Fair Housing: Fundamental to Family Health, and Elusive
by Samantha Morton – CEO, MLPB
and Salin Geevarghese – Senior Fellow, Center for the Study of Social Policy
September 14, 2020
This is a challenging time for progress on equitable, inclusive, fair housing in our country.
If you’re unfamiliar with this term of art, “fair housing” – sometimes known as “equal opportunity housing” – refers to the ability to access housing without experiencing unlawful discrimination. This principle underlies the 1968 Fair Housing Act, which codified many important policy reforms necessary to reverse long-standing residential segregation.
Sounds intuitive, right? But fair housing remains aspirational. Just this summer, a study was released demonstrating that Boston renters face “high levels of discrimination based on race and voucher status.” This is alarming given growing recognition of the links between residential segregation and susceptibility to infectious diseases like COVID-19. And the well-documented links between residential segregation and worse child health outcomes.
One of us – Salin – served in the Obama Administration in 2015 when HUD issued a new regulation to implement the Fair Housing Act’s affirmatively furthering fair housing (AFFH) requirements. The regulatory “re-fresh” offered stronger guidance for municipalities (cities, counties, states, and public housing agencies) on how they could “[take] meaningful actions to overcome historic patterns of segregation, promote fair housing choice, and foster inclusive communities that are free from discrimination.”
The AFFH promised to be a powerful lever for system change at the state and local level. However, as Salin described during MLPB’s annual event on May 13, 2020, the public comments submitted in connection with the proposed regulatory revision were dominated by “racist screed.” This was a precursor to the racism that revealed itself in the 2016 Presidential campaign and stoked xenophobic fears. Now, in lead-up to the 2020 election, these harmful messages are being amplified, through for example the Administration’s recent statements about how fair housing regulations will be used to destroy the “suburbs.” Suburbs once were havens of white flight and past creations of discriminatory federal housing policy. Ironically, the suburbs have increasingly become more diverse.
The other of us – Samantha – has led MLPB’s participation in pioneering research that tests the power of integrating civil rights problem-solving education within communities of care. This research is demonstrating that this fundamental king of problem-solving – including proactive identification of families’ legal rights to non-discrimination in housing, and related legal remedies – is critical to accelerate family access to concrete support and to improve child health and reduce caregiver stress. The national DULCE Learning Network is further demonstrating that this kind of health-promoting, household-level legal rights enforcement can translate into important reform at the system and policy level.
The housing policy landscape in 2020 is dismal from an equity and inclusion perspective. So far this year, the federal government has:
Collectively, these policy shifts disadvantage Black and Latinx families, families of color, and marginalized youth in profound ways. And all of this is happening against the backdrop of staggering pandemic-worsened material hardship (losses of employment, income, housing, and more) that is creating an ”avalanche” of evictions nation-wide. These hardships – including but not limited to evictions – are also playing out in ways that exacerbate racial injustice as well as the prevalence of adverse childhood experiences.
We together ask: Will Americans always live separately, continuing a harmful status quo with long and deep roots in American housing policy? Or will we tackle health-harming NIMBYism through zoning reform and strategies that promote strong mixed-income communities?
Will we fulfill the promise of the American civil rights movement in relation to surging demands for system disruption that will deliver greater equity, justice and opportunity? Segregation is not destiny. It has been our past, and there are powerful forces arrayed to preserve it into the future. However, we must work to create equitable, inclusive, healthier communities where everyone can prosper and belong. It will take courage to prioritize fair, equitable, and inclusive housing for all.
Do we have the courage to create what Michele Norris has described as a New Better instead of a New Normal?
Old or New, "Normal" Hasn't Cut It:
Innovative Strategies to Promote Housing Stability Among Families with Young Children
by Franny Zhang, Content Lead
June 29, 2020
On the morning of Wednesday, May 13th, MLPB convened a (BYO) Breakfast on the topic of Old or New, "Normal" Hasn't Cut It: Innovative Strategies to Promote Housing Stability Among Families with Young Children. In recent months, the COVID-19 pandemic has expanded awareness of the profound inequities that exist in the US, including the struggle for families to access safe and stable housing. MLPB recognizes that a deeply-rooted problem of this size requires an equally broad and multisector solution. As such, we convened thought leaders specializing in family housing stability innovations at the household, systems, and policy level, based on a version of Thomas Frieden’s Impact Pyramid, that was adapted and featured in a Sep. 2019 brief authored by Samantha Morton of MLPB with Stephanie Doyle of The Center for the Study of Social Policy (CSSP). The panelists provided a blueprint to over 100 participants, representing health administration, social work, community health workers, community organizers and more, of how to work together in new ways to promote stable housing for families.
