Emily A. Benfer Emily A. Benfer is a Clinical Professor of Law and the founding Director of the Health Justice Project at Loyola University Chicago School of Law, Beazley Institute for Health Law and Policy. The Health Justice Project, a medical-legal partnership clinic, provides law students with an intensive, challenging education in the fundamentals of legal practice, systemic advo­ cacy and interdisciplinary collaboration necessary to becoming effective problem solvers and socially responsible, service-oriented attorneys. Through highly effective quality representation to low-income clients, law students resolve the legal needs that underlie, exacerbate or could result in health disparity. Professor Benfer graduated cum laude from Providence College with a B.A. in English and Writing. After two years of service in the Peace Corps, which took her to Zimbabwe, Belize and Thailand, and working as a law clerk at the New Haven Legal Assistance Association, Inc., she began stud­ ying law. She received her LL.M from Georgetown University Law Center and her J.D. from Indiana University School of Law, cum laude, where she was an editor of the Indiana International and Comparative Law Review, Order of the Barristers, and President of both the local and national Equal Justice Works. During law school, she clerked for Judge David Hamilton, the Lawyers • Committee for Civil Rights, the Indiana Protective Order Pro Bono Project, and the Washington Legal Clinic for the Homeless. Professor Benfer has dedicated her career to serving the public interest. She received an Arnold & Porter Equal Justice Works Fellowship to implement the advocacy and litigation strategy that she designed in order to represent, and improve the District's response to, homeless families, children and youth. She then represented preschool aged children with disabilities in a successful class action against the District of Columbia. As a Staff Attorney and Teaching Fellow in the Georgetown University Law Center Federal Legislation and Administrative Clinic, she supervised and mentored law students, participated in the successful legislative campaign to pass the ADA Amendments Act of 2008 and represented Workplace Flexibility 2010 in legislative advocacy involving low-wage workers, women in the workplace, family and medical leave, and the federal workforce. In recognition of her achievements, Professor Benfer was awarded Indiana University's Early Career Achievement Award, the Faculty Prize (the only award bestowed at graduation), the Equal Justice Works Martindale Hub­ bell Exemplary Public Service Award and the American Bar Association Judy M. Weightman Memorial Public Interest Award, along with numerous other commendations for her commitment to pro bono and public interest service. She has served on the Equal Justice Works Board of Directors and National Advisory Committee, the District of Columbia McKinney Vento Homeless Assistance Advisory Board, the Washington Council of Lawyers Board of Directors and Executive Committee and as a volunteer for the Homeless Children's Playtime Project. She is currently the Faculty Advisor for the Norman Amaker Public Interest and Social Justice Law Retreat, the Chair of the American Association of Law Schools Poverty Law Section and a member of the Society of American Law Teachers Board of Governors. THE HEALTH JUSTICE PROJECT: A COLLABORATIVE COMMITMENT To SOLVING REAL WORLD PROBLEMS Emily A. Benfer • ' I. INTRODUCTION •.........•••.....•••...••••..••••••.••••.••.•.••.•••.•••.••••......••••.••.•.. 523 II. THE HEALTH JUSTICE PROJECT: ADDRESSING REAL WORLD HEALTH DISPARITIES IN CHICAGO ..•••..•.••.•.••..•...••.......•...•.••...••.••..........••.... 524 II. THE HEALTH JUSTICE PROJECT: MISSION AND LEARNING OBJECTIVES •.•.•..••..••...•••...........•••....••••..•..•..•••••....•.•..•...•..........•..•.. 526 III. THE HEALTH JUSTICE PROJECT: EFFECTING REAL CHANGE FOR REAL PEOPLE ••••••.•..••••••••...••••...••.•..•••••.........••••...••••.....••......•.•..•.••. 528 N. CONCLUSION .................................................................................. 