Unlocking the Power of Medical-Legal Partnerships

Episode Notes

Transcript

Dr. Stan Sonu:

A physician can’t do it all on their own. Just like a lawyer can’t do it all on their own. We need both people to be in a sort of team oriented setting to be able to navigate the complexities of our social system.

Announcer:

Equal access to justice is a core American value. In each episode of Talk Justice and An LSC Podcast, we’ll explore ways to expand access to justice and illustrate why it is important to the legal community, business government, and the General Public Talk. Justice is sponsored by the Leaders Council of the Legal Services Corporation.

Lee Rawles:

Hello and welcome to Talk Justice. I’m Lee Rawles, assistant managing editor at the A B ABA Journal and your host for this episode. Today we’ll be talking about medical legal partnerships. You’ll often hear from people working in legal aid about the value of partnerships that get legal services embedded into communities. Medical-legal partnerships or MLPs are a great service model that benefit both medical and legal professionals as well as patients and the larger health system. There’s lots to dig into. So let’s get started. Joining us today are two guests. Dr. Stan Sonu is the Medical Director of Child Advocacy for Children’s Healthcare of Atlanta. Dr. Sonu is also part of Atlanta Legal AIDS Health Law Partnership. We’re also joined by Rakuya Trice, the Deputy Director of Indiana Legal Services, a nonprofit law firm that provides civil legal services to low income people across the state of Indiana. She is also their Director of Medical-Legal Partnerships and she is an alum of Talk Justice. This is actually your second appearance on Talk Justice Rakuya, thanks so much for coming back.

Rakuya Trice:

Thank you for having me.

Lee Rawles:

So when you were here in 2021, I think that you said you were helping to run 11 MLPs across Indiana. Where are you guys now?

Rakuya Trice:

We still have 11 MLPs across the state, mostly located in central Indiana and in Northern Indiana. We have projects with seven large healthcare partners. Some things have changed since 2021. Our projects look a little different. We’ve added a new primary care MLP with our partner, IU Health, that just began in May this year. And then we are continuing to partner with new partners like Aspire, Indiana, which I think was just beginning when we last spoke with you.

Lee Rawles:

So what kinds of services do these MLPs commonly provide?

Rakuya Trice:

Most frequently we get requests for housing issues like eviction are a fairly common request. We get requests for assistance issues like personal and family stability, so things like minor guardianships for children whose parents are unable to care for them at this time. But we’re also seeing growth in areas like expungements where folks are needing help with that fresh start. They may have had a conviction several decades ago, but it’s a barrier to employment. So it really is a wide range of civil legal issues.

Lee Rawles:

So Dr. Sonu, you’re in Atlanta working with Atlanta Legal Aid on a pediatric MLP, and we’d love to hear more about that. Can you tell us about it?

Dr. Stan Sonu:

Sure. And it’s great to be here. Thank you for this opportunity to share a bit about the work that we do. Our MLP, which is a three part partnership consisting of Children’s Healthcare, of Atlanta, Atlanta Legal Aid, and the Georgia State University College of Law came to be in the year 2004. So last year we were really thrilled to celebrate 20 years of being in existence and the first, I would say five to 10 years of our health law partnership, which we affectionately called help, was really a passion project by three people. Dr. Bob Pano, who is a retired pediatric intensive care unit physician. Sylvia Kaylee, who in addition to being a law professor also had a nursing background and then Steve Gottlieb, who was head of Atlanta Legal Aid for gosh decades. So I’m really happy to actually share their names and give them their kudos because without their passion, we would not have existed for as long as we have.

And I will say back in the late nineties, early two thousands, Dr. Pano, like I mentioned, he’s a PICU physician. He was noticing that all of these children were coming in to the intensive care unit, very, very sick and upstream from many of these conditions that these children were coming into the hospital with were issues that didn’t fall within the conventional bounds of what a hospital or a clinic would address. These problems had a more social nature about them, but nonetheless, they were a running theme among these children who were coming to the hospital. Again, very, very sick to the point of being critically ill. So like any person who is curious and can pick up on patterns, eventually Dr. Bob ask the question like what is going on? And can we as a health system partner with some folks in the community to see if we can get ahead of these problems and go more upstream?

