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Medical-legal partnerships: making a difference in children's health care.

A medical mystery: A child lands in the hospital with asthma. The doctor prescribes medicines. The child uses them--properly. Yet, two months later, she is back in the hospital. --Rosenberg (2014)

Over the past couple of decades, there has been increased recognition among the health care community that health is not just a medical problem. We have begun to formally acknowledge and address the social determinants of health, the factors apart from medical care that can be influenced by social policies and can shape health in powerful ways. To put it simply, social determinants of health are the conditions in which people are born, grow, live, work, and age (World Health Organization, 2011).

Causal relationships have been established between many social including socioeconomic--factors and many health outcomes (Bravemen & Gottlieb, 2014). For example, we know that lead ingestion in substandard housing contributes to low cognitive function and stunted physical development in exposed children, and exacerbation of asthma can occur with exposure to pollution and allergens, which are more common in disadvantaged neighborhoods.

Considering the "medical mystery" described above, Rosenberg (2014) suggests, "Maybe the problem is that the child lives alongside mold, insects, and rats. That child doesn't need a doctor--she needs a lawyer, who can persuade, or threaten, the landlord to clean it up."

Many social determinants are legal in nature. Legal needs are adverse social conditions with legal remedies that reside in regulations, laws, or policies. Low-income households average one to three unmet civil legal needs related to income, housing problems, employment, and family issues, and fewer than one in five legal problems are addressed with help from a private or legal aid lawyer (Sandel et al., 2010). Although individuals are guaranteed legal representation in criminal matters, the same does not hold true for individuals with civil law needs. Most problems are left unresolved (Legal Services Corporation, 2007).

Health care is undermined when patients do not receive the benefit of laws intended to address social determinants of health, such as income supports and insurance, housing and utilities, employment and education, legal status, and personal and family stability. For this reason, a growing number of institutions are bringing legal resources on board to help. Today, according to the National Center for Medical-Legal Partnership (NCMLP) (2015), medical-legal partnerships have been established in 262 health institutions in 36 states.

The medical-legal partnership concept was formally developed in the Department of Pediatrics at Boston Medical Center and the Boston University School of Medicine in 1993. Such partnerships are pioneering the practice of preventive law and have three core components designed to improve health: 1) providing legal advice and assistance, 2) improving health care systems, and 3) promoting change outside the system (Sandel et al., 2010).

Positive Outcomes

The actions of medical-legal partnerships have made differences in the lives of children and their health. For example, the Cincinnati Child Health-Law Partnership (Child HeLP) in Cincinnati, Ohio, identified a pattern of referrals for poor-quality housing from patients living within a portfolio of 19 building complexes owned by a common firm (Beck et al., 2012). The first case in the fall of 2009 involved a mother with two children cared for at a Cincinnati Children's Hospital pediatric primary care center. Both children had a previous diagnosis of asthma, and now one was diagnosed with an elevated lead level. During a well-child care visit, the family reported a pest infestation, peeling paint, and water leakages, and was referred to Child HeLP.

In May of the following year, a physician referred the family of another child with asthma to Child HeLP:
      The child's mother described the
   presence of mold. She also presented a
   letter from her landlord stating that
   she would be evicted if she installed an
   air-conditioning unit in her child's
   bedroom. Three similar referrals were
   made in the 6 weeks that followed.
   Early in July 2010, Child HeLP staff
   recognized that these and other recent
   referrals all originated from families
   living in buildings owned and managed
   by a single out-of-town developer.

Attorneys worked with families to pursue a legal strategy appropriate to their social and environmental situation. As a result of Child HeLP's efforts, of the 14 case units for which outcome data were available, repairs and abatements were completed in 10, and six families were relocated to a safer, up-to-code apartment. Four building complexes received complex-wide mold removal, pest abatement, and window repairs. The Legal Aid Society of Greater Cincinnati helped families form tenant associations, and as a result, 11 of the 19 complexes received significant systemic repairs (e.g., installation of new roofs, ceilings, and drywall; integrated pest management; replacement of sewage systems; refurbishment of air-conditioning and ventilation systems; replacement of hallway lights; repair of playground equipment).

Children's Healthcare of Atlanta, Georgia State College of Law, and the Atlanta Legal Aid Society also report positive outcomes from its medical-legal partnership. In a study on the impact of the MLP on children with sickle cell disease, Pettignano, Caley, and Bliss (2011) list benefits, such as obtaining Social Security insurance or other health benefits, acquiring food stamps, family stability, employment, housing, and/or education (e.g., getting appropriate education accommodations).

