Founded in 1989 as one of the pioneer clinics at the East Bay Community Law Center (EBCLC), the Health & Welfare Practice provides holistic legal services through a medical-legal partnership model to improve the health and well-being of vulnerable individuals. Our experience over the last three decades has taught us that when we partner with medical providers, we are better able to address the underlying social causes of poor health, which include poverty, homelessness, and minimal access to health care.
But what is a medical-legal partnership? A medical-legal partnership is a collaboration among doctors, nurses, social workers, and legal services providers, such as paralegals and attorneys, to improve the health outcomes of patients. Good health is not limited to going to the doctor and getting your shots. Sometimes, what affects a patient’s health the most goes beyond what a doctor can treat in an office or hospital setting, such as safe housing conditions or access to income.
So how does a medical-legal partnership work in practice? Three years ago, sixteen-year-old Miguel met with his primary care physician for a routine checkup. He had a history of mental health impairments stemming from past trauma, including depression, anxiety, and obsessive-compulsive disorder. During the appointment, the doctor asked Miguel and his mother, Cecilia, about their home situation. The physician learned that Miguel had been out of school for months because the school district did not believe it was equipped to handle Miguel’s mental health issues. In addition, Miguel’s family had just received a ten-day notice to vacate their rented home because it had been purchased by a developer. Because Miguel could not attend school, his mother needed to stay home to watch over him. Therefore, Cecilia could not work and, as a result, the family did not have the resources to find a new place to rent or even to cover moving costs. The doctor consulted the clinic’s social worker who referred the case to the Health & Welfare Practice for a holistic legal intake with a law student.
Working hand in hand, the medical team at UCSF Benioff Children’s Hospital Oakland (CHO) and the legal team at EBCLC partnered and ultimately bettered the family’s housing, income, and educational outcomes. This, in turn, vastly improved Miguel’s and Cecilia’s health outcomes as well. On intake, we learned Cecilia had applied on Miguel’s behalf for In-Home Supportive Services (IHSS), but a county worker told her that Miguel was not eligible and closed the case. IHSS is a program that pays for a chore provider, oftentimes a parent or family member, to care for those with disabilities so that they may remain safely in their homes. When we at the Health & Welfare Practice intervened, Miguel’s application for IHSS was reopened, and ultimately we succeeded in obtaining retroactive approval for IHSS. Cecilia began to earn money through the IHSS program as Miguel’s provider.
Further demonstrating EBCLC’s commitment to holistic cross-practice services, we in the Health & Welfare Practice engaged EBCLC’s Housing Practice to provide Cecilia with help negotiating with their landlord. Guided by a Housing Practice attorney, we negotiated with the landlord to get nearly $7,000 and a two-month extension to move out for Cecilia. Furthermore, an EBCLC attorney in our Education Defense & Justice for Youth (EDJY) practice assisted us in successfully advocating for Miguel’s educational needs going forward. Along with Miguel’s psychiatrist, we attended an Individualized Education Program (IEP) meeting where the school district approved one-on-one tutoring to help make up for Miguel’s lost schooling. Also, in response to a compliance complaint that we filed, the California Department of Education ordered the school district to provide 114 hours of compensatory one-on-one home instruction.
I. The Health & Welfare Practice’s Beginnings: HIV/AIDS Law Project (1989–2005)
The Health & Welfare Practice developed its holistic and interdisciplinary approach starting with the HIV/AIDS crisis in the late 1980s. EBCLC applied the lessons learned from that successful model to other contexts and other practice areas.
Long before the term “medical-legal partnership” or “MLP” was ubiquitous in legal aid grant reports, EBCLC served the HIV/AIDS community by partnering with medical providers because it was effective at addressing the underlying social conditions of poverty. This interdisciplinary and holistic model has influenced our work throughout the years and continues to be the underlying philosophy of our collective practice. But in the beginning, to many who were involved, the partnership was not intuitive. Doctors were wary of lawyers even when those lawyers claimed to be helping the doctor’s patients.
Jeff Selbin, now the director of Berkeley Law’s Policy Advocacy Clinic, founded EBCLC’s HIV/AIDS Law Project in 1989. Through a Skadden Fellowship, Selbin sought to respond to the complex needs of low-income individuals living with HIV/AIDS. In those days, our clients living with HIV did not expect to survive. In addition, our clients endured persistent stigma that kept them in the shadows. Selbin believed that one effective way to serve the HIV+ community was to partner with their medical providers who were already treating them for HIV. “I invited Kathleen Clanon [director of Highland Hospital’s Adult Immunology Clinic] to lunch. When she said she didn’t work over lunch, I understood her to mean she wasn’t interested in meeting with a lawyer,” Selbin said.
