appropriate
  venue for launching your program
  We Have a Team, Now What?
• The role of the team is to work together to
  make the program work in your setting.
  This requires:
  – regular communication (i.e. lots of emails!)
  – on-going assessment and re-assessment
  – regular planning/strategy sessions
    (monthly lunch works well!)
  – fund-raising (everything goes better with a little
    money!)
   Charlottesville CHAP Program:
            A Case Study
• April 2004: interested persons meet to discuss the
  idea of a CHAP program; team identified
• October 2004: Initial referral system in place
  using fax and volunteers (not in patient care
  areas); “Family Needs Assessment” designed and
  data collected October 2004–January 2005 to
  assess legal needs of clinic patients; 2 team
  members attended Boston’s “MLPC 101”
  conference
• November 2004: Program presented at Pediatric
  Grand Rounds to faculty and staff
      Initial Materials Developed
•   Advocacy Code Card
•   Webpage
•   CHAP Brochure
•   Comprehensive intake form
•   Client satisfaction survey
•   Referral form (Spanish and English)
•   Family Needs Assessment
       CHAP, the First Year . . .

• 88 families referred during the first year
• Most common issues referred:
  – Family Issues (29%)
  – Housing Issues (25%)
  – Problems with Benefits (18%)
      How We Helped Families . . .
• Advice, phone call, or letter
  (23%)
• In-depth legal assistance
  (47%)
• Other (17%)
• Unable to contact (14%)
       Financial Resources: Year 1
• Local community foundation (paralegal support)
  $5,000
• Hospital Auxiliary Committee (CHAP brochures)
  $600
• UVA Law School Communications Office (initial
  brochure design)
• UVA Department of Pediatrics (initial webspace)
• LAJC (paralegal/attorney support, supplies, etc.)
• Volunteers
         CHAP, the Second Year
• Approximately 180 referrals
• Prepared 4 funding proposals
• Worked with hospital volunteer services to get law
  student/staff volunteers access to patient care areas
• Developed CHAP training manual
• Developed pro bono partnership for certain guardianship
  cases
• April 2005: Team member attended 1st annual MLPC
  summit
• Email network of individuals dedicated to promoting
  children’s issues established; legislative alerts circulated
  (SCHIP)
     Financial Resources, Year 2
• Private foundation (attorney salary) $125,000 total paid
  over three years
• Hospital fund (education/travel expenses) $2,200
• UVA Department of Pediatrics (physician salary support
  of 10% FTE, webspace, ½ office and office furniture)
• Endowment from private foundation (program expenses)
  $1,000,000
• LAJC (paralegal/attorney support, supplies, etc.)
• UVA School of Law (faculty salary support)
• Volunteers
           CHAP, the Third Year
• Over 200 families referred
• Full-time program attorney hired
• 6 law student volunteers, 2 medical student volunteers, 1 summer law
  intern
• Initiated pilot site in Richmond; became operational 3/07
• Provided over 20 Advocacy trainings, reaching over 250 health care
  staff
• Participated in 5 community outreach events
• Presented at 6 professional meetings to share the model and move
  forward with development of a statewide network
• Three team members attended the 2 nd annual MLPC summit
• Core site working with Boston MLPC to identify capacity and
  sustainability strategies for MLPC programs (workgroup)
• Continued email network for systemic advocacy (SCHIP)
            CHAP the      3 rd   Year
•   Education     26%
•   Family        22%
•   Housing       17.5%
•   Benefits      13%
•   Health        11%
•   Immigration   5.5%
•   Consumer      2%
•   Other         2%
CHAP, the Third Year
• Referral source:
   –   Newborn nursery   25%
   –   Social worker     21%
   –   Nurse             21%
   –   Attending MD      13%
   –   Clinic             5%
   –   Unknown            6%
   –   Other              3%
   –   Self               3%
        Materials Developed
•   Updated brochure (Spanish and English)
•   Professional display board
•   Tenant’s Rights Presentation
•   Medicaid/FAMIS Presentation
•   New website under development
•   Initial data assessment completed for
    approximately first 300 cases
                 Financial Resources, Year 3
• Private foundation (attorney salary) $125,000 total paid over three
  years
• Boston MLPC grant (attorney salary) $20,000
• Private foundation (operating expenses) $5,000
• Private donor (paralegal support) $10,000
• Honorarium (operating expenses) $500
• Marketing firm (brochure design)
• UVA Department of Pediatrics (physician salary support of 10% FTE,
  webspace, ½ office and office furniture)
• Endowment from private foundation (program expenses) $1,000,000
• LAJC (paralegal/attorney support, supplies, etc.)
• UVA School of Law (faculty salary support)
• Volunteers
  So, What Does a CHAP Attorney Really Do?


