Patients often leave a medical clinic with the same social and economic problems that caused them to need care in the first place.1,2 Providing legal services in health care settings can help address upstream factors that contribute to poor health.1
Since the 1974 Lalonde report,3 officially titled A New Perspective on the Health of Canadians,3 health professionals, public health authorities, and other stakeholders in Canadian health care systems have placed greater emphasis on the instrumental role of social factors in the health of Canadians. Income and social status, social support networks, education and literacy, employment, social environment, sex, and culture are now among the influential factors, termed social determinants of health, formally recognized by the Public Health Agency of Canada.4 The effect of social determinants of health is seen in a body of evidence that suggests inequalities in society beget inequalities in health, and that this relationship is not always altered by improvements in health care.2,5 Although this claim is now a cornerstone of public health, the disconnect between knowledge and its realization in medical practice represents a long-standing problem.6,7
Social factors contributing to poor health often overlap with specific legal needs, particularly relating to income security, insurance, housing, employment, and legal status.8–11 Vulnerable people—those who belong to “groups that are not well-integrated into the health care system due to ethnic, cultural, economic, geographical, or health characteristics”10—are often deprived of the benefits and protection afforded by the law owing to considerable gaps in access to affordable, appropriate, and timely legal services.9–14 Further, traditional community legal services are typically inundated with acute legal problems and few resources are able to be spared to address systemic and preventive legal needs.10,15
In the United States, efforts to address these gaps via integration of health and legal services within a shared physical setting have been under way since the 1990s, and the “medical-legal partnership” (MLP) model has become a nation-wide movement.9,13,16 In contrast to the United States, where more than 292 MLPs are established,17 only a handful are operating in Canada.
The Health Justice Program (HJP) aims to bridge the gap between social determinants of health knowledge and practice through a multi-partner medical-legal program informed by the MLP model. In 2014, the pilot phase of the program was launched as a partnership among the following groups in Toronto, Ont: St Michael’s Academic Family Health Team, St Michael’s Hospital, the ARCH Disability Law Centre, Aboriginal Legal Services of Toronto, HIV & AIDS Legal Clinic Ontario, and Neighbourhood Legal Services. This commentary describes the development and operation of the HJP and is intended to motivate family practice groups across Canada to implement similar practical solutions in their communities.
Program development
St Michael’s Academic Family Health Team is a multidisciplinary, multiclinic primary care organization in Toronto’s downtown core, serving approximately 45 000 patients, including people who are street-involved and unstably housed. A needs assessment conducted by clinicians estimated that 1980 patients, representing more than half of the patients referred to social workers, had at least one legal issue. The legal issues covered a range of fields handled by community legal clinics, including tenant rights, disability, immigration and refugee, human rights, and employment law.
The development of the HJP involved a systematic review of the literature pertaining to the MLP model and consultation with organizations and individuals in Canada, the United States, and Australia who were experienced in MLP implementation. Clinicians from the health team then approached potential community legal partners and, after 18 months of pre-launch planning, the pilot phase launched in 2014 out of the clinic site where the program’s on-site lawyer was based.
Direct services
Informal screening for legal needs by each patient’s family physician, social worker, nurse, or other clinician serves as a starting point for accessing legal services. Clinicians are encouraged to consider which aspects of patients’ medical concerns might be related to remediable legal issues; there is no tool or standardized method of screening, rather, the particulars of screening are left to the discretion of individual clinicians. A standardized referral form is available via the clinic electronic medical record system; alternatively, the option for patients to self-refer exists, respecting patient autonomy.
The on-site lawyer is assigned an examination room at one of the clinic sites. Services are advertised with posters (available in 6 languages) placed in each clinical encounter room and in waiting areas. As we recognize that many patients will encounter barriers to attending traditional, booked appointments, legal services are offered on both a referral and a drop-in basis. The type and nature of the direct legal service provided is tailored to each patient’s particular needs and his or her willingness to pursue different legal options. Table 1 outlines the types of services offered.
