A. Social and Legal Determinants of Poor Health

Paraphrasing German physician Dr. Rudolf Virchow, Dr. Paul Farmer said, “Medicine, if it is to improve the health of the public, must attend at one and the same time to its biologic and to its social underpinnings. It is paradoxical that, at the very moment when the scientific progress of medicine has reached unprecedented heights, our neglect of the social roots cripples our effectiveness.”^{Reference Farmer and Eisenberg1}

Only 25% of individual health is determined by genetics, medical care, and health behaviors, while 75% of health is determined by social and environmental factors such as income; access to healthcare, healthy food, and housing; education; job stability; and personal safety.² People living in poverty experience adverse health outcomes directly related to socioeconomic status and their environment at a higher rate than higher-income peers.^{Reference Benfer3} Income also plays a role in compliance with medical treatment.⁴ For example, an individual who is unable to pay her electric bill will struggle to maintain good health or treat conditions that require refrigerated medication or electrical-powered medical equipment.

The majority of social conditions contributing to poor health can be traced to unresolved civil legal needs. While one in six Americans has civil legal problems, nearly every low-income individual in the United States has two to three health-harming civil legal needs.⁵ Compounding the issue is the lack of access to legal assistance for low-income individuals.

B. Medical-Legal Partnership (MLP)

The goals of the MLP are accomplished through provision of legal services alongside provision of medical services. For example, a child requiring acute medical treatment for asthma will not recover if the symptoms are a result of mold or infestations in an unmaintained apartment. Over the last decade, MLPs across the United States have doubled, increasing from 82 partnerships serving over 160 hospitals and health centers in 37 states in 2009 to over 300 in 41 states in 2017.⁶ The medical partners include health centers, children's hospitals, Veterans Administration medical centers, safety net hospitals, and community clinics. Health centers represent the fastest growing segment of MLPs. As of 2016, 113 Federally Qualified Health Centers funded by the Health Resources and Services Administration operate MLPs — almost double the number of health centers in 2014.⁷ In 2016 alone, MLPs nationwide assisted over 75,000 patients and resolved legal issues that were impeding their health.⁸

Early MLP studies demonstrate benefits to patients and the healthcare system. For example, when access to an MLP is provided, case studies report that patients with chronic illness have less frequent hospital admissions and patients take prescribed medications more consistently.^{Reference Klein, O'Sullivan and Weintraub9} Surveyed clinicians also have observed the following impacts: improved access to housing and utility needs (82%), reduced stress (79%), improved access to personal and family stability needs (73%), and improved access to education and employment needs (53%).^{Reference Regenstein10} In addition, less money is spent on healthcare services, and healthcare costs are more frequently reimbursed by public and private payers.^{Reference Martin and Teufel11}

C. MLPs and the ACA

It is likely no coincidence that MLPs have come of age in the era of the Affordable Care Act (ACA). The ACA embraces a philosophy of integrated, coordinated, and preventative healthcare, including movement toward a value-based care model that emphasizes population health strategies.

The ACA established accountable care organizations (ACO) with shared savings reimbursement models, incentivizing participating providers to decrease medical costs of their patient population and to improve patient health by addressing social determinants. An MLP can be one component of a successful ACO model, as is the case in Mount Sinai's Medicare Shared Savings Program ACO.^{Reference O'Connor12}

The ACA also incentivized the expansion of MLP programs in non-profit hospitals through its Community Health Needs Assessment (CHNA) requirement, obligating tax-exempt hospitals to analyze the social, economic, environmental, and health challenges in the community, as well as strategies for addressing them.¹³ To maintain their tax exemption, hospitals must assess and address health needs including social determinants of health. Institutional support of MLPs is a compelling method to both identify and address community health needs.

At the same time, tax-exempt, non-profit hospitals are required to use Schedule H of Form 990, their tax return, to evidence the hospital's activities, policies, and “community benefit” justifying their charitable status as tax-exempt entities. A hospital's contribution to an MLP and therefore the community is one such benefit.

In November 2017, CMS issued final rules implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that include “screening for health-harming legal needs” as a recognized improvement activity under Medicare's Merit-based Incentive Payment System (MIPS). Under the final rules, screening patients for health-harming legal needs contributes to physicians' overall MIPS score and may support an increased payment rate.

A. Center for Children's Advocacy MLP Project – Yale New Haven Hospital Pediatric Primary Care Center

Children in poverty are particularly susceptible to social determinants of poor health. Housing instability, food insecurity, lack of health insurance and benefits, among other stressors that are common to poverty, interfere with a child's livelihood and result in poor health outcomes.

