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Thursday, June 15, 2017
Finding a Cure Through Law
Attorney Alice Rosenthal, Dr. Ada Fenick, and Yale Law graduate Olivia Horton '17 at a Yale clinic where they work together as part of a Medical-Legal Partnership assisting children and families.
It was hard to breathe.
Sarah Grusin ’14 and Alice Rosenthal will never forget the overwhelming presence of a thick, moldy carpet that permeated the air of an apartment building just a few short blocks from Yale New Haven Hospital.
Grusin, then a third-year law student, and Rosenthal, a staff attorney for the Center for Children’s Advocacy, had taken a trip to a nearby public housing apartment complex to help a family whose son suffered from chronic, debilitating asthma. Despite numerous medical treatments, his condition was only getting worse.
The young boy was frequently being rushed to the ER and had missed so much school he was now failing fifth grade. His mother, trying her best to help her son, was unable to work due to the amount of care her son required.
“Within an hour of being with the family in that apartment, neither Sarah or I — who don’t have asthma or any pulmonary problems — could breathe,” recalled Rosenthal.
“It was clear right away that the carpet absolutely had to be removed,” added Grusin. “It wasn’t something the family could fix on their own. The family had tried everything already.”
It was a vicious cycle that seemed like it had no end in sight, until Grusin and Rosenthal —both working together on behalf of the Center for Children’s Advocacy Medical-Legal Partnership at Yale New Haven Hospital — came in and used the law to find a solution that changed the family’s life. Medical-Legal Partnerships integrate health and legal services at a single site of care to help improve patient outcomes. New Haven is home to one of the most diverse and robust MLP programs in the country thanks to a partnership between the Solomon Center for Health Law & Policy at Yale Law School, Yale New Haven Hospital (YNHH), and several area non-profits.
As part of the MLP team, Grusin and Rosenthal wrote to the property management company explaining that asthma is a disability that requires an accommodation under the law. It was backed by a letter from the boy’s doctor, Ada Fenick, describing the severity of his condition. Not long after, the carpet was gone.
With that change, the boy’s asthma improved significantly, enabling him to resume a normal life. Through the MLP, Grusin and Rosenthal were even able to get the boy special education resources to address his learning disability and helped his mother apply for supplemental social security benefits. Soon after the boy began feeling better, his mother was able to go back to work full time.
It was a prime example of the dramatic impact that can be made when doctors and lawyers team up to examine the social determinants of health, and look to find remedies that sometimes don’t involve medicine at all.
“The biggest benefit to the families that are referred to the MLP is the ability to understand their legal rights,” explained Rosenthal. “Many families do not know the rights they have. The MLP educates and empowers them to learn their rights and advocate for themselves.”
Dr. Fenick, who treats pediatric patients at the Primary Care Center at YNHH, said having an onsite lawyer available to help patients at no charge has dramatically changed the way things work. “Having someone on site means they can have access to someone right away,” said Fenick. “That immediate face-to-face contact is critical.”
‘THE MOST DIVERSE MLP PROGRAM IN THE COUNTRY’
The MLP model is a relatively new trend in health care that has quickly taken hold in institutions around the country. Today, more than 294 health care institutions have created MLPs in 41 states, according to the National Center for Medical-Legal Partnerships (NCMLP). It is estimated by the NCMLP that one in six people in the U.S. require legal care in order to be healthy. This means that an individual’s health is determined not just by genetics, medical care, and personal choices — but a range of social and economic factors such as income, access to health care, access to healthy food, quality housing, quality education, job stability, and personal safety.
“Health is determined by, among many other things, the conditions in which you live, the stresses on your family, the number of days off you have to go see your doctor when you are sick, and your ability to see a doctor in the first place,” explained Professor Abbe R. Gluck ’00, Faculty Director of the Solomon Center for Health Law & Policy at Yale Law School who has led the charge to launch and support these programs. “And so there is a role for lawyers to play alongside doctors.”
The City of New Haven in particular has a thriving network of MLP programs that help children, veterans, undocumented immigrants, prisoners reentering society, and people who are receiving palliative care. These programs are each staffed with an attorney from local non-profits and Yale Law School student volunteers. Together, they address important legal needs like access to government programs, housing, custody, and a range of other issues.