Lee Rawles:

Well, I love that Dr. Bob was thinking about this this way, and I think it’s so meaningful too that you have someone with a nursing background. I love that he was thinking this way, but I bet when you are a doctor and you’re seeing patients, it’s easy to be more narrowed in and just attention to the healthcare needs and not think about things like Rakuya brought up, oh, maybe this whole family is in danger of losing their home or has lost their home. Does it take additional training now for medical professionals to be able to spot, oh, you know what? This is the kind of problem that I can turn to our MLP and ask for help for my patient?

Dr. Stan Sonu:

I think at some level, yes, there should be some additional training, but I don’t think the problem today that we see in terms of a lack of engagement around these issues is one of training. I think if I would reframe it, it’s a lack of intention and kind of coupled along with that intention is you have to have a resource to respond to the intention of whatever service you want to provide. So I don’t want to take too much time in answering this question, but one of the major blind spots that we’ve had in healthcare in the era of modern medicine has been we have sort of chopped up the body into organ systems. We’ve separated the mind from the body and what we do when we address social determinants of health or the vital conditions for health, such as what our health law partnership does, is instead of having a reductive approach, we are attempting to have a more holistic biopsychosocial approach, understanding that these social factors, these social experiences, the lived environment that families exist in matter tremendously to their health and wellbeing over the entire life. Course.

Lee Rawles:

Kuia, Dr. Sonu mentioned that the program he’s involved with has been around for about 20 years, and that’s about the amount of time Indiana Legal Services has been working in this space for. Have you seen an increasing awareness of medical-legal partnerships among healthcare providers over this time?

Rakuya Trice:

We have one of our partners, Eskenazi Health, is doing a lot of the things that Dr. San just mentioned in the space of screening for social drivers of health. We’re really fortunate in Indiana that the healthcare systems that we partner with understand the holistic approach that’s needed to have a positive impact on patient outcomes. And so what we’re seeing over the years is that the healthcare providers and legal professionals are now far more aware of how civil legal issues impact health. So it’s both on the healthcare side and on the legal side, understanding that the work that we do impacts the health of our clients. And so we’re seeing more healthcare systems screening for social drivers of health as part of their patient registration or check-in process. And then we’re hearing about the impact of law on the health of our neighbors throughout the legal community.

Lee Rawles:

Well, we love hearing about measurable successes. Have you been able to compile any data from the MLPs to talk about how well they’re functioning or the difference that they’re able to make in the communities?

Rakuya Trice:

We have have helped clients avoid or recover nearly $1.8 million since January 1st, 2020. We look in terms of evictions as a barrier to helping people obtain safe inhabitable housing in the future. And since 2023, we’ve helped more than 108 people obtain eviction ceilings. And then just looking in terms of what having access to an MLP means for an individual or family who would otherwise have to pay attorney fees, we looked at a very conservative rate for our area of $300 per hour, and we found that we’ve saved our clients more than 14 and a half million dollars in legal fees. The savings, if the patients, the clients had paid them likely would mean that they would’ve gone without things like medication, housing and food in order to get legal help. So we know that having access to these services means that we’re helping our neighbors improve their living situation.

Lee Rawles:

Wow. Well, it’s great to hear those statistics about the kind of impact you’re able to have. I’d love to hear some of the more personal stories. Dr. Sono, could you tell us about an example from your experience of a patient benefiting from an MLP?

Dr. Stan Sonu:

Sure. And this is one of my favorite things to talk about actually, when discussing why a health law partnership or a medical-legal partnership is so valuable to a health system. About two years ago, we came across a child who was followed by her hematologist who’s a blood specialist. And this child had a condition called sickle cell anemia. It’s a condition that children are born with, so it’s inherited. And the long and short of the disease process is that there is a deformity in one of the proteins that is very important to our red blood cells called hemoglobin. And the consequences of this genetic defect that leads to a deformed red blood cell is that red blood cells in the body can take on this sickle shape and basically get stuck in blood vessels, in organs in the brain. This is a disease that can cause problems all over the entire body, and it’s lifelong

Lee Rawles:

And excruciating pain too.

