Grace (name and some details changed to protect her identity) is a nine year old girl who lives in the northern suburbs of Toronto. Her doctor diagnosed her with asthma last year, and developed a care plan and prescribed her medication. Grace’s family understands and agrees with the care plan. But Grace’s acute attacks have continued, and she has been to the Sick Kids’ Emergency Department repeatedly over the past few months.
At first her doctor assumed that Grace’s family was not following the care plan, but after her most recent trip to the Emergency Department, Grace’s doctor learned that the family’s home has a mold infestation – a known trigger for asthma – but the landlord has refused to have the mold removed.
There is a growing movement within health care to treat – or even prevent – health problems like Grace’s with social, rather than medical, interventions.
While social services such as legal aid already exist outside of the health care system, a growing number of Canadian health care organizations are experimenting with adding professionals such as lawyers and financial experts to health care teams. By embedding these non-health professions as members of health care teams, these organizations hope to improve access to these social services and ultimately, to improve the health of their patients.
Social determinants of health
At a population level, social conditions such as employment, income, housing, education, and access to nutritious food have a larger impact on health than someone’s genetics, lifestyle choices or access to health care services.
While these social conditions extend well beyond the walls of hospitals and doctors’ offices, the health care system has made some efforts to address them. Chief among these has been the relatively long standing efforts to increase the role social workers play in both acute and primary care settings. Social workers can help patients address social issues such as housing and income. Efforts to introduce lawyers and financial experts into health care teams build upon this model and expand the range of social determinants that can be addressed from within the health care system.
Formal partnerships between lawyers and health professionals began in the United States more than 20 years ago, and now include 262 health care organizations in 36 states.
“Legal problems are health problems,” explains Kate Marple of the National Centre for Medical Legal Partnership at George Washington University. According to Marple’s organization, many of the social conditions that negatively affect health can be traced to laws that are “unfairly applied or under-enforced,” and so many of them have a legal remedy.
At Canada’s first medical-legal partnership – between Sick Kids and Pro Bono Law Ontario (a charity established to respond to unmet legal needs) – four-hundred patients a year access an in-hospital lawyer to receive help with legal issues that include immigrant/refugee law, family law, education law, employment law, and health law.
At Sick Kids, medical staff and social workers can refer patients to a “triage lawyer”, who works in the hospital. The triage lawyer can deal with many issues on site, or can refer patients with issues requiring specialized legal services to one of Pro Bono Law Ontario’s partnered law firms. In addition to providing specific legal services, the triage lawyer also provides education to patients about their legal rights and to health care professionals about how to recognize legal problems.
One of the early successes of medical-legal partnerships was to identify patients like Grace whose asthma attacks were being triggered by poor housing conditions such as mold, cockroach or rodent infestations. By taking legal action against delinquent landlords, in-hospital lawyers were able to improve the patients’ housing conditions, which reduced their asthma attacks, explains Lynn Burns, Executive Director of Pro Bono Law Ontario.
This type of intervention was found in a small US-based study to be associated with a substantial decrease in asthma patients’ Emergency Department use and hospital admissions, as well as a reduction in medication use. In addition, both a literature review of medical-legal partnerships and an evaluation of the Sick Kids partnership have documented meaningful benefits to patients and their families, such as decreased stress related to the child’s health and improved financial condition. While medical legal partnerships have yet to be studied with a randomized control trial, evidence to date suggests that some health problems may be more effectively treated with legal remedies than with medical ones.
According to Burns, there is significant demand for these partnerships. Since establishing its first partnership five years ago, Pro Bono Law Ontario has created three more with Children’s Hospital at London’s Health Sciences Centre, the Children’s Hospital of Eastern Ontario in Ottawa and Holland Bloorview Kids Rehabilitation Hospital in Toronto, and another beginning this October with McMaster Children’s Hospital in Hamilton.