“When we started this, very few people around here had actually heard of an MLP,” said Gluck. “Now it’s become an extremely hot trend across the nation, this idea that there are social determinants of health, and when it comes to law student involvement, Yale Law School is leading the way.”
It all began in 2012 when Grusin reached out to Gluck, a health law expert then recently hired to the Yale faculty from Columbia Law School, who was familiar with and enthusiastic about the concept.
With Gluck’s support, Grusin worked to start the first MLP at the HAVEN Free Clinic, which is operated by Yale medical students to provide medical care to underserved or undocumented patients. Gluck and Grusin created a partnership between what was then Yale’s newly formed health law program — now known as the Solomon Center — the HAVEN Free Clinic, and the New Haven Legal Assistance Association to oversee the legal work.
Alexis Smith, Executive Director of New Haven Legal Assistance, said her organization provides direct legal assistance and representation to patients to ensure they can obtain safe housing, access to health care, and appropriate education services.
“The MLPs allow individuals to address their health issue and legal matters simultaneously,” said Smith. “In addition to our individual representation, we also identify systemic issues impacting this client population.”
At HAVEN, a bulk of the cases stem from immigration issues, including helping patients with asylum cases, deportation defense, visa issues, special immigrant juvenile cases, and obtaining immigration status for victims of crime.
From the first pilot program at HAVEN, the idea quickly took off with four other programs opening their doors or partnering their existing programs to engage with Law Students in the last five years. These programs now include the Center for Children’s Advocacy MLP, the Palliative Care MLP, the Transitions MLP, and the Veterans MLP.
In 2013, talks began about forming an MLP at Yale New Haven Hospital (YNHH) through a partnership with the Center for Children’s Advocacy (CCA). Professor Gluck and Grusin got involved to see how the Law School could bring their successful pilot program at the HAVEN Clinic into YNNH to allow law students to work with CCA to focus on issues of childhood poverty and access to services.
“After the HAVEN pilot, we realized this model was something we could handle and it was producing really good work so we wanted to open it to more students,” recalled Gluck, who worked with the General Counsel’s Office at YNHH to establish a relationship and iron out the legal parameters necessary to set it up. “CCA, like New Haven Legal Assistance, has a stellar reputation and has been a terrific partner for the program, as have our wonderful partners at YNNH,” she said.
William Aseltyne, Senior Vice President and General Counsel at YNNH, said the hospital was enthusiastic about the idea and grateful to have the support of the Law School from the start.
“We were not the first to have an MLP program, but my commitment was that we would be second to none in our execution,” said Aseltyne.
Aseltyne noted that adding a lawyer to the clinical setting not only helps patients, but provides huge benefits to the medical staff.
“Alice is embedded with the caregivers and now I think they probably can’t imagine life without her,” said Aseltyne. “We know that what we do here is only part of the healing process. There are socioeconomic obstacles to health care, both getting access to and then follow up from health care. We have social workers and they are a key part of our team, but sometimes they come upon an issue that requires a lawyer.”
Rosenthal supervises students as they engage in both direct client services—working with physicians in the clinic to identify patient-specific and systemic issues, as well as policy research and advocacy.
“Before the MLP, many medical providers were hesitant to screen and identify for social determinants of health,” said Rosenthal. “But now they feel comfortable screening for these issues because they know there is a resource readily available. The MLP works closely with the social workers in the hospital connecting families with appropriate services.”
With the success of the Center for Children’s Advocacy MLP came two more programs at YNHH, including The Transitions MLP serving prisoners reentering society and the Palliative Care MLP, aiding patients dealing with serious and life-threatening illnesses.
The Transitions MLP is a partnership with NHLAA and the clinic in the adult unit of the YNHH Primary Care Center (PCC) that serves those returning home from prison. While there are many Transitions medical clinics across the country, Transitions in New Haven is the only one with a legal component or MLP thanks to student interest in working with the doctors to create it.
