St. Michael’s Hospital Academic Family Health Team has implemented a multidisciplinary program called the Health Justice Initiative to address legal issues that present barriers to their clients’ health. The initiative includes providing clients with onsite legal assistance from a lawyer, educating clinical and legal staff about their respective roles to provide effective services, and advocating for change at the system level using an upstream approach. The program is a partnership with four community legal aid clinics (see below) and Legal Aid Ontario.
In recognition of this work, St. Michael’s Hospital Academic Family Health Team was the 2017 recipient of the Association of Family Health Teams of Ontario’s (AFHTO) Bright Lights Award for the category Strengthening Partnerships. You can view a video of all nominees for this category here.
Health Quality Ontario had a chance to catch up with Linda Jackson, Executive Director of St. Michael’s Academic Family Health Team and Dr. Rami Shoucri, Clinical Champion of the program, to gain a better understanding of the impact the Health Justice Initiative has had on client outcomes.
Partnering with legal organizations to improve client outcomes sets a new precedent in the health care system. How did the Health Justice Initiative first come about?
Between 2013-2014, Dr. Shoucri was a resident under the supervision of Dr. Nav Persaud, the first clinical champion of the program. During this time, he conducted a needs assessment by doing a chart stimulated recall with the social workers of the FHT. The findings revealed that 55% of clients referred to social workers were perceived to have at least one health harming legal issue. Extrapolated to the department, the results suggested that there would be approximately 2000 clients/year with a legal need.
To address this need, we approached potential community-based legal service partners, and after 18 months of planning, the initiative launched in 2014. We now have a partnership that includes:
- St. Michael’s Hospital Academic FHT
- St. Michael’s Hospital
- Neighbourhood Legal Services
- ARCH Disability Law Centre
- Aboriginal Legal Services of Toronto
- HIV&AIDS Legal Clinic Ontario
The initiative is supported by funding from Legal Aid Ontario. The partnership has secured funding through to March 31st, 2019 and future funding is being sought based on the results of an upcoming evaluation.
This model is novel in Canada, but is quite popular in the United States through the National Centre for Medical-Legal Partnerships.
From left to right: Emily Hill, Executive Director of Aboriginal Legal Services of Toronto), Rami Shoucri (Clinical Champion), Johanna Macdonald (first on-site Health Justice Initiative Lawyer), Jack Deklerk (Executive Director of Neighbourhood Legal Services), Kim Radford (Research Coordinator for Health Justice Initiative), Karen Weyman (Chief, SMH DFCM), Linda Jackson (Executive Director SMH AFHT), Sheleca Henry (Health Justice Initiative Program Assistant), Andrew Pinto (Principal Investigator, Health Justice Initiative Evaluation), Gary Bloch (Chair of SMH AFHT Social Determinants of Health Committee), Ryan Peck (Executive Director of HIV&AIDS Legal Clinic Ontario). Not pictured, Jennifer Stone, current on-site Health Justice Initiative Lawyer.
Can you give examples of legal issues patients face that impact their health?
A significant number of our patients have incomes in the lower quintile.They are often in precarious employment and housing, have unstable family structures and uncertain immigration status. As a result, they face loss of income, threat of eviction, domestic violence, problems accessing social benefits, deportation, absent family members and/or involvement in the criminal justice system. Their low income and the nature of their legal issues means access to traditional legal services is difficult.
“The links between legal needs and health are sometimes complex and sometimes straightforward.”
For example, addressing mould in a client’s home with chronic respiratory disease will almost inevitably decrease the number of exacerbations and complications of that disease.
Other clients face more complex issues. For instance, M.B. was a chronically ill client who was homeless for several years and was finally stable in a supportive housing unit. Unfortunately, the housing provider now wanted to evict M.B. for being messy. M.B.’s physician felt that the housing provider seemed to be pressuring M.B. to leave and not following established rules. The result would be further homelessness and deteriorating health.
Our onsite legal staff was able to advise M.B. of their housing rights, and work with the physician to speak with the housing provider. This intervention saved a predicted spike in emergency room and emergency shelter use by M.B., increased M.B.’s stability and trust in the care and housing team, and improved M.B.’s overall well-being.
“We believe that addressing legal issues can almost always alleviate stress that may be hindering our clients’ ability to improve their health.”