Between 2010 and 2014, 3,532 children under the age of five visited an emergency department in New Haven for asthma-related conditions.^{Reference Nepaul16} In 2016, nine percent of children tested in New Haven had lead poisoning and the permanent neurological damage it causes, with higher exposure in neighborhoods with older housing stock.¹⁷ Thirty-five percent of residents in New Haven's low-income neighborhoods report food insecurity.^{Reference Stajduhar and Mollison18}

The MLP Project between Yale New Haven Hospital's (YNHH), including its Pediatric Primary Care Center, and Center for Children's Advocacy, an independent non-profit, is an embedded model in which the on-site attorney is integrated into the treatment team. The attorney is fully-funded by YNHH and located on-site full-time where she is available to accept patient referrals for legal assistance and to consult with providers and hospital staff throughout the day, in both formal and informal settings. In addition, the attorney collaborates with providers to conduct trainings for providers, social service staff, and community organizations about the social and legal issues underlying many health problems affecting children. A YLS student volunteers with the project and assists the supervising attorney with screenings, answering referrals, client representation, and systemic advocacy efforts.

Between 2013 and 2017, YNHH providers referred 1212 patients and families with 1304 distinct legal issues for legal care through this MLP. Patients received brief consultations 76% of the time, in-depth consultations 18%, and full legal representation 6% of the time. The majority of cases involved housing (26%) and education (25%) matters, followed by issues related to utilities (12%), public benefits (6%), family law and immigration (7%), and disability benefits (5%). This MLP also hosts “Keep the Power On” Utility Clinics for families and engages in statewide policy advocacy.

B. Palliative Care MLP – YNHH Smilow Cancer Center

Palliative medicine, a medical sub-specialty focused on relieving the symptoms, pain, and stress of serious illness, is proven to extend survival, improve quality outcomes, decrease death in intensive care settings, and significantly reduce costs.^{Reference McInturff, Harrington and Hallarman19} But, as a 2017 study of palliative care found, social determinants of health affecting dying patients are often overlooked.^{Reference Stajduhar and Mollison20}

For example, even with the assistance of palliative care social workers, patients may encounter challenges securing and maintaining benefits, such as Medicaid, public assistance, Supplemental Security Income or Social Security Disability Income, and housing. In addition, these very ill patients may require legal assistance with issues such as naming an individual to hold power of attorney or medical power of attorney, executing a last will and testament, and planning for guardianship of dependents. In one study, patients reported that medically-related legal needs had a substantial impact on their quality of life.^{Reference Zevon21}

An MLP focused on the palliative care population embraces the same core philosophy as palliative care itself. Providing comfort and reducing stress can improve health, extend lifespan, and allows for a better end of life. On the legal side, getting one's affairs in order and making sure the people in one's life are taken care of, gives patients the peace of mind and comfort that are at the heart of palliative care. Because palliative care teams are inherently interdisciplinary, the culture of collaboration easily translates to MLP work. Social workers, often critical palliative care team members, also play a crucial role in YNHH's MLP.

The Solomon Center and YNNH in 2015 founded the Palliative Care MLP (PMLP) at YNNH Smilow Cancer Center. YNHH physicians, social workers, attorneys, and law students collaborate to provide critical legal services to cancer patients. PMLP cases are supervised by attorneys from New Haven Legal Assistance Association (NHLAA) working closely with pro bono attorneys from two local firms specializing in end of life care. Under their supervision, Yale law students in the PMLP meet with social workers, shadow doctors, and conduct intake interviews at the patient's bedside, in their homes, or shortly before their death.

Given the delicate and stressful nature of the situation, law students and attorneys also undergo sensitivity training at the hospital, facilitated by Smilow's social work team. YNNH social workers and doctors are instrumental in making referrals. Some cases are handled under extreme time pressure, in dire circumstances. Students draft legal documents, meet with families, and execute legal documents. To some, the need for “estate planning” for low-income patients in need of MLP assistance may seem counter-intuitive. However, something as simple as transferring title of a car can be critical — one such PMLP client desperately wanted a will to leave her car to her son because he was living in the car.

Anecdotal evidence from the first few years of operation suggests that the PMLP has reduced patient stress and facilitated better healthcare. Studies of other MLPs have demonstrated that palliative care MLPs can improve the delivery of high-quality medical care,²² and be financially sustainable, with costs recouped by healthcare institutions.^{Reference Rodabaugh23}

C. Transitions MLP – New Haven Transitions Clinic

For the hundreds of thousands of people released from prison each year in the United States, the timeframe immediately following release from prison presents the highest risk of mortality and adverse health outcomes.^{Reference Shavit and Puglisi24} Statistically, 80% of people released from prison have chronic medical, psychiatric, or substance use disorders.^{Reference Shavit25} Recently released prisoners face enormous barriers to reentry as they are more likely to have “lower educational attainment and higher rates of poverty, unemployment, and homelessness than the general population.”²⁶ Their health is often compromised because “managing chronic illness is often a lower priority than finding housing, employment, and food.”²⁷ Risks are exacerbated by policies that restrict access to public benefits, employment, and housing programs.^{Reference Dumont28} These poor health and psychosocial outcomes are also associated with recidivism.^{Reference Kinner29}

New Haven is the site of one of the seventeen Transitions Clinics across eight states and Puerto Rico in the national Transition Clinic network.³⁰ In New Haven, 1,200 individuals are released from incarceration annually, 80-85% with chronic health problems.³¹ Because correctional facilities do not teach individuals how to manage chronic health conditions, the specialized clinic model is critical to patient health. Additionally, formerly incarcerated individuals often lack access to appropriate healthcare, in part due to discriminatory policies that withhold benefits from individuals with felony convictions.^{Reference Maschi and Aday32}

