Integrating legal services with primary care

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.

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.