MetroDoctors Nov/Dec 2019: Healthcare-Legal Partnerships

November/Dec 2019

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Uniting Our Strengths

Healthcare-Legal Partnerships

In This Issue: • • • •

HLP/LawHelpMN – Resource Insert 2019-20 Public Health Advocacy Fellowship Sharing the Experience Conference Luminary of Twin Cities Medicine

“Your patients will thank you for referring them to Dr. Crutchfield.”

A FAC E O F A M I N N E SOTA DE R M ATOL O GIST Recognized by physicians and nurses as one of the nation’s leading dermatologists, Charles E. Crutchfield III MD has received a significant list of honors including the Karis Humanitarian Award from the Mayo Clinic, 100 Most Influential Health Care Leaders in the State of Minnesota (Minnesota Medicine), and the First a Physician Award from the Minnesota Medical Association, for positively impacting both organized medicine and improving the lives of people in our community. He has a private practice in Eagan and is the team dermatologist for the Minnesota Twins, Wild, Vikings and Timberwolves. Dr. Crutchfield is a physician, teacher, author, inventor, entrepreneur, and philanthropist. He has several medical patents, has written a children’s book on sun protection, and writes a weekly newspaper health column.

Dr. Crutchfield regularly gives back to the Twin Cities community including sponsoring academic scholarships, camps for children, sponsoring programs for children with dyslexia, mentoring underrepresented students from the University of Minnesota, and establishing a Dermatology lectureship at the University of Minnesota in the names of his parents, Drs. Charles and Susan, both pioneering graduates of the U of M Medical School, class of 1963.

As a professor, he teaches students at both Carleton College and the University of Minnesota Medical School. He lives in Mendota Heights with his wife Laurie, three beautiful children and two hairless cats.

AES

THET I C

L OF APPROVA L SEA

CRU TCHFIELD DERMATOLO GY

CRUTCHFIELD DER MATOLOGY Experience counts. Quality matters.

Mayo Clinic Medical School Graduate | University of Minnesota Dermatology Trained Top Doctor Minneapolis St. Paul Magazine | Best Doctors for Women Minnesota Monthly Magazine Team Dermatologist for the Minnesota Twins, Vikings, Timberwolves and Wild 1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

CONTENTS 3

An Interesting Collaboration — and it Works!

By Richard R. Sturgeon, MD

4

PRESIDENT’S MESSAGE

Welcoming the Class of 2023

By Ryan Greiner, MD

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Page 32

VOLUME 21, NO. 6 NOVEMBER/DECEMBER 2019

IN THIS ISSUE

TCMS IN ACTION

By Ruth Parriott, MSW, MPH, CEO

6

HEALTHCARE-LEGAL PARTNERSHIPS

• Healthcare-Legal Partnerships: The Power of Collaboration

By Matthew Hunt, MD

8

• Helping Professions Unite for Community Impact

By Amos Deinard, MD, MPH and Theresa Murray Hughes, JD

13 • Colleague Interview: A Conversation with Eileen Weber, DNP, JD, BSN, PHN, RN 16 • Justice is Good Medicine

By Christopher Wendt, JD Page 18

18

• Minnesota’s Cancer Legal Care is Tackling Financial Toxicity

By Jennifer Kuyava, MD and Lindy Yokanovich, Esq.

20 • Preventive Care for the Social Determinants of Health: Medical-Legal Partnership in a Community Health Center

By Laura Pattison, MD 22

• SPONSORED CONTENT:

Delivering Quality Refugee Care

Through the Use of an Interdisciplinary Care Team

By Kathryn Freeman, MD and Cynthia Trevino, LISW

Page 5

25 26

• HLP/LawHelpMN — Resource Insert • A Day in Housing Court

By Katie Hinderaker, MD

28

November/Dec 2019

24 • Medical-Legal Partnership Online: LawHelpMN.org

By Emily Good

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Uniting Our Strengths

Healthcare-Legal Partnerships

• SPONSORED CONTENT:

Eliminating Barriers to Advance Care Planning

By Dawne Starkey, Linda Bauermeister and Thomas VonSternberg, MD

30

• Environmental Health —

Health Equity

By Mark D. Nissen, MD

Page 8 MetroDoctors

31 32

LUMINARY OF TWIN CITIES MEDICINE

Christopher Reif, MD, MPH, MA

In Memoriam/Career Opportunities

The Journal of the Twin Cities Medical Society

In This Issue: • HLP/LawHelpMN – Resource Insert • 2019-20 Public Health Advocacy Fellowship • Sharing the Experience Conference • Luminary of Twin Cities Medicine

Healthcare-legal partnerships provide unique opportunities and resources to enhance the overall health and wellbeing of our patients. Articles begin on page 6.

November/December 2019

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Marvin S. Segal, MD Physician Co-editor Richard R. Sturgeon, MD Physician Co-editor Charles G. Terzian, MD Medical Student Co-editor Zineb Alfath Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Annie Krapek MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS.

November/December Index to Advertisers TCMS Officers

Children’s Hospital.......... Outside Back Cover

President: Ryan Greiner, MD President-Elect: Sarah Traxler, MD Secretary: Andrea Hillerud, MD Treasurer: Rupa Polam Austria, MD Past President: Thomas E. Kottke, MD At-large: Matthew A. Hunt, MD

Crutchfield Dermatology......................................

Inside Front Cover

TCMS Executive Staff

Fairview Health Services..................................31

Ruth Parriott, MSW, MPH, CEO (612) 362-3799; rparriott@metrodoctors.com

HealthPartners.....................................................12

Clinical Scribes, LLC........................................10

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

iCure ....................................................................11

Kerry Hjelmgren, Executive Director, Honoring Choices Minnesota (612) 362-3704; khjelmgren@metrodoctors.com

M Health Fairview............ Inside Back Cover

Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com Annie Krapek, MPH, Program Manager (612) 362-3715; akrapek@metrodoctors.com Amber Kerrigan, Program Coordinator (612) 362-3706; akerrigan@metrodoctors.com

Lakeview Clinic..................................................31

MedCraft................................................................ 7 Minnesota Community Care........................... 2 PrairieCare............................................................21 PrairieCare PAL..................................................27 PSP/LifeBridge....................................................25

At Minnesota Community Care, we believe in health for all.

Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

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MetroDoctors

9/10/19 10:31 AM The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

An Interesting Collaboration — and it Works!

For many of us, a Healthcare-Legal Partnership, sometimes called a Medical-Legal Partnership, is a brand-new concept. We need to “un-learn” existing thoughts about a medical-legal relationship — “us vs. them” — and instead embrace this valuable partnership.

Dr. Matt Hunt’s lead-off submission provides a wonderful introduction. “Our goal in this issue of MetroDoctors is to help raise awareness, not only of the kinds of issues that may be impacted by health-harming legal needs, but also to provide resources to Twin Cities physicians to help address these needs.”

Amos Deinard, MD and Theresa Hughes, JD relate the groundbreaking work by staff at CUHCC and the law firm Leonard, Street and Deinard. This effort in the 1980s laid the groundwork for one of the first healthcare-legal partnerships (HLP) in the nation. It is still one of the only partnerships operated by a private law firm.

Our Colleague Interview features Eileen Weber, DNP, JD, a local, regional and nationally recognized authority and leader on HLPs. Her interview is filled with comprehensive, helpful and practical information. The references included makes this even more valuable to anyone thinking of exploring a HLP within their clinical setting.

The aptly named “Justice is Good Medicine” by Chris Wendt, JD relates important efforts to wisely distribute allocated funds for legal services to vulnerable and low-income citizens. He notes, in some instances, funds have been combined with other grants or operating funds to create healthcare-legal partnerships.

The financial realities of cancer care create life or death situations for some patients. Jennifer Kuyava, MD and Lindy Yokanovich, Esq. describe the work of Cancer Legal Care (CLC). Its mission is to engage the law to resolve the complex challenges facing people and communities affected by cancer.

CLC is a non-profit model that has been working for over a decade to serve those living with cancer. Various programs have helped and educated over 9,000 Minnesotans with cancer-related legal issues including employment discrimination, insurance coverage denials, housing concerns, disability benefits, as well as guardianship and estate planning.

Laura Pattison, MD is with La Clinica, a St. Paul Community Care Clinic that has started a partnership with Mitchell

By Richard R. Sturgeon, MD Member, MetroDoctors Editorial Board

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The Journal of the Twin Cities Medical Society

Hamline School of Law where legal services are considered preventive care for social determinants of health. A weekly civil legal clinic for patients at La Clinica is staffed by second- and third-year law students.

Katie Freeman, MD from M Health Fairview Clinic – Bethesda tells how their clinic and Southern Minnesota Regional Legal Services (SMRLS) formed a healthcare-legal partnership. SMRLS provides free in-house legal services to help low-income individuals and families. A team care model featuring a healthcare-legal partnership not only benefits patients and patient outcomes but may also improve provider burnout.

Katie Hinderacker, MD shares a poignant story of one of her patient’s travails with social determinants of health. Notable was her relief at having an in-place legal advocate to turn to for consultation and assistance.

Emily Good brings to our attention the website LawHelpMN.org. It is a one-stop shop for civil legal information and referrals in Minnesota. This is a useful and practical source of assistance for patients needing legal advocacy. Be sure to save and share the information and resources provided on the removable insert included.

Physicians understand the critical importance of Advance Care Planning (ACP). Dawne Starkey, Linda Bauermeister and Thomas VonSternberg, MD describe how HealthPartners is implementing ACP workflows, expanding educational curricula, exploring better ways to communicate plans via the EMR, and promoting touchpoints along the way to review and align patient preferences. The CMS CPT billing codes for ACP have been utilized by HealthPartners providers to structure time and reimbursement for these important dialogues. HealthPartners promotes and acknowledges the important work that Honoring Choices MN is doing to promote community engagement and foster collaboration among stakeholders.

Our Luminary is Chris Reif, MD, who is passionate about his work serving patients at CUHCC addressing health equity and the social determinants of health. We should all strive to have as much joy in our work.

November/December 2019

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President’s Message

Welcoming the Class of 2023 RYAN GREINER, MD

Each year, the University of Minnesota’s new medical school class comes together for the traditional white coat ceremony. Their families and loved ones join them to celebrate their achievement and to witness their inauguration into a profession whose history dates to the 27th century B.C. The University has a special tradition of having the new class write their own oath of medicine. I was so moved by the insight and foresight of the challenges facing their practice and patients that I wanted to share their oath with you.

The speakers at the ceremony all focused on the importance of empathy and caring, both for their patients We, the University of Minnesota Medical School Class of 2023, and each other. Keynote speaker Associate acknowledge the privilege to pursue the profession of medicine and Dean for Undergraduate Medical Educaeach pledge the following: tion Bob Englander, MD spoke of love I, as a physician, pledge to remain humble and adaptable while for our patients. A love that is grounded serving as a student, partner, and guide. I promise to be present for in a deeply felt respect and a core sense of my patients and colleagues, to be attentive to their individual needs responsibility for the trust and hope that all and goals, and to be an empathetic partner on their journey. I will patients — sick or well — bestow upon us. care for my own physical, spiritual, and mental well-being, always It was a reminder of our own vulnerability remembering the healing power of compassion, humor, and joy. in this complex and challenging profession, but also an acknowledgment of the unique rewards and inherent satisfaction of serving a higher purpose. One could not help but recognize the innocence in their eager faces and the palpable excitement about their coming journey.

Our CEO Ruth Parriott and I had the honor of shaking each student’s hand and presenting them with a pen light and eye chart as a gift from the Twin Cities Medical Society. In our opportunity to address the class and their families, we reminded them that TCMS is poised to help them as their champion, their advocate, and their partner. Our services and programs are available to help them succeed.

We invited them to join us in continuing that tradition of physician leadership and community engagement and ask you, our members, to support their enthusiasm and development. Join me in congratulating the Minnesota Medical School Class of 2023!

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November/December 2019

I will remember that my perspective is but one of many. I acknowledge my limitations and will ask for help when needed. I will have reverence for the wisdom of my team, my patients, and their families. I pledge to draw inspiration from my mentors and learn from the patients that I serve. I will strive to be a leader with medical expertise and high moral character, both in the professional setting and in my community.

I will bear witness to my patients’ stories, serving as an advocate and partner in their care. I will continuously strive to empower those I serve. I will never forget that the bodies and minds of my patients are their own, and will offer my knowledge and skills without judgement or expectation.

I acknowledge that inequity continues to exist in the field of medicine, and recognize that many patients are faced with systemic discrimination that directly impacts their health. Knowing this, I vow to be a positive agent for change. I will be a life-long learner, pushing the boundaries of medicine and sharing knowledge with those around me.

With this coat, we the class of 2023, pledge to maintain our commitment to progress and serve patients with the same enthusiasm that brought us to the field of medicine.

