Transcript Document

Social Determinants of Health:
Making the Case for MedicalLegal Partnerships
Lauren Smith, MD, MPH
Department of Pediatrics
Boston Medical Center
Boston University School of Medicine
Our patients & their families
face many challenges …
 Low-wage work with limited job flexibility
 Substantial child and parent uninsurance
despite employment
 Competing demands for discretionary
income
 Social programs with complicated
requirements & significant penalties for
noncompliance
 Substantial environmental risks
Social Risk Factors & Health
Increased Risk
Child
Decreased Access
Biologic
predisposition
to illness
Development
of illness
Severity of
illness
Social Threats to Child Health
Increased Risk
Poverty
Poor housing quality
Environmental
exposures
Poor nutrition/ Food
insecurity
 Safety
Decreased Access
Language barriers
Geographical
barriers
Inadequate health
insurance
Lack of benefits
Child
Biologic
predisposition
to illness
Development
of illness
Severity of
illness
Child Poverty in Connecticut, 2005
Low income, Poverty, Extreme Poverty
Levels
$50,000
$40,000
$40,000
$30,000
$20,000
$10,000
$33,200
$26,400
$13,200
$6,600
$16,600
$20,000
$10,000
$8,300
$0
2
3
Family Size
4
• 200,000
(24.1%) CT
children are
low income
• 87,000
(10.4 %) live
in poverty
• 50,000
(6 %) live in
extreme
poverty
Child Poverty by State
State
Child Poverty (%)
Rank
31.7 %
51
New York
20 %
42
California
19.5 %
40
Rhode Island
16.9 %
32
Illinois
14.3 %
24 (tied)
Michigan
13.9 %
20
Maine
13.7 %
18
12 %
12 (tied)
Vermont
11.4 %
10
Connecticut
10.4 %
4
7.8 %
1
DC
Massachusetts
New Hampshire
CT Child Poverty
City
< 100% FPL
< 200% FPL
10.4 %
24.1 %
41.43 %
69.3 %
East Hartford
16.0 %
36.5 %
Manchester
11.6 %
27.2 %
0.8 %
4.1%
25.1 %
51.4 %
Danbury
9.0 %
26.2 %
Greenwich
4.2 %
10.3 %
New Haven
32.6 %
59.1 %
Waterbury
23.9 %
50.1 %
Connecticut
Hartford
South Windsor
Bridgeport
Source: 2004 CT Kids Count Data Book, CT Association for
Human Services
Unaffordable and
substandard housing
threatens child health.
Housing influences on health
are well-documented
•
•
•
•
•
Housing conditions
Unaffordable housing
Homelessness
Housing instability
Housing mobility
Fair Market Rents (FMR) and Wages
2005 FMR
for 2 BR
Hourly
Housing
Wage
Mean
Renter
Wage
Hrs/week
@ Min
Wage
$ 1004
$ 19.30
$ 14.50
109
$ 966
$ 18.58
$ 19.07
105
$ 1148
$ 22.08
$ 19.07
124
Hartford/W. &
E. Hartford
$ 979
$ 18.83
$ 13.86
106
New HavenMeriden
$1003
$ 19.29
$ 11.92
109
StamfordNorwalk
$ 1502
$ 28.88
$ 19.07
163
Waterbury
$ 777
$1 4.94
$ 11.92
84
Connecticut
Bridgeport
Danbury
Source: National Low Income Housing Coalition
The Burden of
Unaffordable Housing
80
70
Percent
60
50
All
< 30% AMI
40
30
20
10
0
30 - 50 %
> 50 %
Percent of income spent on rent
Source: National Low Income Housing Coalition
Impact of
Unaffordable Utilities for
LIHEAP Households
35
30
percent
25
20
15
10
5
0
Skipped health
care
Skipped
medication
Skipped food
for a day
Stove/oven for
heat
Missed rent
Source: National Energy Assistance Directors Association,
2005 National Energy Assistance Survey
Utility Disconnections For
LIHEAP Households
35
30
percent
25
All households
20
Households w/
children
15
10
5
0
Electricity
dependent equip
Threatened
disconnection
Utility Shut off
Source: National Energy Assistance Directors Association,
2005 National Energy Assistance Survey
Health Impact of Substandard
Housing Conditions
 Rodent and cockroach
infestation
 Water leaks and
resultant mold
 Peeling paint and lead
paint
 Exposed wires and
uncovered radiators
 Insufficient heat or
running water
 Overcrowding
 Increased asthma
 Increased lead
poisoning
 Injuries
 Radiator burns
 Window falls
 Fires from improper
wiring, lack of smoke
detectors, use of space
heaters
 Increased infectious
diseases
Health Impact of Substandard
Housing Conditions
 Children in families w/ 2 or more
hazards were 2.5 times more likely to
be in fair/poor health
Source: J. Sharfstein, et al, American Journal
of Public Health, 2001.