However, those same doctors noticed that the stress of becoming sick, losing jobs, being evicted, and planning for death, exacerbated their patients’ illness. As Selbin and his students helped their patients get disability benefits, made house and hospital visits, and encouraged patients to stay in care, the medical providers started to come around. “I guess we wore [them] down . . . I think we won them over by making a difference in their patients’ lives,” he said.
Once the doctors and lawyers started working with one another, everyone involved saw better outcomes for their clients. “The doctors couldn’t treat someone’s health problems if they didn’t have a roof over their heads or something to eat. And we couldn’t get people the income and health care benefits to which they were entitled if they didn’t have records documenting their medical condition,” Selbin explained.
As the communities affected by the HIV epidemic began to change in the mid-1990s, so did EBCLC’s approach to providing services. In 1997, the HIV/AIDS Law Project was invited to join the Family Care Network (FCN) as the legal services provider. The FCN was a local coalition of medical providers and community-based organizations that reduced the barriers to services encountered by HIV+ women and their children. At the time, rates of HIV were growing among women, and they faced unique challenges in accessing care and staying healthy.
Holistic and interdisciplinary legal services continue to be necessary for folks living with HIV even as antiretroviral medications have changed the outlook for many of our clients. These days, when treated properly, HIV can be a chronic condition instead of a terminal illness. In addition, from a public health perspective, those who remain in care are less likely to transmit HIV to someone else. But folks must have access to the ongoing medical care that keeps them healthy. Keeping up with medicine regimens, which typically involves several doses of medication daily and frequent medical appointments, is deeply impacted by our clients’ stability. If a client is at risk of losing their housing, losing their income, or losing their immigration status, they are less likely to remain in care and more likely to become unhealthy. Therefore, even as the experiences of those living with HIV have changed, our practice continues to provide holistic legal services.
The holistic nature of the work enabled the HIV/AIDS Law Project to be a laboratory for new practice areas at EBCLC. EBCLC’s Immigration Practice and Education Defense and Justice for Youth program grew out of work serving folks living with HIV. Originally, EBCLC only took immigration and youth cases for our HIV+ clients, but as the need for both services grew, those practices broke off and became their own units.
II. MLPs: CHO, HAs, and DULCE (2006–Present)
The first seventeen years of navigating medical and social systems through our HIV/AIDS Law Project also laid the groundwork for future partnerships.
In the 2000s, UCSF Benioff Children’s Hospital Oakland (CHO) invited EBCLC to partner with them on a medical-legal partnership to meet the varied legal needs of children with disabilities and their families. In 2006, that partnership began and the HIV/AIDS Law Project became the Health Practice (which later merged with the Welfare Practice to become the Health & Welfare Practice). Our clients are children who receive care at CHO, mostly between ages zero and six, with developmental, social-emotional, and medically-related vulnerabilities. Like our HIV/AIDS clients, the health of these children and their families is exacerbated by the toxic stress of unstable housing, income, and immigration status. We work in particular with the social workers at CHO whom we teach to screen for legal needs. The social workers also act as a liaison between the legal workers and the nurses and doctors.
A different take on our Medical-Legal Partnerships (MLP) model has evolved through our collaboration with the Health Advocates of Alameda Health System, Alameda County’s public health care system. The Health Advocates are a team of undergraduate volunteers who serve patients of Highland Hospital, Fairmont Hospital, and Hayward Wellness Center. In 2013, we set up a folding table at the Emergency Department (ED) entrance of Highland Hospital. Following our clinical model, we trained and supervised undergraduate volunteers as they screened for social and legal issues in the ED waiting room. Often, the volunteers spent hours at a time trying to find someone shelter for the night. They also routinely signed up patients for housing waitlists and screened them for public benefits eligibility. When a legal issue arose, we escorted our clients to the semi-private financial advising cubicles behind the ED waiting room.
Within two years, the volunteer desk was named the Health Advocates (HAs), and our medical-legal partnership with Alameda Health System was formalized. As with EBCLC’s other MLPs, this partnership worked to assist individuals and families with a range of legal issues including public benefits, immigration, housing, and health insurance. And as EBCLC does with social workers in our other MLPs, we train the HAs to ask the right questions to detect legal issues for a referral to the Health & Welfare Practice. Once a case is referred to us, we meet with the client on-site or a law student calls the patient to perform a holistic legal intake.
