Megan Sandel, MD, MPH Medical Director, National Center for Medical-Legal Partnership

1. Just What the Doctor Ordered:Using Medical-Legal Partnerships to Address Housing Conditions in Asthma Megan Sandel, MD, MPH Medical Director, National Center for Medical-Legal Partnership Samantha Morton, JD Executive Director, Medical-Legal Partnership | Boston Marcia Peters, JD Consulting Housing Attorney, Medical-Legal Partnership | Boston

2. Agenda • Medical-Legal Partnership 101 • The Role of Legal Services in Abating Unhealthy Housing Conditions • Top 10 Advocacy Tips for Responding to Unhealthy Housing Conditions • How to Launch an MLP in Your Community • Q+A

4. Social Factors & Environment Strongly Influence Health

5. Why Social Disparities are Often Legal: How do health disparities and legal disparities develop?

6. Wide Range of Laws Governing Basic Needs Influence Child and Family Health Food Housing & Utilities Employment & Income Stability & Safety Child and Family Health Health Care Access Childcare & Education Immigrant Status

7. Forcing Families to Navigate Numerous Complex Bureaucracies DTA, DPH, LEAs PHAs and other landlords, utility companies DET, DTA, DOR, SSA Probate & Family Court, DOR, DCF, Juvenile Court, Police Child and Family EOHHS, Private Insurance Cos, DPH, DMH, DDS, DCF DTA, ABCD, DPH, DOE, EEC, BPS, other LEAs USCIS, DHS, ICE, DOJ, EOIR

8. Why Legal Advocacy in the Clinical Setting? Doctors and other health care providers are trusted, credible resources for families, particularly with chronic diseases like asthma Screening for legal issues in the clinical setting facilitates detecting legal problems before they reach a crisis

9. Combine preventive medicine and “preventive law” A powerful strategy to ensure families’ basic needs are met to improve health and address disparities Studies show that every poor family has minimum of ONE to THREE unmet legal needs -- family law, housing, denial of public benefits, etc. Medical-Legal Partnerships: Lawyers – the new subspecialist

10. The Origins of MLP Founded by Dr. Barry Zuckerman in 1993 at Boston Medical Center Frustration of caring for asthma patients who lived in abysmal (a.k.a. illegal) housing conditions, and malnourished patients who were denied food stamps Hired lawyer in the Pediatrics Dept. to advocate for these patients MLP | Boston serves 1,000 patient-families per year at BMC and 6 community health centers Provides 80+ trainings to 750 health care providers

11. Legal Areas/Issues:I-HELPSM Income supports (public benefits, food stamps, health insurance) Housing and Utilities Education Legal (immigrant) status Personal and Family Stability

12. Housing Law is Designed to Protect Human Health • Many of the conditions known to affect asthma are against housing code, commonly known as “sanitary code” in many states • Lawyers know state minimum requirements for human habitation, how to request inspections and how best to document conditions in other ways.

13. The Role of Legal Services in Abating Unhealthy Housing Conditions • There are many ways that tenants can get a landlord to make repairs • Using code enforcement inspections • Rent withholding can encourage repairs but can have adverse results; legal and strategic advice is crucial. • Since withholding rent can lead to eviction, it is important to have documentation of housing conditions as an effective defense. • When going to Housing Court, court actions that show unsanitary conditions can result in money for repairs and monetary damages. • Where health conditions are aggravated by conditions, damages can increase.

14. MLP Case Example Ms. A is a mother of four kids, including one pregnant daughter. She and her family live in a private apartment, paid for with a Section 8 voucher. Her children’s pediatrician referred her to MLP | Boston after attempting to help her address serious substandard housing conditions in her apartment, including a mouse and cockroach infestation and mold, which was exacerbating her children’s asthma. Ms. A had attempted to address the problem by informing her landlord, but he was not responsive. When she found another apartment to move into her landlord would not allow early termination of the lease.

15. MLP | Boston Advocacy Steps • Ms. A was scheduled for the legal clinic with MLP | Boston pro bono attorneys, who advised the client to withhold her rent pending repair of the unit. • The pediatrician made a referral to the Breathe Easy at Home program. Inspections of the home confirmed continuing Code violations of relevance to asthma. • When the landlord attempted to make repairs himself and then sent Mom a retaliatory eviction notice, pro bono attorneys represented the family in Housing Court and secured approval to terminate her lease early and move into a new apartment. • - Mom was approved for and moved into a new, healthy apartment with space to welcome her new grandchild.

