Can Access to a Medical-Legal Partnership Benefit Patients with Asthma who Live in an Urban Community?
Approximately one in 10 children in the U.S. has a diagnosis of asthma. African American and low-income children are more likely to be diagnosed with asthma. They are more likely to suffer the worse outcomes because of low socioeconomic status and environmental exposures. A medical-legal partnership is an interdisciplinary collaboration between a medical entity such as a hospital or clinic and a legal entity such as a lawyer, law school, or legal aid society created to address barriers to health care access and limitations to well-being. Addressing the legal concerns of these patients can improve access to medical services, reduce family stress, and address legal concerns that contribute to poor health. The Health Law Partnership (HeLP) is one such medical-legal partnership that provides a holistic, interdisciplinary approach to health care. During the seven-year study period we found both financial ($501,209) and non-financial benefits attributable to interventions by the attorneys at HeLP.
Medical-legal partnership, lawyers, asthma, outcomes, poverty, low socioeconomic status
Children with asthma who live in urban communities and are of low socioeconomic status (LSES) have higher rates of hospital admissions.1,2 In 2007 the rate of hospitalization for African American children with severe asthma was four times higher than for Caucasian children.3 Other studies suggest that the patient's environment, housing, and exposure to pollutants contribute to the health disparities for patients with asthma.4 In addition, differences in health insurance status, access to care, and medications [End Page 706] contribute to the risks of hospitalization, making low-income minorities more likely to procure asthma care in the emergency department.5,6 Whether this is related to a lack of health insurance, access to care, lack of a medical home, or a combination of these factors is unknown. Nevertheless, poor children have a significantly higher risk of asthma-related morbidity, and higher levels of family turmoil and instability.7
Legal problems associated with LSES have the potential to affect the health and well-being of patients who have asthma and who depend on the health care system to manage their disease. A model that addresses the barriers faced by families of LSES who have children with asthma and experience difficulty in accessing and/or the provision of care is the medical-legal partnership (MLP).8 An MLP brings legal services into the health care setting to address legal needs related to health. An MLP is typically a collaboration between a legal entity such as a law school or legal services office and a medical entity such as a hospital or clinic. The collaboration is based on the recognition that a lawyer can help patients navigate the complex legal systems that may present barriers to patient health and well-being. This holistic interdisciplinary approach can improve family stability, access to care, education and other benefits, thereby improving health.9,10
Since the creation of the first Medical-Legal Partnership for Children (MLPC) in Boston similar collaborations have steadily proliferated across the United States. In 2004, three community partners in Atlanta created the Health Law Partnership (HeLP). HeLP is a collaboration among Children's Healthcare of Atlanta (Children's), Atlanta Legal Aid Society and Georgia State University College of Law forging a multifaceted, interdisciplinary, and holistic approach to patient care. Healthcare staff members, educated about MLP and the legal problems of the population, refer patients to the attorneys at HeLP for assistance in addressing those legal problems.
In a previously published review, we found that families of children with sickle cell disease frequently encountered legal concerns related to their health and well-being and that many of those concerns were addressed by HeLP.11 We hypothesized that families of children with asthma would also encounter legal concerns related to their health and well-being and that HeLP could address those concerns. We also hypothesized that intervention by the attorneys at HeLP would be associated with significant improvements in care, cost savings and general benefit to the patients/ parents/guardians.
The HeLP model
In order to provide on-site services a licensed attorney is located at each of the three Children's campuses. A legal clinic for students of the law school located near the downtown medical campus also assists in handling cases for patients referred by the medical-legal partnership.
While patients present with at least one legal problem, attorneys identify additional legal concerns by performing a comprehensive "legal check-up" (Figure 1), which is a series of questions modeled after the medical history and physical. The legal check-up occurs in two stages where an initial intake interview determines the nature of the legal problem for which the patient has been referred, determines whether the family meets the financial eligibility requirements for free legal assistance, and identifies additional legal challenges the family is facing. Eligible families have incomes below 200% of the [End Page 707] federal poverty level (FPL). If the problem is beyond the scope of HeLP service or if the family exceeds the financial eligibility threshold, families are referred elsewhere.