MetroDoctors

The Journal of the Twin Cities Medical Society

TCMS IN ACTION RUTH PARRIOTT, MSW, MPH, CEO

It’s Hard to Tell Who is Happier: White Coat Ceremony

What is more exciting than seeing the culmination of a family’s hopes and dreams as they witness their loved one enter medical school and don a white coat for the first time? Well, it was a close match to Dr. Ryan Greiner’s thrill at meeting impressive, dedicated new students who will soon join him in his journey in medicine. You don’t have to believe me; I offer photographic evidence.

Twin Cities and Duluth campuses. In September, we gathered for breakfast with several of the students’ physician mentors who shared with us the lessons they’ve learned from their years of advocacy. Mentors stressed the importance of building momentum with coalitions and the community, thinking creatively, and persevering through disappointments.

This year’s students are engaged in advocacy areas ranging from equitable access to health care for women and children of color, to environmental justice for Minnesota tribal communities, to expanding Minnesota’s syringe exchange program, and more. Find the full list of this year’s students, their mentors, and their areas of focus at www.metrodoctors.com/2019-fellows.

Dr. Greiner joins Dacotah Anderson, MS1 and Lucas Ray, MS1 as they unbox and wear their new stethoscopes.

African Americans, East African and Hmong individuals and families. We are especially excited about how these community-led models could reduce disparities in populations with a checkered history with traditional healthcare systems. Breakout sessions included discussions related to: decision-making with dementia; Solos and patients within skilled nursing and assisted living facilities; as well as the unique roles for community health workers and POLST. The closing plenary session focused on populations not often served by advance care planning: young adults in college and pre-operative patients. The conference was filled with collaborative ideas and rich discussions. More information will be on the website: honoringchoices.org.

2019 Physician Mentors: Drs. Frank Rhame, Courtney Baechler, Edward Ehlinger, Sarah Traxler and Pete Dehnel. Not pictured: Drs. Emily Brunner, Matt Kruse, Jack Lake, Eva Pesch, Lisa Saul and Laalitha Surapaneni.

Dr. Greiner congratulates featured student speakers Michelle Grafelman, MS4 and Abigail Schnaith, MS4.

Inspiring the Next Generation of Physician Advocates

We have so often witnessed the magic that occurs when a seasoned physician is paired with a medical student who shares their passion for physician advocacy beyond the clinic walls. TCMS is proud to have received another two years of funding from the Physicians Foundation to continue to host the Dr. Pete Dehnel Public Health Advocacy Fellowship with 10 medical students from the University of Minnesota MetroDoctors

Honoring Choices Minnesota’s Sharing the Experience Conference

Honoring Choices sponsored its 9th annual Sharing the Experience Conference in October. Over 80 professionals devoted to patient-centered end-of-life experiences gathered at the Earle Brown Heritage Center to spend the day exchanging opportunities, challenges, and new goals to increase access to quality advance care planning in our state. The day opened with a fascinating panel detailing some of the first measurements of community-based ACP experiences and new, culturally-appropriate models of ACP developed by and for Minnesota communities of Native Americans,

The Journal of the Twin Cities Medical Society

Dr. Mary Owens, University of Minnesota Duluth, is joined by panel participants Reid Haase, Stratis Health; Craig Solid, PhD, Solid Research LLC; Monisha Richard, CHW, Volunteers of America; and Mangan Golden, MA, Center of American Indian and Minority Health. Richard Shank, MD, served as conference moderator.

Kerry Hjelmgren, Executive Director, Honoring Choices MN, and Lynn Betzold, Program Coordinator, greet guests at the 9th Sharing the Experience Conference.

November/December 2019

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Healthcare-Legal Partnerships

Healthcare-Legal Partnerships: The Power of Collaboration

F

or many healthcare providers, the legal system is one that we are trained to avoid. Most of our interaction revolves around malpractice, risk management, or personal injury cases, creating a relationship that is often suspicious at best. Only rarely do we see the power of the legal system positively impact our patient’s lives in our dayto-day practices. Health-harming legal needs (HLN) are “social, financial or environmental problems that negatively impact a person’s health, but that can be addressed through civil legal services” (Schuster, 2018). These legal needs can impact many areas, but the most common can be summarized by the acronym I-HELP: Income, Housing and utilities, Education and Employment, Legal status (i.e. immigration status or eligibility for services), and Personal and family stability (Schuster, 2018, p. 11).

Each of these areas can have significant downstream health impacts. For example, substandard housing conditions can lead to serious exacerbations of childhood asthma, or loss of food benefits might lead to hunger and malnutrition.

In addition, these HLN are another driver of systemic inequality. A majority of households with incomes <125% of the federal poverty level face civil legal problems, the largest of which by far are health-related issues (Legal Services Corporation, 2017).

Healthcare-Legal Partnerships (HLPs) are collaborations between the

By Matthew Hunt, MD

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November/December 2019

By helping providers identify the health-harming legal needs that patients face and having a convenient referral destination so that patients can access legal support, HLPs provide a direct way to improve health. legal and health professions to address the social determinants of health that are linked to the law. “For example, housing and residential conditions may directly and negatively influence individual health. Their consequences can be treated medically, but their causes are social, rather than medical, and better addressed through legal advocacy” (Shin, 2010, p.

2-3). To use the asthma example again, healthcare providers can use the tools available to them in the clinic, emergency department, and hospital to treat a patient with an exacerbation of asthma caused by poor housing conditions, but the legal system can force the landlord to correct the conditions leading to these problems in the first place. By helping providers identify the health-harming legal needs that patients face and having a convenient referral destination so that patients can access legal support, HLPs provide a direct way to improve health.

HLPs are often based in FQHCs

and hospitals and can identify the health-harming legal needs as they arise using screening tools and referrals from providers. Most of the HLPs in our region are five years old or less, but the Deinard Legal Clinic at the Community-University Health Care Center (CUHCC) has been serving patients for over 25 years as one of the first HLPs in the nation. Other models exist as well where HLPs may be partnered at multiple locations or based in a hospital.

Most of the legal partners for HLPs come from legal aid organizations, but private firms such as the Deinard Legal Clinic, and law schools like the Community Practice Clinic at the University of Minnesota School of Law, also service these partnerships.

HLPs can be effective in dealing with a broad range of issues, not just housing, and serve a broad range of the population. Many specialize in populations such as children, the homeless,

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The Journal of the Twin Cities Medical Society

immigrants, elderly, veterans, and Native Americans. While most HLPs do not target services based on medical conditions, some focus their resources on those with mental health disorders, chronic illness, or the disabled. Of the five I-HELP categories of HLN, most saw all of these categories, with personal and family stability being the most common, and legal status and veterans’ issues being least common (Regenstein, 2017).

Median budgets for most programs are approximately $150K, and most programs service 250-300 patients per year, for a rough cost of $500 per patient.

The largest concern for most HLPs is being able to expand the scope of the work they do to meet the needs of their patients (Regenstein, 2017). Given this

limitation, providing additional funding to meet patient’s needs would provide effective support where patients need it.

Our goal in this issue of MetroDoctors is to help raise awareness, not only of the kinds of issues that may be impacted by health-harming legal needs, but also to increase financial resources to support HLPs in the metro area. TCMS is working with our colleagues in the School of Nursing at the University of Minnesota and with local clinics, to achieve these goals.

References: 1. Legal Services|Community-University Health Care Center–University of Minnesota. (n.d.).

Retrieved October 13, 2018, from https:// www.cuhcc.umn.edu/patient-care-services/ legal-services.

2. Legal Services Corporation. 2017. The Justice Gap: Measuring the Unmet Civil Legal Needs of Low-income Americans. Prepared by NORC at the University of Chicago for Legal Services Corporation. Washington, DC. 3. Regenstein, M., Trott, J., & Williamson, A. (2017). The State of the Medical-Legal Partnership Field–Findings from the 2016 National Center for Medical-Legal Partnership Surveys.

4. Schuster, L. (2018). Healthcare-Legal Partnerships in the Upper Midwest: Innovating to Address Health-Harming Legal Needs. Retrieved from https://midwesthlp.org/.

5. Shin, P., Byrne, F., Jones, E., Teitelbaum, J., Repasch, L., & Rosenbaum, S. (2010). Medical-Legal Partnerships: Addressing the Unmet Legal Needs of Health Center Patients, Geiger Gibson/RCHN Community Health Foundation Research Collaborative; Policy Research Brief No. 18, (18).

Matthew Hunt, MD is past president of the Twin Cities Medical Society, a practicing neurosurgeon in the South Metro and Adjunct Professor of Neurosurgery at the University of Minnesota.

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Healthcare-Legal Partnerships

Helping Professions Unite for Community Impact Physicians take the Hippocratic Oath to do no harm and lawyers promise to uphold the federal and state constitutions. Overall, both pledge to use their training and skills for the benefit of others. In essence, both are “helping” professions.

A Young Lawyer on the Streets of New York City

This fact was driven home to Theresa Hughes when she was a new lawyer in the mid-1980s working at an international homeless youth shelter in New York’s Times Square. In that role, she learned that when joined together, medicine and law have an even greater impact on an individual’s overall security, health and well-being.

The Times Square shelter provided a full range of services for its residents, including housing, job skills development and employment, dental, an onsite school, and a clothing room. However, it was the staff from the medical and legal programs, who, in addition to their nine-to-five duties at the shelter, ventured out onto the dangerous streets of Times Square on Saturday nights from 11:00 pm to 4:30 am to offer homeless youth basic healthcare and legal services. The outreach team, comprised of a physician, a lawyer and two street-hardened ex-cons, traveled into some of the worst neighborhoods of New York City to entice youth off the streets and into the shelter. The medical issues encountered on the streets included infections, physical and sexual violence injuries, and, in colder months, hypothermia.

Legal issues ranged from clearing

By Amos Deinard, MD, MPH and Theresa Murray Hughes, JD

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November/December 2019

outstanding warrants and low-level legal infractions such as turn-style jumping (in order to access the city’s subway system) to shoplifting and pickpocketing charges — remember the Artful Dodger in Oliver Twist? Once a youth was brought back to the shelter, the medical and legal teams were able to offer a broader range of essential healthcare services and provide the youth with more in-depth social services including legal representation and referrals. This model has now been replicated in cities across the nation. Additionally, expanding that model to include other professionals such as social workers, case managers, Adult Rehabilitative Mental Health Services (ARMHS) workers, dental staff, pharmacy professionals, and nurses helped create the healthcare-legal partnership concept as we know it today.

Fast-forward 15 years to 2002, when Ms. Hughes was hired by Stinson LLP (then Leonard, Street and Deinard) as its Pro Bono Director, a role that included joining an existing healthcare partnership as the legal liaison between the law firm and its medical partner, the Community-University Health Care Center (CUHCC). The collaboration was launched in 1993 under the vision, passion and protective care of Dr. Amos Deinard, Executive Director of CUHCC at the time.

A Doctor Born Into a Culture of Service

Amos Deinard, MD was raised in a family of lawyers; however, following a year of law school, he knew he would be much happier in medical school and enrolled at the University of Minnesota Medical School in 1958. By 1962, he began a three-year Pediatric residency followed by a Pediatric fellowship, where he had many encounters

Amos Deinard, MD, MPH

Theresa Murray Hughes, JD

with families who were in need of pro bono services to address their social health issues, including landlord-tenant disputes and immigration issues for which they needed assistance but could not afford to pay. It was Dr. Deinard’s vision that adding legal professionals to the overall healthcare delivery system for his patients would provide an invaluable benefit.

Working for the Minneapolis Health Department’s Maternal and Child Health Program in the late 1960s-early 1970s, Dr. Deinard worked with the most proactive group of social workers he had ever met.

And yet, he encountered problems that often required more skills for resolution than a social worker possessed. In his opinion, they needed a lawyer on the team. In Dr. Deinard’s mind, legal assistance was the “pill” that would improve a patient’s health and well-being. In 1984, the University of Minnesota recruited Dr. Deinard to become the director of Community-University Health Care Clinic (CUHCC).

Deinard recalls that after one day in his role at CUHCC, “it became obvious that the families had a greater need for pro bono services than did those families who used the Minneapolis Health Department’s medical services.” In 1990, he approached Leonard, Street and Deinard, the law firm where his father had been

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a founding member, and spoke to then managing partner, George Reilly, about the possibility of teaming up his lawyers with medical staff and other healthcare professionals at CUHCC to connect patients to legal services. By 1992, the firm’s new managing partner, Fred Rosenblatt, decided to lend the firm’s muscle to the partnership and created an onsite office providing pro bono legal services. With that, the first full-service healthcare-legal partnership in the nation was launched and now nearly 500 programs exist across the country.

