Just What the Doctor Ordered: Using Medical-Legal Partnerships to Address Housing Conditions in Asthma

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Just What the Doctor OrderedUsing Medical-Legal
Partnerships to Address Housing Conditions in
Asthma
Megan Sandel, MD, MPH Medical Director,
National Center for Medical-Legal
Partnership Samantha Morton, JD Executive
Director, Medical-Legal Partnership
Boston Marcia Peters, JD Consulting Housing
Attorney, Medical-Legal Partnership Boston
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Agenda

• Medical-Legal Partnership 101
• The Role of Legal Services in Abating Unhealthy
  Housing Conditions
• Top 10 Advocacy Tips for Responding to Unhealthy
  Housing Conditions
• How to Launch an MLP in Your Community
• QA

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Social Factors Environment Strongly Influence
Health
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Why Social Disparities are Often Legal

• How do health disparities and legal disparities
  develop?

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Wide Range of Laws Governing Basic Needs
Influence Child and Family Health
Food
Housing Utilities
 
Employment Income
Stability Safety
Child and Family Health
Health Care Access
Childcare Education
Immigrant Status
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Forcing Families to Navigate Numerous Complex
Bureaucracies
DTA, DPH, LEAs
PHAs and other landlords, utility companies
 
DET, DTA, DOR, SSA
Probate Family Court, DOR, DCF, Juvenile Court,
Police
Child and Family
EOHHS, Private Insurance Cos, DPH, DMH, DDS, DCF
DTA, ABCD, DPH, DOE, EEC, BPS, other LEAs
USCIS, DHS, ICE, DOJ, EOIR
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Why Legal Advocacy in the Clinical Setting?

• Doctors and other health care providers are
  trusted, credible resources for families,
  particularly with chronic diseases like asthma
• Screening for legal issues in the clinical
  setting facilitates detecting legal problems
  before they reach a crisis

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Medical-Legal Partnerships Lawyers the new
subspecialist

• Combine preventive medicine and preventive law
• A powerful strategy to ensure families basic
  needs are met to improve health and address
  disparities
• Studies show that every poor family has minimum
  of ONE to THREE unmet legal needs -- family law,
  housing, denial of public benefits, etc.

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The Origins of MLP

• Founded by Dr. Barry Zuckerman in 1993 at Boston
  Medical Center
• Frustration of caring for asthma patients who
  lived in abysmal (a.k.a. illegal) housing
  conditions, and malnourished patients who were
  denied food stamps
• Hired lawyer in the Pediatrics Dept. to advocate
  for these patients
• MLP Boston serves 1,000 patient-families per
  year at BMC and 6 community health centers
• Provides 80 trainings to 750 health care
  providers

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Legal Areas/Issues I-HELPSM

• Income supports (public benefits, food stamps,
  health insurance)
• Housing and Utilities
• Education
• Legal (immigrant) status
• Personal and Family Stability

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Housing Law is Designed to Protect Human Health

• Many of the conditions known to affect asthma are
  against housing code, commonly known as sanitary
  code in many states
• Lawyers know state minimum requirements for human
  habitation, how to request inspections and how
  best to document conditions in other ways.

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The Role of Legal Services in Abating Unhealthy
Housing Conditions

• There are many ways that tenants can get a
  landlord to make repairs
• Using code enforcement inspections
• Rent withholding can encourage repairs but can
  have adverse results legal and strategic advice
  is crucial.
• Since withholding rent can lead to eviction, it
  is important to have documentation of housing
  conditions as an effective defense.
• When going to Housing Court, court actions that
  show unsanitary conditions can result in money
  for repairs and monetary damages.
• Where health conditions are aggravated by
  conditions, damages can increase.

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MLP Case Example

• Ms. A is a mother of four kids, including one
  pregnant daughter. She and her family live in a
  private apartment, paid for with a Section 8
  voucher. Her childrens pediatrician referred
  her to MLP Boston after attempting to help her
  address serious substandard housing conditions in
  her apartment, including a mouse and cockroach
  infestation and mold, which was exacerbating her
  childrens asthma.
• Ms. A had attempted to address the problem by
  informing her landlord, but he was not
  responsive. When she found another apartment to
  move into her landlord would not allow early
  termination of the lease.

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MLP Boston Advocacy Steps

• Ms. A was scheduled for the legal clinic with MLP
  Boston pro bono attorneys, who advised the
  client to withhold her rent pending repair of the
  unit.
• The pediatrician made a referral to the Breathe
  Easy at Home program. Inspections of the home
  confirmed continuing Code violations of relevance
  to asthma.
• When the landlord attempted to make repairs
  himself and then sent Mom a retaliatory eviction
  notice, pro bono attorneys represented the family
  in Housing Court and secured approval to
  terminate her lease early and move into a new
  apartment.
• - Mom was approved for and moved into a new,
  healthy apartment with space to welcome her new
  grandchild.