The HeLP team, consisting of staff attorneys, the medical champion, and professional students from various disciplines screen all new cases at a weekly case acceptance meeting where, based on an established set of case priorities, attorneys determine cases that will be handled by HeLP, identify those that may need referral to a pro bono [End Page 708] lawyer, or those that will only need self-help assistance. If the medical problem of the patient/parents/guardian is relevant to the case, the medical champion provides input. For cases that HeLP accepts for legal assistance, the case is either assigned to a HeLP lawyer or to the law school clinic for direct representation. Cases assigned for direct representation are evaluated in more detail a second time, during which the legal check-up is performed again. Referrals for legal assistance are made by physicians, nurses, respiratory therapists, social workers or other health care professionals while some families self-refer after seeing HeLP brochures and signs throughout the hospital.
A descriptive analysis of a retrospective cohort of patients was conducted for this study. Institutional review board approval was obtained from both Georgia State University and Children's. The HeLP database was retrospectively queried for all patients with the diagnosis of asthma who had been seen by the lawyers of HeLP between April 2004 and June 2011. Data collected from this cohort of patients included income of the patient/client, the presenting problem, any patient/parent/guardian problems identified during the legal checkup, and the type of legal assistance provided. Patients/ clients receiving assistance may have more than one legal problem and/or have several cases opened with HeLP. For instance, a client may seek assistance for both a special education matter and a public benefits issue. Estimated annualized financial outcomes were calculated using an estimate of the present fair market value of the individual benefit obtained. Monthly benefits were annualized assuming a 12-month cap since it is unknown whether clients renew their benefits, coverage, or leases after HeLP's assistance. This methodology probably underestimates the true value of benefits received because many of the children receive SSI/disability, health coverage, and education benefits that continue until the child is 18 years of age. Average and overall financial impact attributed to obtaining public benefits, education, employment, health care, and housing was calculated. Additional benefits related to matters of family law and wills/ estate planning that do not have a direct monetary value were also identified.
Two hundred ninety five parents/guardians with 313 children having asthma were referred to HeLP for legal assistance during the 87-month period described (Table 1). Median patient age for affected children was 8.7 years (range 3.7-12.9). One hundred twenty six (40.3%) were female and 187 (59.7%) were male. Approximately 54% of school-aged patients were in school. For the 130 patients who were enrolled in school, 77 were in an age-appropriate grade. Sixty-two (47.7%) of the children in school reported missing a total of 1,208 days due to asthma-related illness.
The median parent/guardian age was 34.3 years (28.3-42.0). Of the 295 parents/ guardians, 147 (49.8%) were at or below 100% of the federal poverty level (FPL), 72 were between 100% and less than 200% FPL and the remaining 31 greater than 200% of FPL (Table 2).
A total of 1,390 social problems were identified by parents/guardians at the time of the HeLP case-intake interview (Figure 2). Problems for which legal interventions might be provided were identified in 450/1390 (32%). Sixty-nine (15.9%) of the 450 of the legal cases were rejected because the parent/guardian did not meet HeLP eligibility [End Page 709]
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requirements. One hundred sixteen cases (26.7%) were closed prior to completion because the parent/guardian ceased contact with HeLP. Fifteen cases were open and active as of June 30, 2011. Legal interventions were provided to the remaining 250 cases. Problems (940) identified by clients that were not of legal nature were addressed through referrals to relevant organizations and agencies (Figure 3).