530 I. INTRODUCTION Across the United States, low-income individuals, children and fami­ lies experience adverse health outcomes that are a direct result of their soci­ oeconomic status and environment. The following problems, which have devastating consequences for health, frequently emerge: food deserts1 that contribute to malnutrition and food .insecurity; substandard . housing that results in respiratory distress, lead poisoning and developmental delays among children; and trauma, such as domestic and community violence, that has been shown to lead to chronic illness and disability in adulthood? Social determinants of health3 in turn affect an individual's capacity to * Emily A. Benfer is a Clinical Professor of Law at Loyola University of Chicago School of Law and the founder and Director of the Health Justice Project. Professor Benfer received her LL.M in Advocacy from Georgetown Law Center, her JD, cum laude, from Indiana Uni­ versity and her B.A., cum laude, from Providence College. Prior to joining the Loyola facul­ ty, Professor Benfer taught iti the Federal Legislation & Administrative Clinic and trained in Clinical Teaching at Georgetown Law Center. She practiced in multiple areas oflaw at legal services and public interest law organizations and assisted in the design of a medical-legal partnership in New Haven, Conn. She served as an Equal Justice Works Fellow at the Washington Legal Clinic for the Homeless and as a Peace Corps volunteer. 1. Food deserts are areas that lack access to fresh produce, whole grains, milk. meat and other foods that make up the full range of a healthy diet. Community Food Assessment, CTRS. FOR DISEASE CONTROL & PREVENTION, http://www.cdc.gov/healthyplaces/healthtopics lhealthyfood/community_assessment.htm (last visited May 8, 2012). 2. Paul Tough, The Poverty Clinic, NEW YORKER, Mar. 21,2011, at 25. 3. The World Health Organization defines social determinants ofhealth as: "the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities-the unfair and avoidable differences in health status seen within and between countries." Social Determi­ nants of Health, WoRLD HEALm ORO., http://www.who.int/social_determinants/en/ (last 524 INDIANA HEALTH LAW REviEW [Vol. 9:2 work or succeed in school, further exacerbating health and socioeconomic problems. To address the social determinants of health and improve health outcomes for low-income individuals and families in the community, the Health Justice Project involves students and faculty of law, medicine, social work and public health to address health disparities in the community. II. THE HEAL1H JUSTICE PROJECT: ADDRESSING REAL WORLD HEAL1H DISPARITIES IN CHICAGO The Health Justice Project was developed to respond to an urgent and unaddressed need in the Chicago community surrounding Loyola Universi­ ty Chicago. Local statistics reveal social inequalities that contribute to sig­ nificant deterioration of health among low-income populations. Poor housing conditions are to blame for the 200/o of inner city children who be­ come sensitized to rodent allergens and develop asthma 4 as well as the es­ timates of more than 81,000 children being harmed by lead paint in Illinois.5 An overwhelming number of Chicagoans are part of the 24 mil­ lion low-income households in the United States that have to choose be­ tween a balanced diet or energy access.6 Even if income were available, 609,034 Chicagoans live in a food desert and are part of the 44 square miles lacking fresh produce or meat.7 More than 827,000 adults in lllinois have diabetes, 8 with the largest concentration in the Humboldt Park area of Chi­ cago (the primary site of the Health Justice Project).9 Compounding the. health risk among low-income individuals is immi­ gration status. The state of Illinois has one of the largest and poorest immi­ grant populations in the United States. These households are more likely to have legal problems than the average low-income household in Illinois (fif­ ty-four percent compared to forty-nine percent of all low-income house­ holds ).10 Yet, this population is less likely to seek out legal assistance or to apply for public benefits because they incorrectly believe that doing so will visited May 8, 2012). 4. Municipal Rodent Management, ILL. DEP'T OF PUBLIC HEALTH, http://www.idph. state.il.us/envbealtb/pcmunicipal_rodents.htm (last visited May 8, 2012). 5. FRIDA D. FOKUM ET AL., THE IMPACT OF LEAD: ILLINOIS LEAD PROGRAM ANNuAL SURVEILLANCE REPoRT 2008 (Dec. 2009), available at http://www.idpb.state.il.us/ en­ vbealtb/pdf7Lead_Surv_Rpt_08.pdf; CHn.o LAW POLICY INST., BENCHBOOK ON LEAD PAINT POISONING FOR THE CIRCUIT COURT OF COOK COUNTY MUNICIPAL DiviSION HOUSING COURT 1-4 (2008), available at www.leadsafeillinois.orgluploads/documentslbenchbook.pdf. 6. ADAM SEGE, UTILITY ACCESS AND HEALTH 3 (June 2010). 7. Jennifer Wehunt, The Food Desert, CmcAGO MAGAZINE, July 2009, available at http://www.chicagomag.com/Chicago-Magazine!July-2009flbe-Food-Desert/. 8. Diabetes Prevention and Control, ILL. DEP'T OF PUB. HEALTH, http://www.idph. state.il.us/diabetes/index.htm (last visited May 8, 2012). 