Drawing upon recent evidence generated in the pediatric and early childhood landscape, the piece:
Orients readers to the concept of preventive law and why – alongside preventive health care – it is essential for health, wellbeing and dignity yet is out of reach for so many people.
Lauds the promising evidence generated over the last 15 months by two initiatives – DULCE and Housing Prescriptions as Health Care – that integrated legal rights education within interdisciplinary care teams. (MLPB was the team-facing legal partner in the original DULCE trial and in the Housing Prescriptions pilot – a capacity-building role that is unique and distinct from the more familiar legal role of providing direct representation/case handling.)
Reinforces that legal problem-solving is not the exclusive province of licensed attorneys; rather, many care team members can responsibly share empowering legal information with the people they serve.
Urges close attention to legal partner recruiting since conflicts of interest can and do arise between systems and the people they serve.
“Investing in legal rights education is critical for effective social care – this goes well beyond dominant ‘screen-and-refer’ protocols and not only strengthens team-based care, but surfaces where system and policy change are urgent,” said Jeannine Casselman, MLPB’s Law & Policy Director.
Morton will present on the blog’s themes on Wednesday, 6/9/2021 at 11:15am EST/ 8:15am PST as part of the National Virtual Health Equity Summit, a convening drawing 6K+ attendees. Registration (which is free) is open here. Also, on Monday, June 21 at 3pm EST / 12n PST, MLPB will host a one-hour virtual public event – Strengthening the Social Care Toolbox with Legal Rights Education – featuring colleagues from both DULCE and Housing Prescriptions as Health Care. Registration information is available here.
About MLPB: MLPB pioneered team-facing legal partnering, which equips communities of care with legal education and problem-solving insight and fosters prevention, health equity and system change. Human-centered care must systematically account for people’s legal rights, risks and remedies; and empower care team members to be active partners in legal problem-solving in scope-of-practice-aligned ways. Through training, consultation, telementoring and technical assistance, MLPB helps teams and organizations understand their power to unlock access to health-promoting resources and legal protections. MLPB stands independent of any health, legal or academic institution, operating under the 501(c)(3) umbrella of TSNE MissionWorks and serving partners in MA, RI and nationally through the DULCE Learning Network and other initiatives. www.mlpb.health
I’ve been honored to attend the DULCE National Forum this week, during National Public Health Week (NPHW) 2021. Wednesday’s NPHW theme was Strengthening Community, and spending that day with members of the growing national DULCE Learning Network was a perfect fit.
DULCE (Developmental Understanding and Legal Collaboration for Everyone) is a universal, evidence-based pediatric care approach. It supports healthy newborn development, partners with families of infants to meet their social needs and promotes healthy communities.
all of whom are committed to working with – and trusting-building with – each other in new and different ways. DULCE planning and implementation currently is underway in 9 states (CA, FL, KY, MI, MS, NJ, RI, VT, WI).
The theme of the National Forum was Building for the Future: Promoting Family Resilience. Centering Anti-Racism. Sustaining our Work, and the gathering launched with a Fireside Chat with Dr. Joia Adele Crear-Perry, Founder and President of the National Birth Equity Collaborative. Dr. Crear-Perry spoke to a range of strategies that can promote optimal, healthy births for all moms and babies – and how those strategies must account for racial and social inequities that have long harmed Black maternal and infant health.
Yesterday, Kay Johnson of Johnson Group Consulting, Inc. presented on the centrality of Medicaid policy in reducing racial disparities in child and family health and well-being. She also noted DULCE’s many intersections with the American Rescue Plan Act (APRA) of 2021. Among other things, the APRA expands the Child Tax Credit in ways that set the stage for a potential child allowance (a form of guaranteed minimum income). This kind of policy evolution could be transformative for families with young children for whom the “Math of Life” does not add up, due to entrenched barriers to income and wealth-building.
These are critical developments and calls to action. We must optimize life course health for all, meaning that we should strive for a new equilibrium between primary prevention (public health), primary care (including OB/GYN) and complex care in ways that hopefully avoid zero-sum-framed resource battles. And this means, among other things, re-balancing how parents and caregivers, infants, children and youth figure into healthcare system priority-setting in new and deeper ways.
DULCE is an important, and momentum-ful, step in this direction. Interested in exploring DULCE in your community? Contact Azieb Ermias, Senior Program Analyst at the Center for the Study of Social Policy, at firstname.lastname@example.org.
