The "Cavalry" Isn't Coming:
We All Must Become the Cavalry
The barriers that block families’ access to health-promoting benefits, services and legal protections are numerous and complex. While many supportive federal and state laws and entitlements exist, less-resourced people often:
- Are unaware of these supports and protections
- Are aware, but lack counseling and coaching to enable informed decision-making about their legal options in high-stakes situations (i.e., the kind of legal support accessed by people and businesses of means during tax season, in preparation for a divorce, etc.)
- Wish to pursue legal rights, but do not because of system navigation complexity, experiences of discrimination, and other experiences of trauma, intimidation, and alienation
- Experience unlawful denials of their benefit applications or non-recognition of their legal rights at the hands of both public systems (e.g., agencies administering SNAP, WIC, TANF, subsidized housing, Medicaid, etc.) and private actors (e.g., landlords presiding over unhealthy/unsafe conditions and employers engaged in wage theft)
This gulf between a lower-income family’s legal rights and their ability to vindicate them is outrageous. Not only do these system/enforcement failures contribute to intensified early life stress for young children, but they are an affront to the ideals of our democratic society.
Against this backdrop, a new approach to scaling legal problem-solving knowledge and coaching with families is urgent. This “team-facing” legal partnering strategy pioneered by MLPB was recently detailed in a Sep. 2019 publication of the Center for the Study of Social Policy and calls for direct embedding of legal resources within systems that serve families – like early education and care and family home visiting programs – to equip members of these workforces as legal problem-solving partners to families.
The core components of this capacity-building model include:
System design support in the planning and implementation of programs
• Informing development of screening tools that effectively detect barriers to concrete supports;
Workforce Training and Interprofessional Education (IPE) for allied colleagues
• Bolstering effective screening and triage of barriers to concrete support that are linked to families’ legal risks, rights, and remedies—as well as identification of scope-of-practice-aligned problem-solving strategies.
Continuous consultation by embedding in regular interdisciplinary team meetings and supplying “rapid response consults” outside meetings
• “Issue-spotting” potential legal risks, rights, and remedies.
Informing potential care delivery system modifications and policy change efforts
• Learning from training and consultation encounters that reveals trends in family needs or barriers at the population level.
Why integrate legal problem-solving capacity directly within sectors like early childhood?
Because the gears of justice are jammed for too many families.
While the public interest law community has valiantly represented the interests of marginalized families in a range of foundational contexts – as described in detail at pp. 5-9 of the CSSP brief – that community is radically under-resourced and weakened by structural limitations. For instance:
- Efforts to disseminate Know Your Rights information to individuals, families, and communities are most often reactive, primarily in response to a legal development such as the proposed public charge rule impacting immigrant households. This dynamic likely is driven by the sheer density, complexity, and dynamism of laws and policies governing people’s lives – overwhelming and challenging to wrangle and distill for sure. Though many state-level websites expertly summarize a multitude of priority public interest law topics for lay people, these tools are dormant until accessed by someone who (a) knows they have a problem, (b) understands that resources exist, (c) can access the resources, and (d) possesses sufficient time, energy, and self-confidence to study the material and apply it to their particular problem. A breakdown at any of these nodes may – and often does – extinguish hope because there is no systematic, proactive approach to educating families with young children about their legal risks, rights, and remedies across the many areas of life impacted by them.
- The professional culture of law largely is transactional, focusing on direct service delivery at the individual/household-level. With notable exceptions like class actions, impact litigation, and legislative/regulatory drafting undertaken on behalf of groups/populations, the notion of leveraging, for example, civil rights law as a public health lever is fairly young. Most families in need are not benefiting from legal strategies that operate at a population level.
- Government funding of civil legal aid organizations is not only dramatically inadequate, it also limits – formally and informally – the populations they can serve and the strategies they can undertake. For example, Legal Services Corporation (LSC)-funded organizations cannot sue the federal government in domains such as immigration law and policy and disability benefits administration (SSI and SSDI). In addition, state funds are generally available through annual state legislature-driven budget allocations, and an organization may opt to not proceed with a lawsuit against a state agency whose practices are harming families for fear of repercussions in the next budgeting cycle. While many organizations supplement their government funding streams with philanthropy and other dollars, those supplements do not mitigate the primacy of the governmental funding streams. These dynamics can create barriers to zealous advocacy for marginalized people and call for increased alliance-building with independently financed public interest law networks.
