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The Civil Legal Aid Toolkit for
HRSA-Funded Health Centers:
Understanding & Optimizing the
Public Interest Legal Community
www.medical-legalpartnership.org
About this toolkit
Using these slides
Acknowledgements
This presentation is intended to help civil legal
aid practitioners highlight the composition, role,
limitations, and impact of civil legal aid to their
health center partners. This presentation is
intended to be used alongside the two-page
messaging guide that was downloaded with
these slides.
The Advisory Board Company contributed significant
pro bono technical support and expertise to the
development of this toolkit. Special thanks to
contributing consultant Laura Datz.
Practitioners are welcome to use slides 3-20 in
their trainings and presentations.
If you have questions about how to use this
resource, please contact Ellen Lawton at
[email protected].
This project is supported by the Health Resources and
Services Administration (HRSA) of the U.S. Department
of Health and Human Services (HHS) under National
Training and Technical Assistance Cooperative
Agreement number U30CS26936 in the amount of
$300,000 with 0% of the total NCA project financed with
non-federal sources. This information or content and
conclusions are those of the author and should not be
construed as the official position or policy of, nor should
any endorsements be inferred by HRSA, HHS, or the U.S.
Government.
Understanding & Optimizing
the Public Interest Legal
Community
www.medical-legalpartnership.org
Understanding the Goals of Civil Legal Aid
Promoting Equal Access to Justice and High-quality Legal
Services For Low-income People
Remove Economic
Barriers to Legal
Representation
Improve
Opportunities
for Low-Income
People
Provide Quality
Legal Services
An Overview of the Industry
Funding Sources
Legal Aid Providers
• Federal and state
government
• Attorneys and non-attorney
staff (paralegals)
• Legal community
contributions
• Law school legal clinics
• Academia
• Private foundations and
philanthropy
• Pro bono volunteers
Clientele
• Individuals with incomes at
or below 125% of the
poverty level
Classifying Civil Legal Aid: By Funding
No Unified Delivery System or Funding Source in the U.S.
Federally Funded Legal Aid
Services
State & Locally Funded Legal
Services
• Funding: $425M
• Funding: $600M (estimate)
Private Pro Bono
Resources
• Funding: $180M
Academia: Law School Clinic
• Funding: $75M (estimate)
Leading National Providers of Civil Legal Aid
Key Legal Aid Sectors
Federally Funded
Legal Aid Services
)
State & Locally Funded
Legal Services
Private Pro Bono
Resources
Academia: Law School
Clinic
Case Priorities
Scope
Basic needs: housing,
income, safety
134 organizations +4,000
attorneys
Basic needs: housing,
income, safety, but with
a broader range &
greater focus on policy
800+ civil legal services
offices
Vary widely; also
supports
self-help service centers
1,200+ pro bono programs
Vary widely
200+ law school clinics
Civil Legal Aid: Key Staff Roles
Legal Allies for Medical-Legal Partnerships
1
2
Civil Legal Aid
Executives
3
Civil Legal Aid
Frontline Staff
Law School
• Board of Directors
• Staff attorneys
• Dean
• Deputy Director
• Paralegals
• Legal Clinic Faculty
• Executive Director
• Managing Attorney
4
Pro Bono Programs
•
Law Firms
•
Corporate Law Departments
•
Bar Associations
•
Individual Attorneys
Who Needs Civil Legal Aid?
Huge Population of Low-Income People With Unmet Civil Legal Needs
Legal Aid Provides Otherwise Unaffordable Legal Services
The Need
• 1 in 6 live people live in poverty
The Services
•
Legal aid primarily serves people
who live in households with annual
incomes at or below 125% of the
federal poverty guidelines
•
65M+ qualified for legal aid
in 2013
• Every low income person has 2-3
unmet civil legal needs that negatively
affect their health
• There is no guarantee to legal
services in civil matters
Legal Need
Legal Aid
Why Do People Need Civil Legal Aid?