More recently, EBCLC’s Health & Welfare Practice has partnered with the Pediatrics Clinic at Highland to work with newborns and their families. Since 2015, we have been working with the Center for the Study of Social Policy, First 5 Alameda County, and five other MLP sites throughout the country to pilot Project DULCE (Developmental Understanding and Legal Collaboration for Everyone). Through DULCE, a family specialist at Highland’s Pediatrics Clinic works with parents of newborns and espouses the dual goals of improving child development and reducing family stress. As the legal partner, EBCLC’s Health & Welfare Practice provides consultation to the family specialist as she screens patients for legal issues. We also attend weekly DULCE case rounds where we join pediatricians and social workers to troubleshoot social issues. Through this practice, we have resolved medical insurance issues for moms and babies, helped put parents on the path to lawful immigration status, interrupted evictions, and recovered past-due food stamps benefits.
III. Our Latest Project: Name and Gender Change Workshop (2016–Present)
Throughout the Health & Welfare Practice’s history, we have expanded the services we provide to be more holistic and inclusive of the communities we are serving. In 2016, we started to offer services specifically for transgender people. Given the high rates of HIV among transgender people and the number of transgender clients we were seeing through our HIV work, it became apparent that we were not adequately reaching folks in the transgender community. We also recognized that it would take time and work to create a safe space for the community at EBCLC and to integrate services for transgender people in all practice areas. As a first step in that direction, EBCLC’s Health & Welfare Practice founded the Name and Gender Change Workshop (NGCW) in 2016.
The NGCW offers assistance to folks who are navigating the process of changing their name and gender on identification. For many transgender people, updating their name and gender marker is an important part of their transition. But it can be a confusing, frustrating, and expensive process. Typically, the paperwork to update one’s name and gender in California requires filling out around twelve pages of forms. Once those forms are submitted to the court, there is usually a filing fee of around $435 and a hearing scheduled for months later. After the hearing, assuming the name and gender change order is granted, folks have to make individual trips to the Social Security Administration, the DMV, the State Department, and their birth state’s Department of Vital Records to update their social security card, driver’s license, passport, and birth certificate, respectively. Each agency has its own application process, forms, and fees.
And these are only the most common forms of identification documents that require updating. There may be more. Each time transgender individuals interact with any of these government bodies, there is a reasonable fear of discrimination or harassment. The NGCW helps clients navigate this process and introduces them to EBCLC and the services that we provide.
On the part of the students who staff the NGCW, the workshop also has strengthened the sense of community among LGBT students and their classmates interested in LGBT issues. It is another opportunity to work alongside like-minded folks, and those relationships and professional skills continue beyond EBCLC.
IV. The Future
The Health & Welfare Practice continues to evolve its interdisciplinary and holistic approach to improve the health outcomes for its clients and to be a laboratory for EBCLC. In the current political climate, we anticipate that we will have to respond to attacks on social safety net programs under the Trump Administration, including attempts to weaken the Affordable Care Act (ACA) and the imposition of work requirements on Medicaid and the Supplemental Nutrition Assistance Program (SNAP). In addition, we have already begun to collaborate more deeply with the Immigration Practice because of growing fear among immigrants that they will be deported for using social safety net programs and to advise immigrants about their rights and family preparedness should they end up in immigration detention. As the needs of our clients change, so will our services and the ways in which we provide them.
Erin Le: Interim Director of the Health & Welfare Practice, East Bay Community Law Center (EBCLC).
Daniel Faessler: Staff Attorney and Clinical Supervisor, East Bay Community Law Center (EBCLC).
. HIV rates among transgender people are significantly higher compared to that of the general population. When the data is broken down by race and gender, the rates are even more startling. Some studies have shown that the rate of HIV for black transgender women is around 56%. Jeffrey H. Herbst et al., Estimating HIV Prevalence and Risk Behaviors of Transgender Persons in the United States: A Systematic Review, 12 AIDS and Behavior 1, 1–17 (2008).
Recommended Citation: Erin Le & Daniel Faessler, Holistic Healing: From Medical-Legal Partnerships to Future Collaboration with Community-Based Organizations, 9 Calif. L. Rev. Online 22 (Nov. 2018), https://www.californialawreview.org/holistic-healing-from-medical-legal-partnerships-to-future-collaboration-with-community-based-organizations.