LegalHealth, a division of the New York Legal Assistance Group, has weekly, onsite legal clinics at 16 teaching hospitals, community hospitals or health clinics, and trains physicians and social workers at those sites.10
LegalHealth serves over 3,500 patients annually, operating legal clinics within internal medicine, geriatrics, oncology, palliative care, family medicine, pediatrics, emergency medicine and social work departments.11
Core trainings are listed in Table .
Pre- and post-survey data evaluating LegalHealth training curricula were collected from three hospitals at which 143 residents completed pre-surveys and 48 residents completed post-surveys (33% response rate). The data revealed changes in attitude about the responsibility of the physician to help patients find free legal services (21% to 52%) and changes in behavior in referring patients to legal services (15% to 54%), in assisting patients with obtaining government benefits (45% to 54%) or obtaining appropriate housing (24% to 37%). Changes in knowledge regarding completion of forms for patients seeking government benefits increased (42% to 62%).
Legal Assistance to Medical Patients (LAMP)
The Legal Assistance to Medical Patients (LAMP) program is a collaboration between Legal Services of New Jersey and Newark Beth Israel Medical Center (NBIMC) medical and pediatric residency programs. In its first year, the LAMP program received 175 referrals, leading to 100 active cases, the majority from internal medicine. The most common issues were disability-related income supports, Medicaid and other public benefits, housing, family law, immigration and guardianship. Approximately 20 teaching sessions were conducted during the year on topics similar to those developed by LegalHealth (see table).
During development of the LAMP program, 114 residents responded to a survey regarding their knowledge of and attitudes about legal issues among their patients. While 57% felt it was likely that “free access to an attorney can help patients” in their practice, only 33% felt “comfortable raising and discussing legal issues” with them. Follow-up survey data are not yet available, but referrals from residents have steadily increased over the year, and many residents commented on feeling relief knowing that they have this resource available for their patients.
MLP | Boston
Medical-Legal Partnership | Boston12
is the founding site of the National MLP Network. It serves more than 1,500 patients annually at Boston Medical Center (BMC) and six community health centers, and teaches residents, students and health care providers in internal medicine, geriatrics, oncology, infectious disease, family medicine and pediatrics (Table ). Three examples of innovative curricula developed by MLP | Boston are described below.
Leadership in Advocacy Block (LAB)
Piloted during the 2008–09 academic year, the Leadership in Advocacy Block (LAB) is a 4-week course required of Boston University Primary Care Training (PCT) Program interns in Internal Medicine. Beginning in 2009–10, LAB also will be offered to Boston University School of Medicine fourth year students and all PCT medical residents.
The LAB has four components:
- Clinical experiences with vulnerable populations, such as those who are homeless, transgender and undergoing methadone treatment;
- Didactic sessions focused on the legislative process, media advocacy and physicians’ role in advocacy at the individual and systemic levels;
- Community exposures such as tours of homeless shelters, urban neighborhoods, the state house and housing court;
- Project work to address a socially caused health disparity of their choice, such as methadone treatment in prison, access to alternative medicine and the role of physicians in palliative care.
The five interns gave the rotation 5 out of 5 points, with more formal evaluation occuring over the next year. Qualitative feedback included “I feel much more encouraged in my ability as an MD to make changes.” The residency director now views this as “an essential component of internal medicine training” and is investing in further in-depth evaluation.
Advocacy Boot Camps
On a quarterly basis, MLP | Boston offers Advocacy Boot Camp (ABC), a 3-h advocacy training session for physicians and allied health providers. CME credits, including risk management, and social worker credits are offered. Topics reflect all I-HELPSM areas.
In 2008, 76 (84%) of 90 participants completed evaluations. Sixty-seven of 76 (89%) indicated that they would make changes in their practice after attending the session. One example is the training on custody, paternity, birth certificates and domestic violence; all 29 people attending returned evaluations. Twenty-four of 27 (83%) reported they planned to make changes to their practice after training. Twenty-eight (97%) participants reported they could “screen” for two unmet basic needs after training.
During resident orientation at the Boston Combined Residency in Pediatrics (BCRP), MLP | Boston facilitates a 2-h Poverty Simulation for 35 interns, and this will be conducted with internal medicine in May 2010. The Poverty Simulation was developed by the Missouri Association for Community Action to educate about the day-to-day realities of poverty.13
During four 15-min sessions, participants assume roles representing 4 weeks in the life of a low-income family. Activities include paying bills, buying food and working. This is followed by a reflection session to discuss the meaning and relevance to medical practice. Nineteen residents evaluated this exercise after participating in 2008; 74% strongly agreed and 21% somewhat agreed the experience helped them understand poverty. All participants agreed “This experience has helped me better understand how poverty can affect health” (42% strongly, 58% somewhat).
Peninsula Family Advocacy Program (FAP)
Established in 2004, Peninsula Family Advocacy Program (FAP) is a collaboration among Lucile Packard Children’s Hospital at Stanford, Ravenswood Family Health Center in East Palo Alto, San Mateo Medical Center and its affiliated clinics and the Legal Aid Society of San Mateo County. In 2008, FAP provided advice, representation or referrals to approximately 280 individuals and families.
An evaluation of pediatric interns was conducted from 2005 to 2007. Interns were evaluated during their community advocacy block and received didactic training following I-HELP training topics (Table ). Sixty interns completed pre-surveys prior to training; 19 completed post-surveys via SurveyMonkey online. One example of the evaluation showed intern attitudes to legal screening for needs improved, as fewer providers reported concerns about making patients “nervous” with legal questions (from 38% to 21%).
In 2007, FAP developed an interdisciplinary course for law and medical students: “Medical-Legal Issues in Children’s Health.” Annually, ten medical, law and social work students learn about the legal basis for social determinants of health and advocacy skills as they impact on the individual and policy level. The course is structured around a series of lectures and discussions with a service learning component including collaborative case and policy work. Qualitative feedback includes: course does a whole lot to empower medical students to effective action and advocacy; seeing how lawyers prioritize components of a patient case differently than physicians gave me a new perspective on how I might approach a patient; offers an initial channel to begin conversation on how we can work together.