Against this backdrop, planning for telehealth in the social care context should proceed both with urgency and with carefulness. This kind of care cannot be deployed responsibly – taking care to minimize risk of harm to human beings – without adequate supports for the health workers who are navigating uncharted virtual waters with people experiencing homelessness, immigration-related concerns, gas and electricity shut-off, and domestic violence and sexual assault, among other things. The stakes are incredibly high for individuals, families and communities – and the workforces who partner with them.
On the one hand, if care teams keep their distance from social health because they lack (or perceive they lack) problem-solving tools, people will further suffer negative social, economic and environmental consequences. We cannot accept that kind of outcome, even while health and human service policymakers hash out how collective responsibility for social health care and financing should be allocated across sectors and budgets.
On the other hand, when we ask care teams to lean into a new frontier like social health, they must be supported with, among other things:
Accurate information about people’s legal rights, risks and remedies in a dynamic and complex landscape;
Telehealth and telementoring are related, but different. A telehealth relationship is between a healthcare worker and patient, and the provider/worker delivers health care to the patient during a telehealth encounter. In contrast, a telementoring relationship is between a healthcare worker – often a primary care provider/team member – and a subject matter specialist. During the telementoring encounter, the specialist – like a psychiatrist – is deepening the provider’s/team member’s capacity to deliver quality care to patients.
As the only independent program in the country exclusively dedicated to offering communities of care with team-facing legal support (as opposed to patient-facing legal services), MLPB has been well-positioned to offer telementoring on social health topics to Community Health Team members. Through this partnership:
MLPB offers its Unlocking Access trainings to the CHT workforce, spotlighting common barriers people confront when trying to meet health-related social needs, as well as scope-of-practice-aligned legal problem-solving strategies a community health workforce can offer to people.
An MLPB team member virtually integrates within standing CHT Best Practice meetings to provide care team members – on a continuous basis aligned with a community of practice framework – with key legal information and coaching on role-aligned problem-solving strategies they can offer to patients.
MLPB also is available for on-demand telementoring consults with CHT members and their supervisors.
From a system design/change perspective, we are thrilled to support the work of the Rhode Island Telemedicine Project. MLPB’s Legal Director Jeannine Casselman serves on the project’s Steering Committee and brings a social health and legal problem-solving lens to this ongoing design and learning process.
A Case Study:
Legally-Informed “Triage” with a CHT member*
At a recent Best Practice Meeting, a CHT colleague presented a complex case involving a patient who suffered a work-ending injury. In addition to the profound medical and employment aftermath, the patient was struggling to secure worker’s comp benefits, navigating potential foreclosure, and trying to fix a long-standing error in a pivotal identity document.
Not surprisingly, it felt daunting to develop a social care plan that would be effective and humane. Merely trying to establish priorities with the patient – in ways that would honor their autonomy! – was difficult because many of these needs/barriers are legally interdependent. Even if the patient wanted to prioritize one goal over all others, the CHT member might need to educate the patient about why tackling that top goal successfully would be contingent on addressing another item.
MLPB’s ambassador partnered with the CHT member to support their development of a care plan that accounted both for the patients’ goals and for a number of legal contingencies they might encounter during the problem-solving journey. MLPB’s social health telementoring took place during a virtual Best Practice Meeting as well as multiple follow-up 1:1 consults between the CHT worker and MLPB – devoted not only to clarifying what kind of problem-solving was in-bounds, not out-of-bounds, for the CHT member, but also to supporting sound expectation management with the patient about where the law was, and wasn’t, on their side.
With this support and coaching, the CHT member was more empowered to provide quality, human-centered social health care to this patient, and now could cross-pollinate the learning from this MLPB telementoring to their work with many other patients!
*Some information has been changed to assure de-identification.
This team-facing legal partnering investment is an important step toward ensuring that people’s legal rights, risks and remedies are accounted for in community health-centered care planning and delivery.
We are excited to dream big with our CTC-RI/PCMH Kids colleagues and other stakeholders about how this low dose of legal partnering can be scaled to support a high dose of high-impact CHT contributions to the health of Rhode Islanders and the Ocean State!
This is a challenging time for progress on equitable, inclusive, fair housing in our country.
If you’re unfamiliar with this term of art, “fair housing” – sometimes known as “equal opportunity housing” – refers to the ability to access housing without experiencing unlawful discrimination. This principle underlies the 1968 Fair Housing Act, which codified many important policy reforms necessary to reverse long-standing residential segregation.