How does this partnership benefit clients?
Clients have stated that they are more comfortable talking about their legal issues in a health care setting versus a legal office, often because there is a relationship of trust established. They can be referred to legal services via their primary care provider or can get in touch with the lawyer directly. Clients have also had the opportunity to seek advice via weekly drop-in sessions.
“Legal resources are available in the community, but clients often don’t know how to access them.”
Our model allows the health care and legal system to work together so that clients can maximize access to these resources. Ultimately, by addressing our clients’ legal issues, we can help address the social determinants of health and contribute positively to our clients’ overall health.
Were legal organizations open to your proposal of partnership?
Our legal partners were very eager about this initiative and this initiative would not be successful without their full engagement and participation. The legal clinics we approached are community-based, and they see this partnership as a way to innovate and increase access to justice and legal services for clients; this is a shared goal among all community-based organizations.
The partnership allowed both legal and health professionals gain a greater understanding of their respective roles and illustrates how positive our collaboration can be for clients. The funding from Legal Aid Ontario has been key to bringing these organizations together.
What have been the outcomes of the Health Justice Initiative thus far?
Over a two-year period beginning in December 2014, a total of 474 clients received direct legal services from the lawyer in our program, representing 760 distinct legal issues and resulting in 1,574 legal services.
An evaluation of the project is underway to analyze client outcomes and provider experiences.
The evaluation will include:
- Surveys and interviews to capture health care providers’ perspectives (including doctors, nurses, social workers, and income security workers) and how the initiative has impacted their day-to-day practice.
- Surveys and interviews with our legal partners to capture their perspective and how the initiative has impacted their practice.
- A retrospective review of our database to look at trends around impact of services.
- A prospective cohort study to demonstrate impact of this initiative on individual clients.
- A review of our advocacy efforts to demonstrate impact. For example, one of our advocacy initiatives was to submit recommendations to the Standing Committee on Citizenship and Immigration to amend the Citizenship Act to explicitly honour a citizenship applicant’s right to accommodation for a disability and compliance with the Convention on the Rights of Persons with Disabilities (CRPD).
What were your lessons learned?
- Review and analyze your patient population/health equity
data to establish the need for these services. By demonstrating the need,
this may help create a case for the investment of time, resources and funds
needed to kick start a program. Perhaps your client population’s primary need
is not legal services, but housing services. Whatever the need is, the data
will help point you in the right direction.
- Identify team members who can make up a social
determinants of health committee and lead the planning and development of this
type of initiative. A physician clinical champion is a powerful advocate to
move the work forward. It also helps to have expertise on your committee to
review and analyze your data.
- Carve out protected time to develop the initiative. Without
the dedicated time of team and committee members, it becomes very challenging
to move the work forward. Time is required to work out logistics, to create
mutual understanding between health care and legal providers, and ensure the
program is meeting the needs of clients and providers alike.
- Include the initiative in your organization’s strategic
plan. Addressing the social determinants of health is a complex issue.
Having leadership and your organization behind you will help to ensure the work
continually moves forward.
- Develop a solid partnership with legal organizations in your
community. At first, we thought that having an employed lawyer on site to
provide legal services would be enough to address the legal needs of our
clients. But having someone occupy an office within a health care facility does
not have the same value as a more integrated partnership. Our advice is to
develop a solid partnership with your community’s legal organization(s). When
you develop a partnership, you are able to continuously draw on different
perspectives and resources, and engage in real knowledge sharing. Connecting
with an organization also means you have access to a wider range of skills and
services for more effective referrals. Legal Aid Ontario was extremely
supportive, but each community has its own neighbourhood legal clinic(s) you
can reach out to in order to start the conversation.
- Join the Community of Practice. We currently have a
Community of Practice (CoP) that meets every two months consisting of
organizations across the province who are developing similar joint legal/health
models. The CoP meets in person and via teleconference. The CoP represents
about a dozen programs at various stages of development. Our goal is to share
and disseminate best practices, discuss challenges and learn from each other.
Interested to learn more about the CoP? Connect with
Rami Shoucri,
on Quorum.
Are you considering a health care/legal model of care within your organization? Add a comment below or connect with Rami Shoucri.