 Welcome everyone, we're so glad to have you, so glad to see you. My name is Kelsey Berry and I'm a faculty member at the Center for BioEthics and in the Department of Global Health and Social Medicine here at Harvard Medical School. And it's a pleasure for both me and my co-chair, Charlotte Harrison to welcome you today to the Organizational Ethics Consortium. So we have a really good topic for you today on medical legal partnerships. It's really near to our hearts because we've been thinking in this consortium several times lately about how hospital systems can advance health equity and especially care for their vulnerable patients more holistically in attention to both their medical and social needs. So, Julie, if you would advance the slide. Thank you. So this is a monthly consortium that we run during the academic year. Charlotte Harrison and I are the co-chairs and it was started with Jim Saban about eight years ago. And what we do is we bring together experts and leaders in the health sector who are grappling with controversial issues that arise for health organizations and health systems or who might be working on ethically driven organizational change which is the case for our program today. Generally speaking, our aim in the consortium is to engage you all in considering ideas and models for health organizations to ground their work in ethical values. And that's somewhat perhaps easier said than done especially when you consider some of the organizational realities of resource limitations, market realities and also the diversity of moral views in society generally speaking. So this is one of a number of different consortia that the Center for Bioethics runs. You can see on the right that there are still two sessions in the organizational ethics consortia coming up this season. And then there are a lot of other opportunities to get involved in discussions at the Center for Bioethics as you can see there. And the details are all gonna be in the Center for Bioethics events calendar if you'd like to follow up there. So next slide please. All right, so you can all tell that we were in a meeting format today. The reason being that we like to encourage some more robust conversation than a webinar might have otherwise supported. So we hope that those of you who are with us and who are comfortable doing so will actually turn on your videos. We do welcome everyone to kind of introduce yourselves in the chat. There are far too many people to do it live but I will give you a little example there to introducing myself. We'd love to hear who you are, where you're coming from and we're going to start with a presentation from our group here. And then more towards the end we'll invite you to participate by sharing your questions and thoughts. You can either do that in the chat if you'd like or you can use the raise hand function at the bottom of your screen in order to let us know that you'd like to speak and then we'll call on you and you can unmute yourself and ask your question when we get to the Q and A at the end. So with all of that, next slide please. Okay, here is where we're going today. The overall plan is to start high level with what are medical legal partnerships. Then we're going to zoom in to the particular story of Beth Israel Medical Deaconess, Beth Israel Deaconess Medical Center and help advocates and how they set up their medical legal partnership and some of the ethical and strategic choices along the way. And then we're going to broaden back out a little bit again to hear from some other medical legal partnership providers in the state of Massachusetts. And as you can see, we have quite a large number of presenters to take us through here today. So I'm just going to introduce everyone very briefly so that we can get to the content right away. So we're going to start off with Ellen Lawton. Ellen is an attorney and a national expert in the integration of legal professionals into the healthcare setting to address social determinants of health. And that includes having founded the National Center for Medical Legal Partnership at George Washington University. She is currently a senior fellow at Health Begins which is a national health consulting team that focuses on social and structural drivers of health and health inequity. And then we have kind of three folks from our BIDMC HLA team. So first we have David Sontag who's an attorney and bioethicist and currently senior associate general counsel and director of ethics at Beth Israel Leahy Health where he developed system-wide initiatives in ethics and also co-chairs the ethics committee at the system's largest hospital which is BIDMC. So we're also really privileged to have David S faculty at the Harvard Center for Bioethics where he directs and teaches the capstone course for our master's students. And then Nancy Cason is also at Beth Israel Leahy Health as managing director of their community care alliance which cares for about 120,000 love resource patients on an annual basis. And Nancy is also vice president of community benefits and community relations for the hospital system. And then Andrew Cohen is the director and lead attorney of access to care and coverage at the Massachusetts based health law advocates. And Andrew brings over two decades of experience and advocacy, community organizing and healthcare policy expertise to secure rightful access to healthcare for vulnerable populations. And then as we broaden back out again we'll also be hearing from Yoni and Sarah. So Yoni