In September 2014, a newly-minted lawyer joined the team of healthcare providers at Rising Sun Health Center, a nurse-led federally qualified health center (FQHC) located in a shopping center in northeast Philadelphia. Rising Sun is one of five FQHCs operated by Public Health Management Corporation (PHMC), a public health institute that, along with its affiliates, runs a range of public health programs, services, research and evaluation, and policy initiatives on the local, regional and national level.
PHMC prides itself on advancing public health innovations that help build healthier communities. Among the PHMC clinic network, 97.5% of patients are at or below 100% of the federal poverty line; 63.5% are experiencing homelessness; 88% of patients are racial and/or ethnic minorities, and 60% are on Medicaid or CHIP. The PHMC health centers go “Beyond Care” to create patient-centered medical homes in which interprofessional teams of care experts—such as behavioral health consultants, social workers, insurance navigators and diabetes educators—respond to the varied and often compounded social and clinical issues contributing to poor health. Thus, operating a medical-legal partnership (MLP), through which legal services and training are integrated into the healthcare setting, fits naturally with PHMC philosophy and patient-centered models of care.
The story of the PHMC MLP started years before that recent law school graduate first entered Rising Sun’s modern, new twelve-exam-room facility. The MLP grew from sparks of interest in a new model of care delivery fostered by months of intra- and inter-organizational strategizing, accelerated through “innovation” funding and ultimately realized through a substantial grant award. Through every phase, champions of the MLP developed an infrastructure to ensure that this social innovation could evolve into a standard aspect of our healthcare institution.
About Medical-Legal Partnership
Legal services have long been integrated into healthcare settings in a variety of forms, but it has been less than a decade since advocates first formally branded the concept, subsequently founding the National Center for Medical-Legal Partnership (NCMLP) in 2006. MLPs integrate legal services into healthcare settings to prevent and resolve health-harming legal issues, such as those related to housing, employment and food insecurity. In other words, MLPs add legal expertise to the range of strategies health providers employ to address the social determinants of health.
Through interdisciplinary provider training to identify and respond appropriately to potential legal issues, delivery of integrated direct legal, social, and health services, improved operational strategies for delivering that care, and system-level changes that advance population health, the MLP framework has the potential to not only provide higher-quality, more comprehensive patient care, but to actually prevent the negative health impact caused by “untreated” legal issues for communities as a whole. Today, there are nearly 300 MLPs, operating in a range of healthcare settings and serving populations in public housing, children, the elderly, chronically ill adults, veterans, Native Americans and more.
Unlike many of the nonclinical services found in patient-centered medical homes, legal services provided within an MLP are not reimbursed through Medicaid, Medicare or private insurance. Thus, funding for MLP has, to date, looked more like legal aid funding—philanthropic dollars provided to nonprofit agencies to provide free legal services—than like a healthcare delivery model. Legal aid funding successfully drove the grassroots adoption of the MLP model for the past decade and continues to be a critical source of funding for individuals that could not otherwise receive civil legal aid and the agencies dedicated to meeting that need. MLPs struggling to identify sustainable sources of funding have been unable to scale to their potential, but MLPs are increasingly developing a business case to support their already-proven social worth.
Sparks of Interest
In 2012, members of PHMC’s strategy division, in partnership with PHMC’s Specialized Health Services (SHS) and the National Nursing Centers Consortium, began to explore the feasibility of creating a MLP within the PHMC Health Network. The exploration followed from conversations with PHMC Network clinicians and administrators and a legal needs assessment conducted at Rising Sun Health Center, all of which indicated that PHMC clinics and their patients could benefit from the MLP model.
Meanwhile, Community Legal Services (CLS), a 501(c)(3) nonprofit organization that has provided free legal services to over one million clients in Philadelphia, was also exploring the idea of medical-legal partnership as a strategy for making services available to high need, sometimes difficult-to-reach communities. Although CLS had previously partnered with health providers on trainings and policy issues, they had not yet taken the step toward true integration with a health center, one in which a lawyer becomes a real member of the healthcare team. As an organization with a strong history of both direct service and systems-level change, CLS made a promising potential legal partner for the nascent MLP.
Fanning the Flame
Although the conversations within and between the two institutions were promising, it was not until the project received an innovation grant from the Public Health Fund that words began to translate into action. The Public Health Fund is a foundation affiliated with PHMC that, in addition to regional grantmaking, dedicates a funding stream to foster innovative ideas within PHMC. Thus in 2013, PHMC staff has funding and institutional support to pursue the idea of developing a MLP at PHMC.
Over the course of the PHF innovation grant, PHMC continued the important work of cultivating administrative, systems and clinical buy-in throughout both organizations. The team worked with CLS and PHMC’s compliance officers to execute a HIPAA- compliant Business Associate Agreement and drafted a Memorandum of Understanding between PHMC and CLS outlining the roles, expectations and responsibilities of each party. They also arranged for the PHMC Health Center Finance Director and Health IT systems director to visit CLS, review the database used by the partner organization, and discuss strategies for sharing information in conformity with legal, technological and organizational policies. By developing MLP “champions” at all levels of the organization, the team sought to create a system that would continue to support the MLP as it evolved.
Through the PHF innovation grant, PHMC also reviewed the literature on MLP return on investment (ROI), and consulted national ROI expert Dr. James Teufel. Dr. Teufel talked with PHMC and CLS about the impact of the cultural shift to accountability and importance of making sound business cases to support MLPs. Thus, early on in the project, advocates for the MLP were learning about the necessity of developing evidence that documents positive return on investment, so that healthcare teams can see how MLPs actually provide more benefit to center operations than cost. Evaluators from PHMC’s Research and Evaluation Group (REG) also attended the workshop to assist REG in becoming adept at MLP evaluations.
Simultaneously, the Independence Foundation—a local philanthropy dedicated to providing services to the underserved—was evaluating a fellowship application of an entrepreneurial law student interesting in becoming the on-site lawyer for the burgeoning MLP. Having funded multiple MLPs in the Philadelphia area, Independence Foundation was already known to be a strong supporter of MLP, but there are many competing interests of similar importance and philanthropic dollars can only go so far. In addition to a strong resume and stand-out interview, the applicant needed to show how this MLP would be sustainable. Between CLS and PHMC, Independence Foundation had compelling reasons to believe that the MLP would be supported by strong infrastructure with potential to produce powerful results for the individuals touched by the MLP and beyond. The Independence Foundation agreed and provided two years of funding for the Rising Sun MLP lawyer.
Sustaining the Fire
The MLP could not exist without the philanthropic support of the Independence Foundation, but it cannot be sustained without the institutional commitment for sustainability. The years spent planning for this MLP, ensuring that databases would capture the relevant information, leveraging resources to provide the on-site lawyer with training, supervision and support, and inspiring administrative champions to commit to the success of this pilot, have allowed the first year of the MLP to produce real results not only for the patients who received legal services but toward building the case for sustainability. The onsite lawyer has taken charge not only of building clinical relationships, managing a growing case load and doing the on-the-ground work of making a successful MLP, she also collects data and works with PHMC administrators to demonstrate the return on investment to the health center. As the MLP enters its second and last year of funding, there is every reason to believe the MLP will keep burning brightly and maybe even spread.