Growing up in a legal family with his father, Amos Sr., and his uncle, Benedict, together with their friends and law partners George Leonard and Arthur Street, he always understood that pro bono served as “the cornerstone of the culture at the firm.”

Deinard recalls that it was the firm’s belief that, while they were there to serve the affluent businessperson and corporation, the little individual who had no ability to pay for legal services nonetheless, also needed representation. In fact, Dr. Deinard shares “it may well have been the case that my father’s or uncle’s first words to me as a child were ‘go forth and provide pro bono service.’”

healthcare-legal partnerships — sometimes called medical-legal partnerships — in the nation and is still one of the only full-service partnerships operated by a private law firm.

Through the Deinard Legal Clinic healthcare-legal partnership, free legal services are provided to CUHCC patients, many of whom face multiple barriers to health and well-being. Representation includes family law, guardianships, estate planning, immigration, housing, and government benefits, among other legal services.

Over the past 26 years, Stinson attorneys, paralegals and staff have donated over 120,000 hours of pro bono legal representation to more than 3,000 CUHCC patients, providing legal services with a monetary value in excess of $25 million.

In 2017 and 2018, over 100 lawyers and paralegals donated pro bono legal time through the Deinard Legal Clinic. With the aid of a part-time pro bono law clerk, Stinson meets with approximately 200 CUHCC patients a year, providing advice and referral legal services.

Firm lawyers assist around 100 patients a year in full-representation cases.

Many of these patients are immigrants, often refugees from east Africa who do Deinard Legal Clinic not speak English as their first language, The work of the lawyers and staff at and who are referred by the behavioral Leonard, Street and Deinard, in tandem health department at CUHCC. As noted with Dr. Deinard’s staff at CUHCC,

by Colleen McDonald Diouf, CUHCC’s laid the groundwork for one of the first CEO, “Stinson’s 26 years of service to our patients has contributed immeasurably to fostering a fundamental security that anyone needs to live their lives. Our clinic and our patient community views this legal clinic as a key part of our holistic care system here at CUHCC.” Stinson’s commitment to CUHCC is ongoing as noted by firm managing partner, Mark Hinderks, who says, “Our commitment to the Deinard Legal Clinic is an integral part of the Theresa Murray Hughes (L) and Jewelean Jackson (R). Photo by way that we serve and Brian Peterson, Star Tribune, April 2018.

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take our place in the Twin Cities community. In fact, throughout our 12-city footprint, pro bono is embedded in our DNA. We are proud of our dedicated leadership to the legal clinic, as well as the contributions of Minneapolis attorneys, paralegals and staff members.”

CUHCC and Stinson have provided legal services to thousands of patients over the last 26 years, and with the assistance of a University of Minnesota undergraduate research student, have conducted a focus group of patients who received legal services in 2018. The results of the focus group indicate that patients are deeply reliant on the clinic for more than their medical care and that, especially for non-English speaking patients and those with mental health challenges, the safety of the clinic setting and the wrap-around services provided, are an integral part of their lives.

One patient in the focus group noted, “nowhere else really helps me the way the CUHCC clinic has helped. This is the only place where I feel comfortable.”

The patient, an immigrant, noted that the legal clinic had assisted her with her divorce. She had been in an abusive relationship and had earlier felt forced to cancel the divorce because her unstable immigration status made her dependent on her husband. With the assistance of the Deinard Legal Clinic, she was able to get a divorce and to access other paths to an immigration status, while at the same time accessing medical services at CUHCC for navigating the abusive relationship and her clinical depression.

She noted that even though there was “still some pain,” the help she received through her divorce and immigration services helped her to get to a healthier place in her mental health and reduced her stress. She believed that having access to legal services at a safe place like her health clinic helped her figure out next steps for herself and for her children. She shared that she is now in a stable place in her life and living independently with her daughter. She doubted she would have had

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Healthcare-Legal Partnership Helping Professions Unite for Community Impact (Continued from page 9)

the courage to make these decisions if it were not for a place like CUHCC where she felt supported, safe and protected.

Patients repeatedly share that they come to CUHCC for their culturally-appropriate wrap-around services that embolden them to take steps to address larger issues in their lives. This tends to be especially true for recent immigrants from Africa and Latin America who rely strongly on CUHCC’s nurturing environment and the support they receive beyond the frontline medical, dental and behavioral health services. It would be very difficult for clients to identify and address legal and social services needs without the support of case management, ARMHS, and social workers. The critical support that CUHCC and the Deinard Legal Clinic provide, and the ongoing nature of the relationship, allows these patient-clients to follow through until legal and social issues have been resolved.

Many individuals in need of legal

services may access them on their own by reaching out to a legal aid office or another legal provider, yet some of the most vulnerable patients at CUHCC may not take the first step without having a legal advocate available on site at the clinic.

While the majority of healthcare-legal partnerships are run through a legal aid program and a medical clinic or hospital, the experience of CUHCC and Stinson via the Deinard Legal Clinic these past 26 years demonstrates that “one size does not fit all.” A variety of options, including legal aid, private law firm volunteers, and law school clinics to name a few, are available to bring these two helping professions together to provide holistic patient-client care. With the resources and dedication of 170 attorneys and paralegals in Stinson’s Minneapolis office, patients at CUHCC benefit from the legal talent and commitment of the law firm’s volunteers. Theresa Hughes says, “It has been an honor to be a part of this longstanding, dedicated partnership between health care and law.

Thank you Amos Deinard for your vision and dedication to make this happen!”

Amos Deinard, MD, MPH received his medical degree from the University of Minnesota Medical School and completed a pediatric residency program followed by a pediatric fellowship at the University of Minnesota. In 1984, Dr. Deinard became the director of the Community-University Healthcare Center (CUHCC), a position he held for 15 years.

It was due to his vision that the pro bono legal clinic at CUHCC was established — the first medical-legal partnership in the country.

Theresa Murray Hughes, JD is the Pro Bono Director for Stinson LLP a law firm offering sophisticated regional and national practices in 12 states and the District of Columbia.

Murray Hughes has served as Pro Bono Director for the last 13 years and oversees, along with the Stinson LLP Pro Bono Committee, pro bono work across the firm including staffing and managing the Deinard Legal Clinic located in the Phillips neighborhood of Minneapolis. Murray Hughes received her BA from the University of Minnesota-Duluth and her Juris Doctor from William Mitchell College of Law (now Mitchell Hamline School of Law).

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Healthcare-Legal Partnerships

Colleague Interview: A Conversation with Eileen Weber, DNP, JD, BSN, PHN, RN

E

ileen Weber, DNP, JD, BSN, PHN, RN, is a nurse attorney and clinical associate professor at the University of Minnesota School of Nursing, where she teaches ethics, leadership, and public policy in the context of a continuum of interprofessional health care.

She founded and chairs the Healthcare-Legal Partnership (HLP) Collaborative, a growing network of healthcare providers with embedded civil legal services to serve patients who need legal help in overcoming negative social determinants of health. Weber is certified as a public health nurse and was a faculty advisor for the UM Academic Health Center’s Hotspotters and initiated the nursing preceptor program for the interprofessional student-run Phillips Neighborhood Clinic. Dr. Weber earned both her BSN degree and Doctor of Nursing Practice (DNP) degree in Health Innovation and Leadership from the University of Minnesota.

She earned her JD degree at the University of St. Thomas School of Law in Minneapolis.

What is a Healthcare-Legal Partnership?

A healthcare-legal partnership (HLP) is a solution to the challenge clinicians face every day knowing that most of the factors impacting health are far beyond what the conventional healthcare delivery system addresses. When legal champions and healthcare champions integrate their respective expertise to tackle health-harming legal needs in any setting, that is a healthcare-legal partnership.

Typically, the HLP framework is defined by a Memorandum of Understanding between a clinical setting, whether inpatient or outpatient, and civil law attorneys (as opposed to criminal law specialists). Usually the civil law attorneys are from local legal aid offices, have separate offices in clinical settings and do not charge clients any fees for their services. But they sometimes include pro bono attorneys or law students. Since their beginnings in Boston and Minneapolis in 1993, HLPs have spread to 47 states.

In what setting does a healthcare-legal partnership work best? Is the legal participant and/or the organization subject to any special malpractice risk?

HLPs are not limited to either inpatient or outpatient settings.

The truth is that integrating medical and legal expertise produces the best outcomes in settings where there are champions dedicated to facilitating the partnership and transcending the historical silos and stereotypes that each profession’s culture may bring to the integration. Healthcare professionals are accustomed to thinking lawyers are either “ambulance chasers,” or their organizations’ MetroDoctors

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developers of risk avoidance guidelines — “defensive medicine.”

Lawyers serving patients in a HLP do not represent them in medical negligence proceedings. In fact, legal aid attorneys are excluded by law, with only very rare exceptions, from representing clients on the contingency basis common to medical negligence lawsuits. For instance, a legal aid attorney might legally take such a case if there were no other attorneys in the community who could take it; certainly not true in the Twin Cities.

What are some examples of topics that would benefit from healthcare-legal partnerships?

I-HELP is an acronym for common categories of health-harming legal needs assessed and addressed by HLPs. I: income support and insurance, which includes food stamps, disability benefits, cash assistance and health insurance; H: housing and utilities, which includes eviction, housing conditions, housing vouchers and utility shut-offs; E: employment and education, which includes accommodations for disease or disability in education and employment, family medical leave and other employment issues; L: legal status, which includes criminal background issues, consumer law, military discharge status, and immigration status; P: personal and family stability, which includes domestic violence, guardianship, child support, advance directives and estate planning.

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Healthcare-Legal Partnerships Colleague Interview (Continued from page 13)

Are there patient intake checklists or screening tools to indicate or predict social and/or legal needs?

Various tools exist to help clinicians screen for health-harming legal needs. They often overlap with existing screeners used to assess negative social determinants of health, such as PRAPARE and others. But a curious, trusted clinician educated in health-harming legal needs can be an excellent screening tool. After being oriented to her clinic’s HLP, a nurse practitioner at the former HLP at Hennepin Healthcare Whittier Clinic asked her diabetic patient what was going on in his life to make his A1C levels persistently rise and negatively impact his kidneys and blood pressure. His answer, that his food stamps had been cut by two-thirds for some reason, severely diminishing the nutritional quality of his food, further raised her suspicions. She sent him to speak to the clinic attorney, who asked more questions, pursued the matter with the county, and found that not only his own SNAP benefit, but those of 200 other people, had been wrongly slashed. As Minnesota Public Radio reported,1 once the lawyer successfully appealed the wrongful benefit cut, the patient’s blood sugars and related health downturns improved, with corresponding reductions in his medication needs.

Is legal expertise positioned onsite or remotely connected?

It varies. As many clinics are finding, the more convenient you can make a service for patients, whether legal help, dental care, or other health promoting services, the more likely a positive outcome will result. We see this in the growing number of clinics that combine non-medical services, food shelves, etc. That means in outpatient settings, having an attorney located in the clinic improves access for a patient who already is there or for whom the location is familiar and trusted. But there are exceptions: one of the oldest HLPs in the country is between the Stinson Law Firm in Minneapolis and the University of Minnesota’s Community-University Health Care Center (CUHCC). The director of Stinson’s pro bono (“for the good”) department takes referrals, usually from a CUHCC social worker, and then arranges to see the patient at the clinic. If she spots issues in the patient’s story that one of her firm’s lawyers can address, she assigns a lawyer to the case. Another off-site example is Cancer Legal Care (CLC), which has found that given how ill many of their patients are, some patients prefer a separate visit away from the oncology clinic to discuss all the ways that CLC’s lawyers, free of charge, can help people who may face financial devastation and/or family disruption as a result of their life-threatening diagnosis. As one of the most enduring HLPs in Minnesota, CLC is now partnering with the Minnesota Department of Health and the CDC to demonstrate how legal help improves survival from cancer and its rigorous treatment.

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What are the advantages of embedded legal expertise on a clinical team?

Clinicians have found that their own work is less frustrating and more rewarding with the help of embedded legal services for their patients. Physician frustration and burn out are well-recognized problems in US health care and one of the reasons the former Triple Aim of health care has been expanded to the Quadruple Aim that now includes provider well-being. Physicians in Minnesota HLPs, once they learn the value of embedded legal services in their practice settings to improve patient self-management and health outcomes, extol the need for continuing those services.

If legal service is on site as a volunteer, any HIPPA issues?

HIPAA issues are most commonly and directly addressed by simply getting patient consent, constructed and obtained in ways most consistent with the patient and workflow of the respective environment. Often, patients need clarification that any lawyer involved with their care is not an arm of law enforcement. They need to understand that any discussion with the HLP lawyer is protected by attorney-client privilege, even from the healthcare provider they see, unless they consent to sharing the information protected by that privilege. There are important differences between attorney-client privilege and the confidentiality afforded by the therapeutic relationship between a clinician and a patient.

