Voices from the Field

Medical-legal partnerships (MLPs) integrate public interest law services into medical settings to address social determinants of health. PHP supports four legal service organizations operating MLPs in Philadelphia County: Legal Clinic for the Disabled, Philadelphia Legal Assistance, Community Legal Services, and Friends of Farmworkers.

April 2018

In 2012, Philadelphia Health Partnership (PHP) took a bold step to promote health equity by supporting Medical-Legal Partnerships (MLP), a nationally-recognized strategy that integrates public interest law services into medical settings to address social determinants of health. Colleagues in the health care field, particularly physicians, were initially skeptical of welcoming an attorney onto their teams. Six years later, MLPs are recognized as important partners because of their contributions to helping patients, their families, and/or caregivers address legal needs that influence health and well-being.

What is an MLP and how is it different from other types of legal services?

MLP staff train members of the health care team (e.g., doctors, nurses, residents, behavioral health consultants, social workers, etc.) to identify patient needs that are legal in nature and influence positive healthcare outcomes. Patients are then referred to MLP attorneys for legal consultation and representation to address issues such as health insurance access, wrongful benefits determinations, utility shut-offs, landlord/housing disputes, immigration and naturalization concerns, and wage claims. MLP staff educate medical staff on these and other legal issues to deepen their understanding of how non-medical factors impact patients. In addition to directly benefiting patients served, prevalent challenges faced by clients serve as important sources of data and testimony that can inform policy and systems-change efforts.

Since 2012, PHP has invested nearly $600,000 in MLPs in Philadelphia, beginning with an inaugural grant to Legal Clinic for the Disabled’s MLP at St. Christopher’s Hospital for Children. PHP is currently supporting four organizations operating MLPs in Philadelphia:

For the last two years, PHP has partnered with the Independence Foundation to convene a community of practice that brings together MLPs across southeastern Pennsylvania to share learning and work together on relevant policy issues. In 2017, members of the community of practice were instrumental in advocating for the City of Philadelphia to provide improved legal services to tenants facing eviction. This year, members are committed to working together to support eligible participants and providers in navigating Pennsylvania’s shift to mandatory managed care for long-term services and supports through Community HealthChoices.

We invite you to learn more about the power of MLPs by reading the following interview with PHP’s four grantees.

How is your MLP contributing to advancing health equity and addressing social determinants of health?

Legal Clinic for the Disabled (Linda Peyton and Theresa Brabson)

We established one of the first MLPs in Philadelphia at Magee Rehabilitation Center in 1990, when we realized the necessity of taking legal services into low-income communities where people with disabilities live. Given the prevalence of legal issues among low-income people with disabilities and the negative impact of those issues on health, independence, and quality of life, it made sense for us to provide legal services where people receive their healthcare. Today, LCD operates five MLPs across seven sites in Philadelphia: at Magee Rehabilitation Center, St. Christopher’s Hospital for Children, Project HOME’s Stephen Klein Wellness Center, Hahnemann University Hospital’s Cancer Center, and three Family Practice and Counseling Network federally qualified health centers.

We established the MLP at St. Christopher’s Hospital for Children in 2011 with the Ambulatory Pediatrics practice and subsequently expanded to include the Center for Children with Special Health Care Needs and the Asthma Clinic. To date, 46% of families screened at St. Christopher’s have reported at least one unmet need, including eviction and habitability concerns, child custody and support, domestic violence, public benefits, food insecurity, and disability benefits.  This year, with support from PHP, we are expanding our work at St. Christopher’s Hospital to include the Newborn Clinic and Neonatal Intensive Care Step-Down Clinic. Providing services in the newborn clinics will allow us to identify and address social determinants of poor health at the child’s infancy, thereby reducing the compounding effects of unmet needs over time.

Philadelphia Legal Assistance (Anita Santos and Cynthia Haskin)

Our Medical-Legal-Community Partnership work arose from a study conducted by Maggie Eisen, a Stoneleigh Foundation Emerging Leader Fellow, in partnership with the Health Federation of Philadelphia, in 2012. The study found that patients at Health Center #3 had a median of five distinct socio-legal needs, of which the most common were access to insurance; paying for medication; affording utilities; and concerns among families with young children that homes were unsafe or insecure due to second-hand smoke, lead paint, or eviction threats. Consequently, they remained un- or underinsured, accrued medical debt, and became vulnerable to the health effects of homelessness and substandard housing.

