“You just don’t know how magnificent you might be. Think big.” Dr. John Tyler Caldwell, 8th Chancellor of NC State University (1959-1975)
I recently ran across this quote from Dr. Caldwell from NC State and it reminded me of the opportunity we all have as we begin 2015. It also reminds me of the work and passion of the Bernstein Fellows present and alumni…they think BIG and challenge us all to do the same! There is no work worth doing unless we do it together…partnerships, team-based care, community…these are not separate discussions, it’s inclusive. It’s not new but it is hard! The Fellows continue the ideals, passion and courage demonstrated by Jim Bernstein to be bold, think big and work in communities to “imagine how magnificent” they can be.
In the past year, I’ve attended numerous meetings that focus on what communities (rural in particular) don’t have, lack and need. Hmm…recalling Dr. Caldwell’s words, is that really the place to start? The NC Institute of Medicine’s Task Force on Rural Health released its NC Rural Health Action Plan in August. As a participant, it was wonderful to see a variety of community members not always included in healthcare discussions: public safety officers, county managers, and church council members, to name a few, working together with a common goal. I enjoyed the comradery of my fellow participants, particularly their passion for their communities and their sense of pride, fellowship and commitment. In fact, the group was insistent that the report reflect a balance of strength and opportunities for improvement. This quote from the report perhaps best represents this sentiment:
“NC’s rural communities face many challenges, but they are also quite resilient. There is a strong sense of place and an understanding of community assets. Rural people know the needs of their community. They know what strategies to improve health and well-being will not work and are also open to learning from others. While rural communities are often under-resourced, there is an innate sense of commitment to the community and to each other. And because of this, rural communities are often able to accomplish a great deal with limited resources.”
Since the report was released the work has continued. The Foundation is working with a large group of stakeholders across North Carolina as part of the NC Rural Health Leadership Alliance. This group has met for over 20 years beginning with a small group that included Jim Bernstein, Gene Mayer of AHEC, Harvey Estes, MD and Tom Irons, MD. The Alliance is restructuring its work to address the goals set out in the recommendations of the NCIOM report. Stay tuned….
The new Rural Forward NC program at NCFAHP works with communities as part of the Kate B. Reynolds Trust Healthy Places NC to highlight and identify the strengths in community with the community. Calvin Allen and Brandy Bynum are working in partnership with communities in Halifax and Rockingham Counties to begin.
While we have a lot of work to do, I will keep Dr. Caldwell’s words firmly fixed within my view. As we continue this work together, let’s see just how magnificent we can be: think big!
-Maggie Sauer, CEO & President
People go to see a provider at a health care institution because of health issues. But what happens when the root causes of patients’ health problems, such as life stress or not having enough healthy food, can’t be resolved in the doctor’s office? National organizations estimate that millions of people have unmet legal or resource needs that have an effect on their health.
Rebecca Whitaker, a Bernstein Fellow Alumni, has been working on the issue of medical-legal partnerships (MLPs) in North Carolina for the past several years. Rebecca has always been interested in the social determinants of health – the environmental, economic, and social factors that can influence health – but a few years ago she had the chance to dig deep into the issue.
Medical-legal partnerships are a nationwide initiative to better integrate medical and legal services, particularly for vulnerable people and populations. MLPs recognize that legal problems can contribute to health problems, and that many vulnerable patients seen by health care providers also have unmet legal needs. Medical-legal partnerships establish formal relationships between health care organizations and legal services agencies so that health care providers can be trained to screen and refer patients with unmet legal needs to an affiliated legal team. The level of integration between medical and legal teams varies across MLP programs. Sometimes, the legal team is fully integrated into the health care team. In other models, legal partners are available at the health care organization for a designated number of clinic hours each week.
Rebecca, who hails originally from Charleston, SC, moved to North Carolina to pursue her Master of Science in Public Health at UNC’s Gillings School of Global Public Health. After school, she worked for five years at the North Carolina Community Health Center Association, most recently serving as the Director of Health Policy & Governmental Affairs. The North Carolina Community Health Center Association is the membership association for the state’s federally qualified health centers, or community health centers. Federally qualified health centers provide access to comprehensive primary medical, dental, behavioral health and pharmacy services for all patients regardless of ability to pay. Over half of NC health center patients are uninsured. There are 34 federally qualified health center organizations in NC. These organizations operate over 180 clinical sites that are located across the state.