For the 250 legal cases that were accepted and completed, the most common case topics included housing (19.6%), family law (18.0%), disability/SSI (17.2%), education (16.4%), and Medicaid (10.0%). [End Page 711]
Of the 250 cases accepted for legal intervention and closed by June 30, 2011, 65 had measurable outcomes. A measurable outcome is any outcome to which a dollar amount can be attributed. The most common benefits among the 65 cases included obtaining SSI benefits, family stability, housing, education, estate planning, consumer finance, and health insurance (Table 3). Estimated annualized benefits totaled $501,209. The greatest benefit ($142,702) was ascribed to obtaining SSI and other public benefits for 11 patients, followed by education benefits, access to health care coverage or services, and housing benefits. Two other benefits were also described in the database: estate planning and family stability. No annualized savings or direct monetary values were attributed to these benefits. A total of 242 other social matters were addressed that had no direct financial benefit attached to them (Table 4). These non-financial outcomes contribute to the numbers of individuals who experience increased stability because they had access to free legal services provided by attorneys. The number of people assisted in various categories of legal problems included consumer finance (15), education (16), estate planning (46), family stability (23), health care coverage and services (13), housing and utilities (121), and other (8). When parents/guardians are counseled about ways in which to avoid accumulating debt or legal steps are taken to save or protect their homes from foreclosure, the entire family, including the child diagnosed with asthma, benefits.
Asthma is a chronic disease characterized by reversible airway obstruction with wheezing, trouble breathing, chest tightness, and coughing. Triggers for asthma exacerbation vary. Common triggers include infection, extreme changes in weather, emotional stress, secondhand smoke, mold, pets, outdoor air pollution, and pests such as cockroaches and rodents. Many of these triggers are found in the urban environment in which our patients live. According to the National Asthma Education and Prevention Program report, even with improved care and adherence to nationally published guidelines for care, there are still 4,000 asthma-related deaths annually.12
In 2010, almost six million children had no health insurance.13 Approximately one in 10 children has asthma, with children from poor families more likely to be diagnosed with asthma. Children of working poor families are most likely to be uninsured (followed by non-working poor) which impedes the family's ability to manage the child's care.12 The greatest rise in the diagnosis of asthma was in African American children who are four times more likely than others to be hospitalized for a severe asthma attack, have higher emergency department utilization and higher mortality.14 These disparities in care and outcomes are linked to LSES, urban environment, culture, ethnicity and possible nutritional deficiencies.15 In a study of children with asthma of LSES in New York City, Claudio et al. found that there was a 70% increase in current asthma compared to children of the same ethnicity from more affluent families.16 Creating an interdisciplinary team to address health issues and the socioeconomic drivers of health can help in the delivery of high-quality care.
Patients with asthma must minimize their exposure to triggers of asthma exacerbation. For our population, triggers exist inside the home. Exposure to residential allergens contributes to a 40% risk of asthma in minority children.17 Certain housing conditions [End Page 712]
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may result in exposure to environmental risk factors and increased psychological stress.18 Such conditions include inadequate heat or poor ventilation, mold and mildew, dust, rodents and insect infestations. Families of patients with asthma who are of LSES are more likely to experience such risk factors.
A significant finding over the study period was that almost half of the school-age patients reported missing school because of their disease. The number of patients reporting missing school is consistent with the number reported by the CDC (59%).19 The total number of school days missed in our study was 1,208 days. Using 180 as the number of school days required per year in Georgia a total of 6.7 years of school were lost during the study period. The average number of days missed per patient/year was 19.5 days. In a study from Israel, children aged 13-14 years reported being absent from school on the average of 7.3 ± 9.8 days. A subsequent study correlating asthma severity and school absence reported a mean absence of 9.2 days.20,21 Our average number of days of school missed exceeds that reported in the literature and may be related to environmental factors affecting schools in urban areas such as Atlanta. During the time of this study, Fulton and DeKalb counties, the two counties in which a majority of our patients reside, had on average 18.7 and 15.7 days, respectively, of air quality that was either unhealthy for sensitive groups, unhealthy, or very unhealthy.22
Through client intake and problem identification, and development of solutions to client problems, HeLP attorneys often observe patterns. In some cases, these patterns may be addressed more effectively using systemic approaches. HeLP services include advocacy on these systemic matters. HeLP has addressed concerns such as teen cellphone use while driving, safety for young passengers in motor vehicles, and improving the business community's participation in emergency preparedness. HeLP contributes to community efforts to improve the availability of decent, affordable housing in our area and reduce exposure to other environmental triggers, such as tobacco smoke and poor air quality. HeLP also collaborates with community organizations that engage in public policy development and provides assistance through research, developing proposed legislation or regulations, and prepares collateral materials necessary to support the partner in promoting change. A coordinated approach that includes individual client representation and the development of effective public policy can improve circumstances for low-income children suffering from asthma.
