Cook County Health (CCH) has a longstanding history of providing high-quality, comprehensive care to all Cook County residents, regardless of background, immigration status, or ability to pay. For our patients who have insurance, Medicaid is the predominant payer. Our system includes two hospitals, four regional outpatient centers, ten community health centers, correctional health for adults and juvenile detainees of Cook County, a state-certified public health department, and CountyCare, the largest Medicaid managed care plan serving Cook County residents.
CCH is also the largest provider of charity care in the region. In 2018, CCH’s two hospitals provided over 50% of all hospital-based charity care in Cook County. As a result, CCH holds a unique perspective and understanding of the upstream social factors, rooted in poverty and racism, that directly impact our patients’ ability to achieve optimal health.
In 2015, we partnered with Legal Aid Chicago (at that time, Legal Assistance Foundation) and the Chicago Department of Public Health for the inaugural round of funding from The BUILD Health Challenge® (BUILD), to support planning and implementation of a medical-legal partnership at CCH.
Nationally, 7 in 10 low-income adults experience at least one civil legal challenge on an annual basis, but only 1 in 10 seek out legal assistance1. Medical-legal partnerships (MLPs) seek to close this gap by integrating civil legal services into a health care setting, and providing a patient-centered approach to holistically address social needs such as access to income/employment, healthy and stable housing, public benefits, and other issues that can impede someone’s ability to get and stay healthy.
Most MLPs rely on physicians or other health care providers to identify and refer patients to legal services. At CCH, MLP referrals are generated by members of the Integrated Care Department, a multi-disciplinary team of nurses, social workers, and community health workers who screen and identify the health and social needs of CCH patients and CountyCare members, and who provide support and assistance in navigating health care and human services systems to address these needs.
Health Forward/Salud Adelante is the name of the MLP between CCH and Legal Aid Chicago. The BUILD award supported Health Forward/Salud Adelante through 2017; in 2018, after the end of the grant, CCH began funding the initiative through operational dollars. In reflecting on the lessons learned from BUILD the CCH-Legal Aid Chicago MLP, the use of and sharing of data remains critical to the success of this work in three primary ways:
Data to Referrals
First, the CCH-Legal Aid Chicago MLP regularly reviews data in relation to referrals (i.e., number of referrals, types/categories or referrals, teams generating referrals, time it takes to resolve, etc). These reviews take place during brief, weekly check-ins between CCH and Legal Aid Chicago staff, and helps us monitor and stay in constant communication to identify trends, troubleshoot issues, and determine whether additional training or technical assistance are necessary.
From March 2017 through June 2020, CCH generated 1,212 referrals to Health Forward/Salud Adelante. Six hundred of these cases were “closed” as a result of further Legal Aid Chicago action, ranging from counsel and advice to full representation. Many of the remaining referrals are open cases/pending further action, fall outside of the MLP priorities, or halted due to unsuccessful contact with the patient. The majority of cases referred to the MLP concern access to public benefits.
In response to a high number of referrals that did not merit legal intervention, a consult process was launched during the second year of the MLP. Members of the CCH Integrated Care team are encouraged to reach out to the Legal Aid Chicago staff with general questions about whether a patient’s social needs could be addressed through a referral and legal assistance. These consults help avoid inappropriate referrals that will ultimately not meet the bar for legal assistance, and save time and effort for care coordinators who would otherwise need to obtain patient consent to make an MLP referral. Patients are also spared from completing another screening process that could lead to frustration and disappointment if they don’t ultimately benefit.
While referrals fell slightly during the Illinois shelter-in-place order due to the COVID-19 public health emergency, referrals are now back to the same levels for the same period in 2019. We also anticipate higher volumes of housing and public benefits referrals in the coming months and are supporting CCH Integrated Care staff by sharing new resources and program changes to best assist and communicate this information to patients.
Data to Impact
Second, qualitative data shared in the weekly meetings and quarterly reports helps the team and our organizational leadership better understand the impact of this work on our patients. These data reports also share the breadth and depth of the work that is often required to help patients address health-harming legal needs that may not be comprehensively conveyed through raw numbers alone.
In the fall of 2017, CCH referred a patient experiencing chronic homelessness with serious mental illness, for assistance with an initial disability application. Legal Aid Chicago represented this patient in his application for Social Security disability benefits, which began with an initial application, continued with a request for reconsideration, and concluded with a Social Security hearing in May 2020. The hearing resulted in the patient being approved for SSI benefits moving forward, as well as back payments. With this reliable source of income, the patient was able to afford a subsidized housing unit, which he moved into in June 2020, nearly three years after the initial referral and hospitalization at CCH.
CCH referred a patient experiencing homelessness to Legal Aid Chicago. Due to errors with the patient’s name and social security number, his Medicaid applications were denied on previous occasions, forcing him to delay care and using emergency department services in lieu of primary care. Legal Aid Chicago and a CCH community health work collaborated to build a relationship with the patient, who was then able to obtain a birth certificate and correct social security number. Legal Aid Chicago also resolved the Medicaid application issues, which resulted in an approved case AND backdated coverage, allowing CCH to recover more than $150,000 in reimbursement that would have otherwise been written off as uncompensated care.
Data for Health Equity
Third, both the quantitative and qualitative data contributes to CCH’s efforts to address health equity and support evidence-based approaches. CCH’s continued investment in the Health Forward/Salud Adelante partnership is a clear demonstration of this.
In 2019, CCH increased funding to add an additional Legal Aid Chicago attorney and a paralegal to the MLP. This helped manage referrals from Integrated Care staff working with justice-involved individuals who faced unique challenges with housing and employment. Moving forward, we are interested in building and expanding on supporting this population, given the disproportionate representation of Black and Latinx individuals in the justice system.
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As the partnership between CCH and Legal Aid Chicago approaches its fifth year, we are excited to continue supporting our patients and Cook County residents through Health Forward/Salud Adelante and using the lessons learned to help achieve common goals of justice and equity.
Kathy Chan joined Cook County Health as Director of Policy in October 2013. She helps provide leadership on policy issues that impact CCH and its patients, as well as with special initiatives that address social determinants of health. Kathy previously served as Associate Director and Director of Policy for EverThrive Illinois, where she oversaw government relations and advocacy activities. She serves on the boards of the Michael Reese Health Trust and the Midwest Access Project (MAP), and lives in Chicago with her husband and two sons.