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Top 10 Advocacy Tips for Responding to Unhealthy
Housing Conditions

• 1. The Sanitary Codes in each state provide
  minimum standards for healthy housing standards
  apply to landlords and tenants.(see www.ncls.org
  for listings in each state)
• 2. Documented unhealthy housing conditions that
  violate the Sanitary Code give tenants legal
  rights and remedies to improve housing.
• 3. Most unhealthy housing conditions that
  exacerbate asthma violate state law cockroach or
  other infestation, chronic dampness and resulting
  mold, lack of weather tightness.
• 4. Most patients will tell you about housing
  conditions in great detail, but only if you ask.
  Screen for housing conditions problems and advise
  patients of their legal rights.

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Top 10 Advocacy Tips for Responding to Unhealthy
Housing Conditions

• Advise patients to notify the landlord in writing
  of unhealthy housing conditions.
• Know where your housing code enforcement agency
  is locally, in most cases it is at the local
  Board of Health. In some large cities it is
  separate.
• If the tenant is concerned about contacting the
  local Board of Health, consider working with a
  Dr. to write a letter to the landlord using legal
  language
• Specify request, describe medical condition in
  lay terms, state that conditions violate the
  housing code.
• Can be a good use of Electronic Medical Records

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Top 10 Advocacy Tips for Responding to Unhealthy
Housing Conditions

• In extreme cases, consider immediate needs of
  tenant and possibility of a Temporary Restraining
  Order (TRO).
• E.g. A TRO can be obtained when a landlord is not
  providing heat despite his legal obligation to do
  so.
• If conditions are unresolved, tenant may file
  suit against landlord to get damages (by
  expanding TRO action or otherwise). Possible
  claims
• Breach of Implied Warranty of Habitability,
  Interference with Quiet Enjoyment, Commission of
  Unfair and Deceptive Practices.
• Retaliation is against the law in most states.
  Advise patients to call immediately if they
  receive notices of eviction. A patient cannot be
  evicted without a court order.

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Reasonable Accommodation

• Federal law forbids discrimination on basis of
  handicap/disability.
• A housing provider may have to treat a person
  with a disability differently if thats the only
  way the person can benefit from the program
  equally with others.
• Definition of disability is not same as for SSI.
  Its only that the person have an illness or
  condition that interferes with a major life
  function such as breathing, walking, thinking.

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Accommodation types

• Modification to unit
• Change in policy or procedure
• Children of same gender must share bedroom
• Transfers for life-threatening emergency only
• Transferees must accept any offer
• Tenants must wait while code violations are
  repaired, not expect a transfer
• Likelihood that change will benefit disability is
  all doctor must certify

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Medical-Legal Partnerships How they start

• Pair a Medical Partner (Hospital, Community
  Health Center) with a Legal Partner (Legal Aid
  Society, Bar Association, Law School)
• MLP lawyers
• Primarily legal aid and pro bono private
  attorneys
• Charged with advancing the legal rights of
  patients
• Different from General Counsel
• Employed / engaged by the health care institution
• Charged with advancing the legal rights of the
  institution and its staff
• Medical-legal partnership is by definition
  collaborative

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The Core Functions of an MLP Differ from
Traditional Legal Aid
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Clinical System Improvement The Missing Element

• Redesign health care procedures to identify and
  resolve legal/social problems
• Automate utility shut-off letters
• Simplify SSI support documents
• Provides leverage
• Uses frequent interactions with individuals to
  identify problems
• Resolves individuals issues without using lawyer
• Builds on health care Quality Improvement trends

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Medical-Legal Partnerships Partner Widely to get
Legal Needs Met

• Breathe Easy at Home Program
• Boston Public Health Commission
• Inspectional Services Department
• Can get legal needs met without even seeing a
  lawyer

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MLP in 2000
Number of Healthcare Sites with an
MLP ___________________________ 0 1 2-4
5-9 10
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MLP in 2005
Number of Healthcare Sites with an
MLP ___________________________ 0 1 2-4
5-9 10
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MLP in 2010
Number of Healthcare Sites with an
MLP ___________________________ 0 1 2-4
5-9 10
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The MLP Network March 2009
The MLP Network March 2009
81 partnerships in over 180 hospital and health
centers
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QA- Frequently Asked Questions

• Are legal services free?
• Most communities have federally- or state- funded
  legal aid for low income people
• Often are started with joint funding between
  legal aid and healthcare funds
• How do you serve undocumented populations?
• Many legal aid agencies have restrictions
• Pro bono networks can help some legal issues

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For More Information

• National Center for Medical-Legal
  Partnershipwww.medical-legalpartnership.org
  ContactKate Marple, National Program
  Coordinator617 414 7439Kate.Marple_at_bmc.org
• Presentation materials will be available on
  www.AsthmaCommunityNetwork.org
• National Asthma Forum, June 17-18
• www.epaasthmaforum.com