While some communities have innovated access to counsel in eviction cases in exciting ways as well as the consumer-friendliness of court service centers geared to supporting people who must represent themselves in court proceedings, these exceptions prove the rule. The pace of progress cannot keep up with the needs of families experiencing unlawful benefit denials, sanitary code violations, evictions, and many more health-harming challenges now. There is an ocean of unmet need, so focusing primarily on increasing the ratio of lawyers to clients will only mean justice delayed and thus justice denied. We must extend legal problem-solving knowledge and strategies beyond lawyers to expand the “army” of legal problem-solvers who can partner with families. By building capacity in – for instance – the early childhood workforce (which, importantly, is geared to maintaining high-trust, longitudinal relationships with families), we can accelerate and scale conveyance of legal information to families and empower more informed decision-making by them.
How is this Connected to Traditional Medical-Legal Partnership?
Team-facing Legal Partnering is Driven by a New Framework for
Recognizing Levels of Impact and Professional Responsibility Boundaries.
While the medical-legal partnership movement has admirably spotlighted the population health dimensions of public interest lawyering, its “open tent” culture has created challenges in discerning (a) which programs (and legal partners) are best-equipped to tackle a range of family health-promoting activities, and (b) how best to manage challenging ethical imperatives of legal partnering. MLPB generated and is guided by the Health-Promoting Legal Partnering Impact Pyramid reproduced below, which maps specific kinds of legal support to specific levels of impact – and illustrates that individuals, families and communities should be linked to a “village” of legal partners who are well-equipped at each level of impact.
Health-Promoting Legal Partnering Impact Pyramid
Morton, Samantha J. (2019). “Legal Partnering for Child and Family Health: An Opportunity and Call to Action for Early Childhood Systems.”
Washington, DC: Center for the Study of Social Policy.
“[B]uilding teams’ and organizations’ capacity to engage with families in legally informed . . . problem-solving” is the “team-facing” function that MLPB pioneered and committed to organizationally. Importantly, drawing these boundary lines around intended legal partnering impact also means revisiting key professional responsibility considerations for legal partners. When legal partners focus on “family-facing” case handling or “community-facing” law reform (the ‘top’ and ‘base’ of the impact pyramid), it is families and communities who are relying on the quality and comprehensiveness of their legal support. In the capacity-building zone (the ‘middle’ of the pyramid), the team/organization/system is relying on the quality and comprehensiveness of the legal partner’s guidance. Moreover, in the team-facing capacity-building mode, legal partners bear witness to the messiness of systems as those systems endeavor to improve their care for and service to families. This messiness can involve mandated reporting of families in instances of suspected abuse or neglect, errors in care/service delivery, and even misconduct by rogue ‘bad actors’ – all of which can cause harm to families. For all of these reasons, “team-facing” legal partnering and “family-facing”/”community-facing” legal partnering should not be conducted by the same legal advocate or organization in a single community. Undertaking both functions ignores the conflict of interest potential inherent in such a dual role.
While envisioning an ideal justice infrastructure, let’s imagine the power of investment in family-centered legal problem-solving partners in sectors outside of law – like early childhood. By democratizing access to legal problem-solving knowledge and strategies through new capacity-building partnerships (“we all must become the cavalry”), we will:
- Accelerate family and community access to concrete supports like food, income, and housing;
- Spread critical knowledge and problem-solving skills across key systems serving families;
- Strengthen the efficacy and morale of allied workforce colleagues; and
- Advance the cause of an accessible justice system designed less for lawyers plying their trade and more for people asserting their rights.
To get from here to there:
- The early childhood sector should explore Impact Pyramid-aligned legal partnering relationships in their communities; and
- Legal community members should undertake the challenging but urgent process of role differentiation so they are prepared when cross-sector colleagues (from early childhood and beyond) outreach to their “village.”