We decided to call ourselves the Medical-Legal-Community Partnership (adding a C to the MLP) because we are in a community health center and because we work collaboratively with many different community stakeholders to address our clients’ socio-legal needs. Legal needs of the poor affect not only individual health but also the efficacy of medical and social services, as even the best of care is undermined by unmet legal needs. The MLCP model demonstrates that by placing qualified attorneys within medical care teams, health centers are better able to serve the often complicated, interwoven socio-health needs of their patients. Collaboration between the healthcare and social services communities allows us to provide innovative, effective services that meet the total needs of our clients and over time can contribute to transforming health centers into patient-centered, holistic hubs for care.

Community Legal Services (Debby Freedman, Kristen Dama, and Lydia Gottesfeld)

We have learned in our decades of representing clients that the traditional legal services model, where clients self-identify as having a particular legal problem and access services through intake, is not realistic for all. Many populations face additional obstacles, such as language barriers and geographic isolation, to getting critical legal help. This is overwhelmingly true in the Olney section of Philadelphia where Rising Sun Health Center (RSHC) is located. Over 94% of RSHC’s patients live below the poverty line, and 62% of MLP clients are primarily proficient in a language other than English. The MLP has represented a very linguistically diverse group of patients, including patients who speak Spanish, Haitian Creole, Khmer, and Vietnamese. Many RSHC patients are new immigrants and lack connections to resources in other parts of the city.

Prior to the start of the MLP, RSHC conducted a needs assessment of patients that revealed the many legal issues they face: 47% of respondents needed health insurance for themselves or their families, 27% needed help obtaining income supports, and 22% received utility shut-off notices. Given the high need of RSHC patients and the neighborhood’s distance from the City’s network of legal aid providers, we saw an opportunity to reach clients who might otherwise go without critical legal representation. Over the last year, we have experienced the additional importance of offering accessible legal assistance during a time when many immigrants are fearful of seeking public benefits. Embedding legal services into a community site builds trust with clients and ensures that eligible people receive the care and services they need to stay healthy.

Friends of Farmworkers (Meredith Rapkin)

Through our MLP at Puentes de Salud, we at Friend of Farmworkers (FOF) seek to help people decrease the barriers to services that patients at Puentes frequently face. Puentes is a free clinic that helps the growing Latino immigrant community build long-term prosperity by addressing immediate educational, health, and social service needs. As a member of the Puentes team, FOF provides free legal consultations and representation on a variety of matters including employment issues and immigration issues. The MLP has allowed us to connect with people who normally do not have time to seek legal help or may not even identify a problem they are facing as legal in nature. Through this partnership, we have been able to support and inform immigrant patients who access care at Puentes, engaging them in meaningful conversations about legal rights and possible solutions.

By proactively collaborating in a single location, FOF and Puentes staff have the capacity to identify and serve community members in need of multiple interventions across disciplines, eliminating obstacles that prevent clients and patients from resolving issues that touch on varied needs. The cross-training of staff increases the knowledge of all parties involved, so that legal staff are better able to identify and refer clients in need of medical and behavioral health services, and medical staff are better able to identify red flags that could indicate a need for a legal referral for a patient.

How do you apply the relationships and knowledge gained through your MLP to inform program adaptation and policy changes?

Community Legal Services (Debby Freedman, Kristen Dama, and Lydia Gottesfeld)

As an organization, CLS works to offer immediate relief to those with urgent legal issues, while solving systemic problems at the root through advocacy and community education. We have been fortunate to be part of a data project through George Washington University and the National Center for Medical-Legal Partnerships, which has challenged us to refine our data collection and documentation practices and engage in quality improvement at the MLP. We translate practice into policy change by analyzing case data at regular meetings and engaging with our clients to identify opportunities for large-scale advocacy.

For example, in 2017, the Low-Income Heating Assistance Program (LIHEAP) faced severe funding cuts that would have left thousands without heat during winter. CLS advocated strongly for steady funding for this essential program. We educated and empowered RSHC clients and staff to make their voices heard and also participated in a public forum on the impact of LIHEAP. Our advocacy contributed to increasing funding, keeping the heat on for those in the community who rely on LIHEAP. RSHC staff testified at the state hearing on the LIHEAP program, directly contributing to the positive changes.

In the last year, the MLP was also an important springboard for an advocacy victory around ensuring that immigrants have access to life-saving health care to treat urgent medical conditions. Based on the experiences of numerous RSHC patients who the MLP represented, CLS worked to establish better systems to review and approve health insurance coverage for immigrants with serious health care needs. We are now focusing on supporting effective statewide implementation through continued communication, training, and advocacy.

Friends of Farmworkers (Meredith Rapkin)

Many of our immigrant clients are reluctant to assert their legal rights because they believe that by doing so, they could be at risk of facing collateral consequences related to their immigration status. The community has expressed great relief at having the ability to speak with a lawyer in a trusted setting, and many of the people we talk to are doing so for the first time in their lives.