9. Humboldt Park Diabetes Task Force, SINAI URBAN HEALTH INST., http://www. suhichicago.orglresearch-evaluationlbumboldt-park-diabetes-task-force Oast visited 20 I 0). 10. ROB PARAL, THE LEGAL NEEDS OF IMMIGRANTS IN ILLINOIS: A REPoRT TO THE LAWYERS TRUST FuND OF ILLINOIS, http://www.robparal.com/downloadsllmmigrantll/o 20Legal%20Needso/o20Report%2010-22-04.pdf(last updated Oct. 22, 2004). 2012] HEALTH JUSTICE PROJECT: SOLVING REAL WORLD PROBLEMS 525 make them ineligible for permanent residency and citizenship.11 The statistics demonstrate that members of the Chicago immigrant community suffer poor health outcomes associated with low socioeconomic status, such as malnutrition, asthma, diabetes and lead poisoning, that could be addressed by members of an interdisciplinary team. The Health Justice Project, which began as a law school clinic, quickly united the surrounding community, attracting partners from the medical, social work, public health and legal professions, including Erie Family Health Center,12 Northwestern University Family Medicine Residency Program, 13 Equip for Equality, 14 Lawyers' Committee for Better Housing/ 5 and AIDS Legal Council of Chicago.16 These community partners provide a wealth of expertise and knowledge necessary to overcome social, legal and systemic barriers to health. Within Loyola University Chicago, Health Justice Project partners in­ clude the School of Law's Beazley Institute for Health Law and Policy17 legal clinic (named, Health Justice Project) and the School of Social Works' Institute on Aging and Intergenerational Study and Practice. 18 In addition, the Health Justice Project hosts Loyola University Masters of Public Health students who study the effect of the partnership on patient health and Schweitzer Fellows19 who select a discrete public health project in the community and collaborate with partners to develop solutions. For exam­ ple, one fellow is addressing food insecurity and food deserts in the low­ income community of Englewood in Chicago. All of the Health Justice Project clients are patients of Erie Family Health Center, a federally qualified health center that has been serving Chi­ cago's medically underserved communities for over fifty years. Erie serves 11. KENzy V ANDEBROEK, OPENING DOORS TO HEALTH CARE FOR IMMIGRANTS AND REFUGEES 11 (Sept. 7, 2006), available at http://www.cityofchicago.org/content/dam/city/ depts/cdph/policy ___planning!PP _ Open%20Doors%20to%20Healthcare%20fof'llo20Irmnigrant s%20and%20Refugees.pdf. 12. ERIE FAMILY HEALTH CTR., http://www.eriefamilyhealth.org (last visited May 8, 2012). 13. Nw. UNIV. FAMILY MED. RESIDENCY PROGRAM, http://www.familymedicine.north westem.edu/residency (last visited May 8, 2012). 14. EQUIP FOR EQUAL., http://www.equipforequality.org (last visited May 8, 2012). 15. LAWYERS' COMM. FOR BEITER HOUSING, http://www.lcbh.org (last visited May 8, 2012). 16. AIDS LEGAL COUNCIL OF CHICAGO, http://www.aidslegal.com (last visited May 8, 2012). 17. Beazley Institute for Health Law and Policy, LoY. U. CHI. SCH. OF LAW, http://www.luc.edu/healthlaw/ (last visited May 8, 2012). 18. Institute for Aging and Intergenerational Studies and Practice, LOY. U. CHI. ScH. OF SOCIAL WoRK, http://www.luc.edu/socialwork/intergenerational.shtml (last visited May 8, 2012). 19. The Chicago Area Schweitzer Fellows Program, ALBERT SCHWEITZER FELLOWSHIP, http://www.schweitzerfellowship.org/features/us/chi/ (last visited May 8, 2012). 526 INDIANA HEALTH LAW REVIEW [Vol. 9:2 33,000 patients annually through 148,000 visits at 11 sites across Chicago.Z0 Erie's patients are 68 percent female, 84 percent Hispanic, 34 percent unin­ sured and 86 percent live below the Federal Poverty Level.21 Erie staff and healthcare providers are committed to serving low-income individuals and providing culturally competent care with compassion and respect.22 In ad­ dition, the majority of providers are faculty at the Northwestern University Feinberg School of Medicine and understand the importance of investing in students. Erie Family Health Center also partners with the Northwestern University McGaw Medical Center to host residents from the Northwestern Family Medicine Residency Program. This presents a unique opportunity to engage law, social work and public health students with residents, in ad­ dition to the front line medical providers. II. THE HEALTH JUSTICE PROJECT: MISSION AND LEARNING OBJECTIVES The mission of the Health Justice Project is to "overcome the social, legal and systemic barriers that prevent long-term health and stability for low-income individuals and families in Chicago.'m To achieve the mis­ sion, students and professionals: 1. Provide highly effective quality representation to low-income clients in order to resolve the legal needs that underlie, exacerbate or could result in health disparity. 