Levy is a partner at the global law firm Ropes and Gray in their asset management practice. And pertinent for today, he also oversees Ropes and Gray's medical legal partnership with the Dorchester house which is a community health center in an underserved area of Boston. And then finally, we have Sarah Boomen who is a clinical professor of law at Suffolk Law School where she serves as associate dean for experiential learning and the director of clinical programs. And Sarah designed and teaches Suffolk's health law clinic which we'll hear more about later. All right, we are really thrilled to have this incredible group with us. So with that I'm going to turn it on over to Ellen to get us started with the high level. What is an MLP? Great, thank you so much Kelsey. Hi everybody, I'm really excited to be here with you today. And I'm just gonna do a quick fly over about what an MLP is and then you're gonna learn the brass tacks from our other speakers and look forward to your questions and your insights and just acknowledging that, you know, I started my MLP work at Boston Medical Center and I know that there's probably a number of folks here today who have experienced with MLP in different ways along over the years would love to hear from all of you in the chat if you have that kind of experience or if this is brand new and you've never heard of MLP in your life. Either way, hopefully we're gonna have a rich discussion. Next slide, great. I'm coming to you from, as mentioned by Kelsey on that health begins and we're a small healthcare national consulting firm and we focus on social and structural drivers of health. Next slide. We're a national design and implementation partner helping Medicaid serving health systems, plans and community-based organizations to move upstream and advance health and social equity for people in communities that are harmed by societal practices. Next slide. Part of my role at health begins and I was formerly at the National Center for Medical Legal Partnership is to build medical legal partnerships in healthcare systems and settings around the country. So we're gonna talk a little bit about that but what are we talking about when we talk about medical legal partnership? It's a proven intervention. So significant evaluation and support and evidence demonstrating the effectiveness of medical legal partnership. It embeds access to legal services within the healthcare delivery system to help care teams treat patients' immediate social needs and also deploy upstream strategies to address the social determinants of health. MLP activities include, as you can see what we call lovingly, the pizza pie here, right? So on the left-hand side when we talk about medical legal partnership and really what we're talking about is building very strong crosswalks between legal organizations such as health law advocates you're gonna hear from Andy in a minute from between community-based legal organizations and health systems, right? Bringing the lawyers closer to the patients to address patient social needs and help the health system workforce to operate atop of license. As we move along this continuum of MLP activities we see a broadening of the impact, right? So the next activity that MLP's practice is training around building knowledge, capacity and skills to strengthen the health systems response to social determinants of health. And then what we see in MLP is as legal assistance and training occur, clinic level changes that are gonna leverage that legal expertise and shape clinical practice. And we have lots of examples of where that's occurred. And then ultimately what we're all driving towards is these upstream drivers of social and structural inequities, policy change strategies to advance a range of different policy solutions for entire communities. Next slide. Medical legal partnerships have been operating around the country nationally and also internationally now for almost 20 years. And this is a breakdown of National Center data. It's about four years old now. So I would say that there's been some significant growth over the past couple of years in particular through COVID. There's been addition of a number of different small and large MLP activities. But you can see the breakdown of where these medical legal partnerships are active in terms of health systems, HRSA funded health centers. You can see the significant percentage of children's hospitals including Boston Children's Hospital and other major benchmark children's hospitals that have adopted the strategy and been practicing medical legal partnership for a long time. Next slide. And just again for the non-lawyers in the audience, if there are any out there, we'd love to share, right? How do lawyers tackle social determinants of health issues? And this was an acronym that was developed at the National Center for Medical Legal Partnership that really captures what are lawyers doing to support addressing social determinants of health for patients, individual patients. And along the left-hand side here, you can see the range of different issues that affect patient well-being. And then on the right-hand side, the different types of interventions that lawyers support and lead in order to improve well-being, patient health and well-being. Next slide. Great. So I'm coming to you again from Health Begins, formerly at the National Center for Medical Legal Partnership. And my role at Health Begins is to lead national training and technical assistance for a major initiative with Kaiser