Civil Legal Aid Helps People Solve Legal Problems of Every Day Life
Legal Needs That Impact Health (I-HELP Model)
Income &
Insurance
Insurance access
& benefits
Food stamps
Housing &
Energy
Shelter access
Access to
housing
Education &
Employment
Americans with
Disabilities Act
compliance
Discrimination
Disability benefits
Social Security
benefits
Sanitary housing
conditions
Utilities access
Individuals with
Disabilities in
Education Act
compliance
Debt relief
Unlawful termination
Legal Status
Personal &
Family Stability
Immigration
asylum, Violence
Against Women
Act)
Guardianship,
custody, divorce
Criminal record
issues
Domestic
violence
Child abuse &
neglect
Advance
directives, estate
planning
Even When Need is Acute, No Guarantee to Aid
No Clear Access Path to Civil Legal Aid, No Right to Representation
Even Compared to Health Care’s Complex Model,
Legal Aid is Challenged to Serve
A Patient’s Path to Emergency Health Care
Patient suffers
• Patient can selfidentify what
constitutes medical
need, requiring
medical attention
Patient presents
• Patient knows to
goes to ED in
case of acute
medical need
• ED still not a
source for primary
care, but a viable
last resort
With or Without Payment, Treatment provided
• Patient is required to be treated
regardless of ability to pay
!
Early intervention
improves outcomes,
and lowers costs in
both settings
Even When Need is Acute, No Guarantee to Aid
No Clear Access Path to Civil Legal Aid, No Right to Representation
A Client’s Path to Civil Legal Aid
Client Struggles
• Client struggling
with issue may or
may not
understand it is
legal in nature (ex:
housing issues,
benefits, access to
education)
Client Seeks Legal Aid
No Payment, No Requirement to Help
• Even if client recognizes
problem requires legal
support, there is no one,
clear provider of civil
legal aid services
• No matter how acute the need, there
is no entitlement to free legal services
in civil legal matters, unlike in criminal
legal matters
• Scarcity of civil legal aid
attorneys to support vast need; many
turned away
!
Early intervention
improves outcomes,
and lowers costs in
both settings
Need for Legal Services Far Surpasses
Resources
>50%
Qualifying for legal aid turned away
because of limited resources
80%
Legal needs of low and moderate
income individuals unmet by current
resources
800,000
Low income people whose civil legal
aid needs were met by only 8,000
federally funded attorneys
Classifying Civil Legal Aid: By Types of Services
A Range of Offerings, Not Just Full Representation by an Attorney
Self-Help Plus Advice:
Paralegals, lay advisors,
phone services, advice
paired with web-based
services
Self- Representation
Self-Help & Community
Education:
Court-based self-help,
workshops, informational
websites, downloadable
court forms, libraries
Formal Representation
Pro Bono Representation
From Non-legal Aid
Organizations: volunteer
attorneys, law students,
paralegals
Representation From
Legal Aid Organizations:
attorneys, law students,
paralegals
Patient-Centered Health Care Model
Includes an MLP
Pilot Medical Legal Partnership Targets High-Need, High-Use Patients
Lancaster General Hospital’s Pilot Program Embeds Attorney in the Health
Care Team
Attorney
Social
workers
Nurses
Patientnavigators
Physicians
Psychologists
Pharmacists
Targets highest
utilizing patients
95% of high
use patients
enrolled in
program had 2
or more legal
needs
Source: “Embedding Civil Legal Aid Services in Care for High-Utilizing
Patients Using Medical-Legal Partnership”; Health Affairs, April 22, 2015.
Patient-Centered Health Care Model
Includes an MLP (cont.)
Pilot Medical Legal Partnership Targets High-Need, High-Use Patients
One Patient’s Story Shows Positive Impacts From Program Participation
• Chronically ill • Patient incurs debt due to
patient heavily co-pays and uncovered
utilizes ED
services and medications
• Patient has unmet legal
needs: difficulty enrolling
in Medicaid, Social
Security benefits are
being unlawfully
garnished
• Through program, patient
receives health care with
patient navigator and
social worker
• Patient receives legal aid
services to enroll in
Medicaid and restore SS
benefits
• 0 Visits
to ED
since
program
• Saved
costs for
patient
and
hospital
Source: “Embedding Civil Legal Aid Services in Care for High-Utilizing
Patients Using Medical-Legal Partnership”; Health Affairs, April 22, 2015.
