Doctors and Lawyers Working Together Could Be Cure for Many

and Charles McDaniel, Daniel Schaffzin, Dr. Lauren Mutrie, Audrey Dorrough Seamon, Linda Warren Seely and Elizabeth Slagle Todaro.

On this weekday evening, as people across Nashville turn their office lights off and head home, the Shade Tree Clinic in east Nashville turns its lights on to serve the vulnerable. Every Tuesday from 6 to 10:30 p.m., after completing a busy workday, 20 to 25 dedicated students and volunteer professionals occupy the clinic to help underserved residents of Nashville and surrounding areas. With Shannon Jordan, a social worker from Vanderbilt University, and Audrey Seamon, a lawyer from the Legal Aid Society of Middle Tennessee and the Cumberlands (LAS), these individuals come together to orchestrate the medical legal partnership between Legal Aid Society and Shade Tree Clinic (Shade Tree MLP).

At the Shade Tree MLP, there is a ”health” team, not a just a legal team and a medical team. This allows providers, students and patients to see firsthand that health care is more than medicine; it can also be legal aid.

Medical-Legal Partnerships (MLP) are innovative tools for improving the health and well-being of patients and the community by creating better and more comprehensive care teams that can provide legal support in settings where individuals are already receiving health care services. This intervention is particularly well-suited for low-income individuals, children, families and others who may be isolated or not even recognize that the challenges they are experiencing have legal remedies.

In Tennessee, there are already several MLPs in place that address these issues. More are likely on the way, and the Tennessee Bar Association has formed a working group to help bring together health care and legal professionals to explore opportunities and expand the reach of MLPs even more.

The magic of Shade Tree MLP happens in an office at the clinic. A team of volunteer doctors, medical, nursing and law students, a lawyer and a social worker conduct holistic intake of each patient. The intake is then presented to the social worker and lawyer, who work through a series of questions to gain insight into the patient’s real life problems that impact wellness — the social determinants of health. Throughout the process, medical and law students shadow them, engaged with the topics discussed and resources exposed. A product of this process is students’ discovering the significance of being well-rounded in their education on social and economic conditions that influence a patient’s health. As a result, the MLP produces a medical student with a basic understanding of Medicaid expansion, TennCare options, legal remedies for victims of domestic violence and more. Through the experience, students gain tangible experience about legal remedies for social problems that patients face.

A challenge associated with growing and sustaining an MLP in a clinical setting is ensuring that the legal partner has a meaningful physical presence in the clinic, Seamon says. “Without physical presence, the MLP runs the risk of becoming simply a lemonade stand, a referral portal between the medical and legal entities and nothing more.” At Shade Tree Clinic, the MLP’s hours of operation coincide with the clinic’s. Not only is the MLP’s physical presence at the clinic important to the patient for convenience sake, she points out, but the presence is also a reminder to the medical provider that there may be legal solutions to social or economic challenges plaguing a patient’s health.

With the skill and passion under the clinic’s roof on Tuesday evenings — and also Saturday afternoons from noon to 4 p.m. — much good comes out of Shade Tree MLP. “Our future is about measuring that good,” Seamon says. “Shade Tree MLP is working to identify and implement a framework for performance measures. These measures will help the MLP to benchmark its activities and impact on patients’ health and stress levels, to conduct local research, to compare data with other sites, and to set goals for improvements.” Once there is a measurement, this MLP model can be used by other providers and they too will turn their lights on to serve.

Working Together, Getting the Big Picture

More than 60 percent of low-income households in Tennessee experience at least one civil legal need a year,1many are significant issues, and of course, some households are dealing with multiple legal problems. In these situations, many people do not have access to legal support. Additionally, adverse social circumstances continue to have a significant impact on the health of these individuals. The civil legal needs in our state are so great that it takes pursuing a diverse set of options to try and close the justice gap: continued advocacy for increased legal aid funding, a commitment to pro bono programs, quality education and outreach, engaging law students, exploring new ways to utilize technology and supporting clinics and other collaborative projects.