16. Top 10 Advocacy Tips for Responding to Unhealthy Housing Conditions 1. The “Sanitary Codes” in each state provide minimum standards for healthy housing – standards apply to landlords and tenants.(see www.ncls.org for listings in each state) 2. Documented unhealthy housing conditions that violate the Sanitary Code give tenants legal rights and remedies to improve housing. 3. Most unhealthy housing conditions that exacerbate asthma violate state law: cockroach or other infestation, chronic dampness and resulting mold, lack of weather tightness. 4. Most patients will tell you about housing conditions in great detail, but only if you ask. Screen for housing conditions problems and advise patients of their legal rights.

17. Top 10 Advocacy Tips for Responding to Unhealthy Housing Conditions • Advise patients to notify the landlord in writing of unhealthy housing conditions. • Know where your housing code enforcement agency is locally, in most cases it is at the local Board of Health. In some large cities it is separate. • If the tenant is concerned about contacting the local Board of Health, consider working with a Dr. to write a letter to the landlord using legal language: • Specify request, describe medical condition in lay terms, state that conditions violate the housing code. • Can be a good use of Electronic Medical Records

18. Top 10 Advocacy Tips for Responding to Unhealthy Housing Conditions • In extreme cases, consider immediate needs of tenant and possibility of a Temporary Restraining Order (TRO). • E.g. A TRO can be obtained when a landlord is not providing heat despite his legal obligation to do so. • If conditions are unresolved, tenant may file suit against landlord to get damages (by expanding TRO action or otherwise). Possible claims: • Breach of Implied Warranty of Habitability, Interference with Quiet Enjoyment, Commission of Unfair and Deceptive Practices. • Retaliation is against the law in most states. Advise patients to call immediately if they receive notices of eviction. A patient cannot be evicted without a court order.

19. Reasonable Accommodation • Federal law forbids discrimination on basis of handicap/disability. • A housing provider may have to treat a person with a disability differently if that’s the only way the person can benefit from the program equally with others. • Definition of disability is not same as for SSI. It’s only that the person have an illness or condition that interferes with a major life function such as breathing, walking, thinking.

20. Accommodation types • Modification to unit • Change in policy or procedure • Children of same gender must share bedroom • Transfers for life-threatening emergency only • Transferees must accept any offer • Tenants must wait while code violations are repaired, not expect a transfer • Likelihood that change will benefit disability is all doctor must certify

21. Medical-Legal Partnerships: How they start Pair a Medical Partner (Hospital, Community Health Center) with a Legal Partner (Legal Aid Society, Bar Association, Law School) MLP lawyers Primarily legal aid and pro bono private attorneys Charged with advancing the legal rights of patients Different from General Counsel Employed / engaged by the health care institution Charged with advancing the legal rights of the institution and its staff Medical-legal partnership is by definition collaborative

22. The Core Functions of an MLP Differ from Traditional Legal Aid 22

23. Clinical System Improvement: The Missing Element Redesign health care procedures to identify and resolve legal/social problems Automate utility shut-off letters Simplify SSI support documents Provides leverage Uses frequent interactions with individuals to identify problems Resolves individuals’ issues without using lawyer Builds on health care Quality Improvement trends 23

24. Medical-Legal Partnerships Partner Widely to get Legal Needs Met • Breathe Easy at Home Program • Boston Public Health Commission • Inspectional Services Department • Can get legal needs met without even seeing a lawyer

25. MLP in 2000 Number of Healthcare Sites with an MLP ___________________________ 0 1 2-4 5-9 10+

26. MLP in 2005 Number of Healthcare Sites with an MLP ___________________________ 0 1 2-4 5-9 10+

27. MLP in 2010 Number of Healthcare Sites with an MLP ___________________________ 0 1 2-4 5-9 10+

28. The MLP Network – March 2009 The MLP Network – March 2009 81 partnerships in over 180 hospital and health centers

29. Q+A- Frequently Asked Questions • Are legal services free? • Most communities have federally- or state- funded legal aid for low income people • Often are started with joint funding between legal aid and healthcare funds • How do you serve undocumented populations? • Many legal aid agencies have restrictions • Pro bono networks can help some legal issues

30. For More Information • National Center for Medical-Legal Partnership:www.medical-legalpartnership.orgContact:Kate Marple, National Program Coordinator617 414 7439Kate.Marple@bmc.org • Presentation materials will be available on www.AsthmaCommunityNetwork.org • National Asthma Forum, June 17-18 www.epaasthmaforum.com