During the last year, in response to a marked increase in concerns raised by community members, FOF and Puentes joined forces to provide structured education sessions where people could learn about their rights and then have individual consultations to address their own specific situations. We collaborated with Puentes artists, including the student coordinators, to produce a large Know Your Rights poster in Spanish about workers’ rights, which we set up in the waiting area. We also provided workshops for parents and children on emotionally and practically handling the increase in anti-immigrant rhetoric and aggressive immigration enforcement tactics. Finally, we helped Puentes staff create a clinic safety plan as a result of the uptick in hate crimes against immigrants and people of color in order to ensure that staff members and community volunteers are prepared to handle an emergency.

Our willingness to quickly react to emerging needs has strengthened our relationships with the individuals we serve, as well as with allied organizations working to mobilize change. We are also working to evaluate the impact our direct legal services has on individuals’ sense of self-efficacy, through pre- and post- survey questions that gauge a client’s understanding of their rights if an injustice occurs and knowledge of how to access community resources available if an injustice occurs.

Philadelphia Legal Assistance (Anita Santos and Cynthia Haskin)

Through our MLCP, we are working to identify and address systemic issues in partnership with the Philadelphia Department of Public Health, the Pennsylvania Department of Health, and other local MLPs. For example, a number of clients have been incorrectly rejected from medical insurance and public benefits enrollment due to their immigration status. Additionally, many of our clients who are immigrants have reported barriers to care because of language, indicating an underutilization of Language Line and interpretation services. We have also recently seen a number of clients who have received additional medical bills after they become uninsured because they were unaware of the channels through which to appropriately access care, such as networks and referrals. We are working to address these issues through advocacy as well as direct information and follow-up with clients.

Constituent voice and leadership is a critical component of our process of continuous improvement. In addition to conducting and updating needs assessments in our MLP sites, we regularly survey clients, health center staff, and volunteers to solicit feedback about their experiences. The client surveys are overseen by the Philadelphia Department of Public Health Institutional Review Board and include a telephone survey conducted after every client’s case is closed. Moving forward, we are interested in continuing to build our capacity to actively engage residents in the neighborhoods surrounding the health centers where we work and to deepen our work with the community boards at each health center.

Legal Clinic for the Disabled (Linda Peyton and Theresa Brabson)

At St. Christopher’s MLP, we assess our services through ongoing engagement with clients to understand the quality and impact of their experiences, including through pre- and post-representation surveys. We also track the connection between screening, referral, and services to determine whether a family’s total needs are met. With our expansion to the newborn clinics, we are complementing direct client engagement with a longer-term assessment of our impact. We will partner with St. Christopher’s Hospital to study the pool of clients who receive MLP services at birth and compare them to children who received intervention at a later age and those who received no MLP services, with the hope of demonstrating that earlier intervention reduces unmet needs and produces better health outcomes.

In addition to funding our St. Christopher’s expansion, the PHP grant is allowing us to dedicate time to convene all LCD MLP attorneys across our seven sites on a monthly basis to learn from each other’s work and engage in collaborative efforts. Each of our MLPs operates at a different healthcare setting and is at a different stage of development, regarding issues such as provider engagement, screening, and data collection. As we work to expand the capacity of LCD’s MLP sites throughout the City, we are also dedicated to deepening our relationships in the neighborhoods that surround our sites. LCD is unique in offering both on-site services as well as home visits for those who need it, which brings us directly into our clients’ communities. We are interested in increasing our partnerships with community organizations in order to co-host education events about substantive legal issues (e.g., tenant rights), while also identifying issues on which we can work together to advance our collective goals.

Building Capacity for Sustainability

This year, PHP is working closely with all four of our MLP grantees to develop the systems needed to assess the quality and impact of their work over time, which is critical to diversifying their funding sources and building capacity for sustainability. All four MLPs currently receive in-kind contributions of space. LCD and CLS additionally receive co-investment from their respective medical partners: St. Christopher’s Hospital for Children and Public Health Management Corporation.  In other states, MLPs have experimented with integrating financing for legal services into Medicaid payment arrangements. Making the case for financial support – whether from public, private, or philanthropic sources – requires developing effective data and evaluation systems to demonstrate that legal services can contribute to promoting better health outcomes. PHP is committed to partnering closely with our MLP grantees as they build their capacity to make the case for the value of their work. Over the coming year, we look forward to working with diverse partners to raise awareness of the important role that MLPs play in advancing health equity and addressing social determinants of health.