Making Ends Meet?
• 69% of CT children in low income households spend
> 30% of income on housing
• Low income families paying > 50% of income for
rent spend 30% less on food & 70% less on
health care
Food
insecurity
Unaffordable
Housing
Household
Budget
Trade-offs
Housing
instability
↓ Health care
spending
Child
Health
Impact
Food insecurity &
undernutrition
threatens child health.
Making Tough Choices:
Food vs. Basic Necessities
•
•
•
•
Housing
Heat
Medical expenses
Transportation
• “Rent or eat”
– Children eligible for
but not receiving
housing subsidies
are 8 times more
likely to have
stunted growth
• “Heat or eat”
– Low-income
children show poor
growth in the
winter
Food Insecurity’s
Child Health Impact
• Even mild-moderate undernutrition 
long-term effects
• Young children especially vulnerable
•  Risk of fair/poor health &
hospitalization
• Nutrient deficiencies
• Learning & development deficits
• Emotional & behavioral problems
Food Insecurity &
Infection Malnutrition Cycle
Impaired
Immune
function
Poor
Nutritional
Status
 Infection &
Illness
Weight loss &
Poor growth
Poor
Child Health
Outcomes
Food Insecurity Linked to
Developmental Risk
• Poverty + Food insecurity= Double
jeopardy
• Food insecurity in kindergarten predicts
lower 3rd grade performance
• Black and Latino food insecure children
at increased risk compared to white
peers
• Development may be affected even if
not underweight
Source: , JT Cook, et al, J Nutrition, 2006;
Child Sentinel Nutrition Assessment Project. 2005
Child Food Insecurity &
Food Stamps in CT
US Child Food Insecurity
by Poverty Level, 2004
50
40
30
20
10
0
Total
< FPL
1-1.3
FPL
1.3-1.85 > 1.85
FPL
FPL
Food Insecurity
– 8.6% (11.4% in US)
– 113,000 households
Food Stamps
– 327,000 eligible
people in CT
– Participation rate
24% in 5 yrs
– 53 % eligible families
receive FS
– $ 91.11/person – avg
monthly benefit
Source: USDA, State Food Stamp Participation Rates in 2003, Household
Food Security in the US, 2004; Food Research and Action Center
Food Stamps Make a Difference!
“Food Stamps are good medicine”
• Loss or reduction of Food Stamps
increases the risk of food insecurity
• Food stamps buffer, but don’t eliminate
the health effects of food insecurity
Source: , JT Cook, et al, J Nutrition, 2006;
Child Sentinel Nutrition Assessment Project. 2005
Lack of health
insurance threatens
child health.
Child Enrollment in Husky A, 2004
City
%
# Children Enrolled
Connecticut
23.3
209,705
Hartford
64.2
25,514
East Hartford
38.7
4,828
Manchester
28.1
3,690
5.9
418
Bridgeport
50.5
21,202
Danbury
25.0
4,419
Greenwich
4.8
776
New Haven
57.4
19,669
Waterbury
53.2
15,929
South Windsor
Source: 2004 CT Kids Count Data Book, CT Association for
Human Services
Child Uninsurance in CT by
Poverty Status, 2003
25
20
15
10
5
0
< FPL
1-1.24FPL
1.25-1.49
CT (%)
1.5-1.74
1.75-2
US (%)
Source: Kids Count, Annie E. Casey Foundation
Child Uninsurance:
Health Consequences
Different patterns of care seeking
 Are 3 times more likely to lack a regular source
of care.
 Are 2 times more likely to be inadequately
immunized.
 With asthma are 2 times more likely to have
had no physician visit in past year.
 Are 50% more likely to go without treatment for
common health problems.
CT Immigrant Family
Experience, 2002-2004
35
30
percent
25
CT-Imm
CT-US
US - Imm
US - US
20
15
10
5
0
< FPL
Crowded Housing
Linguistically
Isolated
Source: Kids Count Databook, 2004
Disrupting the Link Between
Poverty and Poor Health
Increased Risk
Poverty
Poor housing quality
Environmental
exposures
Poor nutrition/ Food
insecurity
 Safety
Decreased Access
Language barriers
Geographical
barriers
Inadequate health
insurance
Lack of benefits
Health
Care
Child
Biologic
predisposition
to illness
Development
of illness
Severity of
illness
Role of Clinicians in Uncoupling
Poverty from Poor Child Health
• Modify systems of care
• Modify methods of practice
• Ensure connections with safety
net programs
Public Policy Matters
for Low-income Populations
 Public policies have been developed to
ensure that families can meet their basic
needs and those of their children.