Permanente. Those of you familiar with healthcare systems know that Kaiser Permanente is the largest private integrated health system in the country. And so they have taken a huge leap forward in supporting medical legal partnership integration through a major grant to the National Center two years ago, whereby they're building, we're building medical legal partnerships across their markets and learning a lot about how to do it efficiently and effectively and learning a lot about what it takes to build medical legal partnerships and also tracking and evaluating exactly what the impact is. And so that's a project that's in motion and is contributing, I think to the, you can see on the left-hand side here, Kaiser Permanente's mission to address patients' total health. Right now, this project is focused exclusively on housing. It came about through COVID and the deep concerns around housing stability and how it affects patient wellbeing. Next slide. And then just rounding out and getting specific here for the Kaiser Permanente initiative, but really broadly in what you're gonna hear from our panelists is how MLP lawyers can help care teams to meet patients' needs, whether that's specifically in housing or more broadly in immigration, for example, with the project that's happening at BIDMC. You can see two core activities, right? Capacity building and training for care providers and staff and then legal advice and representation for patients. So with that, I'm gonna, I think that's my last slide, is that right? All right, and I'm gonna hand the mic over to the team so you get to hear what's happening locally. Thanks. Awesome, thanks, Alan. I really appreciate you giving us the high level of MLPs. And before I start, I just wanna again thank our panelists for coming together at my request to really bring this program to the group. So my name is David Sontag. I, as Kelsey said, I'm a Senior Associate General Counsel and Director of Ethics for Beth Israel Lakey Health, or BILH. BILH is based in Eastern Massachusetts and soon to include a location in Southern New Hampshire. Consists of 13 soon to be 14 hospitals, multiple outpatient centers, primary care, behavioral health, home health and hospice, a performance network, which is for contracting and accountable care, and some community health centers. BIDMC is the largest hospital in the system. It's a world-class academic medical center located in Boston and is a teaching hospital of Harvard Medical School. Like Kelsey said, I'm a co-chair of the Ethics Advisory Committee at BIDMC. And I started my in-house career at BIDMC and migrated with the Office of General Counsel to the system level after the merger brought BILH together in 2019. BILH's community of clinicians, caregivers and staff includes approximately 4,000 physicians and 35,000 employees. BIDMC is one of BILH's premier institutions with 673 licensed beds and over 1,200 active physicians. It prides itself on its ability to combine exceptional and compassionate patient care with advanced medical knowledge, research and technology and ways that allow it to achieve the best outcome for its patients. BIDMC also has one community health center on its license, Bowdoin Street Health Center, located in Dorchester. And it also has a licensed outpatient location in Chelsea, Massachusetts. Additionally, it is a founding member of the Community Care Alliance, a health center network including Bowdoin Street Health Center and four other federally qualified health centers serving approximately 120,000 low resource patients annually. So that's kind of who we're talking about today. I started thinking and learning about MLPs when I arrived at BIDMC almost 12 years ago. Picture it, Boston, 2011. With my background in bioethics, I have always been interested in participating in or driving efforts to improve the health and health care of people. Maybe my passion for MLPs developed because I'm a lawyer and I was coming to realize that the most direct way for me personally to make a positive impact in patients' lives is through a legal remedy. As psychologist Abraham Maslow famously wrote and I'm paraphrasing, when the only tool you have as a hammer, everything looks like a nail. And also, many social drivers of health can be effectively addressed with legal assistance and some can only be addressed with legal intervention and advocacy. But affordable legal assistance is not available for many and even when it is available, many do not know how to access it. I don't remember the first time I heard about MLPs but 10 years ago, I attended a conference about MLPs hosted by MLP Boston, a leader in the field in Boston and nationally. The focus of the conference was on utilization of MLPs by accountable care organizations. And although it is clear that MLP goals allied well with the goals of an ACO, I was naive to think that merely mentioning this option to ACO leadership would be sufficient to make any progress on establishing an MLP. I returned to another MLP Boston sponsored event in November, 2014 and left that conference even more convinced that the IDMC should be investing in an MLP. So I reached out to my colleague, Nancy Jason who's here today, who at the time was BIDMC's director of community benefits and managing director of the community care alliance so that we could start strategizing about how to get an MLP in place for BIDMC. Again, though, for a lot of reasons we were not able to get any traction at BIDMC at that time to start an MLP. So fast forward