MLP presents a unique opportunity for professionals from both fields to collaborate to improve health and well-being outcomes for at-risk patients. Through collaborative planning, reciprocal training efforts and integration of legal services in the clinical setting, health care providers and legal professionals team up to address key social determinants of health, including unsafe housing, hunger and domestic violence.

The findings of a recent study released by the American Bar Foundation2 further illuminates significant challenges to providing meaningful access to justice: many people do not recognize that some of the most common issues they face might be resolved with legal help. Unfortunately, unless potential clients experience a thorough and insightful screening process, even some of their most pressing and immediately relevant legal issues may never come up in an interaction with a health care provider. Moreover, even in settings where physicians may be inclined to ask about social, economic and legal issues, without a familiar resource or clear system of referrals, they may be deterred from pursuing concerns.

MLPs can provide the necessary training, support, resources and consistent practice to add legal services to address issues before they become legal and, potentially, medical emergencies.

Laying the Groundwork for MLPs

It is crucial to understand that MLPs need very different things from the health care and legal professionals who collaborate on programs. There is still quite a bit of disconnect between responding to legal needs and providing health care. In the absence of a collaborative, each partner identifies different priorities and utilizes a completely different set of tools. However, with education and a re-orientation to building an integrated care team with both health care and legal professionals, these different approaches provide the opportunity for new expertise and solutions.

As health care providers are increasingly focused on the social and economic conditions that may have an adverse impact on the health of their patients, there is a recognition that MLPs may be uniquely suited to address these needs through the hospital or clinic that the patient is already utilizing. (Since many of the patients may not even be aware that they are experiencing a legal issue, it is vital that lawyers are able to meet the clients where they are already receiving services.)

There are several studies and much anecdotal evidence that demonstrate a significant return on investment as a result of MLPs. The examples range from direct benefits to the client such as accessing public assistance or preventing foreclosure or eviction to benefits for the medical partner, such as decreasing costly re-admittance when an underlying issue is resolved.

Other key elements to building successful MLPs include securing support from leaders in both the legal and medical fields. An example that is frequently shared is that this breakthrough support comes when the medical provider experiences first-hand the benefit of having a lawyer on the care team.

Tennessee Is Already a Leader

Medical-Legal Partnerships are not a one-size-fits-all concept, and successful programs must be tailored to meet the particular needs and resources of the community it serves.

There are several MLPs in Tennessee that address issues ranging from establishing conservatorships, preventing foreclosures, resolving landlord/tenant issues, securing access to public benefits or private insurance, addressing domestic violence issues, family law matters and other civil legal concerns. In addition to the critical direct services they provide, all of the programs also engage in outreach and education to medical providers, law and medical students, and volunteers.

Chattanooga: A Lawyer Inside the Hospital for Three Years

The Erlanger Health Law Partnership began in Chattanooga in January 2012 and provides free, direct legal services to patients whose household incomes are at or below 200 percent of the federal poverty level. The program has been welcomed by Erlanger’s medical staff and Legal Aid of East Tennessee (LAET) Staff Attorney Emily Lay is an integral part of the hospital’s care team. Since it began, the program has successfully served hundreds of clients and secured hundreds of thousands of dollars in benefits.

“I think I was mindful of the issues low-income people face, but knowing and feeling (enduring?) the hassles put it in a much different light,” wrote one resident physician after a poverty simulation for hospital staff conducted by the Erlanger Health Law Partnership (eHLP). “The waiting, the delays, the fact that assistance doesn’t appear out of thin air, etc. And if I felt socially or educationally inadequate, I’d be embarrassed to even ask.”

Simulations such as this are designed to place the health care team in the shoes of their indigent patients in order to facilitate their understanding of the daily pressures their patients may be facing. The situations presented are based on real-life patients who have come through eHLP.

eHLP opened its doors on Jan. 3, 2012, as a partnership between LAET and Erlanger Health System, a multi-hospital system located in Chattanooga, affiliated with the University of Tennessee College of Medicine Chattanooga campus. The plan for eHLP was simple: put a Legal Aid lawyer inside the hospital full-time to engage with doctors and hospital staff on a daily basis and be ready to respond to client emergencies at a moment’s notice.