One of us – Salin – served in the Obama Administration in 2015 when HUD issued a new regulation to implement the Fair Housing Act’s affirmatively furthering fair housing (AFFH) requirements. The regulatory “re-fresh” offered stronger guidance for municipalities (cities, counties, states, and public housing agencies) on how they could “[take] meaningful actions to overcome historic patterns of segregation, promote fair housing choice, and foster inclusive communities that are free from discrimination.”
The AFFH promised to be a powerful lever for system change at the state and local level. However, as Salin described during MLPB’s annual event on May 13, 2020, the public comments submitted in connection with the proposed regulatory revision were dominated by “racist screed.” This was a precursor to the racism that revealed itself in the 2016 Presidential campaign and stoked xenophobic fears. Now, in lead-up to the 2020 election, these harmful messages are being amplified, through for example the Administration’s recent statements about how fair housing regulations will be used to destroy the “suburbs.” Suburbs once were havens of white flight and past creations of discriminatory federal housing policy. Ironically, the suburbs have increasingly become more diverse.
Through the Department of Homeland Security, implemented a new Public Charge rule that discourages immigrant households from applying for federal subsidized housing for which they may be eligible
Collectively, these policy shifts disadvantage Black and Latinx families, families of color, and marginalized youth in profound ways. And all of this is happening against the backdrop of staggering pandemic-worsened material hardship (losses of employment, income, housing, and more) that is creating an ”avalanche” of evictions nation-wide. These hardships – including but not limited to evictions – are also playing out in ways that exacerbate racial injustice as well as the prevalence of adverse childhood experiences.
Will we fulfill the promise of the American civil rights movement in relation to surging demands for system disruption that will deliver greater equity, justice and opportunity? Segregation is not destiny. It has been our past, and there are powerful forces arrayed to preserve it into the future. However, we must work to create equitable, inclusive, healthier communities where everyone can prosper and belong. It will take courage to prioritize fair, equitable, and inclusive housing for all.
On the morning of Wednesday, May 13th, MLPB convened a (BYO) Breakfast on the topic of Old or New, “Normal” Hasn’t Cut It: Innovative Strategies to Promote Housing Stability Among Families with Young Children. In recent months, the COVID-19 pandemic has expanded awareness of the profound inequities that exist in the US, including the struggle for families to access safe and stable housing. MLPB recognizes that a deeply-rooted problem of this size requires an equally broad and multisector solution. As such, we convened thought leaders specializing in family housing stability innovations at the household, systems, and policy level, based on a version of Thomas Frieden’s Impact Pyramid, that was adapted and featured in a Sep. 2019 brief authored by Samantha Morton of MLPB with Stephanie Doyle ofThe Center for the Study of Social Policy (CSSP). The panelists provided a blueprint to over 100 participants, representing health administration, social work, community health workers, community organizers and more, of how to work together in new ways to promote stable housing for families.
At the household level of impact, moderator Baraka Floyd of Stanford School of Medicine & MLPB guided a conversation between panelists Allison Bovell-Ammon, Director of Policy Strategy, Children’s HealthWatch at BMC and MLPB’s own Legal DirectorJoHanna Flacks. Allison and JoHanna spoke primarily about their work with Housing Prescriptions as Health Care, a research study funded by The Boston Foundation. In this randomized controlled trial, families with complex medical needs were divided among two groups:
The experimental “Housing Prescriptions” group received what Allison termed a “wrap-around set of services,” in the form of care that integrated legal problem-solving insight from MLPB as well as case management and financial counseling provided by partners represented in the photo to the right.
The control “Resource List” group received the current standard of care in the form of informational lists.
Initial findings from this study were recently published in Health Affairs and include comparative data on improvements in parent/caregiver mental health and child health scores. Allison noted that, “at six months, the majority of families in the intervention had not moved into a form of stable housing…but what we saw and what parents reported qualitatively was that having someone on their team, having someone walk through this process with them, to hear their concerns really made a difference…the problems seemed now solvable.” Housing Prescriptions adds to the body of evidence supporting a more holistic approach to health and the crucial role an interdisciplinary care team can play in accelerating measurable gains in a family’s well-being.