Patient-Centered Health Care Model
Includes an MLP (cont.)
Pilot Medical Legal Partnership Targets High Need, High Use Patients
Case in Brief: Lancaster General Hospital
• A 630 bed not-for-profit health system located in Lancaster, Pennsylvania, developed pilot
program to address high use, high need patients, that embedded a lawyer within an interprofessional care team
• Goal of the pilot was to deliver on the patient-centered model of care, and to determine what
effect integrating civil legal aid services into the care of high use, high need patients would
have on health care costs
• During the pilot year, 55 patients were enrolled in the program, with 95% of those patients
having 2 or more unmet civil legal aid needs, the most prevalent being housing issues and lack
of access to public benefits
• Lawyer provided direct legal services for minor issues, referred more complex issues to
external lawyers, and trained other members of the care team to identify and document civil
legal aid needs
• By addressing patients’ civil legal problems, the pilot reduced health care utilization and
costs. Results include: decrease in both 30-day and 7-day readmission rates among
participating patients, upward of 50% reduction in utilization of inpatient and ED services and
overall costs (as defined by charges) dropping by 45%
Source: “Embedding Civil Legal Aid Services in Care for High-Utilizing
•
Source: Partnership”;
“Embedding CivilHealth
Legal Aid
ServicesApril
in Care
for2015.
High-Utilizing
Patients Using Medical-Legal
Affairs,
22,
Patients Using Medical-Legal Partnership”; Health Affairs, April 22,
Patient-Centered Health Care Model
Includes an MLP (cont.)
Pilot Medical Legal Partnership Targets Health Center Patients
Case in Brief: Erie Health Center, Chicago IL
• A multi-site urban health center on the West side of Chicago developed an MLP
to address legal needs for health center patients, working with Loyola Law School
and Legal Aid Foundation of Chicago
• The health center detailed a VISTA volunteer to help the legal team screen, refer
and conduct trainings for the providers.
• The MLP conducts focus groups with staff across all locations to raise awareness
about health-harming civil legal needs
• The law school also helps develop policy strategies for health-harming legal
needs that have a population health impact, such as lead poison rates at Chicago
Public Housing.
• Erie Health Center now funds a full-time legal aid attorney on site at the health
center, citing it as a key strategy to address patient needs and boost health
center team capacity.
•
Source: “Embedding Civil Legal Aid Services in Care for High-Utilizing
Patients Using Medical-Legal Partnership”; Health Affairs, April 22,
MLPs Strengthen Value-Based Strategy
Partnerships Essential Component of Higher Quality, Lower Cost Care
Performance
Category
Utilization
Accountable Care Imperatives
• Proactively manage chronic
illness to avoid low-margin
inpatient utilization
Role of Medical-Legal Partnership
• Improves at-risk patient management and
ongoing wellness, reducing unnecessary
hospitalizations
• Reduce inappropriate or
duplicative care delivery
Expense
Management
Clinical
Outcomes
• Manage total cost of care for
a defined patient population
• Target avoidable spending
across health system
• Minimize preventable
admissions, readmissions
• Promote community wellness
for at-risk populations
• Minimizes overall costs by addressing the
social determinants driving downstream
spending
• Supports better population health by
targeting the environmental risk factors
influencing clinical outcomes
Source: The Advisory Board Company interviews and analysis.
Health Care Equivalents of Legal Services
Federal
Legal Aid
State & Local
Legal Aid
Private Pro Bono
Resources
Academia: Law
School Clinics
Healthcare Federally Qualified
equivalent Health Centers
Look-alike CHC
Free Clinic
Medical student
rotation
Scope
138 offices
8,000 attys
700+ civil legal aid
offices
900+ pro bono
programs
125+ law school
clinics
Funding
$600 million
$500 million est
$180 million est
$75 million est