It’s Monday morning, and the pediatric primary care center at the Yale New Haven Hospital buzzes with activity. A mother and a nurse kneel on either side of a squirming toddler, trying to keep the child still long enough to take a height measurement. One doctor rushes through the hallways, searching for an Arabic interpreter; another stops to chat with a social worker. The walls are brightly colored, and some of the ceiling panels are painted with rainbows, clowns, stars in a blue sky. Children tend to be scared of white coats, so the doctors here don’t wear them.
Alice Rosenthal has been called into a patient’s room in the middle of the primary care center. After chatting with the patient’s father, Rosenthal emerges from the room and explains why she’d been requested by the patient’s pediatrician. The family’s utilities keep being turned off — even though the father says he’s been paying the bills. And even though their utilities are working now, Rosenthal wants to act preemptively. The family are immigrants from Turkey, she explains, and they have two young children. They also have a caseworker through a New Haven nonprofit called IRIS, or Integrated Refugee and Immigrant Services. Later, Rosenthal reaches out to the family’s IRIS caseworker, hoping to connect and work together if necessary.
Rosenthal is a lawyer with the Center for Children’s Advocacy, or CCA, in Hartford, but she works full time at the hospital. Here, she’s the attorney at Yale New Haven’s pediatric medical-legal partnership — a program which integrates her legal services into the hospital’s medical team.
Rosenthal has worked at the hospital since the MLP’s inception in 2013. This kind of partnership is informed by an evolving understanding of social determinants of health: all of the factors, from socioeconomic status to housing to food security to education, that can influence someone’s health. “People aren’t just lungs and hearts and brains,” Rosenthal said in an interview this summer.
In other words, if the heat in a child’s home gets turned off in the winter, it affects their health. And so too do moldy carpets in rental apartments, a lack of access to disability resources at school and whether their parents can take time off of work to attend their surgeries without fear of losing their jobs. In general, these are challenges faced most pressingly by low-income children and children of color. They’re more likely to have these kinds of health-harming legal needs, and their families are less likely to be able to hire a lawyer if they need one. About half of Rosenthal’s referrals come from the hospital’s primary care center, where 96 percent of patients are on Medicaid; the other half come from the rest of the hospital, including inpatient and outpatient care.
The pediatric MLP at Yale New Haven got its start in part because a physician named Ada Fenick — who is now the medical director of the program — kept pushing for it. Fenick had attended a national conference on medical-legal partnerships, and she wanted one at Yale New Haven. The children who were her patients sometimes had health-harming legal needs, problems Fenick couldn’t solve as a physician. “You want to help your patients and you can’t,” she said.
In 2013, Yale New Haven and CCA launched the partnership. Rosenthal, who grew up in New Haven, got the job.
Rosenthal highlighted one patient’s story as a classic example of the MLP’s work: A child with severe asthma was frequently in and out of the hospital, and he was being treated with a high dosage of steroids. At one point, the child’s mother mentioned that their carpets at home were filled with dust and mites. Rosenthal suggested the family get the carpets removed, but the mother said the landlord had already said no. So Rosenthal visited the family’s home. “And I don’t have respiratory issues, but after an hour, I couldn’t breathe,” she said.
Rosenthal ended up drafting a demand letter which she paired with a letter from the child’s pulmonologist. Within 24 hours, the management company granted the carpets to be removed. It took another six months — and threats to file federal lawsuits and complaints — for the removal to actually happen. Afterwards, the child was weaned off the steroid medication. “He was so much healthier,” Rosenthal said. But when he started attending school regularly again — he’d missed a lot of class while he was sick — he struggled to keep up. Rosenthal said the child had tested for a learning disability, but she had to step in to ensure he received special education services. Now that the child is back in school — and doing better with the additional resources — his mother has been able to secure a full-time job.
Much of Rosenthal’s work involves this kind of direct interaction with patients’ families: counseling them on their legal rights, writing demand letters to landlords, attending meetings in schools. And in about 10 percent of her cases, she represents the patient in court.
“There’s all these interconnected things that are impacting each other, and when we address them holistically together, then we actually get healthier and happier families,” she said.
In addition to direct client work, Rosenthal works to equip pediatricians with the tools to identify and address health issues stemming from patients’ environments. She conducts outreach throughout the hospital, helping physicians and social workers become more aware of their patients’ legal needs and potential remedies. Though she’s a CCA employee, her salary is paid by Yale New Haven, which also receives donations from local law practices for the partnership.