Dr. Stan Sonu:

Right, and I was going to say it’s really characterized by frequent and repeated episodes of pain episodes or pain crises because when these sickled blood cells get stuck in the small capillaries of our joints and various back muscles, leg muscles, even the chest, they clump up and draw and create a lot of inflammation and it leads to excruciating pain. And so it’s well known that early in life, children who have sickle cell anemia are going to be going to the hospital quite frequently and very often they are exposed to very strong pain medicines like opioids at an early age. So we were referred this child because the hematologist had run into a major wall, and what happened was, well, let me back up and say a very promising development in the treatment of sickle cell anemia came about a decade ago when researchers had discovered that if a person gets a bone marrow transplant and receives a bone marrow that’s healthy and doesn’t have sickle cell anemia, obviously, but receives a bone marrow transplant from a healthy donor, that individual could potentially be cured of the disease.

And it turns out that this hematologist discovered that the patient’s sister, older sister, so the child was about 10 around the time when we met her, her sister who was two years older, was a perfect bone marrow match. The hematologist was just so thrilled because it actually isn’t that common to find a perfect bone marrow match. It’s a very extensive process of making sure that the odds of rejection are low. But everything that the hematologist had discovered was reassuring. And when she went to Medicaid to apply to have the bone marrow transplant approved, she received a rejection letter. And this hematologist was not deterred initially. She, she wrote letters, she sent emails. She basically did everything that she could within her power and training to try to get this decision appealed, try to get an appeal and get the decision reversed and just kept hitting wall after wall.

Eventually, a social worker in her clinic said, why don’t you refer this child to the health law partnership, see what they can do? And so that’s when we met the child and family. One of our attorneys, Kathryn Morris was assigned the case, and Kathryn is just an amazing individual altogether, but she’s extremely dedicated. And when she feels inspired and motivated to do right by a family, nothing can stop her. So she found all the right contacts at the Medicaid office, made some phone calls, knew who to reach. Finally got in touch with counsel at the Medicaid office and said, Hey, what’s going on? Why is this child not able to receive her bone marrow transplant? And the long and short of it was that their attorney at the Medicaid office eventually discovered that there was a major typo in the initial packet of information that was sent to their office that indicated the child had a less severe kind of sickle cell than she really did.

And once that record was cleared up or corrected and all the details were cleared up within a month, the Medicaid office approved the bone marrow transplant. A couple months after that, the child then got the bone marrow transplant from her sister, and to this day has been cured. She hasn’t had another pain episode. And the bone marrow transplant was, for all intents and purposes, very successful. So this story, I think is, it’s to me special because it’s not often that we get to say we helped cure sickle cell. I mean, I never imagined in my training I would actually be able to utter that phrase. But what I think this story really highlights is that this physician did everything she could. She wasn’t limited by apathy, but she was very passionate. She went above and beyond what we would typically expect of any physician trying to advocate for these issues on behalf of their patients.

And she just hit a wall. And that wall wasn’t for lack of effort or intention, it was just a training wall. It was a barrier related to her training. And so to be able to proceed in a productive way required the expertise of an attorney who understood Medicaid policy, who knew who to call, who knew what records to ask for, who understood the whole process. And so I think this story really illustrates the importance of that partnership piece, that a physician can’t do it all on their own just like a lawyer can’t do it all on their own, that we need both people to be in a sort of team oriented setting to be able to navigate the complexities of our social system.

Lee Rawles:

As you were telling this story, it really made me think of a relay race, and the doctor had the baton ran as far as she could with it, and she needed to hand off that baton to someone, and there was a hand there waiting to take that baton.

Dr. Stan Sonu:

Yeah, that’s a perfect analogy of this because right, even if the doctor wanted to run the entire race, she just couldn’t. And yeah, I think again, just that the partnership of both stakeholders was necessary to do what was right for this family and child.

Lee Rawles:

Having access to this kind of legal assistance, the ability to partner this way, does that change how you practice medicine?