For example, healthcare professionals are among those considered mandatory reporters of suspected child abuse by law, while the same is not true of those “under the cone” of attorney-client privilege. Similarly, medical records can be “discoverable,” obtained by an adverse party in a lawsuit, while attorney-client privilege and related work product are not discoverable. So health records in which a referral to the HLP attorney is documented should be careful to not include more legal detail than the health outcome of the legal intervention, such as food stamps being restored or a wrongful housing eviction being defeated or a Medicaid benefit denial being successfully appealed so that a patient can now miss fewer appointments and can afford to be seen in accordance with their health needs.

Any working relationships with local legal pro-bono groups?

This is a logical question given that the HLP at CUHCC involves the Stinson law firm’s pro bono attorneys. Cancer Legal Care also relies on a fairly regular group of private attorneys who donate their time, support staff and talents. These are unique situations.

For example, the founder of the Leonard, Street and Deinard law firm that preceded Stinson LLP and the former medical director of CUHCC, were father and son Amos Deinard, Sr. and Jr., who shared a commitment to the common good. That kind of familial connection would be hard to find and replicate today.

There are also HLPs in which the legal partner is a group of law students. Mitchell Hamline (with United Family Medicine) and the University of Minnesota (with several healthcare sites) are examples of local HLPs that not only serve the health-harming MetroDoctors

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legal needs of patients, they also educate future legal experts on what health professionals do and on the unjust social structures that harm individual and public health.

What are the typical costs? When an organization cannot fund this service out of an operations budget, what are other possibilities? To inform planners, any cost-benefit analysis data?

In the Twin Cities, the annual total compensation for a legal aid attorney working in a HLP is roughly $120,000. For the usual partnership with a lawyer on site, there needs to be a room that can serve as the attorney’s office where clients can be seen and counseled in private. Most HLPs in our state have started with philanthropic investments, but the most reliable path to sustainability, once the potential of a successful HLP is demonstrated, is for healthcare financing systems to invest in HLPs to improve their clinicians’ and patients’ well-being. We would not expect other effective health promotion interventions integrated into healthcare settings to be routinely funded philanthropically. In the St. Cloud area, once the initial grant from the Blue Cross Blue Shield of Minnesota Foundation ended, CentraCare, having found that people receiving legal help had fewer ED visits and more primary care visits, invested more of its own budget in its HLP. CentraCare and Mid-Minnesota Legal Aid now partner in six clinics with three lawyers. Likewise, Children’s Minnesota’s HLP in each of its hospitals in St. Paul and Minneapolis does not rely solely on philanthropy; it includes its own substantial organizational investment. This thinking can result in not only meeting the ACA and IRS mandates, but also in meeting regulatory incentives from Medicaid and Medicare to avoid rapid hospital readmissions and avoidable emergency department use. In an era of “value-based medicine” and “total cost of care” financing paradigms for healthcare delivery, integrated accountable care systems that invest in legal services to combat the negative social determinants of health can see multifaceted returns on those investments. For more information about funding, check with the respective leaders listed in the 2018 report, “Healthcare Legal Partnerships in the Upper Midwest” at http://bit.ly/midwestHLP. Another less widely considered source of HLP funding are the obligations that non-profit, tax-exempt hospitals have to improve their communities’ health. The ACA mandates that all nonprofit, tax-exempt hospitals complete a Community Health Needs Assessment (CHNA) at least every three years with input from the broader community, including public health experts.

They must adopt an implementation strategy (community benefit plan) to meet the existing health needs identified in the assessment, as well as identify any needs not being addressed and explain why not. Compliance with this new regulation is to be made widely available and is reported to the Internal Revenue Service, in line with the tax code’s 501c3 provision regarding tax exempt status awarded to organizations providing community benefit. CHNA is a systematic process involving the community to identify and analyze community health needs and assets in order to prioritize these needs, and to plan and act upon unmet community MetroDoctors

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health needs. In Illinois, CHNAs and the funding of their related community benefit plans have been used to support HLPs. The Minnesota Hospital Association’s resource on CHNAs in our state can be found on their website: mnhospitals.org and search for “Community Health Needs Assessment.”

Looking up the funding stream, the former Medicaid and Medicare director, Cindy Mann, is working with a consulting group called Manatt to inform HLPs how they can use those programs, particularly Medicaid, to improve financial support.

According to Mann, North Carolina includes in its RFP for managed care organizations (MCOs) who wish to participate in its Medicaid privatization effort, Pre-paid Medical Assistance Program (PMAP), that they must offer care management services including MLP access “for legal issues adversely affecting health, subject to availability and capacity of medical-legal assistance providers.” Minnesota also has a PMAP and could include such a requirement. Elsewhere in the nation, states are proposing similar ideas in which MCOs could be required to pay for efforts, including legal services, that combat social determinants of health.

As for return on investment, an example is the appeal of a left ventricular assist device (LVAD) compensation denial by Nebraska’s Medicaid office. Once the HLP attorney worked on that denial, the $750,000 for the LVAD changed from uncompensated care by the hospital to compensated care. Similar successful appeals in Minnesota when Medical Assistance eligibility is wrongfully denied could likewise be a significant return on investment for providers. The National Center for Medical-Legal Partnership provides a lot of authoritative information on the healthcare cost-effectiveness of integrated legal services. Minnesota’s HLPs have begun collecting information to provide a more aggregate analysis of HLP’s value.

Please relate an example of an actual healthcarelegal partnership collaborative effort.

Beyond the examples previously given, additional collaborations within Minnesota can be found: i. Within the 2018 report, “Healthcare-Legal Partnerships in the Upper Midwest,” located at http://bit.ly/midwestHLP. Permission granted to use. The report was funded by United Way but they were not the publisher. ii. On YouTube by searching “CentraCare Medical-Legal Partnership Benefits Patients,” and “Legal Aid Whittier Clinic Minneapolis.”

Further HLP collaborations from across the United States can also be found on YouTube by searching “Medical Legal Partnerships.”

References: 1. https://www.mprnews.org/story/2015/05/26/medical-legal-partnerships and https://www.youtube.com/watch?v=t1tulK_LBJE.

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Healthcare-Legal Partnerships

Justice is Good Medicine

“In evaluating a patient’s aggravated asthma condition, a pediatrician learned that the family’s apartment had extensive mold and rodent issues.

She made a referral to the Healthcare-Legal Partnership and the attorney successfully negotiated with the St. Paul Public Housing Agency to address these housing conditions. The family reports that the child’s asthma is better controlled.”

This example, reported by the Healthcare-Legal Partnership at Children’s Minnesota, is just one of many stories of how lawyers and doctors are working together in the state to improve social determinants of health.

As an attorney at the Mayo Clinic, I am privileged to support world-class, highly talented, and empathetic professionals striving to heal the sick and treat the afflicted. But I was asked to write this article in another role, as Chair of the Minnesota Supreme Court’s Legal Services Advisory Committee (LSAC). LSAC is charged with making strategic decisions statewide to guide the distribution of over $18.6 million in funding to organizations providing legal services to nearly 50,000 low-income clients statewide. LSAC supports legal services to Minnesotans in every county in the state. We focus on helping Minnesotans facing critical legal needs, who live at or below 200% of the federal poverty guidelines ($51,500 annual income for a family of four in 2019). We also strive to improve coordination among the numerous legal services providers in

By Christopher Wendt, JD

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funding earmarked for healthcare-legal partnerships (HLPs), the US Health Resources and Services Administration allows “enabling services” funding to be used for civil legal aid. In addition, our innovative grantees have used the general operating funds LSAC provides, combined with other grant funding, charitable donations, and often generous support from partners, to create a number of such partnerships to the great benefit of low-income Minnesotans. the state, with a goal of improving client access and efficiency.

We operate in an environment where there is no insurance, no EMTALA-equivalent requiring law firms to “stabilize” those with legal emergencies, and where funding continually falls short of need.

Even in Minnesota, one of the better-performing states with regard to legal services, approximately 60% of eligible clients have to be turned away due to lack of resources.

You read that correctly, but it bears repeating. Almost two-thirds of income-eligible Minnesotans, with real legal problems an attorney could likely address, do not get help because there simply aren’t enough resources available. In the face of these realities, the dedication and skill of those who work to ensure access to justice continue to inspire hope and humility every day. Clearly, I am also privileged to serve the legal aid community, an equally inspiring group of world-class, highly-talented, and empathetic professionals helping those whose remedies may be legal, rather than medical in nature. As we are learning from experience with medical-legal partnerships, sometimes the legal and medical problems are intertwined.

Although LSAC does not have specific

Current Activities by Region

In the northwest region of the state, Legal Services of Northwest Minnesota has two HLPs: one with Northern Dental Access Center with locations in Bemidji and Halstad, and another, cross-border collaboration called Legal Advocates for Health with Family Healthcare and Legal Services of North Dakota. Through the Northern Dental Access Center, thousands of patients receive dental care and oral health education, while on-site attorneys are available to assist in cases of domestic violence, housing conditions, employment barriers and income stability. This project was started with funds from Blue Cross Blue Shield Foundation but continues without dedicated funding because of its unique ability to reach the civil-legal needs of rural isolated clients. The Legal Advocates for Health project has an emphasis on improving social determinants of health, but a strong secondary goal is to build relationships and trust in the legal system within the refugee population in the Fargo-Moorhead area. This project has received funding by a Bush Community Innovation grant and will continue with a grant from the Otto Bremer Foundation.

The south metro and southern region

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are served in large part by Southern Minnesota Regional Legal Services (SMRLS).

SMRLS currently has healthcare-legal partnerships with five different providers: Children’s Hospital in St. Paul, Bethesda Hospital in St. Paul, Wilder in St. Paul, Proof Alliance, and the Open Door Clinic in Mankato. These partnerships focus on addressing the social determinants of health through legal intervention and create additional access points for clients across the region through partners with whom clients have built trusting relationships. SMRLS reports that between 60% and 70% of new clients met through HLPs are new to legal aid overall, and most have multiple legal issues. SMRLS is working to develop a groundbreaking, consistent, replicable data collection framework allowing both legal and healthcare partners to assess and report on the partnerships’ impact. In addition to the in-kind support of SMRLS healthcare partners, this work would not be possible without the generous support of Children’s Minnesota and its philanthropic partners, the Legal Services Corporation’s Pro Bono Innovation Fund, the Otto Bremer Trust, the Blue Cross Blue Shield of Minnesota Foundation, the Greater Mankato Area United Way, the St. Paul Foundation, Richard M. Schulze Family Foundation, and the Mankato Clinic Foundation.

In the central region, Mid Minnesota Legal Assistance (MMLA) has been actively supporting HLPs since 2015, and now staffs clinics in St. Cloud, Melrose, Paynesville, Sauk Centre, Long Prairie, and Willmar. Attorneys provide a broad range of services to patients of CentraCare in rural areas as well as population centers, serving both aging populations and immigrants whose limited English or other social/legal barriers pose additional challenges. Support to establish and continue these clinics has come from a variety of sources, including Blue Cross Blue Shield of Minnesota Foundation, St. Thomas School of Law, and Equal Justice Works, as well as generous ongoing support from the clinical partner, CentraCare, which has been critical to make these activities self-sustaining.

In the metro, MMLA is also active and partnering, like SMRLS, with MetroDoctors

Children’s Hospital, but in Minneapolis.

Attorneys work as an on-site resource, offering immediate access to advice and legal services assisting clinical partners to identify, prevent, and remedy health-harming factors that are rooted in legal problems.

They report that an overwhelming 80% of health outcomes are tied to a broad set of factors including the availability of nutritious food, adequate housing, personal security, quality education, and social

overcome social determinants of health which may be impacting their care. In this issue you will learn about a vital resource that you should bookmark to use or pass along to patients, regardless of income level: LawHelpMN.org is a comprehensive website featuring a guided interview to match users with the best available legal resources in their area. The site is optimized to work on mobile devices and a variety of fact sheets and forms can be downloaded

Even if you don’t have, and can’t advocate for creation of an HLP where you work, every healthcare provider can help patients overcome social determinants of health which may be impacting their care.

support services. HLPs are uniquely situated to address these disparities.

Finally, Minnesota has a unique resource which serves clients regardless of geography. Cancer Legal Care, about whom you will learn more elsewhere in this issue, exists to assist with the many legal issues arising from diagnosis through survivorship. Issues of employment, insurance coverage, disability, and estate planning are faced by nearly every cancer patient and survivor. Cancer often brings a crushing financial blow, sometimes including loss of housing. LSAC funding targeted for foreclosure prevention has allowed Cancer Legal Care to help 96% of their lowest income clients avoid this result.

What Can You Do?