At the household level of impact, moderator Baraka Floyd of Stanford School of Medicine & MLPB guided a conversation between panelists Allison Bovell-Ammon, Director of Policy Strategy, Children’s HealthWatch at BMC and MLPB’s own Legal Director JoHanna Flacks. Allison and JoHanna spoke primarily about their work with Housing Prescriptions as Health Care, a research study funded by The Boston Foundation. In this randomized controlled trial, families with complex medical needs were divided among two groups:
- The experimental “Housing Prescriptions” group received what Allison termed a “wrap-around set of services,” in the form of care that integrated legal problem-solving insight from MLPB as well as case management and financial counseling provided by partners represented in the photo to the right.
- The control “Resource List” group received the current standard of care in the form of informational lists.
Initial findings from this study were recently published in Health Affairs and include comparative data on improvements in parent/caregiver mental health and child health scores. Allison noted that, “at six months, the majority of families in the intervention had not moved into a form of stable housing…but what we saw and what parents reported qualitatively was that having someone on their team, having someone walk through this process with them, to hear their concerns really made a difference…the problems seemed now solvable.” Housing Prescriptions adds to the body of evidence supporting a more holistic approach to health and the crucial role an interdisciplinary care team can play in accelerating measurable gains in a family’s well-being.
In the second panel focused on system-level impact, moderator Jeannine Casselman, Legal Advisor at MLPB, spoke first with Brenda Clement, Director of HousingWorks RI at Roger Williams University. Brenda described HWRI’s efforts to bring together programs and resources -- including government, healthcare, private and public housing systems -- to improve systems intended to promote housing access for families. She acknowledged that the great complexities of these systems can be a barrier to those navigating them. Brenda also highlighted the Housing Fact Book that HWRI publishes every year to track housing affordability in RI. This valuable resource is curated by HWRI and its partners and is a living example of how different institutions can unite to create comprehensive resources that further housing stability by demystifying a complex landscape that impacts so many families.
Housing-related data also was at the center of Jeannine’s discussion with Soojin Conover, Senior Data Analyst, and Yusuf Ali, Network Coordinator, both of Vital Village Network at BMC. Both panelists spoke of their work on Vital Village’s Community Housing Data Tool. This tool is designed provide data maps so that Boston families can access data maps to inform their housing stability and safety choices. According to Soojin, “by linking health and housing data in the Boston area, this tool shares relevant data maps with Boston families.” For example, if a family is looking for housing in Boston, they can search for data such as needle pickup requests, crime density, and blood lead levels to help them determine the safety of the neighborhood. The tool was created in response to feedback from VV’s community, and VV also leveraged relationships across their network to access data such as the lived experiences of single dads and returning citizens to ensure data integrity and usefulness. In addition, MLPB shared a framework with VV to transform the data from random points to categorized points along a continuum of legal, health, and housing needs. The Community Housing Data Tool emphasizes how data sets are a powerful network that has great potential for community-driven systems change.
MLPB’s CEO, Samantha Morton, moderated the third and final panel focusing on policy-level impact. Salin Geevarghese, President & CEO of SGG Insight, LLC and Senior Fellow at CSSP was up first and reflected on his experience as a leader in the Obama administration’s 2015 effort to strengthen the affirmatively furthering fair housing (AFFH) requirements of the 1968 Fair Housing Act. Salin’s account highlighted how individual and structural racism continues to pervade housing policy in the U.S., and he reported that during the public comment period for the proposed new AFFH rule, “three quarters of the [public] comments were pure racist screed.” He also reinforced “the big caveat that we all have to wrestle through is that knowing doesn’t substitute for political will when we are speaking about racial equity.”
