Social Determinants of Health: Making the Case for Medical-Legal Partnerships

1. Social Determinants of Health: Making the Case for Medical-Legal Partnerships Lauren Smith, MD, MPH Department of Pediatrics Boston Medical Center Boston University School of Medicine

2. Our patients & their families face many challenges … • Low-wage work with limited job flexibility • Substantial child and parent uninsurance despite employment • Competing demands for discretionary income • Social programs with complicated requirements & significant penalties for noncompliance • Substantial environmental risks

3. Social Risk Factors & Health

4. Social Threats to Child Health

5. Child Poverty in Connecticut, 2005 • 200,000 (24.1%) CT children are low income • 87,000 (10.4 %) live in poverty • 50,000 (6 %) live in extreme poverty

6. Child Poverty by State

7. CT Child Poverty Source: 2004 CT Kids Count Data Book, CT Association for Human Services

8. Unaffordable and substandard housing threatens child health.

9. Housing influences on health are well-documented • Housing conditions • Unaffordable housing • Homelessness • Housing instability • Housing mobility

10. Fair Market Rents (FMR) and Wages Source: National Low Income Housing Coalition

11. The Burden of Unaffordable Housing Source: National Low Income Housing Coalition

12. Impact of Unaffordable Utilities for LIHEAP Households Source: National Energy Assistance Directors Association, 2005 National Energy Assistance Survey

13. Utility Disconnections For LIHEAP Households Source: National Energy Assistance Directors Association, 2005 National Energy Assistance Survey

14. Rodent and cockroach infestation Water leaks and resultant mold Peeling paint and lead paint Exposed wires and uncovered radiators Insufficient heat or running water Overcrowding Increased asthma Increased lead poisoning Injuries Radiator burns Window falls Fires from improper wiring, lack of smoke detectors, use of space heaters Increased infectious diseases Health Impact of Substandard Housing Conditions

15. Health Impact of Substandard Housing Conditions • Children in families w/ 2 or more hazards were 2.5 times more likely to be in fair/poor health Source: J. Sharfstein, et al, American Journal of Public Health, 2001.

16. Making Ends Meet? • 69% of CT children in low income households spend > 30% of income on housing • Low income families paying > 50% of income for rent spend 30% less on food & 70% less on health care Food insecurity Child Health Impact Unaffordable Housing Household Budget Trade-offs Housing instability ↓ Health care spending

17. Food insecurity & undernutrition threatens child health.

18. Housing Heat Medical expenses Transportation “Rent or eat” Children eligible for but not receiving housing subsidies are 8 times more likely to have stunted growth “Heat or eat” Low-income children show poor growth in the winter Making Tough Choices: Food vs. Basic Necessities

19. Food Insecurity’s Child Health Impact • Even mild-moderate undernutrition  long-term effects • Young children especially vulnerable •  Risk of fair/poor health & hospitalization • Nutrient deficiencies • Learning & development deficits • Emotional & behavioral problems

20. Food Insecurity & Infection Malnutrition Cycle Impaired Immune function Poor Child Health Outcomes Poor Nutritional Status • Infection & Illness Weight loss & Poor growth

21. Food Insecurity Linked to Developmental Risk • Poverty + Food insecurity= Double jeopardy • Food insecurity in kindergarten predicts lower 3rd grade performance • Black and Latino food insecure children at increased risk compared to white peers • Development may be affected even if not underweight Source: , JT Cook, et al, J Nutrition, 2006; Child Sentinel Nutrition Assessment Project. 2005

22. Child Food Insecurity & Food Stamps in CT Food Insecurity • 8.6% (11.4% in US) • 113,000 households Food Stamps • 327,000 eligible people in CT • Participation rate 24% in 5 yrs • 53 % eligible families receive FS • $ 91.11/person – avg monthly benefit Source: USDA, State Food Stamp Participation Rates in 2003, Household Food Security in the US, 2004; Food Research and Action Center

23. Food Stamps Make a Difference! “Food Stamps are good medicine” • Loss or reduction of Food Stamps increases the risk of food insecurity • Food stamps buffer, but don’t eliminate the health effects of food insecurity Source: , JT Cook, et al, J Nutrition, 2006; Child Sentinel Nutrition Assessment Project. 2005

24. Lack of health insurance threatens child health.

25. Child Enrollment in Husky A, 2004 Source: 2004 CT Kids Count Data Book, CT Association for Human Services

26. Child Uninsurance in CT by Poverty Status, 2003 Source: Kids Count, Annie E. Casey Foundation

27. Child Uninsurance: Health Consequences Different patterns of care seeking • Are 3 times more likely to lack a regular source of care. • Are 2 times more likely to be inadequately immunized. • With asthma are 2 times more likely to have had no physician visit in past year. • Are 50% more likely to go without treatment for common health problems.