All of us, attorneys, physicians, or anyone, can support HLPs in a variety of ways, through volunteering time and resources at a clinic, spreading the word in our communities and by communicating with elected representatives about the critical role state funding plays in creating and supporting these innovative partnerships.

Even if you don’t have, and can’t advocate for creation of an HLP where you work, every healthcare provider can help patients

The Journal of the Twin Cities Medical Society

or texted to your patients. Resources are available in Spanish, Somali, and Hmong.

There is even a live chat function. This powerful tool allows any provider to partner with and empower patients struggling with issues beyond the clinical context, recognizing that for many, justice really is good medicine.

A special thank you to Bridget Gernander for her invaluable research and editorial assistance with this article.

Christopher Wendt, JD has been immigration counsel at the Mayo Clinic since 2003, where he oversees staff coordinating all immigration-related issues and advice. He has chaired the employment practice group since 2015. Chris graduated from Beloit College and from the University of Michigan Law School. He was selected as a Humphrey Policy Fellow for 2014-2015. He currently coordinates Mayo Clinic Legal Department pro bono activities and serves as Chair of the Legal Services Advisory Committee of the Minnesota Supreme Court. His personal pro bono work has included immigration cases, online advice, and eviction clinics in Olmsted County. He can be reached at: Wendt. christopher@mayo.edu, or (507) 538-1156.

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Minnesota’s Cancer Legal Care is Tackling Financial Toxicity

A

study recently published in The American Journal of Medicine highlighted an extremely concerning reality for people facing cancer. The purpose of the study was to learn how a new cancer diagnosis impacted a person’s financial situation. The article, Death or Debt? National Estimates of Financial Toxicity in Persons with Newly-Diagnosed Cancer, looked at 9.5 million cases of new diagnoses of cancer between 2000 and 2012. While it likely doesn’t surprise those of us working in medicine that cancer can place a significant economic burden on people, the actual results of this study might just bring you to tears.

For people 50 years or older with a newly diagnosed malignancy between 2000 and 2012, at two years after diagnosis, 42.4% had completely exhausted their entire life’s assets. The average loss for this already vulnerable group was $92,098.1 In other words, nearly half of the millions of people who are diagnosed with cancer will be depleting all their resources (averaging nearly $100,000) within two years of a cancer diagnosis.

The term that best defines how our current system monetarily burdens already overwhelmed patients is financial toxicity, which “involves the unintended financial consequences of medical treatment, including both objective and subjective attributes reflecting a patient’s financial burden.”1 Financial toxicity is directly related to the cost of medical care, but it certainly extends to all areas of one’s life and can greatly affect one’s quality of life. Patients undergoing cancer treatment may not be able to work during treatment. Without that income, they may need to take out a

By Jennifer Kuyava, MD and Lindy Yokanovich, Esq.

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second mortgage or spend savings meant for their children’s college or their own retirement. Patients may also be plagued with fear of further burdening their families with additional debt. In addition to these incredible stressors, some patients are forced to spend time fighting insurance billing errors (check out Cancer Complications: Confusing Bills, Maddening Errors And Endless Phone Calls on NPR’s All Things Considered 2/26/2019).

Immense economic burden may force patients to refuse further cancer treatment or it may essentially Lindy Yokanovich, Esq. and Jennifer Kuyava, MD. render them unable to bankruptcy than people without cancer. continue a recommended course of treatEven more alarming is that patients with ment — directly affecting their ability to cancer who file for bankruptcy protection engage in and receive medical care. are more likely to die, and this increased The financial realities of cancer care mortality is not related to extent of disease. can be a life or death situation for our Mortality for those with prostate cancer patients. who filed for bankruptcy was nearly twice Cancer is the second leading cause of that of those who did not file for bankdeath in the United States. Many of our ruptcy. For colorectal cancer, patients who patients are not just fighting for their lives, filed for bankruptcy protection were 2.5 they are also fighting to avoid bankruptcy. times more likely to die compared with Medical costs of cancer are over $80 billion 1 those who did not file. Financial toxicity for in the United States. Research examining patients with cancer leads to worse health medical bankruptcy found that in 2001, outcomes.3,4 As cancer increasingly becomes medical reasons were a factor in at least a chronic disease, we as physicians need to 46.2% of all bankruptcies. This number consider how financial toxicity and other increased to 62.1% in 2007. Most of those legal issues may be affecting the more than who file for bankruptcy have health insur13 million adult cancer survivors in the ance, are well-educated, and are middle United States.6 class.2 The economic burden of cancer is Thankfully, there is a bright light here significant in that patients dealing with in Minnesota that is working to advocate cancer are 2.5 times more likely to declare MetroDoctors

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for Minnesotans living with cancer who are burdened with financial toxicity.

Cancer Legal Care’s (CLC) mission is to engage the law to resolve the complex challenges facing people and communities affected by cancer. CLC is a non-profit with a model that is unique in the nation. We are all now well aware that the direct medical care we provide as physicians only plays a small role in an individual’s health (perhaps as little as 10%); whereas social issues, environmental conditions, stable housing and employment, access to healthy food and education, and behavioral factors — the social determinants of health — play a much larger role and affect up to 60% of someone’s health outcome.5 CLC has been working for over a decade to serve those dealing with cancer and help them navigate the increasingly complex medical and legal systems. Since 2007, CLC’s various programs have helped and educated over 9,000 Minnesotans with cancer-related legal issues including employment discrimination, insurance coverage denials, housing concerns, disability benefits, as well as guardianship and estate planning. Since opening its doors, CLC, which includes staff and volunteer attorneys, has provided over $10 million in free legal services to the Minnesota cancer community!

I have the honor of serving on CLC’s board of directors. To learn more about this incredible organization, I asked Lindy Yokanovich, CLC’s Founder and Executive Director, some questions: How do you see legal issues impacting people’s ability to receive medical care adequately and how does CLC help?

Cancer’s financial toxicity remains the driving force behind CLC’s clients’ need for legal care for three key reasons: 1. They simply don’t have the financial ability to pay for a lawyer’s help, especially in the realm of estate planning at end of life; 2. The financial freefall they are facing as a result of their cancer is something a lawyer can assist in turning around by helping to preserve employment or secure disability benefits; and finally 3. Sometimes legal care makes medical care possible by overturning wrongful insurance coverage denials and successfully navigating the immigration laws so MetroDoctors

that a brother is able to travel to the US and donate bone marrow to his sister.

What prompted you to create CLC? There has been so much cancer in my family and, fortunately, while most of my loved one’s survived their cancer, they often survived into crushing medical and other debt, job loss, and before the protections of the Affordable Care Act, uninsurability. As a lawyer, I knew that many of these issues facing so many people were ones with which a lawyer’s help could be of great benefit.

What has been the success to growing CLC? Great people who understand the need and dig in to be part of the solution: medical providers who champion the cause, compassionate volunteer attorneys, visionary board members, dedicated staff, generous donors, and trusting, grateful, and resilient clients.

What have been the most significant challenges CLC has faced?

Like most start-up nonprofits, creating a sustainable funding stream has been challenging.

What would you like Minnesota physicians to know?

Don’t be afraid. Lay down the historical and real division between physicians and lawyers.

Legal care is a critical part of whole patient care, ringing all the bells of the quadruple aim: improves the patient experience, can help to lower costs, leads to better health outcomes, and enhances the clinician experience.

We often hear from physicians that they feel uncomfortable asking their patients about things like the security of their housing/job/ finances, especially when they feel that they don’t have any or all of the answers to help them. Knowing that they can make a quick referral to legal care without vetting the issue(s) is a great boon to the constraints on physician time and the understandable limits of what they feel comfortable delving into.

Most of all, physician buy-in and support are key to making these changes happen.

What are your hopes for the future of Cancer Legal Care?

My goal is that every oncology clinic in the state will provide funding to have legal care clinics accessible to its providers and patients within its four walls and virtually by 2030.

If you or your patients have a question

The Journal of the Twin Cities Medical Society

or issue that Cancer Legal Care might be able to help, please call (651) 917-9000.

You can also find information at https:// www.cancerlegalcare.org/.

Please also feel free to contact CLC if you are interested in donating or volunteering. The annual Legal Care Affair, to be held on May 6, 2020, is a wonderful, heart-warming, and inspiring event. We would love to see you there (check CLC’s website for information in the near future)!

Jennifer Kuyava, MD works as a hospice physician with Allina Health. She attended medical school at the University of Minnesota.

She completed her Family Medicine residency and her Hospice and Palliative Medicine fellowship at Mayo Clinic. She serves on the boards of Cancer Legal Care and Twin Cities Medical Society.

Lindy Yokanovich, Esq. is the founder and executive director of Cancer Legal Care, a non-profit legal services organization that has provided over $10,500,000 in free legal care services to the Minnesota cancer community since 2007. Compelled to bring Cancer Legal Care to life after witnessing firsthand the many legal questions and difficulties cancer survivors in her own family have faced, Lindy counts her work with Cancer Legal Care as the most profound and gratifying of her legal career.

References: 1.

Gilligan AM, Alberts DS, Roe DJ, Skrepnek GH. Death or Debt? National Estimates of Financial Toxicity in Persons with Newly-Diagnosed Cancer. The American Journal of Medicine.

2018;131:1187-1199.

2. Himmelstein DU, Thorne D, Warren E, et al.

Medical Bankruptcy in the United States, 2007: Results of a National Study. The American Journal of Medicine. 2009;122:741-746.

3.

Mapes D. Cancer bankruptcy and death: study finds link. Fred Hutch News Service. January 25, 2016.

4. Ramsey SD, Bansal A, Fedorenko CR, et al.

Financial Insolvency as a Risk Factor for Early Mortality Among Patients With Cancer. Journal of Clinical Oncology. 2016;34:980-986.

5. Trott J, Regenstein M, Peterson A, Rallos E. Clinician Perceptions of Medical-Legal Partnerships: Lessons for Adopting Social Determinants of Health Interventions in Health Care Settings. National Center for Medical-Legal Partnership White Paper. June 2019.

6. Zajacova A, Dowd JB, Schoeni RF, Wallace RB. Employment and Income Losses Among Cancer Survivors: Estimates from a National Longitudinal Survey of American Families.

Cancer. 2015;121:4425-32.

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Healthcare-Legal Partnerships

Preventive Care for the Social Determinants of Health: Medical-Legal Partnership in a Community Health Center

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remember an attending physician once telling me, years ago when I was a medical student on one of my first clinical rotations, that you can tell how anxious a patient feels by how anxious they make you feel.

This came to mind recently when I met a patient whose shoulders were held nearly at his ears, his fingers tremulous and his speech rapid. The man (whom I’ll call Mr. Z, though identifying details have been changed to protect his privacy) came to see me for management of hypertension, hyperlipidemia, and chronic headaches. I soon learned that his main concerns, however, were well beyond my scope of practice.

Mr. Z had recently been fired (unfairly, he told me), and soon after that he lost his housing. He had enough money saved for a rental application and first month’s rent, but in the meantime he was staying in a hotel, the cost of which was rapidly eating away his savings. Complicating the situation was the fact that he had sole custody of young children, and all of them had a history of significant emotional trauma within the last few years. He said that his online applications at a few apartments had been approved, but when he’d arrived in person he’d been told they had nothing for him. “Is it because I’m not white? I speak English, but I have an accent — is that why? I think there might be racism. I have rights, am I correct?… DO I have rights?” He was unable to afford his blood pressure and cholesterol medications, although he knew they were important and worried even more when he thought about the effects of these uncontrolled conditions on his health.

This kind of situation is not as unusual as I wish it were here at La Clinica, one of Minnesota Community Care’s (MCC)

By Laura Pattison, MD

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St. Paul locations. MCC, formerly known as West Side Community Health Services, is Minnesota’s largest Federally Qualified Health Center (FQHC). Our mission is to “strengthen the well-being of our community through health care for all.”

Since 1969 (incorporated 1972), MCC has been serving underserved and marginalized communities by providing health care, support, and advocacy. It consists of two ambulatory care clinics, La Clinica and East Side; a dental clinic; three Healthcare for the Homeless sites; 10 school-based clinics; and a co-located Public Housing Primary Care Clinic, McDonough Homes Clinic.

In 2018, we provided over 140,000 visits to over 37,000 individuals. Our 2018 UDS data (Uniform Data System, a standardized reporting system used by health centers funded through HRSA) shows that a majority of our patients identify as people of color (87%), low wealth (65% patients at or below 100% of the federal poverty level) and un- or under-insured (39% patients uninsured, 48% patients publicly insured).

