Dr. Colleen Cagno recalls a patient who urgently needed help renewing his public housing.
She and a lawyer who works down the hall documented how his medical condition qualified him for public housing, and expedited the process to prevent an eviction that would have taken a toll on the patient's health, said Dr. Cagno, associate residency program director in the department of family and community medicine at the University of Arizona, Tucson.
In October 2005, the faculty and residents started offering such services to low-income patients and families under a medical-legal partnership known as the Tucson Family Advocacy Program. Now, two lawyers are available in the teaching clinic for a total of 40 hours per week. Since opening its doors, TFAP has assisted more than 370 patients with more than 770 legal matters affecting health, including disability benefits, Medicaid, Medicare, housing conditions, public benefits, advance directives, and domestic violence.
The program is one of more than 70 medical-legal partnerships operating or soon-to-be operating across the country, explained Anne M. Ryan, J.D., director of TFAP. Across the country, medical-legal partnerships are found in a variety of settings, from universities to legal aid offices, hospitals, and law schools, Ms. Ryan added.
A wealth of literature indicates that “if we don't address our patients' [basic nonmedical] needs, we [as physicians] end up spending more time in other ways,” Dr. Cagno added.
These are the patients who often come in again and again. At first glance, they might appear to have a difficult time complying with their medication regimen, but often at the root of that problem is a social or financial obstacle.
With half of her clinic's patients on Medicaid, Dr. Cagno noted that it's not unusual for them to struggle with basic needs such as housing and food, so paying for medications becomes a second-tier priority.
Patients with asthma have needed legal assistance dealing with landlords who are slow to eradicate a roach or mold infestation problem. Others are living with domestic violence, a situation in which having the clinic's legal and social services on hand makes all the difference.
In another case, a 46-year-old man who was used to living from paycheck to paycheck from his store clerk job worried about providing for his family after he was diagnosed with advanced cancer and was no longer able to work. In conjunction with his physician, TFAP helped him obtain temporary state assistance and expedited Social Security disability benefits, enabling the family to keep its home and car. Without the coordination of medical and legal services, his family would have needed to wait 6 months for disability benefits to begin, Ms. Ryan noted.
“It's providing that kind of patient-centered holistic care that really gets to the concept of the medical home,” Dr. Cagno added.
Funding for TFAP comes from a variety of sources, including the Arizona Foundation for Legal Services and Education, Southern Arizona Legal Aid, the United Way of Tucson and Southern Arizona, and the University of Arizona Foundation. In addition, the university's department of family and community medicine pays for the staff time of the physicians who are involved in the partnership, and the clinic provides the office space for the lawyers, a social worker, and interns.
Physicians practicing outside of academic medicine may lack the backing of such funding sources, Dr. Cagno and Ms. Ryan acknowledged. But they both insist that there are resources out there. To start, every state has legal aid offices, which provide free legal services to individuals with limited income. In addition, there are free legal service providers in every state that help disabled individuals, Ms. Ryan said. And in many communities, lawyers volunteer their services to those in need either pro bono or on a sliding scale.
Physicians frequently get discouraged because they don't have the time to find services for their patients who are in need, Dr. Cagno said. But in every community there are at least one or two key social service providers who will do the digging to help patients find services.
Screening patients for social or financial problems is a good first step, Dr. Cagno and Ms. Ryan agreed. Ms. Ryan suggested asking just a few open-ended questions, such as “Every family has fights. Tell me about fights in your home.” Or “Have you ever cut your medicine dose in half or skipped it because you couldn't afford it?” Many patients do not want to apply for public assistance. The key is to destigmatize the need by having their physicians ask questions that validate their needs, she said.