And in all of these evolutions, we should be guided by the wise words of Chief Justice Ralph Gants in the recent Massachusetts Supreme Judicial Court opinion in Adjartey:
|“In a complex, high-stakes process where the right to counsel is not guaranteed and professional assistance is not universally available, the assistance provided by non-attorneys may be the only way for many litigants to learn about and assert their rights.”|
|In the healthcare context, these barriers – when they operate at the individual or household level – are increasingly referred to as health-related social needs; in the early childhood system context, they are understood as barriers to concrete support in times of need, a Strengthening FamiliesTM protective factor. To learn more about the important difference between health-related social needs and social determinants (dimensions) of health, check out this important blog.|
Got rights? You bet families do.
They impact child and family health and well-being.
And they matter well before getting to the courthouse door.
Legal partnering is about more than connecting individuals and families to scarce public interest lawyers to represent them in housing and family law cases – at which point the stakes for children and families are exquisitely, unacceptably high. An eviction for non-payment of rent does not appear out of nowhere, but rather evolves in ways illustrated by the graphic below.
The trajectory of an eviction case reflects a continuum of prevention opportunities, nodes at which eviction risks can be detected and often managed (e.g., income loss due to illness or employer wage theft, unlawful reduction or termination of SSI/TANF/SNAP benefits, landlord retaliation re: a tenant’s lawful request that unhealthy housing conditions be remediated, and much more). That’s why MLPB is committed to building the problem-solving capacity of health, human services, and early childhood workforce members who – by virtue of their increasingly strengths-based relationships with families – are often the trusted “first responders” to families confronting barriers to resources and legal protections.
Got lawyers? Most people don’t.
Systems of care must innovate to assure that families can access
the resources they want and for which they are legally eligible.
That’s why MLPB pioneered the “team-facing” legal partnering model described in the brief – to build and sustain role-appropriate legal problem-solving capacity in valued workforce colleagues. Importantly, this role is an intentional capacity-building function focused on supporting allied colleagues who are in direct service – and often high-trust problem-solving – relationships with families. The role does not involve provision of direct legal representation to individuals or families, though this work can (and should) support improved facilitation of such resource connections for families. Rather, team-facing legal partnering:
- Prioritizes a range of legal partner contributions to team-based care that keep individual-, family- and population-level legal risks, rights and remedies front-and-center in system design, program implementation, and policy development; and
- Commits to integration as opposed to co-location, through embedding in regularized interdisciplinary team meetings, among other things. Indeed, a team-facing legal partner is accountable to the team it is supporting for the accuracy, quality, and comprehensiveness of the legal information and support it is supplying. (This has implications for sound structuring and staffing of this role, to be covered in forthcoming material.)
Got the Big Picture? It’s all about impact.
Team-facing legal partnering is a paradigm shift that calls upon systems of care – including but not limited to the healthcare and early childhood sectors – to recognize that helping people to Know Their Rights under state and federal law – and pursue them if they wish – can be just as important as vaccines and home visiting programs when promoting people’s health and stability. This means – initially – that systems of care should keep families’ legal risks, rights, and remedies front-and-center when designing and administering programs and policies that are intended to promote family health and well-being. It also means that systems of care should observe and act on barriers that are impacting the health of populations of families, such as when other systems are not performing in accountable ways.
When embarking on a co-design process, think intentionally about your goals for impact at the individual, family, community, and population level. Inspired by Thomas Frieden’s Health Impact Pyramid, we’ve adapted and introduced in the brief a Health-Promoting Legal Partnering Impact Pyramid to support teams and systems to co-design with impact in mind.
While providing direct legal representation to individuals and families is central to a just society (and resources for this critical function must not only be preserved but expanded), scarce legal problem-solving resources increasingly must be deployed in ways that positively impact populations of families through (a) systems of care that are readier, through their workforces, to engage in effective, strengths-based legal problem-solving partnering, and (b) increased accountability for the many other systems that directly control families’ access to resources, benefits, services and legal protections.
If we expand the concrete support problem-solving “toolbox” in these ways, the prevention payoffs for children, families and communities will be exponential.