2. Provide law, medical, public health and social work students with an intensive, challenging education in the fundamentals of legal practice, systemic advocacy and interdisciplinary collaboration neces­ sary to becoming effective problem solvers and socially responsible, service-oriented professionals. 3. Collaborate with other community members, advocates, and stakeholders in order to identifY and eradicate the social, legal, and sys­ temic barriers that cause health problems among low-income individuals and families from an interdisciplinary and multifaceted approach. 4. Create public policy to invigorate our community to overcome barriers to health. For the law students involved in the law school clinic component of the Health Justice Project, the experience provides an opportunity to learn lawyering skills by connecting theory and practice through direct client in­ teraction and participation in the clinic. Students participating in the clinic 20. ERIE FAMILY HEALTH CTR., 2010 ANNuAL REPORT 5 (2010), available at http://issuu.com/eriefamilyhealthldocs/fylO. 21. /d. 22. See The Erie Promise, ERIE FAMILY HEALTH CTR., http://www.eriefamilyhealth. org!about-erie (last visited May 8, 2012). 23. Welcome to the Health Justice Project!, LOY. U. Cm. ScH. OF LAW, http://www.luc.edu/healthjustice (last visited May 8, 2012). 2012] HEALTH JUSTICE PROJECT: SOLVING REAL WORLD PROBLEMS 527 may earn up to ten credit hours over four courses. The clinic courses em­ phasize the development of skills in interdisciplinary practice, client inter­ viewing and counseling,· fact finding and analysis, legal research and document drafting, pursuit of administrative and other legal remedies, poli­ cy advocacy and reform where appropriate, and creative problem solving for the benefit of clients. These skills are learned in the context of team­ work with an emphasis on collaboration and interdisciplinary problem­ solving. Using this collaborative model, all clinic members are exposed to the range of cases handled in the clinic, terminology and culture of healthcare, and delivery of services to low-income people. Students are encouraged to reflect on these experiences in developing lawyering skills, interacting with the social, justice and healthcare systems in which the cases originate, and realizing their own personal philosophy of lawyering. The learning objectives for the law students complement those of the medical residents involved in the Health Justice Project through the North­ western Family Medicine Residency Program. Residency program faculty designed a curriculum that is aimed at overcoming social determinants of health through an interdisciplinary health partnership. The learning objec­ tives include 1) work within an interdisciplinary team and demonstrate pro­ fessional behavior throughout the medical-legal partnership curriculum; 2) ability to successfully assess patients' needs by screening for unmet social needs and referring patients to an appropriate resource; and 3) ability to de­ scribe the ways in which social determinants of health present in patients. Through the achievement of these objectives, residents meet multiple Ac­ creditation Council for Graduate Medical Education Milestones and Core Competencies, including patient care, medical knowledge, practice based learning, interpersonal and communication skills, professionalism, advoca­ cy and systems based practice.Z4 Residents encounter law and social work students during "precepting," didactics and grand rounds presentations, through direct requests for consultation and advice and through assigned interdisciplinary teams. Similarly, the social work students, who are onsite as members of the law school clinic and supervised by School of Social Work faculty, collabo­ rate with the law students. They also engage in activities that meet the School of Social Work's learning objectives, including direct service, psy­ chosocial assessment of patients and clients, patient and client consultation, linking clients to community resources, evaluating the social services avail­ able in the community and developing resources. The public health students complete their practicum requirement through placement in the Health Justice Project. The most recent public 24. Michael G. Stewart, Core Competencies, ACCREDITATION COUNCIL FOR GRADUATE MED. Eouc., http://www.acgme.org/acwebsite!RRC_280/280_corecomp.asp (last visited May 8, 2012). 