Recommendation 5: Greater CollaborationBack to table of contents
Recommendation 5. Foster greater collaboration among legal services providers and other trusted professionals—such as doctors, nurses, and social workers.
As the field of civil justice expands beyond lawyers to help provide more assistance to people in need, it should also build more systematic collaborations with trusted professionals from other fields. Such partnerships—for example, between lawyers and medical professionals—are among the most important innovations in civil justice in the last two decades. They help identify problems that clients are not aware of or do not realize have a legal dimension, such as illnesses related to substandard living conditions. They connect clients to legal professionals. And they accelerate the process of finding a legal remedy. They also provide a blueprint for a redesign of many legal services organizations’ programs.
The most successful and established of these collaborations is the medical-legal partnership, which grew out of a pilot project at Boston Medical Center in the early 1990s. That project was based on two related premises: 1) that complex nonmedical problems like housing, education, and economic stability are often (as much as 40 percent of the time) contributing factors to adverse health outcomes and disparities; and 2) that such problems have remedies in civil law.57 In these partnerships, hospital and clinic intake teams can be trained to recognize problems in a patient’s case history (such as an injury from domestic violence or asthma caused by mold in an apartment) and refer patients to lawyers or other civil justice problem solvers. As a result, legal solutions become part of healthcare solutions, and the efforts of legal partners are integral to those of medical partners.
As of May 2020, nearly 450 medical-legal partnerships had been established in the United States, in general hospitals, children’s hospitals, veterans’ medical centers, community clinics, tribal clinics, behavioral health clinics, and substance abuse treatment centers.58 In 2019, these partnerships helped more than 75,000 patients resolve legal issues impeding their health and trained more than 11,000 healthcare providers to better understand and screen patients for health-related social needs.59 The growth and success of these partnerships remain largely below the radar of the American public, but they are exciting advances that promise similar growth and success if applied on a much wider scale, and they should be publicized and promoted enthusiastically.
Medical-legal partnerships promote a broader understanding of health, one that encompasses not just illness and wellness but their social determinants—the external conditions that make health better or worse. Domestic violence is a paradigmatic social determinant affecting health. Violence causes physical and psychological harm, traumatizes children and keeps them from school, and can prevent victims from functioning well at work and at home. Uninhabitable housing is another paradigmatic determinant: moldy housing can trigger asthma, impair students’ ability to complete schoolwork, and undermine economic well-being.
Medical-legal partnerships represent a significant step toward a holistic approach to civil justice, a version of the “community legal practice” to which legal services lawyers have aspired since the 1960s. But they are only one model of a connecting partnership between trusted professionals and legal experts. Many other direct-service fields—workforce development, housing and family services, educational institutions, veterans organizations—offer similar opportunities, and each would be a valued partner in the effort to close the civil justice gap. In addition, collaborative work, between lawyers and social workers, for example, can help equip individuals with greater capacity to ask the right questions in pursuit of social services and benefits and then more effectively advocate for themselves.60
Collaboration at Its Most Promising in Civil Justice: A Medical-Legal Partnership in Indianapolis
In 2017, Community Hospital East, in Indianapolis, formed a medical-legal partnership with Indiana Legal Services, the largest provider of free civil legal aid in the state. The partnership’s mission is to improve health outcomes for patients by providing legal services that address the social determinants of health—unmet obligations for child support, for instance, or a notice of eviction.
To be represented by the nonprofit group, a patient must be referred by a doctor, nurse, case manager, resource coordinator, social worker, or other member of the patient’s treatment team. The partnership has trained these health professionals to look for signs that patients might have legal problems affecting their health.
Initially, the partnership focused on patients being treated for mental health issues, who may have great difficulty navigating legal challenges, like pressure to provide child support, efforts to expunge criminal records, or problems related to housing. Legal aid seems to work best for this population as a value-added service accompanying medical, counseling, and related services. Outcomes of the partnership were excellent. In 2018, it completed about 220 intakes for legal help at the hospital and received more than 400 legal referrals.
This collaboration is among the most promising innovations in legal and wrap-around services in the state, in part because of its potential reach.
Community Hospital, in Indianapolis, opened in 1956 with 300 beds and 111 employees. It grew into today’s Community Health Network, which encompasses ten hospitals (including the original) and employs 2,500 doctors and a total of 16,000 caregivers. The network focuses on output: numbers served annually (618,000 patients in 2018, 274,000 of them in emergency room visits); accessibility to the community (in more than 200 sites of care, including in small clinics, public schools, city kiosks, and Walgreens); and the overall well-being of its members, in addition to their physical and mental health.
Poor nutrition and insufficient food significantly affect health and well-being. In Indiana, one in eight people struggles to get enough food; in the area the network serves, it is about one in six. Community Health Network runs a community farm and a food pantry called the Community Cupboard, which, in 2018, served 63,000 individuals and 16,000 households, providing fresh vegetables and prepackaged meal kits.
Community Hospital, now Community Hospital East, has applied a range of innovations to address community needs. Its Baby and Me Tobacco-Free program helps pregnant women and new mothers quit smoking. A branch of the nationally successful Nurse Family Partnership connects each mother-to-be in the program with a registered nurse who provides prenatal care and makes home visits through the child’s second birthday, with goals of increasing the rate of breastfeeding and reducing drug addiction and child mistreatment.
Each of these programs offers an opportunity to identify people who have legal as well as health needs, an opportunity to pursue holistic healthcare and community legal practice.