Delaware Medical-Legal Partnership helps vulnerable patients overcome obstacles to health

After suffering a stroke and a heart attack, David Jester of Wilmington faced another crisis at the worst possible time. A gap in his insurance coverage threatened to burden him with significant financial hardship as he worked to bounce back from cardiac catheterization and triple-bypass surgery. But thanks to an innovative new program at Christiana Care, he got fast help when he needed it to solve his insurance challenge so that he could focus on his health.

Jester, a 54-year-old disabled mechanic, was on the mend after successfully going through cardiac rehabilitation. Unfortunately, he was about to lose his Medicaid coverage, as he began to receive Social Security Disability Insurance (SSDI) but was subject to a waiting period for Medicare. The SSDI made him over-income for his Medicaid, and he was sent a termination notice.

His Christiana Care social worker realized what was happening and put him into contact with the innovative Delaware Medical-Legal Partnership, a new program at Christiana Care that helps patients to address legal problems that might be barriers to good health. The Delaware Medical-Legal Partnership lawyer discovered that the Medicaid termination was incorrect and successfully advocated, on Jester’s behalf, for the coverage to be reopened in a special Medicaid eligibility category for people like Jester, who are waiting for their Medicare eligibility.

“I have serious health issues and it could be a disaster for me to lose coverage,” said Jester. “I couldn’t believe how fast the lawyer with the Delaware Medical-Legal Partnership took care of things and made sure there was no break in coverage.”

The Delaware Medical-Legal Partnership, which began in early 2016, represents a movement beyond the traditional bounds of medicine to impact the social determinants of health. The partnership is a collaboration between the Christiana Care Health System and the Community Legal Aid Society Inc., of Delaware (CLASI).  CLASI is a private, non-profit law firm that provides free civil legal services to Delawareans who have disabilities or low incomes, or who are age 60 and over.

“The concept of the Delaware Medical-Legal Partnership is to solve —or assist with solving — medical problems with a legal intervention for some of our neediest patients,” said Julie Silverstein, M.D., FACP, associate service line leader of the Primary Care and Community Medicine Service Line.

A common need in the first few months of the program has been safe housing. From February to October 2016, 20 patients were determined to have serious housing and utility needs. Thirteen patients were identified with issues related to income support. Nine patients had needs connected to personal and family stability. Four patients wanted help with personal rights or immigration status, and one patient sought help with a bankruptcy. Overall 289 patients were screened for eligibility.

The program does not address cases involving criminal matters, wills, traffic offenses or medical malpractice.

“It’s frustrating as a physician to see medical problems that you have no answers for unless you address the social determinants of health,” said Dr. Silverstein. “We have wonderful social workers, but often they can only go so far in their assistance by connecting patients to community resources. What you sometimes need are legal services that allow you to get at the root of a social problem impacting a patient’s health.”

An example is the case of a patient who was homeless, despite having been approved to move into a low-income housing complex. She was having difficulties getting her electric utilities turned on because of an outstanding balance with the utility. Through the Delaware Medical-Legal Partnership, a lawyer was able to negotiate a smaller initial payment and set up a monthly reimbursement plan for her, enabling the patient to move into her new apartment.

Delaware Medical-Legal Partnership services are available to patients throughout Christiana Care’s primary care network. The program is based at the Rocco A. Abessinio Family Wilmington Health Center, with offices adjacent to Patient Support Services, where health guides assist with screenings for eligibility and issues that can impact health.

Patients eligible for Delaware Medical-Legal Partnership services are those who:

• Receive primary care from a Christiana Care Medical Group practice.
• Have had at least one hospitalization or two emergency department visits in the past six months, though patients 18 and younger do not have to meet this utilization criteria.
• Have household or personal income at or below 200 percent of the federal poverty level.

More than 90 percent of an individual’s health relies on social factors that occur outside of hospital walls, and civil law is often an effective tool in achieving positive outcomes for patients, said Daniel Atkins, Esq., executive director of the Community Legal Aid Society. For example, a child with asthma might visit the Emergency Department repeatedly because of mold or pest infestations that should be removed from the child’s home. For poor, at-risk patients, this is a problem that is more readily addressed by a medical-legal partnership than by a physician alone, according to the National Center for Medical Legal Partnership, which reports almost 300 such partnerships in more than 40 states.

A growing body of research suggests that embedding a lawyer in a medical practice can improve patient health, reduce stress, reduce hospital re-admissions and lower overall care costs, he said.

Christiana Care’s Value Institute is gathering data on the effectiveness of the new partnership in Delaware.

“We hope that research will show the value of the partnership to patient health and illustrate cost savings for Christiana Care,” said Marissa L. Band, Esq., supervising attorney for the Delaware Medical-Legal Partnership.

This research is supported by a $150,000 grant from the Harrington Value Institute Community Partnership Fund to launch the Delaware Medical-Legal Partnership. The Harrington Fund was established to foster innovative partnerships between Christiana Care and the community, supporting population health research and program development to address community needs and reduce health care disparities for underserved and disadvantaged populations.

In appreciation for their work in creating the Delaware Medical-Legal Partnership, CLASI honored Dr. Silverstein and two other Christiana Care physicians — David Paul, M.D., chair of the Department of Pediatrics and clinical leader of the Women and Children’s Service Line, and Robert Locke, D.O., MPH, director of neonatal research — with a special Founders Award on Oct. 20 at The Queen Theater in Wilmington.

“With Julie, Rob, and David, we are so fortunate to have such smart, hard-working and caring medical champions on our side,” Atkins said.

In recent years, Dr. Paul and Dr. Locke have served as board members and advocates of the Delaware Healthy Mother and Infant Consortium, which has worked to reduce Delaware’s high infant mortality rate. In 2013, at the urging of Dr. Paul and Dr. Locke, the consortium began an experimental medical-legal partnership to assist high-risk pregnant women in New Castle County, a program that was later expanded across the state. This partnership was designed to address the social determinants of maternal stress, and it continues as a collaboration between CLASI and the Delaware Division of Public Health, which has funded the effort.

“This has been an important program because there is a strong relationship between toxic stress and health, and the program has shown benefits for newborns in our state,” said Dr. Locke.

Impressed with this initial partnership, Dr. Paul and Dr. Locke advocated for a similar partnership at Christiana Care, where Dr. Silverstein was also hoping to start such a program. Dr. Paul said the new partnership was supported in its launch by Christiana Care champions that included Brenda Pierce, Esq., RN, corporate counsel of Legal and Risk Management, and Linda Brittingham, LCSW, BCD, director of Social Work.

“It’s because of the transformative thinking of Christiana Care that we’ve been able to have a lawyer be an advocate for a primary care practice and achieve even better health outcomes for our patients,” said Dr. Paul.