seven-ish years when we actually restarted efforts to establish an MLP at BIDMC, now at this point a component of the ILH. So there were a few events that inspired me to be more intentional and deliberate in working towards an MLP. First, I felt like the time was right to really push this forward because BILH had recently named its first chief diversity, equity and inclusion officer Juan Fernando Lepera. I knew he would be focused on addressing health equity throughout the system and so I thought he would be receptive to any idea that could help address social drivers of health that disproportionately affect our communities of color and other marginalized patients. And as a system, BILH was speaking more about addressing these issues, not just through Juan Fernando. So in some early conversations with Juan Fernando I mentioned MLPs to pique his interests. Next, my colleague Hannah Glass, so I see in the audience here, joined the Office of General Counsel in fall of 2021 from Ropes and Gray where she worked with our MLP with the Dorchester House and you'll hear from Yoni later a little bit more about that program. I remembered this fact from interviewing Hannah and so when she joined I asked her if she would be interested in doing some work to build the foundational argument for why BILH should be investing in one or more MLP programs. She thankfully agreed. Our colleague Carol Gee also in the audience today also expressed interest in working on this project and then Carol also helped coordinate the work of some interns and externs that are rotated through our office. So I'm not a slide person, but I did create some because I knew everyone else would be. So I'm just gonna share them intermittently when it kind of comes up with what sort of tips we might have from our learning, right? So number one, find the right people at the leadership level who will champion the initiative and either have access to money for funding or are willing to go to the people with money to help secure funding. You will need allies with influence for the initiative and the money. Be proactive, approach the potential allies and help them and tell them, sorry, why this initiative is something they should be thinking about and eventually promoting. Number two, you will also need allies willing to do the foundational and granular work with you. Starting an initiative like this takes a lot more time and energy than you think you will, particularly if it is not technically an assignment from your managers or your clients, you will need help. And I'm very thankful that Hannah and Carol were able to help and continue to. All right, so finally, as of January 22, so we're now kind of near current, I had 0.2 FTE of my time carved out to be the director of ethics for PIH. As you've heard, an MLP is a program that can accomplish ethical goals and values of the system through legal means. So it was nice fit for me in my now official roles in both ethics and legal. And now, at least in theory, I had some time to work on this project. So in early 2022, Hannah, Carol and I started working collaboratively on research about MLPs. We focused first on collecting and reviewing articles and documenting in an annotated bibliography. Then at the suggestion of Juan Fernando with the help of some excellent interns, we began writing a white paper about MLPs and why the ILH should be investing in one or more of her. I'm not gonna give you all the details of the arguments we make in the white paper, but here are the high level summaries of the arguments. And if there's time later and interest from the audience, we can discuss this more in depth. So first, it's the right thing to do. I always start there. Start with the ethics, do the right thing and everything else will follow. Sometimes that even works. More specifically, in the paper, what we argue is the obvious goal of healthcare providers is to improve the health of all of his patients. To be successful, one must take a holistic approach rather than trying to address certain causes or even merely symptoms while others are left unchecked. An MLP bridges that gap between medical sequelae and social causes and allows healthcare providers to support their patients holistically. Because social drivers of health affect our vulnerable patients at much higher levels, more effectively addressing SDOH, as we call them, through an MLP, furthers the principles of beneficence, autonomy, and justice. That is addressing social drivers of health provides a good to individuals, gives them more control of their lives, and it gives people equal opportunities to achieve better health. This alone should justify establishment of an MLP. Of course, we don't stop there, right? So the second argument, in addition to the ethical obligations to patients, we have an ethical obligation to our staff to provide a safe and supportive work environment. There's a negative impact on staff when they cannot deliver on their promise to help improve health due to causes outside of their control, particularly as we require them to screen for social drivers of health. This then leads to burnout, turnover, and exodus from the field. It is worth noting that the recent push to screen for social drivers of health is both an internal decision and an external requirement by the Joint Commission for Inpatients and by Massachusetts Medicaid known as MassHealth for members of any MassHealth ACOs. Next argument, establishing an MLP aligns with BILH's stated goals, stated values and mission. We