Leading organizations in law and medicine are providing visible support for the MLP concept. In 2008, for instance, the American Academy of Pediatrics (AAP) passed a resolution in support of medical-legal partnerships (Gitterman & Sandel, 2008). The resolution specifies that the AAP encourage closer and more frequent collaboration between legal served and medical professionals, and promote medical-legal partnerships.

Nurse-MLP Initiative

In July 2013, the National Nursing Centers Consortium received a three-year, $600,000 grant from the Kresge Foundation to expand medical-legal partnerships into its network of over 200 nurse-lead health centers across the country. The initiative is a partnership between the National Nursing Centers Consortium (NNCC), Philadelphia's Legal Clinic for the Disabled (LCD), Family Practice and Counseling Network (FPCN), and the National Center for Medical-Legal Partnerships (National Center).

At least three MLPs will be operating in nurse-managed settings across the country at the end of the three-year grant period. The Nurse-MLP Initiative will also recommend best practices based on evaluations conducted and experience gained throughout the project.

The Future

Mounting evidence suggests that the effects of medical care may be more limited than commonly thought, particularly in determining who becomes sick or injured in the first place (Adler & Stewart, 2010; Braveman, Egerter, & Williams, 2011; Braverman, Egerter, Woolf, & Marks, 2011). One review of the impact of social factors on health estimates that medical care is responsible for only 10% to 15% of preventable mortality in the U.S. (McGinnis, Williams-Russo, & Knickman, 2002).

According to the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, in the future, interprofessional collaboration and coordination will be the norm. In July 2014, the U.S. Human Resources Services Administration (HRSA) awarded the NCMLP a three-year National Cooperative Agreement (NCA) to cultivate and support more medical-legal partnerships at community health centers across the country. Let's welcome our legal partners and the significant contribution they offer to help assure that what we do has the greatest benefit for the children and families we serve.


Alder, N., & Stewart, J. (Eds.). (2010). The biology of disadvantage: Socioeconomic status and health. New York, NY: John Wiley & Sons.

Beck, A., Klein, M., Schaffzin, J., Tallent, V., Gillam, M., & Kahn, R. (2012). Identifying and treating a substandard housing cluster using a medical-legal partnership. Pediatrics, 130(5), 831-838.

Braveman, P., Egerter, S., & Williams, D. (2011). The social determinants of health: Coming of age. Annual Review of Public Health, 32, 381-398.

Braveman, P., Egerter, S., Woolf, S., & Marks, J. (2011). When do we know enough to recommend action on the social determinants of health? American Journal of Preventive Medicine, 40(1, Suppl. 1), S58-S66.

Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It's time to consider the causes of the causes. Public Health Reports, 2(129), 19-31.

Gitterman, B., & Sandel, M. (2007). Medical-legal partnership: Promoting child health through preventative law. Retrieved from wp-content/uploads/2014/02/AmericanAcademy-of-Pediatrics-MLP-Resolution.pdf

Legal Services Corporation. (2007). Documenting the justice gap in America. Washington, DC: Author.

McGinnis, J., Williams-Russo, P., & Knickman, J. (2002). The case for more active policy attention to health promotion. Health Affairs (Millwood), 21, 78-93.

National Center for Medical-Legal Partnership (NCMLP). (2015). Main page. Retrieved from

Pettignano, R., Caley, S., & Bliss, L. (2011). Medical-legal partnership: Impact on patients with sickle cell disease. Pediatrics, 128(6), e1482-e1488.

Rosenberg, T. (2014, December 11). Big ideas in social change, 2014. The New York Times. Retrieved from http:// 11 /big-ideas-in-social-change-2014/ ?_r=0

Sandel, M., Hansen, M., Kahn, R., Lawton, E., Paul, E., Parker, V., ... Zuckerman, B. (2010). Medical-legal partnerships: Transforming primary care by addressing the legal needs of vulnerable populations. Health Affairs, 29(9), 1697-1705.

World Health Organization. (2011). What are the social determinants of health? Retrieved from social_determinants/sdh_definition/en/
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Title Annotation:From the Editor
Author:Rollins, Judy A.
Publication:Pediatric Nursing
Article Type:Editorial
Geographic Code:1USA
Date:Jan 1, 2015
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