The conversation then segued to Emily A. Benfer a Visiting Associate Clinical Professor & Director of the Health Justice Advocacy Clinic at Columbia Law School and her national work around eviction moratoria. Her efforts have taken on a greater significance given COVID-19’s impact on employment rates, income, and therefore housing, as people struggle to pay rent or mortgages. Emily partnered with law students to “analyze moratorium documents nationwide and thousands in-state and partnered with the Eviction Lab to create a Housing Policy Scorecard.” Like Vital Village’s Community Data Tool, this scorecard uses data from multiple sources and assesses the strength of eviction protections across the US. The scorecard reveals that eviction and foreclosure protections vary greatly even in geographically close states such as MA and RI and that there are many areas where new policies can help bring relief to renters and homeowners. In addition to spotlighting the need for more housing instability screening, better usage of tools such as telemedicine, and expanding access to justice, she stressed that ‘nonprofits, churches, hospitals are all critical for housing stability,” returning again to the idea that a problem with multiple dimensions also will require a solution with multiple dimensions.
The final panelist of the (BYO) Breakfast was Kristina Contreras Fox a Policy Analyst at RI Coalition for the Homeless. Her organization anchors many shelters and service providers throughout the state, and they “seek to be the bridge between people who are affected by policy and people who are making policy.” They have dedicated themselves to bringing Rhode Islanders who have or are experiencing homelessness into the policy-making process to ensure that their voices are heard and that policies will truly meet their needs. Like Salin, Kristina also called out the racialized context of the pandemic, providing data that 46% of all RIs who have tested positive for COVID-19 are LatinX and 75% of LatinX Rhode Islanders are renters and that they will be disproportionately impacted once evictions resume. Kristina concluded her remarks on policy and equity with an urging all attendees to join in advocacy by calling upon their policymakers to support a range of housing protections.
The breadth and depth of ideas and actions on display at the Breakfast was inspiring. A common theme was how siloed many sectors and services remain in 2020 – with persistent health and housing harms to families with young children. MLPB is proud and gratified to partner with healthcare organizations, housing authorities, public health commissions, and early childhood programs, among many others, and eager to welcome new partners invested in expanding their legal problem-solving ‘toolbox.’ For next steps in this important work, see below!
- Curious about partnering with MLPB? Email us to learn more!
- Want to access MLPB insight on how interdisciplinary teams can more effectively partner with families experiencing housing instability? Check out our new Unlocking Access Report.
- Want to connect at our next public event? Join us on November 10, 2020.
The "Cavalry" Isn't Coming:
We All Must Become the Cavalry
by Samantha Morton, CEO
November 14, 2019
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;
• Identifying role-appropriate responses to positive screens when legal risks are detected (through process mapping and other steps); and
• Curating a complex—or barren—legal services landscape to enhance the likelihood of successfully connecting families to appropriate advocates.
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.
• Equipping colleagues with valuable legal information that can (a) then be conveyed to families, and (b) enable implementation of creative, role-appropriate problem-solving strategies when families are informed and can make decisions.
• Assuring that families have realistic expectations when no solutions exist under current law or public policy.
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.
Available at: https://cssp.org/resource/legal-partnering/
“[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.”
Legal Partnering as Prevention
by Samantha Morton, CEO
October 4, 2019
How we support young children and their families to not merely survive but thrive is a measure of our integrity as a society. Too many families living in the United States confront barriers to resources, services, and legal protections that can promote housing stability, food security, and personal safety, among other things – and these barriers converge to create early life stress and, in turn, worsen health and well-being over the life course. Against this backdrop, MLPB was honored to partner with CSSP and the JPB Foundation to bring Legal Partnering for Child and Family Heath: An Opportunity and Call to Action for Early Childhood Systems to life – spotlighting an important and under-utilized lever that can expand the “toolbox” of strategies available to connect more families with the supports they need and want.
|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
by Ciara Malaugh and Samantha Morton
Published by the Center for the Study of Social Policy (CSSP)
January 29, 2019
Integrating a legal partner as a member of the health team can help children and families get the comprehensive services for which they qualify and can also improve the functioning of public benefits systems for the broader community. DULCE, a pediatric primary care intervention for children in the critical first six months of life, demonstrates how this powerful strategy can work. For example, legal partners working in California-based DULCE sites have helped to assure timely newborn enrollment in Medi-Cal and have spurred policy change efforts in LA County.
Read the full blog entry on CSSP's website.
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:
Yet leadership has much work to do:
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.
Managing Health-related Social Needs: The Prevention Imperative in an Accountable Health System