“What has really been great about the Transitions MLP is it has allowed us to work with a population who we did not necessarily serve on a regular basis,” said Smith. “We handled some cases on behalf of people with criminal records, but now it has become a regular part of our work.”
Dr. Emily Wang, co-founder of the clinic, said a number of their patients have worked with Yale Law School students to apply for benefits, obtain disability payments, and deal with child support, custody, and visitation.
“This leads to less stress in the long run, which I suspect leads to improved health,” said Wang. “We have also seen that our patients start to regain trust in a legal system which most — prior to their interactions with the clinic — feel has all but abandoned them. This has been critically important for our patients to reconnect with the community.”
Smith agreed that by alleviating some stress involved with reentering society from prison, the outcomes for the patient are better on all fronts.
“So many of these clients face critical health situations, but neglect their health care because they endure such stressors as finding employment or securing housing,” Smith explained. “The MLPs allow individuals to address their health issue and legal matter simultaneously. In addition to our individual representation, we also identify systemic issues impacting this client population.”
The Palliative Care MLP is the newest MLP in New Haven. Established by Gluck and students from the Solomon Center, the Palliative Care program provides civil legal services to palliative care and cancer patients at the Smilow Cancer Hospital at YNNH. The MLP receives legal support from NHLAA and pro bono lawyers from Czepiga Daly Pope LLC, a law firm that handles estate-planning matters. Students in the Palliative Care MLP conduct intake interviews with clients and draft desired documents, such as wills, power-of-attorney agreements, and advanced health care directives. Depending on patients’ needs, students may also work on ancillary issues such as real-estate transactions or guardianship issues. Much of the work occurs in the hospital, under the extraordinarily difficult circumstances at the end of life. All students receive sensitivity training before beginning this work.
Gluck said she had a particular interest in the Palliative Care MLP after attending a conference on the topic.
“Palliative medical care and the idea of this type of MLP embrace the same core philosophy — making someone comfortable and reducing stress can improve health, extend lifespan, and allows for a better end of life,” explained Gluck. “On the legal side, the idea that you are getting your affairs in order and making sure the people in your life are taken care of, gives patients the peace of mind and comfort that are at the heart of the whole concept of palliative care.”
Hillary Vedvig ’17 volunteered to work at the Palliative Care MLP after seeing her mom struggle with legal paperwork after losing her great-grandfather.
“Because of this personal experience, I wanted to be of service to people who are facing the toughest situation imaginable, but still have legal hurdles to overcome,” said Vedvig. “These are literally matters of life and death and I feel honored and humbled to play a small role in facilitating our clients' wishes.”
The Veterans MLP is another program in New Haven that operates through a partnership between the Connecticut Veterans Legal Center (CVLC) and VA Connecticut’s Errera Community Care Center (ECCC). While it began in 2009, in recent years, students began to work directly with the attorneys at CVLC, including Margaret Middleton, CVLC's Executive Director and one of the clinical lecturers for the Veterans Legal Services Clinic. The program provides direct client services to help veterans deal with mental health and substance abuse and find ways to connect them to financial, employment, and housing resources. The group also works on policy research and advocacy.
“With VA support, we are there to make sure that legal issues aren’t the barrier to our clients’ success,” said Middleton. “I think that Solomon Center’s direction for the students is really going to help create a generation of people who are tuned into the special values that this MLP model offers.”
Grusin, who now works for a civil rights law firm in Chicago, said that she cannot believe how quickly the MLP program has grown in the years since she graduated.
“It was really exciting to see it take off,” said Grusin. “I think a lot of it is due to Professor Gluck. To have that sort of institutional support was critical.”
Gluck, in turn, gave the credit for the program’s launch to Grusin, and said she is also amazed with the incredible progress of the growing program and the positive difference it makes in peoples’ lives.
“The program has been going on now for fewer than 5 years and every year we make enormous strides,” said Gluck. “We went from having 1 MLP to 5 and we have an MLP class at the Law School, which includes a scholarship component. We had a major MLP academic conference this year. To my knowledge there is no Law School in the nation that has anything close to the kind of program that we have.”
As the Medical-Legal Partnerships have taken hold in New Haven, those working on the front lines said they have seen strong and clear benefits in every patient that they work with.