specifically called out statements made in the system's strategic plan, various community health needs assessments from throughout the system, and the assurance of discontinuous discontinuance issued by the Attorney General's Office and signed by BILH prior to the establishment of the system. We also highlighted the ability of an MLP to positively impact extended lengths of stay of certain patients, which is bad for the patients, it's bad for their families, and it's bad for the hospital. And finally, we showed that an investment in an MLP generally has a positive return on investment or ROI. And now I do not believe this should be the primary driver of the decision to invest. It is an increasingly important factor, although we'll learn later that depends in part on where the funding is coming from. All right, slide number two. Okay, I'm not sharing, now I'm sharing. Okay, so align with the organization's stated missions and goals, particularly those made public, like on websites or in public testimony from leadership. Number four, don't wait for leadership to ask for something from you. Develop it and give it to them. Tell them why they should be thinking about your initiative and why it should be prioritized. Like my somewhat self-deprecating characterization of everything looks like a legal solution for me, the converse is also true. Nobody else is gonna think of legal tools. All right, we're back. All right, so then coincidentally around this time, two different legal aid organizations approached just at BIDMC and BILH respectively, seeking a partnership. First, who I don't think is here with us today is lawyers for civil rights. After Juan Fernando joined BILH, Yvonne Espinoza-Madrigal, executive director for LCR reached out. The two of them had worked together in the past. We're still working out the details of that potential partnership. The second, which you will hear from in a bit is health law advocates. We've had a long-standing relationship with HLA, so this was a natural outgrowth of that. As you will hear, this structure requires funding from BIDMC to cover the cost of legal staffing that will provide the services. All right, back to our slides. Okay, so put yourself in a position to act on opportunities quickly when they arise. So although I had been thinking about MLPs for a long time, I had not yet done the work to establish the foundational argument. Then I got some help and we got to work because we had the white paper mostly done by the time HLA and LCR reached out, we were able to quickly move from preparation into advocacy with the appropriate decision makers. Number six, prepare answers to as many questions as possible in advance, like what populations and legal issues you wanna focus on and where in your healthcare organization you can best meet those goals. Recognize where you need other affected parties by them and when to seek that input. Of course there's a balance too because you don't wanna ask for too much of anyone's time for a project that may go nowhere. So we're getting close to the end. While discussing details around the MLPI with health law advocates, we had an inpatient at BIDMC who we thought could have benefited if the MLPI was already in place. HLA agreed to take on the case and treated how it would be treated through the MLP. We determined that if we had the MLP in place at the time the patient's discharge barriers were first identified, we could have saved 60 inpatient hospital days which would have allowed the patient to start receiving the right level of care sooner and relieved his agitation of being in the hospital for so long. It also would have saved the hospital over $200,000 in costs of caring for the patient during those 60 extra days. Based on these results, we developed a memo separate from the white paper to go to the BIDMC chief financial officer arguing for funding for the MLP with the test case justifying the ROI. My last slide. Okay, find a test case to show value. So even if ROI should not be the focus or the main driver. Last long, be realistic and comprehensive in your assessment of the costs to the organization. Even in models that do not require an out-of-pocket spending like the law firm model you hear about later, there is the cost of staff, which is significant. Staff include a coordinator or liaison between the legal services provider and the clinical team. It also includes the time of existing members of the clinical team who may now spend more time addressing social drivers of health and connecting to the MLP, which means they have less time to do other things which in turn may lead to the need to hire more staff generally. And if we fail to include these additional pieces as costs, it will set you up for upset and disgruntled funders and participants. All right, so at this point then, I reached out to Nancy to let her know I thought we were finally getting close to establishing an MLP. I thought she'd be very excited. I told her about the white paper, the proposal from HLA and that we had prepared the memo to send to the BIDMC chief financial officer to make the case for funding for the MLPI. Nancy kindly offered to review and comment on the memo and sooner after said we should talk again because she thought she might have the community benefits funds necessary to start the MLPI. So obviously finding funding is crucial to get an MLP like this started. It is also important to consider where this money comes from though, because it could impact how you structure the program. So