Types of direct legal services provided between December 2014 and December 2016
Patients choose what information, if any, clinicians should disclose to the on-site lawyer. Documents generated by the lawyer or program assistant are primarily stored on an external legal aid network. If paper documents must be retained, they are stored in a securely locked area of the clinic and marked as property of the legal clinic. This arrangement balances efficiency with strengthening the privacy protection of client information.
Multidisciplinary learning
The HJP and community legal clinic partners host a wide array of formal teaching sessions for clinic staff and family medicine residents based at the clinics. Twelve group meetings, using a blend of lecture-style teaching and case-based learning, were provided in each year for this purpose. A 1-hour “grand rounds” lecture was organized and delivered to the broader St Michael’s Hospital community to educate members on social determinants of health and access-to-justice themes. The HJP staff also contributed to a grand rounds panel discussion on medical assistance in dying, which was organized in conjunction with hospital staff, including family physicians, administrators, and a bioethicist.
The HJP also provides an environment in which to train legal professionals in aspects of poverty law and, accordingly, provides practicum opportunities on a for-credit or volunteer basis to law students.
Systemic advocacy
Partnership between health care and legal practitioners yields both enhanced identification of system-level pitfalls and innovative solutions that consider legal and clinical issues together.9 Literature reviews, written submissions, and oral advocacy have been jointly contributed by HJP members targeting various laws, regulations, and procedures of regional and federal governments and agencies that are identified as maintaining conditions promoting inequality, and whose modification has the potential to improve health outcomes.
Community advisory training workshops open to the public are held to increase individuals’ knowledge of their rights, teach practical problem-solving skills, and address the community’s use of individual and systemic social justice advocacy tools.
More than 27 publications have been created by HJP team members, representing a mixture of presentations, fact sheets, case studies, webpages, and template advocacy letters. Fact sheets and template advocacy letters that address topics such as violence, immigration resources, and disability tax credits are readily available for clinician use as printable handouts from the electronic medical record. These tools provide a means for health care practitioners to directly advocate for their patients without the need to involve legal professionals, when the situation permits.
Discussion
The collaborative interprofessional model adopted by the HJP captures legal needs that affect the social determinants of health for many patients served by the primary care centre. The embedded nature of the program can serve as a gateway for accessing legal services aimed at addressing legal issues that adversely affect health. Identified legal needs might be effectively addressed either via direct services offered by the program’s legal team, through referrals to private bar partners, or through identification of chronic overarching justice problems that require legislative reform. In its multidisciplinary approach to addressing patients’ needs, the HJP breaks down silos in health and legal services and equips practitioners with an expanded armamentarium with which to resolve issues that would otherwise frustrate their efforts to effectively serve their patients and communities.
The HJP also promotes interprofessional exchange of ideas and, by extension, institutional change, in addition to increasing the likelihood of broader policy issues being identified and effectively addressed. For those issues that cannot be “resolved” through direct legal services, clinicians learn about the social-legal factors influencing the health of their patients, and can consider involvement in broader advocacy. Patients can also gain knowledge and feel empowered to voice systemic concerns.
Despite considerable advances in public health knowledge and Canadian academics’ leadership role in this arena, critics note that Canada lags behind other high-income nations in application of this knowledge,6,7,18 resulting in suboptimal deployment of resources and public policy that fails to improve health for all Canadians. Collaborative programs such as the HJP might be key innovations contributing to the leveling of social and economic disparities responsible for inequalities in health .
Acknowledgments
Funding support for the Health Justice Program was provided by Legal Aid Ontario and in-kind support was provided by St Michael’s Hospital, St Michael’s Academic Family Health Team, ARCH Disability Law Centre, Aboriginal Legal Services of Toronto, HIV & AIDS Legal Clinic Ontario, and Neighbourhood Legal Services.
Footnotes
Competing interests
None declared
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
This article has been peer reviewed.
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro d’avril 2019 à la page e129.
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