During the past three years, eHLP has addressed more than 250 health-impacting legal issues faced by patients and their families. Erlanger staff has consistently noted that the resolution of these legal issues has allowed the patients to focus on what is most important: becoming well. But, screening for potential legal problems is not necessarily something most doctors or medical staff have been trained how to do. That is why education of the health care team, so they are able to identify legal issues impacting the health of their patients, has been so important. For example, the poverty simulation addressed above took place as a cross-training of Internal Medicine students, faculty, case managers and pastoral care staff. After the simulation, health providers commented they had a better understanding of why low-income patients may not be able to focus on their health: because they are dealing with difficult daily choices and focusing on providing for their families.

Twice a week Erlanger holds multi-disciplinary rounds. Lawyers, physicians, resident physicians, nurses, pharmacists, social workers, case managers and chaplains all gather together to discuss patients with complicated issues requiring a holistic approach. In this way each patient is seen as a whole person with legal, health, social and spiritual needs, resulting in a higher level of care. Additionally, the multi-disciplinary team is able to spot issues that may be appropriate for referral to another specialist or program and are more aware of how each of these fields interact to care for the patient.

The addition of a Legal Aid attorney working full-time inside the hospital has also allowed for systematic legal problems to be identified and streamlined legal service delivery mechanisms to be put in place. For example, parents of children with disabilities may routinely need assistance in obtaining a conservatorship of their children when they turn 18, and patients preparing to undergo surgery may routinely want to talk to a lawyer about advance care plans.

A secondary benefit to serving patients has been a cost reduction seen by the hospital. Emergency room physicians see many patients with frequent, recurring admissions and emergency room visits. Sometimes this is the result of a patient who is in need of a conservator because they are unable to handle their own health care or make their own decisions. As a result of the attorney’s intervention in seeking a conservatorship, someone can be put in place to ensure the patient is receiving an appropriate level of care and is living in an appropriate environment. This results in a drastic reduction of emergency room visits, improvement to the health of the patient and fewer repeat admissions.

Nashville: A Student-Based Clinical Setting

One of the MLPs in Tennessee — the Shade Tree Clinic, described at the beginning of this article — has been operating in Nashville since 2004. It is staffed by medical and nursing students from Vanderbilt University and Meharry Medical College School of Medicine and has been offering legal services in collaboration with LAS since 2012. Vanderbilt law students and social workers help screen patients who then have an opportunity to meet with an attorney right at the clinic.

However, the Shade Tree Clinic is just one MLP that LAS has been involved in. From 2007 to 2011, LAS partnered with the Monroe Carell Jr. Children’s Hospital at Vanderbilt to provide legal services to its pediatric patients and their families. In addition to Shade Tree Clinic, LAS is currently working with United Neighborhood Health Services, which it has been doing since 2011. LAS provides legal services to low-income and homeless clients, as well as training and education to health care professionals to help them be better equipped to identify patients’ potential legal situations. LAS also works with a rural health clinic in Oak Ridge to provide legal assistance to patients there.

Memphis: A Children’s Hospital MLP in Development

Memphis Area Legal Services (MALS) is advancing a partnership with Le Bonheur Children’s Hospital, the University of Memphis Cecil C. Humphreys School of Law and the University of Tennessee College of Medicine that will focus on improving the health of children in Memphis and surrounding communities. This model is based in part on a successful program in Atlanta that brought together similar partners.

Together these groups are working to establish a medical legal partnership – the Memphis Children’s Health Law Directive (Memphis CHiLD) – that will improve the health of children and families in Memphis. Memphis CHiLD’s goal will be to eliminate legal obstacles impeding the ability of the patient, health care team and patient’s loved ones to focus on healing.