Dr. Stan Sonu:

Oh, absolutely. I think the thing that jumps out at me is now, because I know I have a team of attorneys who have seen the housing cases have taken on the education cases and understand guardianship policy and understand SSI and how to navigate Medicaid, because I know I have a team that has this expertise, now I have more permission as a physician to think more holistically for my patient and his or her family. I have a more open posture to these more socially centered concerns and issues. Whereas before, if I didn’t have this team, I think I would have the perspective of why bother asking if I don’t have an effective or meaningful resource to offer a family through however they answer. So absolutely, just knowing that that resource exists, it expands my scope, expands my intention to have an awareness of these, again, unmet social needs that require legal intervention.

Lee Rawles:

So Dr. Sonu, your story about curing this child’s sickle cell also makes me think if she’d not received this level of care that the MLP helped her to access, would she have been repeatedly coming back to the hospital over the span of her life? It just seems like solving these health problems rather than letting them linger, would help the healthcare system save money in the long run.

Dr. Stan Sonu:

You’re absolutely right, and I think that the answer to this question should raise a lot of eyebrows among people in leadership positions across health systems or who are making decisions on health policy. The amount of money in health and hospital and clinic utilization avoided for this child alone is, I would say conservatively tens of millions of dollars in the next 20 or 30 years perhaps. And that’s probably a much more conservative estimate than is actually true. If you think about what we’re avoiding, what we are taking off the table for this child, it’s going to be these hospital admissions and presentations to the emergency room that are very expensive, including EMS charges or the ambulance that also can be quite expensive for families or the insurance payers. We’re talking about taking off costs around pain medicines, imaging, blood tests, all of these expenses that are standard of care for when children come in or adults come in with sickle cell but are very expensive. And so we have avoided all of that in her future. And that absolutely translates to, again, tens of millions, perhaps hundreds of millions dollars saved that would actually burden the health system and the insurance payers. So for just one case alone, if we can intervene early, we can save a lot of money.

Lee Rawles:

So Dr. Nu has shared his story of his experience in the Atlanta area, kuia. Have you heard similar stories from your Indiana partners about the impact that medical-legal partnerships have on their work?

Rakuya Trice:

Absolutely. Our partners leadership at our partners have talked with us and talked with other healthcare organizations that were interested in learning more about MLPs and some of the things that they have shared with us and feedback we’ve received is that because of the partnership and because of having an MLP, it has been a savings to their organization. They’ve told us that it has improved patient outcomes. They’ve also told us that the MLP has reduced the time that their staff are spending on matters other than providing health treatment to patients. Earlier you mentioned it being similar to a relay, and I think that’s an amazing way of describing this partnership because all along the way we’re working together to help patients, and it doesn’t just stop when the MLP has close their case. We think of the MLP and our partners think of the MLP as having long-term impacts. So we’re not just helping that individual with their case that day. It doesn’t end once that case is closed. All of us working together and taking that holistic approach, we really do have the ability to have long-term generational impact on our clients and their families. And so being able to work together is what makes our partnership so successful.

Lee Rawles:

Well, and do you have any stories yourself that you can share to talk about the value that these MLPs have had for your clients?

Rakuya Trice:

Yes. One that sticks out to me most recently, I mentioned that ability to have that generational impact. We received a referral to the MLP for a family that was facing eviction right before the start of Indiana’s worst winter season. And they were facing living in a van with their newborn to this eviction. They’d done everything right that we tell people to do. They paid their rent on time. Their landlord just decided that the landlord didn’t want them to live there any longer. And so they were trying to find somewhere else to live. It wasn’t fast enough and an eviction was filed against them in court. They moved out. So there wasn’t a formal eviction, but having just that case on the record really serves as a barrier for anyone who’s looking for housing, especially during a winter season when housing is not as available. With that referral, our MLP attorney Sarah Everett was able to file a motion to seal the eviction in just seven days after that family was referred to the MLP, the judge signed the order, sealing the eviction, and the family was able to find housing before the cold weather set in.

And so in thinking of the impact that that not only had on the parents, but also their newborn child that was able to live in a nice, safe home.