When Rebecca heard from her CEO about the Bernstein Fellowship, she realized that the Fellowship would give her the opportunity to work on a project she’d been thinking about but never had time in her day-to-day to pursue. She applied and was accepted as a Fellow in 2011. Rebecca admits that her original Fellowship project proposal was much grander than it was realistic: she wanted to complete a statewide assessment of unmet health-related legal needs among health center patients. Collaborating with her Fellowship mentor, Madlyn Morreale, Supervising Attorney for the Medical-Legal Partnership Program at Legal Aid of North Carolina, Rebecca focused her objectives and developed a pilot project to assess unmet health-related legal needs among patients in a smaller number of health centers. The purpose of the pilot project was to call attention to these unmet needs, to encourage more health centers to consider medical-legal partnerships, as well as to inform future program planning and operations.
The study was conducted at 5 community health centers across North Carolina over a 6-month period. Over 330 health center patients completed a pen & paper survey (available in both English and Spanish). The survey asked what types of legal and resource needs patients had experienced over the past year, and their willingness to discuss these needs with a provider. Over 200 health center staff completed a web-based survey that asked what legal or resources issues the staff thought were most important to their patients, their comfort discussing issues with patients, and their likelihood of screening and referring patients if there was an established referral program for free legal services.
Rebecca says the study results were both affirming and surprising. She was not surprised to learn that a large percentage (70%) of health center patients reported having an unmet health-related legal or resource need. But she was surprised to see that the most commonly reported issues among patients dealt with personal finance, including people that were being harassed by creditors, those that couldn’t make rent or mortgage payments, and others that couldn’t afford to buy food.
Overall, the study results showed the need to develop medical-legal partnerships in community health centers. The data showed that the sickest patients were the most likely to experience a legal or resource need, were the least likely to have sought legal help in the past, and were the least likely to know where to go for help.
Rebecca and her Fellowship mentor, Madlyn, were encouraged to learn that patients were willing to talk to providers about their legal and resource issues, and that health center staff were willing to screen and refer patients for legal assistance. Staff members who were surveyed cited lack of knowledge, lack of resources, and time constraints as the biggest barriers to discussing these issues with patients.
So what now? There are currently 14 North Carolina health care organizations, including health centers and hospitals, engaged in MLPs. Most are in urban areas, yet many high-need communities lack formalized medical-legal partnerships. In order to expand the MLP footprint in NC health centers, Rebecca and her colleagues seek to create a network model that would leverage resources across the state and provide coordinated training and technical assistance for health center staff members and legal partners.
Nationally, MLPs in community health centers are making huge steps forward. Just this year, the U.S. Health Resources and Services Administration (HRSA) formally recognized civil legal aid as an “enabling service” for health centers. Historically, federally qualified health centers have utilized federal grant dollars to provide enabling services like transportation, interpretation and case management to increase access to care for their patients. The recent announcement by HRSA means that health centers can now use those federal funds for enabling services to help connect their patients to legal services and that in the future they may be able to apply for HRSA grants to support medical-legal partnerships.
Though Rebecca’s project has continued beyond the scope of her Bernstein Fellowship, which wrapped up in 2013, she lauds the Fellows program for its excellence in connecting Fellows and Alumni with other health care and policy professionals, and for building a learning community for young healthcare leaders. “We all work in health care, but in very different parts of the health care sector,” says Rebecca. “Through the Bernstein Fellows program, we are able to share ideas and different approaches to tackling similar problems – that exchange of ideas is really fun.”
Rebecca has recently returned to school at UNC to pursue a PhD in Health Policy. Though she’s not focused specifically on MLPs in her schoolwork, she plans to pursue research involving the social determinants of health and the health care safety net. Rebecca says she wants to explore how new health care delivery and payment models can help address the social determinants of health.
And at the same time, Rebecca’s work with MLPs continues. Rebecca and her fellowship mentor continue to write and speak about the importance of medical-legal partnerships in primary care safety-net settings, showing why they are needed across North Carolina.
“I think it’s exciting to engage in cross-sector collaboration and to think more broadly about improving health—beyond simply delivering health care services,” Rebecca says. “The more we can develop partnerships and systems to facilitate improvements in the social determinants of health, we’ll be a much healthier country.”