as Nancy will explain, there are rules about how community benefits dollars can be spent, focused primarily on certain vulnerable populations and specific goals for those populations and communities. And those rules can change over time, which is why we could execute on an MLP now when it was not feasible previously. All right, Nancy, I'm gonna turn it over to you. Thank you. Great, thanks, David. Hi, everyone. So if you can bring up my slides, I'm just gonna do a brief introduction. So I'm Nancy Keisen. As I've already been introduced, I manage a health center network that has one licensed and four federally qualified health centers. You already know the stats of the 120,000 low resource patients. And I also have served as the director of community benefits at Beth Israel Deaconess Medical Center for nearly a decade and then ascended to the vice president role overseeing the community benefit and community relations program for all 10 hospitals as part of Beth Israel Deaconess Health. I think it's important to set the stage related to my role more specifically at the IDMC in the sense that I have always been and played the role of, shall we say, the town crier and the voice of the historically underserved. And so I am always bag borrowing and since there's lawyers on this, I won't stay stealing, but I've bag borrowed and manipulated to get resources for the historically underserved in the community. And even though, and I wanna point this out, we are what I would say to David, we are very lucky to work at an institution that really welcomes the underserved. And there has never been a time at the IDMC for a health center patient where I have picked up the phone and asked anyone within the IDMC for help. And there's never been a time where anyone has said no to me and they have moved heaven and earth to help our patients. So I think that's context that's important because while we say, oh, we couldn't move this MLP forward, there was other activity that was going on at the IDMC but the stars were not aligned for about seven years. And so if you could pull up my slides, I wanna walk through some of the shift that has happened over the past seven years. Next slide, please, related to regulatory requirements. So everybody thinks community benefits and community relations and we're just out there running health fairs and giving out free goods and really community benefits, particularly in the state of Massachusetts but across the nation is a highly regulated aspect. So through the Federal Affordable Care Act, every nonprofit hospital is required to do a comprehensive community health needs assessment every three years. This is promulgated through the Internal Revenue Service and through IRC 501R, which also has the other part of 501R is the financial assistance policy. And with that community health needs assessment, we have to identify priorities and priority cohorts or populations with which we will work in order to address identified needs. We file this with our tax return, our 990 on schedule H and schedule I. So again, this is something to be considering as you're looking at an MLP, how this might fit into your community benefit programming. Additionally, for the state of Massachusetts and I believe that this is also true in other states, anytime a hospital does a large capital expenditure that hits a certain threshold, we are required to file a determination of need. And the Department of Public Health here in Massachusetts is the body that oversees the regulatory and sub-regulatory requirements related to what we must do in order to fulfill these regulations, one of which for Massachusetts is a 5% investment. So 5% of the total capital expenditure must be reinvested back into our community benefit service area. The community benefit service area ties into the federal regulations related to the cohorts that we are, the geography and cohorts that we are serving. Additionally, Massachusetts has the Attorney General's office and we have one of the most robust community benefit requirements in the country related to our investment as a nonprofit organization back into the community. And then throughout the Commonwealth, there are also cities and towns that have requirements of hospitals called payment in lieu of taxes where we either negotiate or make a voluntary payment. And then we get some credit against that payment for the efforts that we do in a municipality related to community benefit. Next slide, please. So BIDMC and Beth Israel Lehi Health or more specifically by BIDMC, we have always historically, as David mentioned, focused our efforts on geographies and cohorts that have historically faced the greatest disparities and the greatest health inequities and been historically underserved. So including Bowdoin Street Health Center in Dorchester and Chelsea, but also the geography surrounding our other federally qualified health centers. As part of the results from our community health needs assessment, we are required by 501R to put forth in three-year implementation strategy to address the needs and or publicly declare and document why we will not address specific needs that the community has identified. So these are sort of our core guiding priorities, equitable access to care. This is obviously fully aligns with the MLP, social determinants of health, the built social and economic environment. Again, fully aligns with the MLP. Mental health and substance use, we know that there is a lot of synergistic and causality and confounding that goes