In one study of Transitions Clinic outcomes directed by Wang and colleagues, the “reduction in ED use resulted in an estimated average cost savings of $912 per patient per twelve months.”³³

Transitions Clinic patients face legal and social determinants of poor health at a disproportionate rate. At the time of referral to a Transitions Clinic, 24.6% of patients were homeless at baseline, 89.9% jobless, 20.1% had food insecurity, and 46.1% reported poor health, 85.2% reported chronic physical health conditions, and 52.7% had mental health diagnoses.³⁴ The high incidence of social issues make legal assistance crucial to successful care delivery.

The New Haven Transitions MLP is the first MLP in the Transitions Clinic Network. It operates as a “one-stop shop” so formerly incarcerated individuals can receive medical care, social services assistance, and legal screenings at one location. Yale law students are onsite at the clinic and collaborate with community health workers to identify patients in need of legal or social services. The students provide legal screening, education, brief advice, and referrals to NHLAA for full legal representation, under the supervision of NHLAA attorneys. The most common legal needs include information about food stamps, social security income, disability benefits, and cash assistance, and child support, custody, and visitation issues. Patients in the MLP have started to “regain trust in a legal system which most — prior to their [MLP] interactions … — feel has all but abandoned them. This has been critically important for our patients to reconnect with the community.”³⁵

D. Veterans Legal Services MLP – Veterans Affairs Errera Community Care Center

Forty percent of veterans struggle with a serious mental illness, and eighteen to twenty-two veterans commit suicide daily in the United States.^{Reference Manchanda36} Overall, veterans far more often experience mental health disorders, such as posttraumatic stress disorder (PTSD), traumatic brain injuries, and depression, than civilian counterparts. Challenges facing veterans are compounded by social determinants of health. In 2016, approximately 50,000 U.S. veterans were homeless; many experience housing instability, unemployment, and lack of benefits and healthcare due to discharge status.^{Reference Tsai37} In Connecticut, 57% reported a lifetime history of homelessness.³⁸ Civil legal needs consistently top veterans' self-identified unmet needs in the annual CHALENG survey of veterans.³⁹

In 2009, to address the social and legal barriers to health and ensure self-sufficiency and easy access to legal services, Connecticut Veterans Legal Center (CVLC) collaborated with VA Connecticut's Errera Community Care Center to develop the first veterans MLP in the country. The seamless integration of the level and health facilities gives veterans access to legal services and builds trust between veterans and service providers. A YLS student has worked at the MLP with supervising attorneys since 2015.

According to a recent study reported by CVLC, from June 2014 to January 2016, CVLC assisted 705 patients who presented with legal issues to the MLP. Eleven percent of the cases were criminal in nature and 89% involve civil legal matters — including family matters (22%), public entitlements (13%), housing (26%), bankruptcy/consumer debts (17%), Military benefits, such as discharge upgrades (11%), employment (2%), estate planning (5%), and tax matters (5%).^{Reference Tsai40}

CVLC keeps veterans facing eviction housed an additional 3.5 months on average.⁴¹ Similarly, when a veteran is ineligible for care due to her military discharge status, CVLC seeks a character-of-service determination appealing the initial VA denial. In 2016, CVLC improved obtained free, high-quality lifetime healthcare for 20 veterans.⁴² Addressing systemic issues, the CVLC has generated a discharge upgrade manual to assist other attorneys and advocates, who have supplemented it with specific guidance for discharged veterans diagnosed with PTSD.⁴³ Following the success of the VA MLP, similar models have emerged across the country.

E. HAVEN MLP – HAVEN Free Clinic

The HAVEN Free Clinic is an adult primary care clinic solely for uninsured patients between 18 and 65 residing in New Haven. Since HAVEN opened in 2005, more than 450 patients have received services, across over 4,000 individual visits.⁴⁴ Because being uninsured is an eligibility requirement, the vast majority of patients are immigrants in need of specialized services they cannot easily access. Importantly, undocumented immigrants often avoid interaction with government or legal services organizations that could provide assistance. Thus, the integration of legal services into the clinic setting is essential to the provision of care and access to services.

HAVEN partnered with YLS's health law program and NHLAA to form HAVEN MLP in 2012. Supervised public health, nursing, school of management, law and medical students jointly staff the clinic to treat patients' medical needs and screen them for legal needs. The majority of HAVEN MLP cases stem from immigration issues: asylum, deportation defense, deportation guardianship planning, visa issues, special immigration, and obtaining immigration status for victims of crime. When legal issues cannot be resolved on-site, students provide a referral to NHLAA.

Law students also give presentations to care teams on how to identify legal needs and their potential impacts on health; they provide other services as needed. For instance, as immigration policy morphed under the new presidential administration, YLS students worked with YNHH's general counsel's office to develop “know your rights” materials for both doctors and patients. They presented to care teams about medical records, immigration status, HIPAA, and immigration enforcement.