528 INDIANA HEALTH LAW REVIEW [Vol. 9:2 health student, supervised by a faculty member at Loyola University Chica­ go Stritch School of Medicine, investigated whether interdisciplinary health partnerships improve health outcomes and have a positive effect on social determinants of health. Through adherence to partnership confidentiality and privacy rules, the public health student was able to access data collected through the partnership and iD.terview clients served by teams of doctors, residents, law students and social work students. For students of every profession, these experiences are unparalleled: rm at the end of my frrst week back on the inpatient service, and with each patient that I see, I am sur­ prised by how much better I've become at connecting with them, listening to their problems, and responding with true empathy (my own way). There's such a . stark difference between the way I engaged patients in the past and the way I do today, and I owe a lot of that to lessons I learned last semester. I can already see that I'm a better doctor-to-be because of the experi­ ence I had with the Health Justice Project. The clinic proved to be one of the most valuable and enriching educational . experiences at Loyola. The Health Justice Project made me a lawyer. I learned how to effectively advocate on behalf of clients. I learned how to write more persuasively. I learned how to think more critically-succeeding in identify­ ing legal issues and developing plans on how to · preempt and/or address client problems. I would like to report that this past semester was my most success­ ful academically, and I owe my improved perfor­ mance to the Health Justice Project. The skills that I acquired in the clinic directly translated to my other coursework. The Health Justice Project not only made me a lawyer-it made me a better law student. . The Health Justice Project not only provides training and practice ex­ perience, but also exposes students to the dire need in their community and the realities of poverty and poor health. Moreover, students realize the im­ portance of collaborating to achieve their goals. lll. THE HEALTH JUSTICE PROJECT: EFFEcTING REAL CHANGE FOR REAL PEOPLE Since taking its first patient/client in 2010, the Health Justice Project has served over 400 patients of Erie Family Health Center, contributed pro 2012] HEALTH JUSTICE PROJECT: SoLVING REAL WORLD PROBLEMS 529 bono hours that are the equivalent of over two million dollars in attorneys' fees, and obtained reimbursement of medical expenses to Erie Family . Health Center after winning Medicaid denial appeals. In the case of just one patient, the reimbursement was valued at over $25,000. To further the interdisciplinary partnership, students regularly train over seventy health care providers in the social determinants of health and work on interdisci­ plinary teams to address policy issues. Together, they have commented on federal and local rulemaking related to public health, met with local policy makers and board of education members, worked with national non-profits, and visited Capitol Hill to educate legislators on the collaborative model. The students engage in creative problem solvin!(5 and devise innova­ tive approaches to their clients' legal issues. The following are examples of recent student accomplishments: Preventing Family Homelessness. When the client's disability pre­ vented her from working and paying her rent, her landlord threatened her with a self-help eviction. After reviewing the landlord's actions, client's rental agreement and notices ofterinination, law students discovered multi­ ple legal violations. What was once a bleak situation, in which the client owed the landlord upwards of $2,800.00 and faced immediate homeless­ ness, was quickly reversed The student reached an unprecedented settle­ ment agreement, reducing the client's debt to $0, awarding her $1,200.00 in damages, and giving her 39 extra rent-free days in the apartment. Social work students worked with the client to help her locate housing and sus­ tainable sources of income. Ensuring Access to Heat and Electricity. A client's health, that re­ quired an environment in which he could regulate his body temperature and refrigerate his medication, deteriorated when his utilities were disconnected. Law students uncovered an unlawful utility shutoff practice on the part of a local utility company. In response, they negotiated with the utility compa­ ny, worked with partners to submit public comments to the lllinois Com­ merce Commission and letters to the editors of local papers in collaboration with medical partners. As a result, the students restored the client's