• On-site at medical facility and available for
  immediate consultation and referrals
• Trainings for medical professionals
• Community Outreach for potential client families
• Supervises volunteer law and medical students
• Triages case referrals and provides legal services
• … Future goals include systemic advocacy
  initiatives and fund-raising
Challenges!
             Challenge 1: Much of Virginia
                          is Rural
What we have developed in Charlottesville
will not suit every community, but will
have to be adapted to suit smaller
communities with different resources.
Mechanisms to utilize clinics or community
hospitals will have to be developed in order
for this program to spread to more rural
areas of the state.
 Challenge 2: Out-of-Area Referrals
• The 4 teaching hospitals in VA serve large
  geographic areas that do not necessarily overlap
  with local legal aid boundaries.
• Development of a statewide network will facilitate
  ease of referral and access to legal aid services.
• Different legal aid criteria for income eligibility.
• Federally funded program restrictions.
  Challenge 3: Out-of-Subject Referrals
• Medical staff are not necessarily willing and able to sort
  out which cases should be referred and which should not.
• Often, families are referred for one reason, but there are
  significant other issues that can be identified and addressed
  with thorough intake procedures.
• Physicians are very slow to adapt and you don’t want to
  place unnecessary limits that may inadvertently prohibit
  referrals.
• Capacity of local legal aid providers may not be adequate
  for family law, guardianship and certain other case types;
  alternative strategies for addressing these common needs
  will need to be developed.
Challenge 4: Engaging Medical Staff

  • Social workers and nurses are the quickest to
    adapt and recognize the value of CHAP.
  • Physicians and other health care providers are
    slower to adapt. Physicians, in particular, need
    repetition and frequent contact in order to become
    engaged.
  • Finding time and opportunities to engage medical
    staff is very difficult. Often, meeting with small
    groups before the day starts or during lunch may
    be most successful.
        Challenge 5: Funding
• Finding money is always a challenge.
• But, this model is well-established and funders are
  interested!
• Some programs are beginning to document concrete
  financial gains as a result of MLPC involvement.
• Some programs are beginning to document concrete health
  outcomes (that ultimately save money) as a result of
  MLPC involvement.
• Some programs are able to secure funding by targeting
  services to a specific population (i.e. re-entry services for
  those transitioning back from prison , adult cancer and
  HIV patients, asthma patients)
        MLPC Annual Budgets
            (2007 MLPC Survey Data)
< $25k            15%   65% of programs have
                          budgets < $150k.
$25-50k           13%
$50-100k          20%   Programs with budgets <
$100-150k         17%     $100k have no more than
$150-200k         9%      3 funding sources.