In April 2014, Memphis CHiLD welcomed the legal and medical champions from the Atlanta Health Law Partnership (Atlanta HeLP) to Memphis for a two-day series of inspiring community presentations and planning sessions. Atlanta HeLP is an interdisciplinary community collaboration between Atlanta Legal Aid Society, Children’s Healthcare of Atlanta and Georgia State College of Law, now into its second decade of work. Modeled after Atlanta HeLP, it is envisioned that Memphis CHiLD will engage in patient and family advocacy by embedding a full-time MALS staff attorney at Le Bonheur; creating a clinical course at the University of Memphis School of Law in which students will receive essential legal training and provide supervised legal services arising out of the MLP; and building a corporate counsel pro bono referral network to assist in MLP-generated representations. Memphis CHiLD will also provide interdisciplinary educational programs and engage in systemic advocacy focused on the non-medical factors that impact children’s health.

In October 2014, two members of the Memphis CHiLD development team — Professor Daniel Schaffzin from the University of Memphis law school and Dr. Lauren H. Mutrie, MD, MS, assistant professor of Pediatrics, University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Research Center — presented a CLE program about medical legal partnerships as part of a MALS Corporate Counsel event at International Paper. The presentation focused on efforts in Memphis to bring an MLP into existence in Memphis between the partners to Memphis CHiLD.

MLP Opportunities in Tennessee

Given all of the creative and committed work that is already being done in Tennessee, what else is there to do? The existing examples of MLPs in Tennessee provide a wonderful prologue to the potential that exists with developing and supporting collaborations between the medical and legal communities. There are so many models, and one compelling aspect of MLPs is that they can be developed specifically for the particular needs and resources of the community they serve.

The Tennessee Bar Association has already taken the first step in engaging this priority with the formation of the Medical-Legal Partnership Working Group. This group includes individuals from civil legal aid organizations, private attorneys, in-house and corporate counsel, physicians and representatives from Tennessee’s medical and hospital professional associations. This group is exploring opportunities and best practices for supporting and expanding the reach of MLPs in our state. In order for MLPs to be successful, this initiative requires a commitment from both the legal and medical communities, including a willingness to consider new ways of approaching the delivery of both health care and legal services and a readiness to collaborate in unique ways.

Notes

1. Statewide Legal Needs Assessment 2014. Prepared by the University of Tennessee College of Social Work, Office of Research and Public Service, Center for Applied Research and Evaluation, November 2014. (Read more about this report on page 19.)
2. "Accessing Justice in the Contemporary USA: Findings from the Community Needs and Services Study,” by Rebecca Sandefur, American Bar Foundation, August 2014. (View the full report at http://www.abajournal.com/files/sandefur_accessing_justice_in_the_contemporary_usa_aug2014.pdf)
    

Contributors: Emily Lay is a staff attorney for Legal Aid of East Tennessee working with the Erlanger Health Law Partnership. She is a graduate of the University of Tennessee School of Law. Charles McDaniel is an attorney in Chattanooga serving as the director of Legal Aid of East Tennessee’s Pro Bono Project. He is a graduate of the University of North Carolina at Wilmington and the University of Memphis Cecil C. Humphreys School of Law. Lauren H. Mutrie, MD, MS, is assistant professor of pediatrics at the University of Tennessee Health Science Center and Le Bonheur Children’s Hospital, Research Center. Daniel Schaffzin is an assistant professor of law and the director of experiential learning at the University of Memphis Cecil C. Humphreys School of Law. He received his undergraduate and law degrees from Temple University. Audrey Dorrough Seamon is the director of Legal Aid of Middle Tennessee’s Medical-Legal Partnerships. She graduated from Faulkner University School of Law and is licensed in Georgia and Tennessee. Linda Warren Seely serves as the director of pro bono projects and the Campaign for Equal Justice for Memphis Area Legal Services Inc. She is a former president of the Memphis Bar Association and currently serves on the House of Delegates for the Tennessee Bar Association. Elizabeth Slagle Todaro is programs director and access to justice/public education coordinator for the Tennessee Bar Association. She received her undergraduate degree from Emory University and law degree from the City University of New York School of Law.