utilities and ensured that others would not be subjected to similar actions. Improving Dangerous Living Environments. Doctors immediately recognized the presence of social determinants of health when three siblings were diagnosed with lead poisoning, respiratory distress and other envi­ ronmentally induced ailments. To complicate matters, the landlord threat­ ened eviction because of the family's complaints. The law student 25. For summaries of recent cases handled by interdisciplinary teams, resources, and additional materials, please visit the Health Justice Project at http://www.luc.edu/ healthjus­ tice or contact ebenfer@luc.edu. For an example of creative advocacy on the part of law, social work, and public health students, see Meribah Knight, Homeless Families Walking a Hard Road, N.Y. TIMEs, Dec. 10, 2011, at A37, available at http://luc.edu/ bealth­ lawlhjplhjp_pdfs/Homelessyamilies_ Walk:ing_a_Hard_Road_-_NYTimes.com.pdf. 530 INDIANA HEALTH LAW REVIEW [Vol. 9:2 intervened, successfully defending against a retaliatory eviction. Ultimate­ ly, when it became clear the condition of the unit was irreparable and too dangerous for the children, the law student helped the family break the lease without penalty, recoup their security deposit and move to a safer unit. The law student also positioned the family to bring a tort claim against the land­ lord for the harm to the children and their property. Reducing Poor Health Outcomes. A disabled client often met with her doctor after interviews with her caseworker at the Department of Hu­ man Services ("DHS"). The doctor quickly identified the DHS meetings as the source of the client's exacerbated symptoms, including high blood pres­ sure and anxiety. The doctor, concerned that repeated visits could result in a medical trauma, suggested the client transfer DHS offices. When the cli­ ent's request was denied, law and social work students appealed the denial and successfully advocated for the transfer of the client to another DHS of­ fice, immediately resulting in stable blood pressure and reduced anxiety. Law and social work students also address client's health problems by engaging in preventative work. Oftentimes, public benefit applications, that could provide the income, food or housing crucial to the health of individu­ als and families, are difficult to complete and result in denials. For exam­ ple, when an elderly client's Social Security payments were garnished, making it difficult for the client to purchase food and medication, a law stu­ dent worked with the Social Security Administration to reduce the garnish­ ment by half, increasing the client's income and ability to purchase necessities. Students also assist clients in applying for Social Security ben­ efits. For one client, whose mental health disorder prevented him from completing the detailed forms required by the Social Security Administra­ tion, Jaw and social work students worked with doctors to help the client understand and complete the documents, resulting in an award of Supple­ mental Security Income. Similarly, students have successfully negotiated with subsidy providers, ensuring that the clients will continue to receive financial assistance despite the pending termination date. The result is the effective and optimal use of resources. By engaging members of disciplines that address the different and complex aspects of an individual's health (social, environmental, mental, physical), the model al­ lows for the transition from an acute care model to the whole patient model. It replaces episodic treatment with treatment of the root problem, even if the "treatment" is not necessarily medical in nature. As a result, the factors that contribute to repeat hospital visits are removed, reducing the utilization rate and allowing the physician time for the remaining patient panel. IV. CONCLUSION The Health Justice Project demonstrates how an interdisciplinary learning environment and collaboration between disciplines can improve patient health among low-income populations. It also brings students of 2012] HEALTH JUSTICE PROJECT: SOLVING REAL WORlD PROBLEMS 531 law, social work, medicine and public health together in order to address the social determinants of health in the community, as well as prepare stu­ dents for the complex problems they will be called upon to solve through­ out their careers. Interdisciplinary health partnerships provide an unparalleled opportunity to foster collaboration, improve community health outcomes and invest in students, the next stewards of public health and so­ ciety. I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I