By RANDY EDWARDS
At the Sr. Mary Philippa Health Center, a charity clinic that sits just across Stanyan Street from the sprawling green space of San Francisco's Golden Gate Park, patients with little income and multiple problems benefit from something most of us don't expect to find at a hospital — free legal help.
"The theory is that patients can have legal issues that are adversely impacting their health," explains Mary L. Rotunno, an attorney who launched the Medical-Legal Partnership at Sr. Mary Philippa in 2010. The health center provides outpatient primary medical care for adults regardless of their ability to pay.
On Fridays, patients can find help with their legal issues as well as their health concerns. Most clients have at least two legal problems, Rotunno said. "If you can advocate for them and resolve some of their legal problems, it will have a positive influence on their health," said Rotunno, who is senior counsel at San Francisco's Dignity Health, parent company of
St. Mary's Medical Center, where the Sr. Mary Philippa clinic is housed.
Adequate housing
That's how it works in theory. In practice, the medical-legal partnership might be best illustrated by the case of the diabetic homeless woman who struggled to keep up with her insulin injections because she had no place to keep the medication secure, much less provide necessary refrigeration. When she first talked to the program's lawyer, she was ranked at 800 on the waiting list for federally subsidized housing in San Francisco. By documenting her medical needs, the attorney was able to get her bumped far up the list and soon the patient had a place to live.
Housing issues are the most common cause of distress for the patients in housing-strapped San Francisco. The lawyers in the program, provided through a partnership with the Volunteer Legal Services Program of the Bar Association of San Francisco, work to block evictions and utility shutoffs, and compel landlords to meet housing codes, Rotunno said.
They also help patients negotiate the complex bureaucratic landscape of federal programs like Medicare or veterans and disability programs. They provide counsel on domestic violence, help with child custody cases and have assisted an elderly patient with bladder problems who was ticketed by police for urinating in the bushes.
Since the program began in July 2010, attorneys have helped 160 clients with a total of more than 323 legal problems. But the numbers don't tell the whole story, said Mairi McKeever, director of the Volunteer Legal Services Program for downtown San Francisco.
As an example, she mentions a problem the program has addressed more than once: a patient with asthma whose symptoms are exacerbated by mold in their rental property. Landlords are required to maintain homes that are free of such health threats, but sometimes need encouragement to follow the law.
"So when the mold is taken away, the person's asthma attacks subside, and now they are able to work," McKeever said. "They can take care of their children, and their children can go to school."
Hierarchy of needs
Medical-legal clinics were pioneered in Boston in the 1990s and have become increasingly common throughout the United States, McKeever said. According to the website of the National Center for Medical-Legal Partnership, today there are nearly 100 medical-legal partnerships serving 54,000 patients a year across the country.
The partnership at Sr. Mary Philippa is somewhat unusual in that it serves a broad range of adult clients, McKeever said. The national movement began in pediatrics, and many of the current programs are at pediatric hospitals or focused on a specific diagnosis, such as diabetes.
The program currently is funded with the support of the St. Mary's Medical Center Foundation and four local law firms that provide both financial and pro bono support.
Dr. Brandon Murguia, a second-year resident at St. Mary's and the current "physician champion" of the medical-legal partnership, said such partnerships are an obvious fit for reimbursement systems anticipated by health care reform. Already, some studies have shown that the programs can be self-sustaining or even revenue generating, as the lawyers are helping low-income patients qualify for government reimbursement programs or disability and veterans' benefits.
And as health reform restructures reimbursement models away from fee-for-service and toward a stronger focus on patient outcomes and preventative care, programs that provide patients with domestic stability will be highly valued, Murguia predicts.
Housing and other legal problems "interfere with follow-up appointments, interfere with medical compliance. We see this all the time in our clinics," he said. "When patients don't have a stable home situation É they tend to worry more about that and are less invested in their own health care."
Murguia will lead the health center's first comprehensive outcomes study on the program this year, evaluating the impact of legal intervention on patient health, preventative care, compliance and other factors.
Murguia, Rotunno and McKeever agree that the partnership strikes at the heart of a Catholic hospital's mission.
"It goes to the core of helping people in poverty and focusing on people having their basic needs met," McKeever said. "These are people who are often on the verge of losing their homes or on the verge of losing the income that helps them buy their food."
Added Rotunno, "One of our values is justice. We have a responsibility to serve persons who are poor and vulnerable. This clinic serves this mission."