Despite the strength of our commitment to our mission to provide health care for all, we struggle. Our social workers serve as our go-to colleagues for non-medical issues that nevertheless impact our patients’

health and quality of life, and they’re often overwhelmed by referrals. Like Mr. Z, many patients have needs that go far beyond the social workers’ professional purview. Without stable employment and adequate income to meet their basic needs, many patients are unable to afford the numerous costs related to accessing health care: sliding-scale fees, co-pays, healthy groceries, transportation, and medications. Poor health literacy hurts the wellness of the community, and there is a growing amount of strong evidence that the chronic stress associated with poverty and racism, for example, have direct negative impacts on health.

Medical-Legal Partnerships (MLPs) are an increasingly common strategy that FQHCs and others are using to address the significant negative impacts of social determinants of health. For FQHCs, MLPs most often entail a cooperative agreement between law schools or civil legal aid nonprofits and the healthcare organization to provide legal assistance to patients, to train clinic staff to recognize potential legal issues (and refer early), and to advocate locally for changes in laws or policies that negatively impact community health. After several years of exploring the idea, Minnesota Community Care has started a partnership with the Mitchell Hamline School of Law to develop a weekly civil legal clinic for patients at La Clinica, staffed by second- and third-year law students, starting in September 2019.

As we’ve learned more about MLPs and the skills and interests of our legal partners, it’s become clear that clinical and non-clinical health center staff, as well as patients themselves, often have a limited understanding of how and when legal services might be useful. Approximately 12% of our patients self-reported a need for legal services in 2018, yet many more reported needs in the areas of housing, employment,

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The Journal of the Twin Cities Medical Society

education, and finances. Healthcare providers repeatedly responded with surprise when told that law students could help with housing needs, fighting discrimination, employment conflicts, worker’s compensation issues, and even navigating school systems so that students with learning problems get the accommodations they deserve. As providers, our first thoughts about MLPs tended to turn towards patients’ specific needs for direct legal assistance, and to improving our own abilities to spot opportunities for legal intervention. Clearly, Minnesota Community Care patients have a high burden of barriers to healthcare access that could be ameliorated by legal services. But as Tamar Ezer argued in the Yale Journal of Health Policy, Law and Ethics in 2017, MLPs are uniquely appropriate entities to engage with communities to develop their abilities to use the law and legal systems to protect their own rights. By enhancing “rights literacy” and making connections with individuals and organizations within communities, MLPs can empower them to advocate more effectively for changes to institutions that contribute to health disparities. Ezer advocates for utilization of community paralegals and engagement with local organizations to advocate for larger policy changes. The legal arms of MLPs often have more of a rightsbased than needs-based approach to patients and communities, which is inherently more empowering.

As a condition of our designation as an FQHC, MCC is required to assess the unmet needs for health services in our service area at least every three years. In 2019, rather than relying only on a review of existing data, we also made a more active effort to seek the engagement of the communities in which we work, and this most recent Community Health Needs and Assets Assessment (CHNAA) was a comprehensive and collaborative effort. The SoLaHmo Partnership for Health and Wellness, Minnesota Community Care’s community-engaged research program, worked to include input from leaders of diverse and intersectional urban communities to identify characteristics of ideal primary care centers. They determined the most essential qualities to be focused on: access, health equity, mental health, historical trauma and structural racism, and long-term high-quality relationships. All of these are factors that contribute, at least in part, to the stressors facing my patient Mr. Z. One

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way that we could address these issues more effectively is through the complementary services of legal experts available through a medical-legal partnership.

Minnesota Community Care is particularly well-situated to be able to develop and utilize an MLP effectively. We’ve been present in this community for 50 years as a stable, known, and trusted entity. We already have established connections with local leaders. Providing a legal clinic on-site will allow “one-stop shopping” for our patients, helping to ease some of the burden of accessing legal services.

Healthcare centers in marginalized communities understand that addressing inequity requires more than providing health care. We need to partner with communities and the right resources to develop effective responses to non-medical issues that affect health.

We can think of legal services as preventive care for the social determinants of health. Healthcare providers simply don’t have the relevant knowledge and skills to navigate policies, laws, systems that create and sustain many barriers to health care, but lawyers do. Our patients have a right to the complementary care and tools of an MLP, and Minnesota Community Care is looking forward to furthering our mission to “strengthen the well-being of our community through health care for all” by developing the partnerships that can help us do it.

Laura Pattison, MD is a family physician at La Clinica, Minnesota Community Care, in West St. Paul. She is a graduate of the University of Minnesota Medical School, Twin Cities, and completed her Family Medicine residency at the University of Minnesota Medical Center at Smiley’s Clinic. Her clinical interests include health equity, women’s health, and immigrant health care. She can be reached at: lpattison@ mncare.org.

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Resources • Community Collaborative Approach to Health Equity: A Community Health and Assets Assessment. Minnesota Community Care. August 2019.

• Ever, Tamar. Medical-Legal Partnerships with Communities: Legal Empowerment to Transform Care. Yale Journal of Health Policy, Law, and Ethics Vol 17, Issue 2, 2017.

• National Center for Medical-Legal Partnership. medical-legalpartnership.org.

• Teitelbaum, J., and Lawton, E. The Roots and Branches of Medical Legal Partnership Approach to Health. Yale Journal of Health Policy, Law, and Ethics, Vol 17, Issue 2, 2017.

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Sponsored Content

Delivering Quality Refugee Care Through the Use of an Interdisciplinary Care Team Contributed by Kathryn Freeman, MD and Cynthia Trevino, LISW

It’s Monday at M Health Fairview Clinic — Bethesda (formerly known as Bethesda Family Medicine Clinic), and patient “Kyaw” approaches the front desk to check in. A refugee originally from Burma, Kyaw has headaches, high blood pressure, and trouble with balance stemming from a chronic condition. He is accompanied by his wife to ensure he’s asking the right questions, though neither speaks English.

He hopes medicine can relieve his headaches but also suspects they are related to his difficulty sleeping. His wife notes that he is more irritable with the kids and is frequently sleepy during the day. As his legs have weakened, he struggles to navigate their third-floor walkup apartment, and now that his wheelchair has broken, he feels uncomfortable taking the kids outside.

Kyaw is one of many of the clinic patients who arrived in Minnesota as refugees. Over a third of visits include an interpreter, and a myriad of languages fill the halls and exam rooms. Patients are at the core of the clinic’s identity; we strive to promote a diverse and welcoming environment. Many of our patients face legal, socioeconomic, or educational challenges that impact their health, and to better meet these needs, our healthcare services continue to expand. Appointments are no longer just one-on-one with a physician and frequently include the expertise brought by pharmacists, social workers, lawyers, and mental health therapists. Working together, our team helps patients access nutritious food; obtain safe and habitable shelter; develop safe, meaningful relationships; and realize opportunities to pursue 22

November/December 2019

education, employment, and economic stability — all significant factors impacting patients’ overall health. None of us in the clinic can solve these complex problems alone. They require the assistance of a diverse, highly skilled team, all pursuing a shared goal of bringing the right people to the table to produce the greatest impact on a patient’s overall health.

Kathryn Freeman, MD

A Visit that Starts With the Social Worker

As a medical assistant brings Kyaw to a clinic room, Kyaw’s first question is not for the physician but for the clinic social worker, who has been coordinating with Kyaw’s care manager about the delay with his wheelchair repairs. It turns out that this particular repair is not covered under his health insurance. Through the assistance of the social worker, Kyaw was assessed and deemed eligible for a county waiver that can supplement his insurance policy and fund medical supplies, including equipment and repairs. The clinic social worker coordinates directly with the waiver case manager on Kyaw’s behalf and will provide close and timely follow-up to ensure the repair is completed.

Social barriers, including limited proficiency in English, make pursuing seemingly simple requests like a wheelchair repair very challenging. The clinic social worker can help navigate the complexities of the social service system, enabling access to services and empowering patient self-advocacy. With the repaired

Cynthia Trevino, LISW

wheelchair, Kyaw can get back outdoors with his family and access health services and programming.

With the Help of a Lawyer

During their conversation, Kyaw mentions that public housing recently denied his request to move to a first-floor apartment that could accommodate his limited mobility. As the social worker leaves the room, she heads down the hall to discuss the patient case with the clinic lawyer. Three years ago, our clinic and Southern Minnesota Regional Legal Services (SMRLS) formed a healthcare-legal partnership to better address patients’ social determinants of health. SMRLS provides free in-house legal services to help low-income individuals and families maintain freedom from hunger, homelessness, sickness, and abuse.

Our in-clinic lawyer assists patients with public benefits, utilities, housing, and issues relating to domestic safety, education, employment, and citizenship. When health-harming legal needs are identified, the attorney meets in-person with patients like Kyaw.

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The social worker and lawyer often partner in this work. A social worker helps patients apply for public housing, while the lawyer provides legal representation in eviction proceedings. A social worker connects patients with food pantries and SNAP benefits, while the attorney appeals wrongful reductions in food support benefits. In domestic violence situations, a social worker identifies shelters and resources, while the attorney helps patients obtain orders of protection. For Kyaw and his family, the clinic lawyer determined that the family was incorrectly denied housing accommodations and coordinates with the physician in advocating for a firstfloor unit that would safely accommodate Kyaw’s medical needs.

for his physician. Refugee and immigrant populations demonstrate increased rates of depression, anxiety, and PTSD and may present with somatic symptoms, such as insomnia, dizziness, headache, or abdominal pain. At the clinic, a culturally validated mental health screening tool, created by provider Darin Brink, helps physicians identify depression in Karen patients. An in-clinic partnership with the Center for Victims of Torture provides access to integrated mental health and targeted case management services designed for those who experienced torture and war trauma. For Kyaw, a short lesson in diaphragmatic breathing and progressive relaxation exercises gives him tools to use when he is worried.

Clarifying all those Medications

Access to a Safe and Stable Home

During Kyaw’s visit, a pharmacist attends to review his medications. Kyaw manages his home medications with help from his wife, taking all his medications in the morning — one pill from each bottle — including his potentially sedating anxiety, allergy, and sleep medications. The clinical pharmacist clarifies which meds are better taken at night and shows Kyaw’s wife how to set up a pill box labeled with sun and moon stickers to indicate day and night dosing. They place a big star on the ibuprofen bottle, so Kyaw knows what to take for headaches. Clinical pharmacists are integrated into many of our patient programs and were the first to join the interdisciplinary team at our clinic over 20 years ago. Most recently, our clinical pharmacists led a latent tuberculosis treatment program, which allowed patients to be treated within their primary care environment. They also prescribe nicotine replacement for patients who use tobacco or betel nut/betel quid, which is commonly chewed by many refugees from Burma.

Addressing Behavioral Change and Mental Health

Moving Kyaw’s sedating medications to the end of the day should improve his sleep and energy, but the pharmacist also recommends that he speak with the behavioral health team. Kyaw has trouble calming down, both when falling asleep and when his children are noisy. While not interested in regularly seeing a therapist, he is happy to chat with the psychologist while waiting MetroDoctors

Nearing the end of the visit, the doctor identifies another reason for Kyaw’s difficulty sleeping. He is worried about qualifying for US citizenship and knows its importance in ensuring he can provide for his family, which relies on programs like medical assistance, SNAP, and public housing. He wants his children to do well here, to succeed in school, learn English, and be successful. He hopes his family still in Thai refugee camps will have the opportunity to come to the US, too.

Over the past year, our clinic’s healthcare-legal partnership has seen a significant growth in immigration and citizenship cases, with over 50 new citizenship cases in the past year. During a citizenship case, the lawyer compiles and organizes information for patients, including documentation of current status and N-648 waiver forms that provide medical exemptions from civics or language testing requirements. They coordinate with US Citizenship and Immigration Services (USCIS) and represent patients in immigration court, if needed.

When families can stay together, access medical services, and receive assistance in navigating health care and social services, they can focus on pursuing a healthy lifestyle and educational and occupational opportunities. For Kyaw, establishing citizenship decreased his blood pressure by greater than 20 points and allowed him to come off of his anti-hypersensitive medications.

For many patients, particularly

The Journal of the Twin Cities Medical Society

refugees, it takes more than medications and physician visits to keep healthy. Addressing how patients live, learn, work, and play can have greater health impact.

For physicians, attempting to address these health challenges alone can feel paralyzing. A team care model featuring a healthcare-legal partnership benefits patients and patient outcomes. It may also improve provider burnout. In a national survey of medical providers working in healthcare-legal partnerships, 86% felt their partnership improved patient health outcomes, 64% noted improved patient compliance, and 38% said they were better able to work at the top of their license.1 At our clinic, working in a multidisciplinary team helps us better provide high-quality, compassionate, patient-centered care. It allows team members to use their unique skills when working with individual patients and when joining together to problem solve challenging cases. For patients like Kyaw, the interdisciplinary team care means improved blood pressure, fewer headaches, more time outside with his family, and improved overall health.