on between mental health and substance use related to social determinants of health and housing and jobs, food insecurity, and then complex and chronic conditions also parlays very nicely with the MLP. And I pause here to bring this to your attention because this really started with a full robust community health needs assessment beginning for BIDMC in 2013 and has evolved over time as regulatory requirements from our state have intensified and been refined. In 2017, there was a task force for the Attorney General's office and they rewrote the guidelines and requirements for our reporting. And around the same time around 2018, the Department of Public Health undertook a comprehensive review of the regulations and sub-regulatory guidelines related to determinations of need. So over that period of time, we started to see, we also saw a change in the federal administration which I won't comment on, but we were starting to see angst happening in the landscape as well as Massachusetts its response to some of that federal angst and some refinement of what was being expected related to our nonprofit status. Next slide please. So this just gives you an example of what has changed and what the Department of Public Health is requiring of us as we begin to move upstream. The built environment is, and these are their priorities that we need to address when we are reinvesting the community benefit dollars related to any capital expenditures that meet a certain threshold. So the built environment or the physical parts where we live, where work, travel and play includes transportation and buildings. Education is a person's educational attainment over their lifetime schooling. Employment obviously is having available safe, stable, quality, well-compensated work for all people. Again, some of the MLP work parlays into this housing is another I think itself explanatory also a synergistic opportunity with MLP. The social environment is really where I think the most synergistic opportunity lies because the social environment also includes the social conditions and cultural dynamics where a person functions and their social environment, their networks, their participation, their social cohesion. We absolutely found as the federal administration changed and laws were changing that cohesion and fear in our immigrant communities was really causing very significant ripple effects around this entire hexagon, I guess. And then obviously violence. Next slide, please. So where we are moving, and this has been sort of the paradigm shift in community benefits that has really supported my ability to provide funding, a community benefit funding for the MLP was we have moved from the individual to the collective or to the community wide. And so the MLP, if you sort of move from left to right, left is really sort of very specific healthcare. And while, as Ellen had talked about sort of in her continuum of triangles starting with sort of the individual, the individual is sort of where care is accessed. And that's very important related to how we might be reaching out and reaching into these, to find individuals. But as we move, the impact of those is more upstream and moves into towards the right, towards the public health, the public policy and the community wide prevention, right? So we're taking an individual, but the impact of getting them access to mass health, getting them access to stable housing, leveraging the benefits and public resources that are available to them, moves them into a more stable social environment that has greater impact in the community. Next slide, please. And so I like to show this because this is also where both the attorney general's office, the IRS and our department of public health and community benefits, excuse me overall, is moving. Again, it's we are moving upstream. The downstream is sort of an individual basis. We're right now functioning in what I would call sort of the midstream where an MLP has both the ability to impact the individual, but also impact sort of specific health risks, the specific issues related to immigration status, enrollment status, maximizing and leveraging benefits for our patients and our community residents at our health centers. And then hopefully informing both from a system of BILH, a BIDMC system, a BILH system, and then a larger system of our community, the legislative and policy decisions related to access to care and services for our most vulnerable neighbors. And I think that's my last slide. Awesome, thank you Nancy. So we're gonna turn to Andrew Cohen, who's gonna tell us a little bit more about his organization health law advocates and the kind of medical legal partnership. I know I kind of glossed over, we're doing a medical legal partnership. I didn't really describe what that's going to entail for us at BIDMC because I knew Andrew was coming up and he's gonna describe it for you. Thank you very much. It's such a pleasure to be here today with all of you. Next slide. I'm Andrew Cohen. I'm the director and lead attorney, as you know, at health law advocates in our access to care and coverage practice. Health law advocates is a nonprofit public interest law firm. We provide free legal assistance for Massachusetts residents earning up to 300% of the federal poverty level, which is a little bit higher than a lot of other legal services organizations. We're the only legal services organization in Massachusetts that is exclusively dedicated to healthcare access. The core issues that we address are helping