International and Domestic Health Equity and Leadership (IDHEAL) UCLA Emergency Medicine

MEDICAL LEGAL NEEDS
Module 10
Dennis Hsieh, MD, JD

Objectives

1. Define a medical legal community partnership.

2. Understand what lawyers (as opposed to social workers, medical case workers, or health
navigators) can do for patients to address the social determinants of health and thereby
improve their health.

3. Become aware of the available local resources/referrals for patients with legal needs.

4. Be able to connect patients to legal resources when appropriate.

Case

A 45-year-old female with a history of depression, hypertension, diabetes and hyperlipidemia is brought to the emergency department on a psychiatric hold (5150) from the Section 8 housing office. The woman was at the office and was told that she was going to lose her Section 8 voucher. She panicked and asked the housing office for help to prevent losing her voucher because she did not want to be homeless and had been on Section 8 for the last 25 years. Her son is graduating from high school in 2 weeks, and she cannot be homeless during this big event. The housing office told her there was nothing that they could do. The patient then threatened to kill herself by taking all her psychiatric medications. The housing office called the police who then placed her on a psychiatric hold (5150) and brought her to the emergency department. The patient tells you, the ED provider, that she doesn’t want to kill herself, but that she had been at the housing office every day for the last three weeks trying to resolve this issue, but no one would help her, and she simply does not want to be homeless.

Psych sees the patient and tells you that the patient does not need a psychiatrist and drops the hold. Social work tells you that they can give your patient a shelter list, but also mention a new program they just heard about, a medical-legal partnership, that deals with all sorts of problems, including housing and public benefits. They advise the patients to call the local legal aid organization to find out more.

Discussion Questions

1. What factors contributed to this patient ending up in the ED?

2. What is a medical legal partnership?

3. Why would you need a lawyer involved instead of a social worker or a case manager?

4. What are the range of challenges that patients face that legal services providers can assist
with?

Teaching Points

1. Legal issues (i.e. loss of Section 8 voucher/eviction) cause patients to present to the emergency department. The Section 8 program is financed by the U.S. Department of Housing and Urban Development (HUD) to provide rent subsidies in the form of housing assistance payments (HAP) to private landlords on behalf of low-income individuals/families, senior citizens, and persons with disabilities.

2. Legal issues affect health. From the National Center for Medical-Legal Partnership, the role of a medical-legal partnership is described by the following:

"The health care system needs the right workforce to tackle social problems once detected. As a result, patient navigators, social workers, and others have become fixtures on the health care team. However, many complex health-related social problems are entrenched in federal, state, and local policies and laws that require expertise in poverty law and administrative law. Attorneys in general—and poverty lawyers in particular—have an in-depth understanding of relevant policies, laws, and systems, and seek out solutions at the individual and policy levels to a range of health-related social and legal needs. When embedded as specialists in a health care setting, lawyers can directly resolve specific problems for individual patients, while also helping clinical and non-clinical staff navigate system and policy barriers and transform institutional practices. Using legal expertise and services, the health care system can disrupt the cycle of returning people to the unhealthy conditions that would otherwise bring them right back to the clinic or hospital."

3. Legal services are free for those who are low income from some publicly funded organizations.

Practical Questions

1. Who are the local legal services providers locally available and what is their contact information?

2. What legal issues do your local legal services assist with?

3. Are there any medical legal partnerships in your local community?

Recommended Screening Question(s)

The LA County SBDOH Workgroup recommends that not all domains have to be asked – each clinical setting can customize the list to those domains they are have resources available for. The Workgroup recommends always including immigration as part of the list.

1. Would you like legal guidance/help with any of the following issues?
(The list may be modified to fit the clinical setting, however, we recommend always including immigration.)

• Immigration
• Trouble with your job
• Trouble at school
• Unpaid tickets
• Eviction
• Outstanding Warrants
• Clearing your record/expungement
• Child Custody
• Child Support
• Getting an ID/birth certificate
• Public Benefits (CalFresh/Food Stamps, SSI/Social Security, General Relief,
• CalWORKs, Medi-Cal, Medicare, etc.)

• Yes
• No

Paired Reading

Sandel M et al. Medical-Legal Partnerships: Transforming Primary Care by Addressing the Legal Needs of Vulnerable Populations. Health Affairs 2010 29(9): 1697-1705.

Discussion Points from the Reading

1. The role of the medical legal partnership includes legal advice and assistance, health system change, and advocacy. On the individual patient level, providing legal advice to help patient focuses on prevention of legal crisis and their subsequent health consequences. An example of health system improvements that could be implemented by medical legal partnerships would be the creation of clinic-based enrollment into social services such as food stamps. On the large scale, medical-legal partnerships can propose and support laws and regulations that benefit vulnerable populations.

2. Medical-legal partnerships can be a core component of a patient-centered medical home and can assist with many social determinants such as income/insurance, housing, education and employment, legal status and personal/family stability.

Additional Readings

1. Hernandez, D. “Extra Oomph:” Addressing Housing Disparities through Medical Legal Partnership Interventions. Hous Stud. 2016 31(7):871-90.

2. Kenyon C, Sandel M, Silverstein M, Shakir A., Zuckerman, B. Revisiting the Social History for Child Health. Pediatrics 2007; 120;e734-38.

3. Murphy JS, Lawton EM, Sandel M. Legal Care as Part of Health Care: The Benefits of Medical-Legal Partnership. Pediatr Clin N Am 2015; 62(5):1263-71.

4. Zuckerman B., Sandel M., Smith L., Lawton E. Why pediatricians need lawyers to keep children healthy. Pediatrics. 2004 Jul;114(1): 224-8.