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

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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

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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

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Social Risk Factors Health
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Social Threats to Child Health
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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

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Child Poverty by State
State Child Poverty () Rank
DC 31.7 51
New York 20 42
California 19.5 40
Rhode Island 16.9 32
Illinois 14.3 24 (tied)
Michigan 13.9 20
Maine 13.7 18
Massachusetts 12 12 (tied)
Vermont 11.4 10
Connecticut 10.4 4
New Hampshire 7.8 1
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CT Child Poverty
City lt 100 FPL lt 200 FPL
Connecticut 10.4 24.1
Hartford 41.43 69.3
East Hartford 16.0 36.5
Manchester 11.6 27.2
South Windsor 0.8 4.1

Bridgeport 25.1 51.4
Danbury 9.0 26.2
Greenwich 4.2 10.3

New Haven 32.6 59.1
Waterbury 23.9 50.1
Source 2004 CT Kids Count Data Book, CT
Association for Human Services
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• Unaffordable and substandard housing threatens
  child health.

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Housing influences on health are well-documented

• Housing conditions
• Unaffordable housing
• Homelessness
• Housing instability
• Housing mobility

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Fair Market Rents (FMR) and Wages
2005 FMR for 2 BR Hourly Housing Wage Mean Renter Wage Hrs/week _at_ Min Wage
Connecticut 1004 19.30 14.50 109
Bridgeport 966 18.58 19.07 105
Danbury 1148 22.08 19.07 124
Hartford/W. E. Hartford 979 18.83 13.86 106
New Haven-Meriden 1003 19.29 11.92 109
Stamford-Norwalk 1502 28.88 19.07 163
Waterbury 777 1 4.94 11.92 84
Source National Low Income Housing Coalition
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The Burden of Unaffordable Housing
Source National Low Income Housing Coalition
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Impact of Unaffordable Utilities for LIHEAP
Households
Source National Energy Assistance Directors
Association, 2005 National Energy Assistance
Survey
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Utility Disconnections For LIHEAP Households
Source National Energy Assistance Directors
Association, 2005 National Energy Assistance
Survey
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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

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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.
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Making Ends Meet?

• 69 of CT children in low income households spend
  gt 30 of income on housing
• Low income families paying gt 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
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• Food insecurity undernutrition threatens child
  health.

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Making Tough Choices Food vs. Basic Necessities

• 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

• Housing
• Heat
• Medical expenses
• Transportation

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Food Insecuritys 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

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Food Insecurity Infection Malnutrition Cycle
Impaired Immune function
Poor Child Health Outcomes
Poor Nutritional Status

• Infection
• Illness

Weight loss Poor growth
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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
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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
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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 dont eliminate the
  health effects of food insecurity

Source , JT Cook, et al, J Nutrition,
2006 Child Sentinel Nutrition Assessment
Project. 2005
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• Lack of health insurance threatens child health.

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Child Enrollment in Husky A, 2004
City Children Enrolled
Connecticut 23.3 209,705
Hartford 64.2 25,514
East Hartford 38.7 4,828
Manchester 28.1 3,690
South Windsor 5.9 418

Bridgeport 50.5 21,202
Danbury 25.0 4,419
Greenwich 4.8 776

New Haven 57.4 19,669
Waterbury 53.2 15,929
Source 2004 CT Kids Count Data Book, CT
Association for Human Services
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Child Uninsurance in CT by Poverty Status, 2003
Source Kids Count, Annie E. Casey Foundation
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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.

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CT Immigrant Family Experience, 2002-2004
Source Kids Count Databook, 2004
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Disrupting the Link Between Poverty and Poor
Health
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Role of Clinicians in Uncoupling Poverty from
Poor Child Health

• Modify systems of care
• Modify methods of practice
• Ensure connections with safety net programs

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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.

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Disrupting the Link Between Poverty and Poor
Health
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Uncoupling Poverty Poor Health DO BOTH!
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• What is Advocacy ?

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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

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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)

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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 .

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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

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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

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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

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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

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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 providers legal responsibility or
  liability.

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MLPPs Six Questions

1. Do you Have Enough Food?
2. Are your housing conditions safe/Is your housing
   stable?
3. Do you have enough money in the house to pay for
   basic necessities (food, clothing, shelter,
   hygiene items?
4. Have you had any problems with your HUSKY/medical
   insurance ( eligibility, denials, rejections,
   bills, etc)
5. Is you child being properly educated?
6. Are there domestic violence issues in your home?

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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 childs school to discuss
  childs learning disability

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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

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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

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The Hegemony of Low Expectations the
Perpetuation of Disparities through Expectations
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Resources

• www.kidscounsel.org
• www.MLPforchildren.org