28. CT Immigrant Family Experience, 2002-2004 Source: Kids Count Databook, 2004

29. Disrupting the Link Between Poverty and Poor Health

30. Role of Clinicians in Uncoupling Poverty from Poor Child Health • Modify systems of care • Modify methods of practice • Ensure connections with safety net programs

31. Public Policy Matters for Low-income Populations • Public policies have been developed to ensure that families can meet their basic needs and those of their children. • Many individuals eligible for benefits do not receive them. • These vulnerable populations suffer preventable health consequences.

32. Disrupting the Link Between Poverty and Poor Health

33. Uncoupling Poverty & Poor Health : DO BOTH!

35. What is Advocacy ?

36. Lawyers - the new subspecialty • Social factors influence development & severity of disease • Many social factors are remediable by enforcement of existing laws and regulations • Inconsistent program implementation results in denials of benefits/services

37. Prevalence of Unmet Legal Needs Nationally is High • EVERY poor family has minimum of FIVE unmet legal needs -- family law, housing, immigration, denial of public benefits, etc • Legal help for poor families is limited – publicly funded legal aid turns away up to 60% of cases due to lack of resources Legal Needs & Civil Justice – A Survey of Americans (American Bar Association 1994)

39. Why do this? “ [We] embrace a comprehensive view of child health and strive for preeminence in helping each child reach for and achieve maximum potential ….”

40. Medical-Legal Partnership Project • Founded April 2000 • 2 main sites - CCMC, St. Francis Hospital • 2003- 2 more sites - Charter Oak Health Center, Community Health Services • Burgdorf/Fleet Health Center & Community pediatricians • Assisted over 2200 families

41. Legal Access v. Clinical Access • Clinical settings have multiple entry points, with capacity for significant prevention through primary care • Legal Services have various entry points and community partnerships, but lack capacity and tradition of “prevention”

42. Legal Advocacy in the Clinical Setting • Provide education and training on advocacy topics and strategies • Provide direct legal assistance to families, enhanced due to partnership with clinician • Engage in systemic advocacy by addressing legal/bureaucratic obstacles adversely affecting family health

43. Lawyers and Social Workers – Part of the Treatment Team • Social workers are knowledgeable about resources and skilled in working with families • Lawyers support and augment work of multidisciplinary treatment team • Lawyers are trained to recognize rights violations and have tools to address illegal denials of benefits & services

45. Education and Training • Advocacy Training • Quarterly didactic resident trainings • Longitudinal elective for PL-2s, PL-3s • Adolescent medicine, Developmental-Behavioral pediatrics rotations • Advocacy tools • MLPP Code Card • “Six questions” • Advocacy Clinical Practice Guidelines • Case consults- provider needs clarification of benefits/service eligibility. Not a question about provider’s legal responsibility or liability.

46. MLPP’s “Six Questions” • Do you Have Enough Food? • Are your housing conditions safe/Is your housing stable? • Do you have enough money in the house to pay for basic necessities (food, clothing, shelter, hygiene items? • Have you had any problems with your HUSKY/medical insurance ( eligibility, denials, rejections, bills, etc) • Is you child being properly educated? • Are there domestic violence issues in your home?

47. Recognizing the Range of Advocacy – Individual/Family • Food Assistance -- Call to welfare agency to help family appeal denial of food stamps • Housing – Letter to landlord addressing child health problems due to conditions • Education – Call to child’s school to discuss child’s learning disability

48. Recognizing the Range of Advocacy -- Systemic • Legislative • MLPP testimony in support of provision of speech, physical, occupational therapy outside traditional home environment • MLPP testimony in support of restoration of continuous eligibility & presumptive eligibility for HUSKY A • Regulatory • Media – Hartford Courant article, Oct 2005

49. Promoting Child Health Through Preventive Law • Combine preventive medicine and “preventive law” • Are a powerful strategy to ensure families’ basic needs are met to improve health

50. The Hegemony of Low Expectations: the Perpetuation of Disparities through “Expectations”