The HeLP data show that clients frequently have more than one legal problem even though they typically present with one. The legal checkup is designed to query clients about all issues that could affect health and potentially benefit from a legal intervention, including family stability concerns, domestic violence, disability benefits, child support, employment, consumer concerns, access to education, access to food and safe housing. Once legal issues are identified, the client and the legal team can make choices about which issues take priority, and provide a directed approach to possible remedies.
Our study is limited by the retrospective nature of the data and the lack of strict statistical analysis. Another limitation is the method of data collection. Families are interviewed and the answers to specific questions may be unknown, undocumented, or subjected to the bias of the person collecting the data. Lastly, we calculated benefits for specific types of assistance based on estimates of the present value of a service rather than actual cost. This methodology can lead to imprecise estimations of benefits. [End Page 715] Although we documented both financial benefits and other benefits, the lack of specific health data limits a demonstrated connection between financial gain and health. These findings suggest that the medical-legal partnership at Children's has added benefit to patients and the health care organization.
Further study is needed to establish the impact of the legal interventions as a means of reducing stress, a known trigger for asthma exacerbation, and potentially reducing emergency department visits, hospital admissions and medication use. Future research should determine the impact of MLPs on patients with other chronic diseases, such as autism, developmental delay, heart disease, cancer, and diabetes. Finally, we must determine if the legal interventions of MLPs positively affect the health of the patient.
Coordinated, holistic care for patients, provided jointly by doctors and attorneys, can address barriers to optimum health for patients with asthma by addressing a range of legal problems that can contribute to exacerbating asthma even in patients that are compliant with their medication regimens. Collaboration between physicians and lawyers can reduce patient and family stressors such as family instability, access to education, substandard housing conditions and access to health insurance or other benefits.
Asthma is the most common disease resulting in admission to the ED or inpatient service at children's hospitals across the U.S. A referral to a lawyer in an MLP can reduce family stress and improve health status. Linking health outcome to the legal intervention has the potential to show a reduction in emergency department utilization. In this population of asthma patients, we demonstrated a positive effect to the clients attributed to the intervention of the attorneys at HeLP, that resulted in estimated annualized benefits totaling $501,209.
Robert Pettignano is the Medical Champion for the Health Law Partnership, Medical Director-Campus Operations Children's Healthcare of Atlanta at Hughes Spalding and Associate Professor of Pediatrics, Emory University School of Medicine. Lisa Radtke Bliss is an Associate Clinical Professor and Co-director of the HeLP Legal Services Clinic at Georgia State University College of Law. Sylvia Caley is the Director of the Health Law Partnership and an Associate Clinical Professor and Co-director of the HeLP Legal Services Clinic at Georgia State University College of Law. Susan McLaren is a Research Associate with the Georgia Health Policy Center at the Andrew Young School of Policy Studies, Georgia State University and Program Evaluator for the Health Law Partnership.
There was no financial support for this study and none of the authors have any conflict of interest to report. We thank Bridget Bier, office manager, for her contributions in collecting and analyzing the data in this report. We also thank Ann Marie Brooks, MD, for her review of the article.
1. Cesaroni G, Farchi S, Davoli M, et al. Individual and area-based indicators of socioeconomic status and childhood asthma. Eur Respir J. 2003 Oct;22(4):619-24.
2. Castro M, Schectman KB, Halstead J, et al. Risk factors for asthma morbidity and mortality in a large metropolitan city. J Asthma. 2001 Dec;38(8):625-35.
3. Agency for Healthcare Research and Quality. 2010 National Healthcare Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality, 2011. Available at http://www.ahrq.gov/qual/nhdr10/nhdr10.pdf.