DULCE Legal Partners Drive Improvements in Medi-Cal Enrollment Procedures for Babies in Two California Counties
January 21, 2019
Authors' Note: Since initial publication of this blog on November 27, 2018, there has been a major development in law and public policy. The Violence Against Women Act (VAWA) -- which funds a range of critical supportive programs for survivors of domestic violence and sexual assault -- expired on December 22, 2018 when the federal government shut-down went into effect. VAWA's expiration jeopardizes the operations and sustainability of many community-based domestic violence/sexual assault service providers, meaning that survivors may have to find shelter, navigate complex legal systems, and seek trauma-informed mental health care without any support. This makes it all the more important that healthcare providers and teams become more proficient in serving domestic violence survivors effectively.
Domestic Violence Homicide Doesn’t Just Happen: Moving from Physician Bystander to Advocate
by Meghan Geary, MD and Jeannine Casselman, JD, MA
November 27, 2018
Meghan Geary, MD is an attending physician at the Rhode Island Hospital Center for Primary Care.
Jeannine Casselman, JD is a Legal Advisor at MLPB.
The physician: Meghan
As the granddaughter of a mailman, I always have stamps in my wallet. When I attached a USPS® Forever Stamp to the envelope containing my patient’s request for funds from a crime survivor’s advocacy group, I thought I was helping her in a minuscule way. It never occurred to me that she would be dead before those funds arrived. Intimate partner violence (IPV) is deadly and not something medical providers are sufficiently equipped to prevent, detect, triage, or treat.
I became a primary care doctor in the year of the #MeToo Movement. As part of my formal medical education, I learned to routinely screen reproductive-age women for IPV as part of a standard protocol. Even with that training, I was under prepared as a healthcare provider to care for women experiencing domestic violence. In hospital medicine, there is an intensive care unit for management of the most life-threatening conditions. But there is no intensive care unit or “treatment algorithm” for IPV. That’s shocking given the morbidity and mortality associated with IPV. One in three women will experience violence from an intimate partner during her lifetime.[i] In 2015 alone, of the 3,500 US-based women who died due to homicide, almost half of those women – like my patient – were killed by a current or former intimate partner.[ii]
My patient had obtained a restraining order and our clinic’s social worker was engaged with her to offer ongoing safety planning. As primary care provider lacking depth in IPV dynamics, I thought this plan was reasonable and that if her abusive partner violated the restraining order and hurt her again, she could call 911 and get safe. “The ED is always open,” I told my patient. While I was taught – accurately – that leaving one’s abuser is the most dangerous time in an abusive relationship with the highest risk of violence escalation, I struggled to operationalize this learning within familiar clinical frameworks. Unlike chest pain or respiratory distress, primary care providers cannot directly intervene with respect to an abuser’s violent and unpredictable conduct. And I knew that my patient was conducting her own risk analysis: at our last visit, she said that her primary goal was to be free – free from abuse at the hands of her husband, free from fear of what he would do to her and free from worry about what he would say to her friends. I just didn’t realize that that appointment would be her last with me.
The attorney: Jeannine
In the last decade, 55 people have been killed by intimate partners in Rhode Island, the state where I live and primarily work.[iii] Laws alone are insufficient to buffer survivors from the myriad health-related risks of domestic violence. As a public interest attorney embedded within care teams to support effective SDOH problem-solving, I have witnessed first-hand clinician unease about how best to support patients experiencing IPV, especially when the most valuable supports (e.g., representation in court proceedings, relocation assistance, behavioral health treatment and family counseling, etc.) often are driven by experts and resources external to the healthcare team. In my legal advising capacity, I often field questions about the legal rights and remedies available for IPV survivors. Healthcare team members should understand that:
- When a survivor attempts to navigate the legal system to secure a restraining order, divorce decree or child support order, they often experience fear, confusion, alienation, and re-traumatization. Every court hearing involves the prospect of direct, proximate contact with one’s abuser – in the parking lot, on the sidewalk, in the courthouse elevator, in the courtroom. In restraining order proceedings, a survivor often attends the hearing alone, without an attorney. If she prevails, a judicial ruling is rendered, paperwork is distributed, and the survivor is sent on her way, many times not understanding the scope and meaning of the protective order.
