Why Health Systems Are Putting Lawyers on the Care Team

Because of the now-obvious link between housing and health, most healthcare organizations screen patients for unsafe and unstable housing. However, as more and more people face rising rent prices, eviction, and unsafe housing conditions, few healthcare organizations have in-house specialists ready to respond to the underlying structural drivers of the housing crisis and assist patients with the systemic barriers they face to safe, stable, healthy housing. But some organizations are turning to an unlikely partner: lawyers.



One year ago, Kaiser Permanente (KP) became the first large, private integrated health system to strategically invest systemwide in medical-legal partnerships and add lawyers to their healthcare teams. In its pilot year, KP partnered with the National Center for Medical-Legal Partnership and HealthBegins, to develop MLPs in five regions, working with local legal aid partners in each of those communities. The partnerships at KP clinics focus specifically on addressing housing stability and eviction prevention within the communities that KP serves.  Clinicians and KP staff can refer patients to MLP lawyers for assistance with housing-related legal problems that affect patient health. Critically, as these partnerships become more established, teams will also work with patients to identify strategies that advance healthy regulatory, administrative, and legislative policies that address the root causes of unjust inequities.



Addressing barriers to safe, healthy, affordable housing


MLP lawyers help patients understand their rights and enforce local and federal laws in cases where the evictions are illegal, such as in cases of discrimination or where COVID-19 eviction moratoriums have been violated. They also help patients access housing subsidies and appeal the wrongful denial of these benefits, assisting individuals in securing funds to remain in their housing. In addition to helping people stay in their homes, MLP lawyers ensure that patients’ housing is safe by enforcing sanitary codes to improve unsafe conditions–from lead and mold remediation to pest control–and protections that prevent households’ utilities from being shut off.



Having lawyers who work alongside the healthcare team also provides opportunities for healthcare staff to grow their own knowledge and capacity for supporting patients’ housing needs. In the first year that the Kaiser Permanente-based MLPs were active, healthcare staff regularly reached out to the MLP legal team for information on how to ensure that patients with disabilities could access housing protections under reasonable accommodation laws, and for advice on what case managers could do to support these individuals. It was also common for KP staff to contact the MLP legal team to better understand requirements and protections for section 8 housing assistance and how they could help patients understand their rights and maintain eligibility for the program.



Lessons learned from getting these partnerships started at KP


The difficulties in starting a medical-legal partnership are rooted in the same thing that can ultimately make them effective: bringing together multiple sectors’ skills and resources in pursuit of the shared goal of making communities healthier and more just. As KP and legal aid teams in five regions worked together to create workflows for screening and referrals, protocols for information-sharing, and criteria for data collection, they participated in a learning cohort guided by HealthBegins and the National Center for Medical-Legal Partnership to share learnings. These sites shared three important lessons about how to merge two different and deeply-ingrained systems to best serve patients.



1) Start with relationships, capacity, and mission alignment. 

Sites where the KP and legal teams quickly identified how their missions aligned readily connected different members of their teams in similar departments and unpacked screening procedures and technology. Understanding their shared ‘why’ opened the door for partners to care about and learn the ‘what’ and the ‘how.’ Having designated KP-based project management capacity from the start was also critical to support meetings and communication as teams figured out how to work together.  



2) Learn each other’s language.

Navigating two different systems–especially one as complex as KP’s–is difficult. The fields of civil legal aid and health care delivery not only have different processes and technology to track data and different professional protocols for working with patients/clients, they also use very different language, often to describe similar ideas. Each sector also has endless terms and acronyms, and it’s easy to get lost in them if partners don’t take time upfront to ask questions, translate for each other, and make analogies. It was critical to adapt, and in some cases, develop new shared language.



3) Celebrate and build on early wins.

Early wins–like preventing a patient’s eviction–fueled engagement about the potential for joint work. It has been important for sites to share what’s working and especially the good outcomes partners are working toward. Getting the infrastructure in place for an MLP typically takes longer than partners anticipate, and that has been doubly true in a larger, more complex health system like KP. Add in COVID-related challenges and staffing transitions, and it has been difficult to maintain the necessary momentum at times. Focusing on early wins helped carry teams through the process, and set the stage for deeper integration, transformation, and impact. Launching several sites at the same time and meeting regularly as a cohort gave KP-based MLP teams peers to lean on who had already forged a path.


Investing in legal services as part of whole-person care


According to the Legal Services Corporation’s (LSC) 2022 Justice Gap study, Americans who have been economically and socially marginalized do not get any or enough help with 92% of their housing or other civil legal problems. Why? There aren’t enough civil legal aid lawyers or funding in the ‘legal pharmacy’ to meet the need. And those individuals surveyed by LSC expressed fear that they couldn’t find a lawyer or afford one if they did. Oftentimes, the same respondents didn’t know that the problem they were facing had a legal solution. Each of these reasons points to the need for more civil legal aid resources while also creating access to these services in places where the people who need them already go and can be screened, such as healthcare facilities.



At the same time, legal services help address many of the social and structural drivers of health equity, making it a natural next place for payers to think about investing. In at least 7 states, funding for legal services is included in a Medicaid managed care contract or other value-based payment arrangement or innovative delivery system reform model, such as the Delivery System Reform Incentive Payment (DSRIP) Program or Medicaid §1115 waiver. In other states, Medicaid programs like CalAIM support whole-person care approaches to social drivers of health, offering community supports to help with issues like housing. Expanding this coverage to include legal services as part of comprehensive care is a natural next step to address structural drivers as well.



Kate Marple is a Boston-based writer who specializes in helping nonprofit, health care, and legal services organizations develop practices to ensure that the stories they tell are shaped by and benefit people directly impacted by the issue(s) those stories are about. Her website is https://whotellsthestory.org


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