Kathryn Freeman, MD, is an Assistant Professor of Family Medicine and Community Health with the University of Minnesota St. Joseph’s Family Medicine Residency Program and practices full-spectrum Family Medicine with Obstetrics at M Health Fairview Clinic – Bethesda. She has served as the physician champion for the SMRLS – Bethesda Healthcare Legal Partnership since its inception in 2015.

Cynthia Trevino, LISW, is the social work care coordinator at M Health Fairview Clinic – Bethesda. She serves the patients of the clinic in care coordinating their biopsychosocial needs. Cynthia has been with the clinic since 2017. Her past experiences include serving as a medical social worker in a hospital, emergency department, and a community health center where there was also a healthcare-legal partnership with an onsite attorney.

Reference 1. National Center for Medical-Legal Partnership. Impacts of MLP participation reported anecdotally by clinicians. From presentation delivered at the 12th annual Medical-Legal Partnership Summit; April 5-7, 2017; National Harbor, MD.

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Medical-Legal Partnership Online: LawHelpMN.org

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awHelpMN.org is a one-stop shop for civil legal information and referrals in Minnesota. LawHelpMN has existed for more than 15 years as a free, trusted resource for understandable legal information. A project of the Minnesota Legal Services Coalition, the site is run and maintained by the Coalition’s State Support office, which also curates and provides guidance for all its content. For patients with legal needs, LawHelpMN is valuable because it is mobile-friendly, free to use, highlights free and low-cost legal options, is up-to-date and reliable, and finds the right referral.

The newest innovation on the LawHelpMN site is the LawHelpMN Guide (see insert). The Guide is designed to make it easier for a user to find the right self-help resources and referrals for their problem. In order to refine the user’s legal problem, the LawHelpMN Guide asks a series of questions. The questions narrow the legal problem type and the LawHelpMN Guide displays a selection of self-help resources, which can be texted or e-mailed.

Among the featured self-help resources on LawHelpMN are its 160 Education for Justice fact sheets, available in multiple languages, to help people learn about the law and their rights. These are written in plain language and reviewed and updated annually by legal aid lawyers. The site also includes guided do-it-yourself forms, including a Power of Attorney form, and a revocation of a Power of Attorney. Seven booklets, covering common topics such as

By Emily Good

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November/December 2019

Debt, Child Support, Divorce, Rights of Unmarried Parents, and Orders for Protection are available to read or download for free.

A second step in the LawHelpMN Guide asks the user some additional filtering questions to gauge their eligibility for legal services. These include their household size and income, what county the person lives in, how old they are, questions about special qualifications such as having a disability, tribal residence, or being a veteran. Based on this information, a list of potential legal referrals is generated.

These can also be emailed or texted.

The legal referrals fall into five categories. The first is the “traditional” model of a free legal aid office, where the patient calls and is screened and then meets with a lawyer. The second is a “clinic,” which is a one-time meeting, often on a drop-in basis, with a lawyer at a community location. The “clinic” can be a good option for a patient with an urgent question, who may not be able to get help from a legal aid office, or for someone with a discrete

question. The third, a “referral service” is the best fit for someone who makes too much money to qualify for the free services, has a legal issue that legal aid cannot help with, or has not been able to get help.

These include bar associations, sliding fee services, unbundled or a la carte lawyers, and community-based lawyering models where the patient pays a fee to a lawyer for their work on the case. The fourth option, “mediation” is available for free or a sliding fee in some legal areas. Finally, “informational service” includes court self-help centers or law libraries where a patient can get assistance researching a legal issue, finding a form to file, or help with the procedural rules. These informational services cannot offer advice or tell the patient what to do, but they offer important help when legal advice is not needed or available.

A patient can be directed to the Guide or may work through it with a social worker or helper. Either way, the questions are designed to help match the person with the best information and referrals for their specific problem. Because the site brings together civil legal resources, law library services, mediation and bar referral, it is a streamlined referral mechanism, taking the confusion out of identifying the legal problem and figuring out where to direct someone for legal help. LawHelpMN.org is here to help you, and your patients, by taking the guesswork out of legal referrals.

Emily Good is a legal projects manager on the small but mighty team at Legal Services State Support, which runs the LawHelpMN. org website. Questions about the site and resources can be directed to statesupport@ mnlegalservices.org or (651) 228-9105.

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Physicians Serving Physicians

Confidential Peer Support for Physicians with Substance Use Disorders Physicians Serving Physicians (PSP) is a discrete program that provides free peer support, mentoring, and referral to physicians, their families and colleagues who are affected by substance use disorders. For 35 years, PSP has supported physicians through recovery and successful return to practice through one-on-one counseling, serving as a liaison between clients and treatment centers, and offering a monthly support group to participants.

We welcome you to join us at our confidential monthly meetings which are held by a community of physicians (only) to offer mutual support, education, and discussion of issues that are unique to physicians in recovery.

Confidential Peer Support and Consultation for Individuals & Organizations: 612-362-3747 • www.psp-mn.com

Free Confidential Wellness Resources for Minnesota Physicians & Their Families LifeBridge provides a safe harbor to empower and equip you with the tools you need to take care of yourself as well as your patients.

Minnesota physicians, residents, medical students, and their immediate family members qualify for four free, confidential counseling sessions to address stressors like: • Depression and anxiety • Relationship issues • Loss and grief • Financial concerns In addition to counseling services, LifeBridge offers a comprehensive, web-based resource with a rich library of interactive tools and information about wellness and other everyday life issues.

Physician Wellness Resources: 800-632-7643 and mention PSP • www.psp-mn.com/wellness

Healthcare-Legal Partnerships

A Day in Housing Court

A

s part of my community health elective during my third year of family medicine residency in St. Paul, I spent a morning at the Ramsey County courthouse to observe housing court. I entered through security and followed directions to a large antechamber with people milling about and sitting in plastic chairs. There was a wide range of attire, ranging from t-shirts and dirty jeans to polished professional suits. All around the room, people were having frank discussions about their upcoming cases. There were loud emotional conversations over cell phones and small groups whispering hunched together.

When I entered the courtroom, people were seated on wooden benches similar to church pews. In front of me, a young man and woman sat together, both appearing to be in their early twenties. They were holding hands, whispering fervently when an older man came up to them and angrily pointed out something in the day’s newspaper to them. The younger man told him he would have to wait until their turn in court. The older man angrily shook his finger at them and said “I’ll show you,” and walked away to go sit on a bench on the other side.

We all stood as the judge entered and we immediately started going through cases. Some parties were represented by attorneys, but I was surprised at the amount of people arguing on their own behalf. The judge was cordial and

By Katie Hinderaker, MD

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professional, and often explained to participants that something else needed to be filed to move forward, or stating that more information was needed and scheduled a longer hearing in the future.

I watched one landlord, representing himself, bring a case to court against tenants who hadn’t paid their rent. When the tenants divulged he had shut off their power, the entire crowd murmured in disapproval. A lady sitting next to me turned and stage-whispered to the rest of the room, “That is SOOOO illegal”.

I realized I wasn’t the only one who had showed up just to watch. I got caught up in the drama myself. I watched the young couple who had been sitting in front of me defend themselves against accusations of their landlord and bring forward issues of safety in their apartment. When the judge demanded evidence that these safety guidelines had been met, I felt a small twinge of victory and realized I had been rooting for them the whole time.

What I remember most about my day in housing court was how intimidated I felt. The courthouse was clearly a place that had rules and a decorum that I didn’t understand and that I had never received training in. I felt nervous and constantly a little afraid that I was going to get called out publicly for an unintentional transgression. When I realized how powerful this feeling was to me, an educated white English-speaking female with absolutely zero stake in the outcomes of the day’s proceedings, I started to appreciate how frightening housing court could be to someone less able to navigate the system, whose very home could depend on taking the proper courses of action throughout the legal process including their appearance in housing court.

I also reflected on how comfortable I felt returning to my own work environment in my clinic, a place which to an outsider also could have intimidating nuances of workflow, specific jargon, and basic expectations inside of a system they don’t really understand. I remembered again how medical care is just a small piece of the pie of overall health, and how a person’s social context plays a much greater role. I am thankful that I was able to spend a few hours in housing court and was even more grateful to return to my residency clinic, where a blossoming healthcare-legal partnership was there to help me address the needs of the whole person.

I have experienced our healthcare-legal partnership in action. As I walked into the clinic exam room, an elderly

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The Journal of the Twin Cities Medical Society

American Psychiatric Association

2019 Community Gold Award!

frail couple who I was very familiar with was sitting in front of me. She was sobbing, tears sliding down her cheeks. He was stoic in the corner, leaning on his cane, but appeared pale, fatigued, and somewhat frightened. I had taken care of them both after falls. I had been with them through hospitalizations for acute illnesses and chronic care of long-term medical issues. I had never seen either of them look so upset.

I asked the woman what was wrong.

A nonstop barrage of her native language erupted from her mouth and the interpreter struggled to keep pace. She was concerned about housing, and told me they were unable to take the stairs due to their chronic medical conditions. This I was aware of, having treated her for a fall off these stairs. I had written a letter to their housing authority in the past, stating they would be unable to safely take stairs. Their apartment complex did make an apartment with an elevator available to the couple, however the moment they tried to take the elevator for the first time, the husband’s vertigo was so severe that he almost passed out. He lost his footing and fell — right in front of someone from his housing authority.

Another doctor from our clinic saw them afterward and wrote another letter to the housing authority stating that they needed a first-floor apartment, as this reliance on an elevator would be unreasonable for daily living and especially unsafe in an emergency.

Through tears, she said they had been told by their housing authority that they needed to move to the second MetroDoctors

floor that very day, or else they would be forced to move to a 9th floor apartment. I knew she struggled with mental illness, and this notification brought her such despair that she didn’t know how to continue. With the patients’ permission, I immediately found the lawyer working in our clinic and provided her with all the letters that the patients’ doctors had written up to this point. She met with my patients and called the housing complex, and eventually she was informed that there would be no moving forced upon the couple that day. I don’t know the exact details of what happened, but I do know that soon after, the couple was continuing to live (safely) on the first floor and I was significantly less worried about both their physical and mental wellbeing. I was, and still am, appreciative of all the help that our legal advocate has provided to our clinic.

The presence of an onsite Healthcare-Legal Partnership at my clinic was a gift — not only for me where I was able to focus on the medical needs of my patients, but more importantly for my patients, who were able to have access to immediate assistance to address their social needs.

Dr. Katie Hinderaker is a former chief resident from the University of Minnesota – St. Joseph’s Family Medicine program. She currently practices broad spectrum Family Medicine in Lake City, MN. She can be reached at kehoff@umn.edu.

The Journal of the Twin Cities Medical Society

Your Link to Mental Health Resources

855.431.6468 mnpsychconsult.com Available Monday-Friday from 8am-6pm

November/December 2019

27

Sponsored Content

Eliminating Barriers to Advance Care Planning Contributed by Dawne Starkey, Linda Bauermeister and Thomas VonSternberg, MD

Many physicians understand the critical importance of Advance Care Planning (ACP), but despite the evolution of office-based practice, the current clinic visit structure is a barrier Dawne Starkey to these discussions.

Further challenges exist as physicians and their teams strive to efficiently prioritize quality measures, improve patient experience, and address ongoing EMR issues.

The clinic visit is relatively short and tends to primarily focus on managing chronic conditions or addressing urgent problems. All clinics are challenged to provide adequate time to manage individuals with multiple chronic conditions; even more so for those with conditions that are progressively worsening. Patients with complex conditions often have not had discussions about their future goals for care in the event they are not improving.

As their illness progresses, visits to the emergency room and hospital increase. Eventually a crisis may occur and if there is no plan in place, the family and care team are left to speculate on the patient’s values and priorities for care. All too often, the default is toward a more aggressive approach.

ACP helps to bridge this gap by delivering a process by which patients can express their future preference for medical care in the event they lose their ability to communicate. This future plan — an advance directive — may include a statuary healthcare directive, an appointment of a 28

November/December 2019

near the end of life.