Marjorie Rosenthal, a pediatrician at Yale New Haven who is serving as interim medical director of the MLP, said that she and other physicians have long been aware of the importance of social determinants of health. Actually having the resources to address those factors, however, empowers physicians to take a more proactive role; this can look like asking patients about things like school absences or housing conditions.
“It’s well documented and not surprising that when you have something that you know you can do, you’re more likely to ask the patient about it,” she said. “If I didn’t have any vaccines, I might not start talking to my patients about immunizations.”
The first medical-legal partnership was founded in 1993 at Boston Medical Center. A pediatrician named Barry Zuckerman had noticed that his patients with asthma weren’t always getting better after being treated with medication. He knew that their housing conditions — mold in their apartments, for example — could be causing or exacerbating their asthma. So he told his patients’ parents to call their landlords. Many times, Zuckerman said, the landlord wouldn’t do anything, so he would pick up the phone himself — and still wouldn’t get anywhere. “It frustrated and angered me,” he said. And it wasn’t just the asthma and the mold; Zuckerman had noticed other issues, like the fact that some of his patients with special needs weren’t receiving the services they were entitled to at school or that some of the children were having their heat shut off in winter.
Zuckerman was the chair of pediatrics at Boston Medical at the time, and he decided to use some of his funds to hire a lawyer for his patients. “I wasn’t sure what the lawyer would do,” he said, and he noted that the project was taking a page from the HIV epidemic, during which lawyers had begun working with sick patients.
In time, Zuckerman said, the partnership was a success. In the early 2000s, attorney Jay Sicklick established a similar program in Hartford, the second of its kind after the program at Boston Medical. Sicklick described the project as a “journey into the wilderness.” But with time and effort, he said, the legal staff became part of the medical team, and the medical team became part of the legal team: “It was a two-way street.” Now, Sicklick oversees the MLP at Yale New Haven and the Center for Children’s Advocacy’s other medical-legal partnership at the Connecticut Children’s Medical Center.
Ellen Lawton, the co-director of the National Center for Medical-Legal Partnership, said there are now MLPs at almost 400 hospitals and health centers nationwide.
“It’s not even a movement anymore,” Sicklick said. “It’s a national practice model.”
Lawton also noted that the model has an “enormous footprint in pediatrics,” a field which she said has a long history of focusing on social determinants of health. By the nature of their practice, pediatricians have always needed to speak with patients’ parents to discern more about a child’s home environment. At Yale New Haven, there are now four other medical-legal partnerships, including a palliative care MLP and an MLP focusing on immigrants. The pediatric MLP is the only one with a full-time, fully embedded attorney like Rosenthal.
Though Rosenthal was almost instantly embraced by the medical staff at Yale New Haven, she still experienced an initial learning curve. “You have to understand their norms and understand how they function,” Rosenthal said. This meant wearing closed-toe shoes, keeping her fingernails short, avoiding dangling earrings. But it also meant understanding what the medical staff needed from her — Rosenthal’s first presentation, in which she explained to doctors how to file complaints, was too far in the weeds, she said. What the doctors really needed to know was simpler, she said: how housing affects children’s health.
“When we all work together, and not in our silos, we all work to the height of our license, and we do better work for our patients and our communities,” Rosenthal said. And there’s no doubt about it: Rosenthal is part of the team. Her first Christmas, she was invited to participate in Secret Santa with the nurses.
On Monday morning, Rosenthal darted through the hallways, stopping to chat with physicians, with social workers, with the mother of a patient she’d worked with in the past. “Everything okay?” Rosenthal asked. The mother nodded, but Rosenthal handed her a business card anyway — just in case. A physician stopped to talk to about a child’s ADHD — he’d been put on a higher dosage of medication, the doctor assured Rosenthal. She wanted to make sure the child was receiving the resources he needed in school, in addition to the medications.
One of the overarching goals of the MLP is to create wide-ranging change through channels like legislative advocacy — affecting the lives of patients not just one at a time, but on a systemic level. Right now, Rosenthal has her eyes on Connecticut’s lead law, which defines lead poisoning at levels three to four times higher than the standard set by the Centers for Disease Control and Prevention. A bill to change Connecticut’s standard stalled in the state legislature last year, but Rosenthal hopes to bring her team of pediatricians to the table.
“Pediatricians with their little white coats and their stethoscopes are powerful voices up in Hartford,” Rosenthal said.
As we spoke, her cell phone rang.
“Medical-legal partnership, this is Alice.”
Talia Soglin | firstname.lastname@example.org