Beyond the clinic

Keeping children healthy is an effort that extends well beyond the walls of any health clinic, and helping the most vulnerable children—those who come from underserved communities— requires a strong, coordinated effort involving doctors, nurses, social workers, teachers, parents and guardians—and now, lawyers. And at the sharp end of that crucial collaboration is the Medical-Legal Partnership.

The Medical-Legal Partnership (MLP) places attorneys on site at health care clinics and hospitals to address the social determinants of health. These factors include access to housing and utilities; education and employment; immigration and insurance status; and personal and family safety. According to a National Academy of Medicine white paper, 80% to 90% of a person’s health is shaped by the social determinants of health, which are known to contribute to poorer health outcomes and increased costs. And these factors disproportionately affect children from low-income and minority communities.

The Medical-Legal Partnership Project at Yale is an interdisciplinary collaboration between the Center for Children’s Advocacy (CCA) and Yale New Haven Health (YNHH). The Medical-Legal Partnership Project serves the Yale New Haven Children’s Hospital, both inpatient and outpatient, but focuses on patients from underserved groups, as well as those in the Connecticut Husky Medicaid program. While the Medical-Legal Partnership Project focuses on pediatric patients, other partnerships at Yale and on the national level address other concerns, including care for veterans, palliative care, and oncology.

Ada Fenick, MD, associate professor of pediatrics, has served as the medical director of the Medical-Legal Partnership Project since its founding in 2013. She worked alongside Alice Rosenthal, the founding attorney of the Medical-Legal Partnership Project, for nine years until Rosenthal’s retirement last fall, when attorney Sarah Mervine joined the Medical-Legal Partnership Project. Fenick and Rosenthal describe MLPs as being like a “three-legged stool,” with three important activities that underpin the work of an MLP.

The first leg of the stool is direct patient care and, when necessary, ensuring the care of individuals through legal representation. “We are an interdisciplinary team, and when we work together, we can work to the height of our licenses,” says Rosenthal. Rosenthal is not a health care lawyer by training, but focuses on child advocacy and public interest poverty law. At the Medical-Legal Partnership Project, she provides legal aid in the three areas of greatest need: education, housing, and benefits. She addresses a subset of the social determinants of health known as health-harming legal needs.

To address these needs, a family may require a lawyer to step in and deal with negligent landlords to handle necessary mold or rodent mitigation, two housing conditions that worsen asthma and cause avoidable hospitalizations. Another family might need to speak up at school to gain Wi-Fi access so that a child's smart diabetes pump can work during class. Someone else may need a lawyer to ensure that a child receives disability benefits. In some cases, Rosenthal can provide advice and alert patients to their rights in a particular area. In other cases, the lawyers can represent patients in court. “Other people might give up a little earlier,” says Fenick. “When a parent can say, ‘I am going to call my lawyer,’ things happen.”

Many of the early medical-legal partnerships were based in pediatric settings. The first was founded in 1993 in Boston in response to the high number of children with asthma returning repeatedly to the hospital with symptoms that did not respond to treatment. The second began in Connecticut in 2000 with the Center for Children’s Advocacy, a Hartford-based organization that entered into a partnership with Yale in 2013. Today, according to the National Center for Medical-Legal Partnership, 37 children’s hospitals in the U.S. employ MLPs. From June 2013 through July 2021, the Yale pediatric MLP, which is fully funded by YNHH, received 2,548 referrals.

Physicians can now also use the electronic medical record to make referrals to the MLP. Additionally, physicians conduct screenings with patients that cover social determinants of health in order to flag medical issues, such as the need for mold mitigation before winter asthma flares.

“It’s hard to have a screening program when you have no opportunity to assist or refer them to help,” says Maryellen Flaherty-Hewitt, MD, associate professor of clinical pediatrics and medical director of pediatric primary care. “It’s difficult for families to share [that] they are struggling, particularly if they feel that there is no help available,” she says. “It’s not that we are collecting data or being nosy about their lives; we actually have resources to share with them and put in place so they can get the help they need.”

Flaherty-Hewitt cares for patients at the children’s hospital’s ambulatory care practice located at 150 Sargent Drive in New Haven—a new location that opened in 2020 in partnership with affiliated community health centers Fair Haven and Cornell Scott. As home to the Yale pediatric residency continuity clinic, the practice is central to the second leg of the MLP mission: education and training. There, the MLP is a crucial part of the care new physicians are learning to provide. “Residents can have that as part of their toolbox to help their patients from the beginning of their training,” says Flaherty-Hewitt.

Much of the education takes place beyond 150 Sargent Drive; talks and didactics reach health care providers affiliated with YSM and YNHH at many locations. Education is also provided to social workers and other community-facing employees, as well as groups within the community.

“We don’t have to know every law,” says Fenick. “But our job is to spot the problem, and knowing the law helps you understand that there is a problem.”

The third leg of the stool is wider advocacy, and the necessary work to change laws that have negative effects on large groups of patients. As one example, Fenick says, a group of residents traveled to Hartford last year to testify in favor of eliminating the religious exemption from the state education laws requiring children attending public and private schools and day cares in Connecticut to comply with immunization requirements to attend school.

In addition to the ambulatory care MLP, Yale is also the home of the first MLP in the country focused on behavioral health. The Yale Child Study Center entered into a partnership with the CCA in 2020 and works with a CCA attorney to provide legal interventions for children suffering from family trauma and health-harming environmental stressors that have severe effects on children’s lives and disproportionately harm children of color.

“I like to think of the MLP as changing the way we provide care and how we teach care to learners,” says Rosenthal. “When learners and providers think of the social drivers of health, they will know that a solution is at hand that can have an impact on how they address the health of the child, and how they can act preventatively.” /yale medicine magazine

Jeanna Lucci Canapari is a frequent contibutor to Yale Medicine Magazine.