$200-250k         6%
                        Programs with budgets >
> 250k            20%     $200k have at least 6
                          funding sources.
    Funding Resources for MLPCs
•   Legal aid (63%)                •   Other corporation (17%)
•   Community foundation (44%)     •   State government (15%)
•   MLPC funding (44%)             •   Local Bar foundation (15%)
•   Family foundation (35%)        •   County government (13%)
•   Individuals (33%)              •   Fellowship (13%)
•   Hospital/health center (28%)   •   Federal government (9%)
•   LSC funding (26%)              •   Other foundation (9%)
•   State Bar foundation (24%)     •   Medical school (4%)
•   Health foundation (22%)        •   Endowment (4%)
•   Law firm (20%)                 •   Fund-raising events (4%)
•   Law school (17%)               •   City government (2%)
    In-Kind Resources for MLPCs
•   Hospital/health center (74%)
•   Law school (35%)
•   Medical school (13%)
•   City government (2%)
Challenge 6: Program Evaluation and
             Outcomes Assessment
• HIPPA
• Legal confidentiality
• Data collection tools
• Lack of statistical support
• IRB approvals for all identifiable patient
  data gathered for study
• Consent
Challenge 7: Collection of Client
             Satisfaction Data
• Family stress
• Change in address
• Loss of telephone access
Challenge 8: The Physician
             Champion
•   Time constraints
•   Health system constraints and barriers
•   Adequate support for program development
•   Relationships take time and nurturing to
    develop
Challenge 9: Re-Defining Legal Work in
             a Preventative Environment
• In the MLPC model, the goal is to address
  social/legal issues before they become more
  complex and more costly to correct.
• Thus, a successful MLPC may do less traditional
  legal activities and focus on many other
  preventative services (advice and information,
  working with agencies to correct problems before
  they become severe, etc.). It may be necessary to
  redefine what will be recognized as legal services.
The Future . . . A Statewide Network
                 of MLPC Programs!
• Connect legal aid offices, the health care system, and law
  schools throughout the Commonwealth to provide services
  to families;
• Develop a statewide database to collect short-term and
  long-term program information, health outcomes data, and
  client satisfaction data;
• Continue to develop long-term funding sources to support
  programs.
• Develop collaborative referral relationships so that families
  are readily and easily served no matter where they live in
  Virginia.
• Develop a statewide systemic advocacy agenda in order to
  seek change and improvement for families in need.
   The Future . . . A Statewide Network of
             MLPC Programs!

• Develop and share training materials
• Develop an annual Virginia MLPC meeting
  where on-going brainstorming and
  improvements can be nurtured
                           The Future . . .




KEY:
       Legal Aid Office, Hospital, and Law School


       Legal Aid Office and Hospital
               We Can Help!
• We are available to help new sites interested in developing
  a medical-legal partnership;
• We have developed materials and will provide training and
  assistance to those interested in developing a program and
  becoming part of the statewide network;
• We have a database under development, to collect basic
  case information, outcomes information, and client
  satisfaction;
• We have a web site under development that can serve as
  the state MLPC website, with links to individual programs
  throughout the state as new programs are developed;
 "UNLESS someone like you
    cares a whole awful lot,
nothing is going to get better.
           It's not."

       Dr. Seuss, The Lorax
       For more information . . .
Kimberly Emery               kac5e@virginia.edu
Diane Pappas                 dep6b@virginia.edu
Christianne Queiroz          Christianne@justice4all.org



See our website at:

http://www.healthsystem.virginia.edu/internet/childadvocacy
                Additional Resources
•   http://www.healthsystem.virginia.edu/Internet/childadvocacy/

•   http://www.mlpforchildren.org/ (Boston program)

•   Kenyon C, Sandel M, Silverstein M, et al. Revisiting the Social History
    for Child Health. Pediatrics. 2007;120:e734-e738.

•   Zuckerman B, Sandel M, Smith L, Lawton E. Why Pediatricians Need
    Lawyers to Keep Children Healthy. Pediatrics. 2004;114(1):224-8, 2004
    Jul.

•   Lawton, E. The Family Advocacy Program: A Medical-Legal
    Collaborative to Promote Child Health and Development. Management
    Information Exchange Journal. Summer 2003

•   Parker S, Greer S, Zuckerman B. Double Jeopardy: The Impact of Poverty
    on Early Child Development. The Pediatric Clinics of North America. 35 (6),
    1988 Dec.
             Additional Resources
• Analysis: An asthma patient’s best friend? United Press International.
  October 25, 2006. upi.com. Susman, Ed.

• Legal services should be a component of standard cancer care.
  Oncology News International. March 2007; 16(3).
  CancerNetwork.com.

• Fact Sheet: Low-income Home Energy Assistance Program. National
  Consumer law Center. Boston: August 2007.


• Fleegler, Eric, et al. Families’ Health Related Social problems and
  Missed Referral Opportunities. Pediatrics. 2007;119:e1332-3134.
             Additional Resources
• Zuckerman B., Lawton E., Morton S. From principle to practice:
  moving from human rights to legal rights to ensure child health. Arch
  Dis Child 2007;91:100-101.

				
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