 Many individuals eligible for benefits do not
receive them.
 These vulnerable populations suffer
preventable health consequences.
Disrupting the Link Between
Poverty and Poor Health
Increased Risk
Poverty
Poor housing quality
Environmental
exposures
Poor nutrition/ Food
insecurity
 Safety
Decreased Access
Language barriers
Geographical
barriers
Inadequate health
insurance
Lack of benefits
Child
Biologic
predisposition
to illness
Public
Programs
Development
of illness
Severity of
illness
Uncoupling Poverty & Poor Health :
DO BOTH!
Increased Risk
Poverty
Poor housing quality
Environmental
exposures
Poor nutrition/ Food
insecurity
 Safety
Decreased Access
Language barriers
Geographical
barriers
Inadequate health
insurance
Lack of benefits
Health
Care
Child
Biologic
predisposition
to illness
Policy &
Advocacy
Development
of illness
Severity of
illness
What is Advocacy ?
Lawyers the new subspecialty
 Social factors influence development &
severity of disease
 Many social factors are remediable by
enforcement of existing laws and
regulations
 Inconsistent program implementation
results in denials of benefits/services
Prevalence of Unmet Legal
Needs Nationally is High
 EVERY poor family has minimum of FIVE
unmet legal needs -- family law, housing,
immigration, denial of public benefits, etc
 Legal help for poor families is limited –
publicly funded legal aid turns away up to
60% of cases due to lack of resources
Legal Needs & Civil Justice – A Survey of Americans (American
Bar Association 1994)
Why do this?
“ [We] embrace a comprehensive
view of child health and strive for
preeminence in helping each child
reach for and achieve maximum
potential ….”
Medical-Legal
Partnership Project
• Founded April 2000
• 2 main sites - CCMC, St. Francis
Hospital
• 2003- 2 more sites - Charter Oak
Health Center, Community Health
Services
• Burgdorf/Fleet Health Center &
Community pediatricians
• Assisted over 2200 families
Legal Access v. Clinical Access
• Clinical settings have multiple entry points,
with capacity for significant prevention
through primary care
• Legal Services have various entry points and
community partnerships, but lack capacity
and tradition of “prevention”
Legal Advocacy in the
Clinical Setting
 Provide education and training on
advocacy topics and strategies
 Provide direct legal assistance to
families, enhanced due to partnership
with clinician
 Engage in systemic advocacy by
addressing legal/bureaucratic obstacles
adversely affecting family health
Lawyers and Social Workers –
Part of the Treatment Team
 Social workers are knowledgeable
about resources and skilled in working
with families
 Lawyers support and augment work of
multidisciplinary treatment team
 Lawyers are trained to recognize rights
violations and have tools to address
illegal denials of benefits & services
Education and Training
 Advocacy Training
 Quarterly didactic resident trainings
 Longitudinal elective for PL-2s, PL-3s
 Adolescent medicine, Developmental-Behavioral
pediatrics rotations
 Advocacy tools
 MLPP Code Card
 “Six questions”
 Advocacy Clinical Practice Guidelines
 Case consults - provider needs clarification of benefits/service
eligibility. Not a question about provider’s legal responsibility or liability.
MLPP’s “Six Questions”
1. Do you Have Enough Food?
2. Are your housing conditions safe/Is your
housing stable?
3. Do you have enough money in the house
to pay for basic necessities (food, clothing,
shelter, hygiene items?
4. Have you had any problems with your
HUSKY/medical insurance ( eligibility,
denials, rejections, bills, etc)
5. Is you child being properly educated?
6. Are there domestic violence issues in your
home?
Recognizing the Range of
Advocacy – Individual/Family
 Food Assistance -- Call to welfare
agency to help family appeal denial of
food stamps
 Housing – Letter to landlord addressing
child health problems due to conditions
 Education – Call to child’s school to
discuss child’s learning disability
Recognizing the Range of
Advocacy -- Systemic
 Legislative
 MLPP testimony in support of provision of
speech, physical, occupational therapy outside
traditional home environment
 MLPP testimony in support of restoration of
continuous eligibility & presumptive eligibility
for HUSKY A
 Regulatory
 Media – Hartford Courant article, Oct 2005
Promoting Child Health
Through Preventive Law
• Combine preventive medicine and
“preventive law”
• Are a powerful strategy to ensure
families’ basic needs are met to improve
health
The Hegemony of Low Expectations:
the Perpetuation of Disparities
through “Expectations”
If your child had asthma symptoms 2 days/wk,
how would you rate his/her control?
35
Percent
30
25
20
15
10
5
0
Ex
Very
Good
Good
Fair
Poor
Very
Poor
Resources
• www.kidscounsel.org
• www.MLPforchildren.org