4. Hill TD, Graham LM, Divgi V. Racial disparities in pediatric asthma: a review of the literature. Curr Allergy Asthma Rep. 2011 Feb;11(1):85-90.
5. Miller JE. The effects of race/ethnicity and income on early childhood asthma prevalence and health care use. Am J Public Health. 2000 Mar;90(3):428-30.
6. Akinbami LJ, Moorman JE, Bailey C, et al. Trends in asthma prevalence, health care use and mortality in the United States, 2001-2010. Hyattsville, MD: National Center [End Page 716] for Health Statistics, 2012. Available at: http://www.cdc.gov/nchs/data/databriefs/db94.pdf.
7. Williams DR, Sternthal M, Wright RJ. Social determinants: taking the social context of asthma seriously. Pediatrics. 2009 Mar;123 Suppl 3:S174-84.
8. Zuckerman B, Sandel M, Smith L, et al. Why pediatricians need lawyers to keep children healthy. Pediatrics. 2004 Jul;114(1):224-8.
9. Cohen E, Fullerton DF, Retkin R, et al. Medical-legal partnership: collaborating with lawyers to identify and address health disparities. J Gen Intern Med. 2010 May;25 Suppl 2:S136-9.
10. Williams DR, Costa MV, Odunlami AO, et al. Moving upstream: how interventions that address the social determinants of health can improve health and reduce disparities. J Public Health Manag Pract. 2008 Nov;14 Suppl:S8-17.
11. Pettignano R, Caely SB, Bliss LR. Medical-legal partnership: impact on patients with sickle cell disease. Pediatrics. 2011 Dec;128(6):e1482-8. Epub 2011 Nov 14.
12. National Asthma Education and Prevention Program Expert Panel. Guidelines for the diagnosis and management of asthma (Report 3). Washington, DC: U.S. Department of Health and Human Services, 2007. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf.
13. Bloom B, Cohen RA, Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, 2010. Vital Health Stat 10. 2011 Dec;(250):1-80.
14. Agency for Healthcare Research and Quality. Black children more likely to be hospitalized for severe asthma attach. Rockville, MD: Agency for Healthcare Research and Quality, 2011. Available at: http://www.ahrq.gov/news/nn/nn062911.htm.
15. Hill TD, Graham LM, Divigi V. Racial disparities in pediatric asthma: a review of the literature. Curr Allergy Asthma Rep. 2011 Feb;11(1):85-90.
16. Claudio L, Stingone JA, Godbold J. Prevalence of childhood asthma in urban communities: the impact of ethnicity and income. Ann Epidemiol. 2006 May;16(5):332-40. Epub 2005 Oct 20.
17. The Asthma and Allergy Foundation, National Pharmaceutical Council. Ethnic disparities in the burden and treatment of asthma. Washington, DC: National Pharmaceutical Council, 2005 Jan. Available at: http://www.npcnow.org/Public/Research___Publications/Publications/pub_rel_research/pub_diversity/Ethnic_Disparities_in_the_Burden_and_Treatment_of_Asthma.aspx.
18. Sandel M, Wright RJ. When home is where the stress is: expanding the dimensions of housing that influence asthma morbidity. Arch Dis Child. 2006 Nov;91(11):942-8.
20. Sholat T, Graif Y, Garty BZ, et al. The child with asthma at school: results from a national asthma survey among schoolchildren in Israel. J Adolesc Health. 2005 Oct; 37(4): 275-80.
21. Moonie SA, Sterling DA, Figgs L, et al. Asthma status and severity affects missed school days. J Sch Health. 2006 Jan;76(1):18-24.
22. AIRNow. Historical profiles. Research Triangle Park, NC: AIRNow, 2011. Available at: http://www.epa.gov/cgibin/broker?_service=aircomp&_debug=0&_program=dataprog.wcj_byyearhealth.sas&geocode=13121%2013089%2013067%2013135%2013063%2013113&condition=lung&citycounty=county. [End Page 717]