- The most important thing care teams can do when supporting an IPV survivor is communicate with them in a strengths-based, trauma-informed way that recognizes the survivor is the expert in their own life and safety. This skill and commitment will increase the odds of successful safe hand-off of the patient to expert safety planning and other resources, whether internal or external to the clinic. Consider the patient’s network of social supports. Are they connected to a community-based or religious organization? Is their membership in a cultural or linguistic group a source of support or a challenge – or both? Will immigration status and income impact their ability to access concrete supports such as SNAP (food stamps) or TANF (cash assistance)?
My role as an integrated legal advisor to interdisciplinary pediatric, family medicine, and internal medicine care teams enables the team to spot and navigate interconnected SDOH. Think beyond a clinical practice guideline framework. Supporting patients to identify pathways to safety is not amenable to a rigid algorithm – it must be an honest, flexible, and holistic effort.
Meghan: I hope to honor my patient who lost her life by building my capacity – and that of my clinic colleagues – to engage in strengths-based, trauma-informed care for patients who have disclosed IPV. In the aftermath of my patient’s homicide, I am reflecting on how healthcare teams can better serve IPV survivors, like going beyond the daily clinical work flow and engaging partners from other disciplines and sectors. Partnering with others such as lawyers, researchers, community-based organizations and activists can help other survivors. We need to work together to advocate for a future with less domestic violence.
If you are (or someone you know is) in need of support, contact the National Domestic Violence Hotline at 1-800-799-SAFE (7233).
[i], [ii] Petrosky, Emiko, Janet M. Blair, Carter J. Betz, Katherine A. Fowler, Shane P. D. Jack, and Bridget H. Lyons. 2017. “Racial and Ethnic Differences in Homicides of Adult Women and the Role of Intimate Partner Violence - United States, 2003-2014.” MMWR. Morbidity and Mortality Weekly Report 66 (28): 741–46
[iii] RI Coalition Against Domestic Violence; http://www.ricadv.org/en/what-we-do/communications/news-releases/?open=1 (accessed 11/13/18)
MLPB Blog Post
by Samantha Morton
March 2, 2018
Accountable care − accountable to whom and for what? Health workforces in Massachusetts and across the nation enter a new normal with SDOH in the job description. As Medicaid ACOs (accountable care organizations) stood up in Massachusetts yesterday and operate in many states across the country, social determinants of health (SDOH) represent a critical frontier of care delivery innovation, workforce quality and satisfaction, cost reduction potential, and health equity progress. Recent developments show promise:
- Housing is now accepted as a "foundational" social determinant of health, with analogies to housing as a "prescription" and "vaccine" being increasingly mainstream. This will support sound priority-setting by health and human services organizations and workforces, and likely will accelerate population-level improvements in housing stability through system and policy change levers informed by large data sets.
- Social risk factors – like housing and neighborhood conditions – are making their way into innovative risk adjustment formulas that drive health financing. This "new math" accounting for SDOH could make it easier for the workforce to sustainably supply more of the services that people actually need to get and stay healthy.
Yet leadership has much work to do:
- Population management is not the same as health equity advancement. Only when systems are incentivized to look beyond the highest-of-high utilization members can meaningful progress on health equity be achieved. An innovative framework for data collection on health disparities in pediatrics is now available to organizations and communities who are pursuing a life course approach to health and wellness.
- The "screen + refer" paradigm driving nascent SDOH care implementation is problematic for many reasons, including the Bridge to Nowhere challenge. And the focus on systematically outsourcing SDOH solutions ignores the fact that plenty of SDOH interventions must happen within the four walls of the health clinic or hospital.
- Health and human services workforces need a blueprint for the central roles they will play in social health integration. Their work comes with great responsibility and some risk – risk that vulnerable individuals, families, and communities will be (further) alienated from health services; risk that workforce members who are not adequately supported will burn out; risk that employers will churn talented staff and fail to meet performance targets; and risk that the health and human services sector simply will not meet the quality and cost imperatives that inspired delivery system transformation in the first place. It’s early days, but exciting new strategies are emerging with demonstrated impact.
Through a blog series for workforce leaders in 2018, MLPB will dive deeper on each of these topics. In the meantime, we are grateful to the organizations with whom we are collaborating in this new landscape – one that promises to better meet the needs of individuals, families and communities through more integrated, human-centered systems and services.