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 firstname.lastname@example.org Diane Pappas email@example.com 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.