By Michael Booth
Mae Pollock felt her apartment had become the enemy.
At age 68, she thought she was aging well, eating right and exercising, and largely avoiding the aches and complaints of her peers. Until she was interrupted on a trip by a phone call: A fire two floors above her apartment had activated safety sprinkers, and soaked her unit with water.
Restoration crews cut holes in the ceilings and walls of Pollock’s Section 8 subsidized apartment, then set up fans that blew gale-force winds for six days in an attempt to dry the water. Dust and exposed insulation were everywhere, and she suspected mold. She began wheezing, and her providers at Salud Family Health Center‘s Brighton clinic called it asthma.
“I felt like my home was haunted,” said Pollock. Apartment managers refused to find her a cleaner space.
That’s when her Salud providers introduced her to a surprising member of her care team—a lawyer.
Attorney Marc Scanlon, based at Salud’s Commerce City clinic as part of Medical Legal Partnership Colorado, told Pollock the Fair Housing Act was a good tool for getting apartment management’s attention. He convinced managers to find her an apartment in a newly constructed building. And when it turned out some residents were violating the no-smoking rules and aggravating Pollock’s respiratory problems, Scanlon got management to post warnings.
“He was very persistent, and did not stop,” said Pollock, who lives in Brighton. “I think my health would have deteriorated if I had stayed there with no help.”
This Colorado-based medical-legal partnership is part of a collection of such arrangements nationwide, each founded on the belief of many legal experts and health care providers that festering legal troubles compound the health issues of many disadvantaged patients. Supporters say integrating attorneys with physicians, psychologists, dentists and caseworkers improves many patients’ lives and health outcomes.
“A care manager can tell you the address of the homeless shelter—but a lawyer can prevent you from getting evicted. That has a substantial impact on their physical health,” said Tillman Farley, MD, Salud’s executive vice president for medical services.
The partnerships can be invaluable to clients and patients who get crucial assistance amid draining legal battles. Some of the programs have also sought to demonstrate their fiscal value, with studies attempting to prove how much a region’s health care system saved in patient care costs by integrating legal, medical and behavioral assistance.
A medical-legal partnership aimed at helping high-use, high-cost patients in Lancaster, Penn., reduced health care costs in the group by 45 percent after taking on common tangles in housing, benefits and domestic violence cases.
The current Medical Legal Partnership Colorado is the third permutation of the idea. It was once run out of Children’s Hospital Colorado with lawyers from Colorado Legal Services, the primary civil legal-aid nonprofit in the state. When that model couldn’t gain enough financial support, the University of Colorado Law School created a different version of the same idea, called the Colorado Health Equity Project, teaming professors with volunteer attorneys and law students.
The program, which included some seed funding from The Colorado Trust, was effective but limited—with 11 students a year, they could handle only 22 cases over two years, said Executive Director Pia Dean, formerly a partner at the law firm Holland & Hart.
Moreover, Dean said, “to be a really successful partnership, it’s very helpful to be on-site” at the medical clinic. Typical clients might have to take two or three buses to get to the volunteer attorneys, and could be intimidated by sleek downtown legal offices. Salud had always been the most innovative and enthusiastic site in working with the attorneys, Dean said.
The Colorado Department of Health Care Policy and Financing (HCPF) was convinced such partnerships could not only improve the health of Medicaid patients, but potentially lower their overall costs by stabilizing lives and reducing ER visits and hospitalizations. Medical Legal Partnership Colorado combined HCPF funding, private donations and help from Salud, and moved into Salud’s Commerce City clinic.
“The idea is to really be in collaboration with all the providers that make up a clinic—integrated providers,” Dean said.
Farley had long been enticed by the promise of the embedded model. A graduate student had once done a survey of Salud’s patient base, and of 600 patients interviewed, two-thirds had an ongoing legal problem, Farley said.
Of those, half felt it negatively impacted their health, meaning that roughly one-third of Salud’s typical patients had a legal tangle that was likely making them sick. Fully integrating legal, medical and behavioral health is the logical next step, Farley said.
Providers and staff at Salud are taught how to screen patients for legal needs using a tool commonly dubbed I-HELP: Income and benefits; Housing and utilities; Education; Legal status and immigration; Personal and family stability and safety. When a patient indicates a need for legal assistance, a Salud provider can walk them right down the hall for a “warm handoff” to an attorney, just as they might make a handoff to a behavioral health specialist.
One lesson Dean said she was not anticipating from the program is the powerful training available to participating lawyers. Law school courses don’t teach how to avoid re-traumatizing an abuse or torture victim who is seeking legal help with asylum and immigration. Salud’s head of behavioral health offers training to lawyers in how to sensitively prepare clients for hearings.
“It’s changed the way I go about interviewing clients, and it’s made us better lawyers, by far,” Dean said.
Colorado’s medical-legal partnership is committed to measuring its effectiveness, even as it struggles to find long-term funding for the program. Researchers followed a Salud patient cohort of 58 people, who used partnership services from 2015 to 2016. In the group, 72 percent had an income below $30,000 a year, 62 percent spoke Spanish at home, and 52 percent had less than a high school education, said Angela Sauaia, MD, professor of public health and surgery at the University of Colorado Denver’s Anschutz Medical Campus.
Patients were re-interviewed six months after they started utilizing legal services, and reported sharp reductions in the number of days they felt in poor physical or mental health. They also missed fewer work days, Sauaia said.
“We did observe significant improvement in their overall health, and that was surprising to me in such a short period of time,” she said.
Sauaia has also collected some information on cost savings from improved client health, but has not yet reached statistically significant findings. Patients reported fewer ER visits, for example, but researchers did not have direct access to ER data from their medical records.
The interviews do show, however, a reduction in both ER visits and hospital admissions, as well as success in linking the uninsured to public insurance, which in turn increased reimbursement to Salud.
“I have no doubts that this is saving [the clinic] money,” Sauaia said.
As with other integrated care models, though, it can be hard to pinpoint just whose money is being saved, and who might therefore be willing to fund more partnerships.
Farley said HCPF is working on proposals for alternative payment models that integrate legal aid, but in the meantime, state funding has run out. The partnership raised donations through a GoFundMe page, combined with ongoing help from Salud, to try to keep things running until the state’s applications bear fruit.
“We’re getting there,” Farley said. “Just surviving is hard.”