Lee Rawles:

Well, when you think about the ways that that also prevented further encounters with the legal system, what if they had been in a van? What if Child Protective Services decided that wasn’t a safe environment for their child and they lost custody and had to be in family court? And so what a powerful story showing the impact that it had for this family. So Rakuya, any lawyers who are now really intrigued by medical-legal partnerships, do you have to be a full-time legal aid attorney to help with this or are there pro bono opportunities?

Rakuya Trice:

You do not have to be a full-time legal aid attorney to help with the medical-legal partnerships or to assist legal aids across the country. Pro bono lawyers who are interested in volunteering or taking on a case will find that they are very much welcome because the need for legal assistance for outnumbers, the number of legal aid attorneys that are available. Recently, we had an eviction ceiling clinic that was staffed by pro bono attorneys in our area. And having those pro bono attorneys there at the clinic meant that instead of being able to help maybe 10 people that came in that day, we were able to help over a hundred. And so pro bono attorneys are always welcome. I encourage them to reach out to their local legal aid, reach out to their local MLP, and I am sure there weren’t enough cases that are available that need their assistance

Lee Rawles:

To switch gears. We talked about how impactful this can be at preventing future legal problems. The Trump administration has proposed to eliminate the Legal Services Corporation. In light of that, is there anything you’d like to share about the impact that LSC funding has had on Indiana Legal services and your whole state to be able to help people like this family with a newborn?

Rakuya Trice:

I can only speak to the impact that a loss of funding will have on our ability to continue to provide quality legal services that we currently provide to our clients. To give a bit of background, we are currently operating at 10% fewer staff members than we had at the same time in 2023. And that is due to loss of funding and reduction in funding in several of our non LSE funders. LSE is our primary funder. What that reduction has meant is that we’ve been able to help fewer of our neighbors this year with the issues that we know are critical to maintaining their wellbeing. So for us, a loss of LSC funding or even a significant reduction in LSC funding will mean that we will have to reduce our staff, and it will mean that we will have to turn away even more of our fellow Indiana residents and we’ll be unable to help them remain in their homes. We won’t be able to help them have access to employment or to quality housing or to help keep them safe through our work with orders of protection. So it would have a significant impact on our ability to help our neighbors.

Lee Rawles:

And Dr. Sonu, I’d love to hear from you on this. I mean, you’re not a legal professional, but through working with Atlanta Legal Aid, you saw the importance of civil legal services and the difference it can make to people in the community. So how would you describe the importance of preserving that funding, that availability of civil legal services?

Dr. Stan Sonu:

It’s so absolutely necessary to keep this funding going. I came into the field of medicine in the late early two thousands with a kind of broad and undifferentiated, but nonetheless, very firm passion to learn a skill that would help me serve the needy or those in need and to be a part of reducing preventable health disparities. And so to that end, I have thrown myself into research and exploring various interventions from the health system that can help achieve those aims. And I have not come across anything that has worked as well than a medical legal partnership. I think there are a lot of reasons for that. One of which is it speaks to what we were talking about earlier in that we actually need more cross sector partnerships to be able to address these cross-cutting problems that affect people’s health and the health of communities as well.

I have not come across any intervention that has the evidence base, has the logic chain and is daily producing favorable outcomes that are providing much needed services and funds and financial benefits that saves families time and helps some navigate a really complex social system in our country. Again, I haven’t seen anything that has worked as well as an MLP. And so with that perspective, yeah, this idea of scaling back funding to one of the largest and longstanding organizations in our country that has provided funding for civil legal services all across the country seems completely, it is just the wrong. It’s just absolutely going in the wrong direction. It’s going to create more problems. And I don’t mean that in an abstract sense. The ripple effect of cutting back on funding for LSC is going to mean more families are going to be sick and their children are going to be sicker because families will not have access to these legal services that absolutely have an impact on health and the development of children.

Lee Rawles:

Well, thank you so much to Rakuya Trice and Dr. Stan Sonu for joining me today and giving us all a deeper understanding of the value of medical-legal partnerships. And thanks to the listeners for tuning in to this episode of Talk Justice. Be sure to subscribe so you don’t miss an episode.

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