Medical-Legal Partnership in Western North Carolina

The health professions are increasingly recognizing the important ways that “social determinants” influence personal health [1]. Legal aid issues often overlap with medical problems: a chronic condition is exacerbated by an eviction; consumer debt issues lead to a utility shutoff and hospitalization; rent is paid instead of filling the prescription; intimate partner violence causes physical and emotional trauma. Research and practice show that when legal aid attorneys work in collaboration with medical providers the impact is 2-fold: attorneys address poverty and improve health [2].

As a part of the health care team, attorneys address social determinants of health by stopping foreclosures and preventing evictions; improving housing conditions and stopping utility shutoffs; requesting reasonable accommodations and/or modifications in rental housing for people with disabilities; counseling patients on how to work with landlords; applying for expungement of non-violent criminal records that would prevent patients from applying for housing or jobs; connecting with community resources to provide food, rent, or other necessities in emergencies; obtaining domestic violence restraining orders and other legal remedies; and assisting with Medicaid and disability applications. These remedies allow patients to have a place to store medicines, receive home-based therapies, and stay safe from the elements, so that they can focus their resources on their health.

The first medical-legal partnership of this kind in Western North Carolina started in 2006 with Health, Education and Legal Support (HEALS) between Mission Health and Pisgah Legal Services. Since that time, HEALS has been a model of partnership work in Western North Carolina. Pisgah Legal Services (PLS) and Mountain Area Health Education Center (MAHEC) formed a medical-legal partnership in 2017. MAHEC serves a broad cross-section of the population of Buncombe County and is also a safety net health care provider serving patients in Western North Carolina regardless of their ability to pay. Likewise, PLS is a nonprofit law firm providing free legal aid services to low-income clients in Western North Carolina. Through the medical-legal partnership, a PLS attorney is embedded at MAHEC and available onsite to consult with low-income patients and to triage health-harming legal issues. Providers from any of MAHEC's family medicine, OB/GYN, and dental clinics can make referrals. Patients can meet with the attorney before or after they visit their provider by appointment or via telephone call.

One early success story is that of David Smith*. Mr. Smith worked as a laborer in Asheville for 20 years until he began having debilitating pain in his stomach and other health issues. He suddenly found himself chronically ill with no health insurance and no income to pay his bills. His initial application for Social Security disability income was denied. He began receiving notices that the bank would soon foreclose on his home.

Mr. Smith's MAHEC physician made a referral to the PLS attorney. PLS was able to assist Mr. Smith in reapplying for Medicaid and disability income, and within 2 months he was notified that he would receive insurance through Medicaid and a monthly disability payment from the Social Security Administration. PLS also stepped in to stall the foreclosure and begin negotiations with the bank to save Mr. Smith's house. He can now receive the treatment he needs for his illness and focus on his health rather than how he will pay his bills.

The role of the legal aid attorney on the health care team is more than that of another tool in the toolbox. The legal aid attorney is an adviser to the patient and physician on what the law is and whether there is a legal remedy to a health-harming issue, an advocate to speak out for the patient and navigate difficult communication channels with social services providers, and a partner to carry out planning and advocacy that providers do not have time to do, such as Medicaid appeals, requests for reasonable accommodation for people with disabilities, and/or requests for relief from utility shutoffs. MAHEC has a strong commitment to team practice; doctors, nurse practitioners, pharmacists, nutritionists, and behavioral health practitioners work in close collaboration. The value added by legal practitioners has been incalculable. As one faculty member observed: “The legal system is like the medical system-very mystifying to the layperson. Adding legal expertise to medical practice opens doors that many did not know existed.”

Within the health care team at MAHEC, PLS attorneys have attended didactic sessions and clinical team meetings, including presenting on the scope of services, referral processes, and specialty areas of the law impacting the health of MAHEC patients. Having an attorney onsite at MAHEC has been critical to building relationships between PLS and MAHEC providers. From such relationships have come physician champions for the medical-legal partnership and idea-sharing to systematically address the social determinants of health that most impact MAHEC's patients. An example of this collaboration is the development of the StreetCred Program at Pisgah Legal that makes MAHEC patients aware of the option for free tax preparation at PLS by volunteer tax preparers.

PLS attorneys and staff also help both MAHEC and patients by offering ACA Healthcare Navigation appointments onsite so that patients can choose affordable health insurance with the best coverage for their needs on a sliding scale. For example, one patient was referred to the medical-legal partnership by her OB/GYN physician when the factory she had worked at for 29 years was permanently closed. The patient had COBRA insurance coverage for several months but had received notice that it would be ending soon with no opportunity for extension. Upon meeting with the PLS attorney, this patient selected a silver plan with a $0 premium, and she will have health insurance with a $400 deductible and $800 out-of-pocket maximum.

After 6 months of operation, the following components of the PLS-MAHEC partnership have been identified as critical: the onsite presence of the attorney in the clinic for visibility, convenience of referrals, and facilitation of warm handoffs of patients from the providers to the attorney; the assignment of an administrative partner to work with the PLS attorney and guide her through the MAHEC landscape; and the formation of a committee consisting of clinical, administrative, financial, legal, and other staff to help improve data collection, referral processes, marketing, and financial sustainability.

Having a legal aid attorney in the health care practice impacts the Triple Aim of reducing costs while improving health and the patient experience [3]. MAHEC's research team is engaged in planning a study to demonstrate change in health status of those patients who have received legal services.

• ©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.