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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. Our patients & their families face many challenges …. Low-wage work with limited job flexibility

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social determinants of health making the case for medical legal partnerships

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

our patients their families face many challenges
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
child poverty in connecticut 2005
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

ct child poverty
CT Child Poverty

Source: 2004 CT Kids Count Data Book, CT Association for Human Services

housing influences on health are well documented
Housing influences on health are well-documented
  • Housing conditions
  • Unaffordable housing
  • Homelessness
  • Housing instability
  • Housing mobility
fair market rents fmr and wages
Fair Market Rents (FMR) and Wages

Source: National Low Income Housing Coalition

the burden of unaffordable housing
The Burden of Unaffordable Housing

Source: National Low Income Housing Coalition

impact of unaffordable utilities for liheap households
Impact of Unaffordable Utilities for LIHEAP Households

Source: National Energy Assistance Directors Association,

2005 National Energy Assistance Survey

utility disconnections for liheap households
Utility Disconnections For LIHEAP Households

Source: National Energy Assistance Directors Association,

2005 National Energy Assistance Survey

health impact of substandard housing conditions
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
health impact of substandard housing conditions1
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.

making ends meet
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

making tough choices food vs basic necessities
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
food insecurity s child health impact
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
food insecurity infection malnutrition cycle
Food Insecurity & Infection Malnutrition Cycle

Impaired

Immune

function

Poor

Child Health

Outcomes

Poor

Nutritional

Status

  • Infection &

Illness

Weight loss &

Poor growth

food insecurity linked to developmental risk
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

child food insecurity food stamps in ct
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

food stamps make a difference
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

child enrollment in husky a 2004
Child Enrollment in Husky A, 2004

Source: 2004 CT Kids Count Data Book, CT Association for Human Services

child uninsurance in ct by poverty status 2003
Child Uninsurance in CT by Poverty Status, 2003

Source: Kids Count, Annie E. Casey Foundation

child uninsurance health consequences
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.
ct immigrant family experience 2002 2004
CT Immigrant Family Experience, 2002-2004

Source: Kids Count Databook, 2004

role of clinicians in uncoupling poverty from poor child health
Role of Clinicians in Uncoupling Poverty from Poor Child Health
  • Modify systems of care
  • Modify methods of practice
  • Ensure connections with safety net programs
public policy matters for low income populations
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.
lawyers the new subspecialty
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
prevalence of unmet legal needs nationally is high
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)

why do this
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 ….”

medical legal partnership project
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
legal access v clinical access
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”
legal advocacy in the clinical setting
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
lawyers and social workers part of the treatment team
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
education and training
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.
mlpp s six questions
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?
recognizing the range of advocacy individual family
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
recognizing the range of advocacy systemic
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
promoting child health through preventive law
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
the hegemony of low expectations the perpetuation of disparities through expectations
The Hegemony of Low Expectations: the Perpetuation of Disparities through “Expectations”
resources
Resources
  • www.kidscounsel.org
  • www.MLPforchildren.org
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