While processes were in place to inquire about ACP for hospitalized, home care and hospice patients, it was apparent that earlier and regular conversations in both Linda Bauermeister Thomas VonSternberg, MD Primary and Specialty Care would be crucial to normalizing these surrogate decision-maker, a clinician-led dialogues. conversation about goals and care prefThe program evolved and in 2013 erences for patients with serious illness, the Life Stages Conversation Model was or a Provider Order for Life Sustaining initiated, which informs ACP discussions Treatment (POLST) form. The advantages based on a patient’s age and stage of health. of advance directives include improved For example, patients age 18 and over apoutcomes and satisfaction for patients/ point a healthcare agent and document families, enhanced clinician satisfaction, their care wishes in a short-form health increased hospice utilization and patient care directive. Upon turning age 60, or autonomy, and decreased resource utiwith the onset of a chronic illness, clinilization.1-5 The Institute for Healthcare cians encourage a more robust healthcare Improvement Leadership Alliance recently directive to further clarify personal valhighlighted the barriers to initiating adues and priorities. The Medicare Annual vance directive discussions. Leading the list Wellness Visit for patients age 65 and over includes discomfort with the conversation, provides another avenue for clinicians to time limitations, and integrating process initiate this conversation. Many clinics into workflow.6 have trained ACP facilitators to follow up HealthPartners is addressing these on these initial introductions with one-tochallenges by implementing ACP workone support and education. Additionally, flows, expanding educational curricula, exfree classes are offered for patients and ploring better ways to communicate plans families at 15 clinic locations as well as onvia the EMR, and promoting touch points going resources via an ACP Help Line. The along the way to review and align patient CMS CPT billing codes for ACP7 have preferences. been increasingly utilized by HealthPartHealthPartners’ ACP program was ners providers as a way to structure time initiated in 2008 when teams at Methand reimbursement for these important diodist Hospital realized the majority of alogues. HealthPartners also partners with ethics consults were a result of conflict and acknowledges the important work over treatment decisions for loved ones MetroDoctors

The Journal of the Twin Cities Medical Society

that Honoring Choices MN is doing to elevate the significance of ACP, promote avenues for community engagement, and foster collaboration among stakeholders.

Issues surrounding comorbidity, frailty, and cognitive decline have created special challenges for older patients in skilled nursing and assisted living facilities. An additional resource HealthPartners has successfully implemented is the Serious Illness Conversation Guide.8 This template has helped clinicians better prioritize advance directive dialogue and documentation. The goals are to increase effectiveness of treatment choices, promote greater involvement of families, and

home-based and nursing home-based consultations and care. This provides patients the opportunity to have these critical conversations in their homes if they so choose.

In addition to offering patients a trusted source to guide these conversations, it’s important that information is readily retrievable in the EMR. Therefore, a visible access point was created allowing all care team members to have rapid access to patients’ expressed wishes. The EMR also houses scanned documents, surrogate decision-makers, documented end-of-life conversations, as well as current and historical code status history. Having a standardized process across an organization

to elicit meaningful advance directives according to their age and stage of health.

Innovative solutions utilizing EMR will undoubtedly play a key role not only to ensure rapid accessibility of key information, but also to improve documentation practices that accurately reflect patients’ changing priorities during advanced illness. Ultimately, the goal of ACP is to provide the best care possible to patients through a greater understanding of what matters most, throughout their lifespan— and especially at the end of life.

Dawne Starkey, Advance Care Planning Program Manager, Park Nicollet.

Linda Bauermeister, Executive Director, Home Care, Hospice and Community Senior Care, HealthPartners.

Ultimately, the goal of ACP is to provide the best care possible to patients through a greater understanding of what matters most, throughout their lifespan — and especially at the end of life.

enhance safety during transitions of care from facility to hospital. The clinicians are measured on rate of POLST completion annually. Results have shown improved documentation, making patient treatment choices consistently visible via clear and transferable medical orders.

Palliative Care teams are uniquely situated because of their interdisciplinary approach and their skills to articulate patient goals of care. In addition to a robust hospital-based program, HealthPartners has expanded Palliative Care services to Specialty Care and also broadened its community-based program. The organization realized there is a greater concentration of advanced illness and need for palliative approaches in some key specialty departments, such as oncology, pulmonary, nephrology, neurology and cardiology. In these areas, palliative care clinicians are now being embedded to partner with the specialist physicians in the care of the patient.

Additionally, it now has multidisciplinary palliative care teams providing MetroDoctors

including documentation practices that prompt regular review/reconciliation, and fosters metric-driven quality improvement, allows for improved ACP conversations.

Over the past 10 years, these combined efforts have substantially increased the number of Methodist Hospital patients who have an advance directive in place prior to death from 35% to 85%.

Likewise, HealthPartners Primary Care enterprise data for patients 65 and over reflects an increase of ACP documentation over the past four years from 20.7% to 40.9%. The health system’s most recent audit shows that over 80% of patients residing in skilled nursing and assisted living facilities have POLST documents in the EMR. Looking forward, the health system will continue to address the barriers through a systematized and standardized approach to engage patients at multiple points and various settings. It will also include ongoing education and processes to ensure care teams work collaboratively

The Journal of the Twin Cities Medical Society

Thomas VonSternberg, MD, Senior Medical Director, Home Care and Hospice, HealthPartners.

References 1. Detering, NM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end-of-life care in elderly patients: randomized controlled trial (published ahead of print March 23, 2010). BJM. http://www.bmj. com/content/340bmj.c1345.long.

2. Teno JM, Gruneir A, Schwartz Z, Nanda A, Wetle T. Association between advance directives and quality of end-of-life care: a national study. Jam Geriatric Soc. 2007; 55:189-94 (PMID: 17302654).

3. Bernacki, R, Block, S. Communication about Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014; 174(12):1994-2003.

4. Tierney WM, Dexter PR, Gramelspacher GP, Perkins AJ, Zhou SH, Wolinsky FD. The effect of discussions about advance directives on patient’s satisfaction with primary care. J Gen Intern Med. 2001:16(1):32-40.

5. Jackson, VA, Mack J, Maysuyama R, et al. A qualitative study of oncologists’ approaches to end-of-life care. J Palliative Med. 2008:11(6):893-906.

6. Institute for Healthcare Improvement Leadership Alliance, “Addressing the Barriers That Prevent Us from Having the Conversations That Help People Live and Die Well: Lessons from the End-of-Life Workgroup”. http://www.ihi. org/Engage/collaboratives/LeadershipAlliance/ Pages/default.aspx.

7. CMS Medicare Learning Network; ACP Fact Sheet. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning. pdf.

8. Ariadne Labs Serious Illness Care Program.

Bernacki, R, Block, S. Communication about Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014; 174(12):1994-2003.

November/December 2019

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Healthcare-Legal Partnerships

Environmental Health — Health Equity

I

magine a young boy gasping for breath during an asthma attack generated by air pollution from the freeway a few blocks away, from the wildfire smoke floating down from Canada, or the metal processing plant across the river. Imagine the teenager coughing in school from the mold exposure at home exacerbated by the prolonged heatwave. Imagine the patient who suffers from constant neurological sequelae from a tick bite she received hiking along the North Shore.

Our changing climate adversely affects different populations in different ways. Many are from marginalized or disadvantaged groups such as people living in poverty, people of color, women, LGBTQ persons, and people with physical or mental disabilities who have difficulty accessing proper medical care.

The Robert Wood Johnson Foundation defined health equity as the principle that “everyone has a fair and just opportunity to be as healthy as possible which requires removing obstacles to health such as poverty, discrimination, and their consequences.”1 The removal of these and other obstacles to health, however, often require legal assistance. For example, getting a landlord to mitigate mold could entail time, money, and legal advice. Unfortunately, many who need to take such actions are unable to afford it.

Most physicians, clinics, and hospitals do not have the expertise to provide legal help to their patient populations. Healthcare-legal partnerships (HLPs) can help by embedding lawyers as specialists in healthcare settings to support actions for healthy living conditions, especially among vulnerable communities. Currently, 333 healthcare organizations, including 98 HRSA-funded health centers, 33 children’s hospitals, and 25 VA medical centers have established HLPs including 17 in Minnesota and North Dakota in the last five years.2 The expertise of HLPs is not just for the individual patient’s needs but also to affect institutional and governmental policy.

Integration of public health and legal services will help address health disparities generated, at least in part, by our changing climate.

References: 1. Braveman P, Arkin E, Orleans T, Proctor D and Plough A, What is Health Equity?, Robert Wood Johnson Foundation, 5:1 (2017).

2. National Center for Medical Legal Partnership, https://medical-legalpartnership.org.

By Mark D. Nissen, MD

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November/December 2019

MetroDoctors

The Journal of the Twin Cities Medical Society

In Memoriam W. BRUCE CLARK, MD passed away on July 14, 2019. Dr. Clark was an ophthalmologist practicing in St. Paul. He joined the medical society in 1966.

THOMAS F. FERRIS, MD passed away on July 19, 2019. Dr. Ferris served as Chair of the Department of Internal Medicine at the University of Minnesota Medical School until his retirement in 1995.

JACK LEES, MD passed away on June 13, 2019. Dr. Lees practiced Obstetrics and Gynecology in St. Paul. He joined the medical society in 1965.

MARIO PETRINI, MD passed away on August 1, 2019. Trained as an OB/ GYN, Dr. Petrini served as Chief of Staff and was on the Board of Trustees of Methodist Hospital. He joined the medical society in 1981.

EDMUND POST, MD passed away on August 26, 2019. Dr. Post received his medical degree from the University of Arkansas School of Medicine and was an ENT physician in St. Paul.

Dr. Post joined the medical society in 1956.

MARTIN SEGAL, MD passed away on August 25, 2019. A pathologist, Dr. Segal founded the Methodist Hospital pathology lab. He joined the medical society in 1986.

HARVEY SHARP, MD passed away on July 21, 2019. Dr. Sharp was the Chief of Gastroenterology at the University of Minnesota where he was active in the liver transplant program and participated in the first small bowel transplant. Dr. Sharp joined the medical society in 2010.

JAMES “CORKY” VANCE, MD passed away on June 9, 2019. Dr. Vance practiced Dermatology with Metropolitan Dermatology. He joined the medical society in 2014.

MetroDoctors

The Journal of the Twin Cities Medical Society

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November/December 2019

31

LUMINARY of Twin Cities Medicine

By Marvin S. Segal, MD

CHRISTOPHER REIF, MD, MPH, MA

A young lad from St. Cloud received his BS degree in 1968 from neighboring St. Johns University. At about the same time, just 80 miles to the south, the Community-University Health Care Center (CUHCC) was established. It’s interesting to track how these two events have meshed in those intervening 50 years.

Over the next few years, Dr. Christopher Reif, the graduate mentioned above, went on to first receive an Environmental Biology MA degree from the University of Colorado and then his MD and MPH degrees from our U of M. His clinical specialty and sub-specialty training choices, Pediatrics and Adolescent Medicine — via Hennepin County Medical Center (HCMC) — blended well with his interest in the environment. He believes strongly that environmental factors play far reaching roles in the determinants of future health and dealing with them early in life can have major positive outcomes as our young folks mature. He states, “Adolescence is the age of great experimentation and it’s great to be helping them to find ways of experimenting effectively and safely.”

Along Chris’ career path — which led to his current Directorship of CUHCC — there were many preparatory site visits and meaningful pauses: he taught Environmental Biology in Colorado, California and to adult Native Americans on the Pine Ridge Reservation in South Dakota; held Family Medicine and Community Health U of M faculty positions; directed the Adolescent Medicine Fellowship at HCMC; and was the Medical Advisor to the Network of Community Clinics of Minneapolis and St. Paul. Other local clinical and administrative involvement has included diverse services with a teen clinic, a public school clinic, the Ramsey County Department of Corrections, a family planning clinic, homeless health care and chronic pain rehabilitation.

These activities, while providing excellent services to a variety of populations, also solidified the inherent talents and clinical ingenuity of Dr. Reif. His work at CUHCC has been performed in a belief milieu anchored by the requirement for the equal provision of care in a community setting. Chris is quick to modestly point out that, along with his clinic’s “supportive team story,” there were many colleagues and collaborators along the way with whom he was fortunate to work with 32

November/December 2019

and learn from — notable among them were: Dr. Amos Deinard (Luminary 2012), former Director of CUHCC who was instrumental in creating one of the first medical-legal partnerships in the US; Dr. Henry Blackburn (Luminary 2018), U of M Professor of Public Health; and Dr. Robert tenBensel, a U of M pediatrician and staunch champion of child safety. Reif ’s south Minneapolis clinic continues to cater to a diverse population who may otherwise have a difficult time obtaining excellent care in the holistic arena of preventive health, urgent care, primary care, family planning, and mental health.

The good doctor is a dedicated family man whose “four beautiful children (now ages 25-33)” have kept him pleasantly busy as he practices what he preaches, leading an active physical, mental and social life. He has been honored numerous times for his community health service, public health achievements and notably as Teacher of the Year by the Minnesota Academy of Family Physicians and his alma mater’s Department of Family Medicine and Community Health.

Chris Reif is dedicated and quietly passionate about his life’s work. He states, “I’m optimistic about the future of population health and family medicine and am blessed to have participated in this pursuit — what a joy and privilege it has been”...and we, in turn, have also been fortunate to have had our Luminary colleague so deeply engaged in our medical community.

We must agree, the above mentioned amalgamation of that dynamic young college grad and his top-notch Twin Cities’ community clinic seems to have worked out very well!

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine.

Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

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