In the second panel focused on system-level impact, moderator Jeannine Casselman, Legal Advisorat MLPB, spoke first with Brenda Clement, Director of HousingWorks RI at Roger Williams University. Brenda described HWRI’s efforts to bring together programs and resources — including government, healthcare, private and public housing systems — to improve systems intended to promote housing access for families. She acknowledged that the great complexities of these systems can be a barrier to those navigating them. Brenda also highlighted the Housing Fact Book that HWRI publishes every year to track housing affordability in RI. This valuable resource is curated by HWRI and its partners and is a living example of how different institutions can unite to create comprehensive resources that further housing stability by demystifying a complex landscape that impacts so many families.
Housing-related data also was at the center of Jeannine’s discussion with Soojin Conover, Senior Data Analyst, and Yusuf Ali, Network Coordinator, both of Vital Village Network at BMC. Both panelists spoke of their work on Vital Village’s Community Housing Data Tool. This tool is designed provide data maps so that Boston families can access data maps to inform their housing stability and safety choices. According to Soojin, “by linking health and housing data in the Boston area, this tool shares relevant data maps with Boston families.” For example, if a family is looking for housing in Boston, they can search for data such as needle pickup requests, crime density, and blood lead levels to help them determine the safety of the neighborhood. The tool was created in response to feedback from VV’s community, and VV also leveraged relationships across their network to access data such as the lived experiences of single dads and returning citizens to ensure data integrity and usefulness. In addition, MLPB shared a framework with VV to transform the data from random points to categorized points along a continuum of legal, health, and housing needs. The Community Housing Data Tool emphasizes how data sets are a powerful network that has great potential for community-driven systems change.
MLPB’s CEO, Samantha Morton, moderated the third and final panel focusing on policy-level impact. Salin Geevarghese, President & CEO of SGG Insight, LLC and Senior Fellow at CSSP was up first and reflected on his experience as a leader in the Obama administration’s 2015 effort to strengthen the affirmatively furthering fair housing (AFFH) requirements of the 1968 Fair Housing Act. Salin’s account highlighted how individual and structural racism continues to pervade housing policy in the U.S., and he reported that during the public comment period for the proposed new AFFH rule, “three quarters of the [public] comments were pure racist screed.” He also reinforced “the big caveat that we all have to wrestle through is that knowing doesn’t substitute for political will when we are speaking about racial equity.”
The conversation then segued to Emily A. Benfer a Visiting Associate Clinical Professor & Director of the Health Justice Advocacy Clinic at Columbia Law School and her national work around eviction moratoria. Her efforts have taken on a greater significance given COVID-19’s impact on employment rates, income, and therefore housing, as people struggle to pay rent or mortgages. Emily partnered with law students to “analyze moratorium documents nationwide and thousands in-state and partnered with the Eviction Lab to create a Housing Policy Scorecard.” Like Vital Village’s Community Data Tool, this scorecard uses data from multiple sources and assesses the strength of eviction protections across the US. The scorecard reveals that eviction and foreclosure protections vary greatly even in geographically close states such as MA and RI and that there are many areas where new policies can help bring relief to renters and homeowners. In addition to spotlighting the need for more housing instability screening, better usage of tools such as telemedicine, and expanding access to justice, she stressed that ‘nonprofits, churches, hospitals are all critical for housing stability,” returning again to the idea that a problem with multiple dimensions also will require a solution with multiple dimensions.
The final panelist of the (BYO) Breakfast was Kristina Contreras Fox a Policy Analyst at RI Coalition for the Homeless. Her organization anchors many shelters and service providers throughout the state, and they “seek to be the bridge between people who are affected by policy and people who are making policy.” They have dedicated themselves to bringing Rhode Islanders who have or are experiencing homelessness into the policy-making process to ensure that their voices are heard and that policies will truly meet their needs. Like Salin, Kristina also called out the racialized context of the pandemic, providing data that 46% of all RIs who have tested positive for COVID-19 are LatinX and 75% of LatinX Rhode Islanders are renters and that they will be disproportionately impacted once evictions resume. Kristina concluded her remarks on policy and equity with an urging all attendees to join in advocacy by calling upon their policymakers to support a range of housing protections.
The breadth and depth of ideas and actions on display at the Breakfast was inspiring. A common theme was how siloed many sectors and services remain in 2020 – with persistent health and housing harms to families with young children. MLPB is proud and gratified to partner with healthcare organizations, housing authorities, public health commissions, and early childhood programs, among many others, and eager to welcome new partners invested in expanding their legal problem-solving ‘toolbox.’ For next steps in this important work, see below!