“Any time we can provide holistic, wrap-around services to our clients the better served they will be,” said Smith. “Being able to communicate and share information with other providers involved in our clients’ lives is critical in providing quality representation. MLPs are a wonderful marriage of two critical services for people — health care and legal advocacy.”
Rosenthal said in pediatrics especially, taking some of the burden off parents dealing with their children’s health issues has been incredibly beneficial.
“We have found that these interventions reduce the overall family stress which can have a long-lasting effect on children,” said Rosenthal. “The goal is that by identifying these issues early and providing appropriate interventions, we are able to prevent poor health outcomes later.”
Fenick, who has treated many patients like the young boy with asthma, said now when she hears patients answer certain trigger questions, she can provide immediate help instead of offering a phone number to a legal clinic.
“There are a million things that we couldn’t do before we had a lawyer here that now we can do,” explained Fenick.
For students working on these issues for the first time, the training has been eye opening and incredibly valuable.
“I am so grateful for the chance to do this work as a law student,” said Olivia Horton ’17, who worked closely this year with Rosenthal at the Center for Children’s Advocacy MLP. “Not only am I learning so much about administrative procedures and a diverse array of laws, but because I hope to be a legal aid attorney working with families, this work is directly relevant to my future career.”
Horton will work in the welfare unit at the Greater Boston Legal Services after graduation through a fellowship funded by the Gruber Program in Global Justice and Women’s Rights at Yale Law School.
“The popularity of MLPs springs from the recognition that legal problems can have a severe impact on health and so legal solutions should be integrated into holistic medical treatment,” said Horton. “I also think there is immense value to having on-site legal services provision, meeting clients in logical and convenient places.”
While there is overwhelming anecdotal evidence of the clear benefits of Medical-Legal Partnerships, the challenge has been measuring the quantitative benefits of MLPs over time.
“There have been small studies, but the impact has been hard to measure, especially when it comes to isolating the particular impact of the legal component of the MLP,” explained Gluck. “MLPs are all the rage — this idea of having holistic, integrated health care — but it's essential to start building the proof of its effect. That's an important role for academics here.”
That is why in addition to supporting and building upon the network of MLPs in New Haven, the Solomon Center is also working to produce a body of research on the topic.
In March, the Solomon Center hosted a Medical-Legal Partnership Symposium titled “Building an Academic Agenda to Enhance Practice.” The event was attended by national experts as well as representatives from the individual New Haven MLPs. The symposium had a particular focus on MLP interactions with health policy, meeting the needs of marginalized communities, and measuring the impacts of legal services on health. Additionally, the symposium presented an opportunity to grapple with the role of MLPs given the uncertain future of the Affordable Care Act.
“Medical-Legal Partnerships have a front row seat to the impact of laws on people’s health and well-being and can be an important voice for justice,” said Tamar Ezer, Executive Director of the Solomon Center. “The meeting highlighted the need for MLPs to connect service delivery with broader advocacy by integrating documentation and data collection in their work, partnering with community groups, conducting know your rights trainings, and mobilizing frontline health workers and the health establishment.”
As a follow up to the symposium, the Yale Journal of Health Policy, Law and Ethics is dedicating a special issue to MLPs in the summer of 2017. The Solomon Center plans to draw on the symposium for a book developing various aspects of the MLP field.
“The Solomon Center will continue to serve as a hub for research, practice, and scholarship on Medical-Legal Partnerships,” added Ezer.
For Professor Gluck, the hope is that with enough research and practical experience, this innovative model merging health and law will continue to grow and serve more people not only here in New Haven, but around the country, and that it will also inform health policy more broadly.
“I hope that we can start putting out quality academic research on the benefits that MLPs bring to the patients, the health care system, and the community as a whole,” said Gluck.
“The MLP not only brings needed medical and legal services to the community, but it helps to create community,” she said. “We have patients who never trusted lawyers, who would never seek out legal help from which they could benefit, but who come to the medical setting and meet lawyers who become their advocates. That work helps build community, while improving health care. The fact that we here at Yale can play even a small role in that makes us all very proud.”