The demand may be even greater in primary care. In preparation for launching Canada’s first primary care-based medical-legal partnership, St. Michael’s Hospital and ARCH Disability Law Centre conducted a needs assessment for the hospital’s Family Health Team, which serves about 34,000 patients in downtown Toronto. They found that more than half the patients referred to their social workers – 1,980 patients – had at least one legal issue, and many had two to three, according to Nav Persaud, the physician spearheading the initiative at St. Michael’s.
Financial expertise in primary care
While some patients’ health problems can be addressed through the law, others suffer from health problems caused by having too little income to afford adequate food or housing. To help these patients, some doctors are experimenting with embedding a financial expert into their care team.
Family doctors at the St. Michael’s Family Health Team can now write a prescription for income security, much like they prescribe medications. Patients who receive this prescription see the in-house income security health promoter, Karen Tomlinson.
Tomlinson helps patients raise their incomes through a number of avenues, from applying for government subsidies to conducting tax clinics. She also works with them to reduce their expenses by helping them access discounted or free services. Another important function of the role is to improve patients’ financial literacy, which can help stretch limited budgets, as well as avoid fraud and predatory lenders.
While this approach is new to Canada, the United Kingdom has had a similar system in place for a number of years. UK studies that evaluated this approach have found that roughly one quarter of patients who used the service benefited from it financially, on the order of £100-200 per month ($180 to $360 Canadian dollars). However, a small randomized control trial looking at patients over 60 years of age was unable to detect any improvements in health status associated with this program, though qualitative interviews with study participants suggested that the program helped them navigate the system, allowed them to buy more nutritious food, and improved their quality of life. A larger randomized control trial of the UK program is currently underway.
The St. Michael’s program is also being evaluated with a randomized control trial. “While the evidence that social factors influence health is very well established at this point, we don’t yet have the same quality of evidence about which social interventions are most effective at improving health,” says Andrew Pinto, the study’s principal investigator and a doctor in the Department of Family and Community Medicine at St. Michael’s. The trial will measure change in income, expense reduction and change in finance literacy.
While the results of the trial will not be available for a few years, the program is proving extremely popular. “My patients love it – it’s made a big difference for several of them,” says a family doctor not associated with the study.
“Breaking down silos”
Providing legal and financial services to low income individuals is not in itself new. But these programs differ from traditional service models by co-locating legal and financial experts within health care teams.
Embedding legal and financial professionals within health care teams brings a number of important benefits, according to Pinto. “People with legal or financial trouble often feel a great deal of stigma,” he explains, “and so many of them are reluctant to seek out the services they need. But when a doctor says to them ‘this problem you have – this legal or financial problem – this is a health problem.’ That can be very powerful in reducing the stigma,” he says.
Ivana Pericone, Executive Director of ARCH Disability Law Centre, explains that another key benefit of this model is accessibility. Some people either do not realize they have problems that legal aid can help with, or do not know where to find this help. By locating legal aid services alongside the health service many of them are already using, and training medical providers to spot legal problems that may be contributing to ill health, lawyers can better reach the people who need their services.
Marple believes one of the greatest benefits is that these models are “breaking down silos,” and allowing for a truly comprehensive approach to treating health problems that have both social and biological roots. Persaud agrees, saying “we can do more together.”
Sustainability and scalability
One of the chief challenges faced by innovative programs like these is finding stable funding.
Unlike medical services that are paid for through the Ontario Health Insurance Plan, legal and financial programs within health care are currently funded by a range of charitable and non-profit organizations.
For example, the partnership between Sick Kids and Pro Bono Law Ontario is supported through core funding that Pro Bono receives from the Law Foundation Society of Ontario and the Law Foundation of Ontario, which are both charities. This can create significant challenges when it comes to scaling up-programs like these, as charities likely do not have the capacity to meet provincial – let alone national – demand.
This is a barrier not just for these programs, but for virtually all interventions aimed at social determinants. The incorporation of legal and financial professionals in care teams is certainly part of what the World Health Organization (WHO) Commission on Social Determinants of Health had in mind when it recommended “acting more coherently through the health-care system to target social causes of poor health.” But even when these programs prove cost-effective, the siloed nature of governments means that the “coherent, cross-sectoral financing” recommended by the WHO commission is rarely achieved in practice.