patients and individuals overcome legal barriers to care and coverage. We help with appeals of insurance coverage or service denials for both private health insurance as well as public health insurance and particular Medicaid or mass health. We do a lot of work on medical debt and collections, helping people protect patients and clients from unaffordable medical bills. And we have a number of different initiatives. Most specifically, our immigrant healthcare access initiative. So throughout our history at HLA, we've been around since the mid to late 90s. We have always served immigrant patients regardless of their immigration status. But over the past few years, we decided to really focus our efforts in our immigrant initiative around building a capacity to provide a medical legal partnership for immigrants. Switch my slide, please. So in 2020, we launched our MLPI, our medical legal partnership for immigrants. Now, one of the reasons why we decided to move in this direction is because the number one source of cases that we receive at HLA came primarily from healthcare institutions. Healthcare institutions who had patients who had unmet healthcare needs. Often the institutions would look at these patients and say, hmm, these folks are undocumented. They only qualify for mass health limited. Well, it turned out that the most common type of case that these healthcare institutions would send us were people who in fact should qualify for better coverage. And so they were being underserved. These were people who were not getting the care they need because they were not enrolled in the right kind of coverage, even based on the paperwork or status or category of immigration that they were in. So the core of our MLPI is about better healthcare coverage plus better access to care equals improved health outcomes. Now, I'm a lawyer and this is a math problem here, but thank goodness it's a word problem. We're safe there. So our MLPI is a direct collaboration between HLA and medical providers. Now, there's a lot of different ways to run MLPs. Ours is somewhat of a distributed model where HLA as one organization actually has multiple different partners. And our MLP is focused much more narrowly on this access to care access to coverage. Whereas many other MLPs may do housing or nutrition assistance, getting access to disability benefits, things of that sort. We are much more narrowly focused on access to health insurance, access to care. But we feel like this focus is so important because it really does address the structural barriers to care that exist for immigrants in Massachusetts, but of course across the country as well. What's special about Massachusetts is that there's often much better access that people could have if they just have the legal assistance to help them. And so we see so often immigration status function as a social determinant of health, creating bad health outcomes both for individuals and communities. And our goal is to help people improve those health outcomes and also do many of the things that David was talking about in terms of built staff capacity with our medical provider partners, help do trainings for them and really improve the system not only from an individual standpoint but also an institutional standpoint. But we also do a lot of advocacy with policymakers and policy advocacy can clearly, when it's specifically, when it's really driven by patients' experiences, clients' experiences, the community experience, it can, we can change policies to make them more friendly and actually expand access to care and coverage. And so all of this is at the core of of course, health equity, which is so crucial to the bedrock of why we do this work. Next slide, please. Here's a list of some of our partners. Of course, we have Bethrazeral Deaconess Medical Center and particularly the Bowdoin Street Health Center as part of that partnership. We serve the Dana-Farber Cancer Institute, Boston Healthcare for the Homeless Program, which is another community health center and Boston Medical Center's Immigrant and Refugee Health Center. We've worked with them as well. Next slide. So at HLA, our focus generally is always direct representation of individuals training the community and doing policy advocacy. So unsurprisingly, that's really what our MLPI is focused on. We're representing individual clients around their health insurance eligibility, if they have denials of claims that should be paid or services that should be covered. Of course, if they have medical bills, they can't afford and other kinds of health care rights, including around discharge and other issues that may arise. We also provide a role in advising immigration attorneys at times in terms of what kinds of pathways people may have that could give them access to the best kind of coverage possible for their circumstances. Of course, we do a lot of work directly with the provider organization, helping their staff, training them about all of these different issues that we're working on, building systems to support their patients, and then of course, conducting policy work, as I was mentioning before, to help change systems for the better. Next slide. As David mentioned, our MLPI with BIDMC was really built on a very longstanding relationship. And that's been really crucial in terms of getting this project going. Prior to a formalized project, we've done trainings, we've done a lot of case consults with BIDMC staff, but now in this partnership, what we're doing is we're also taking on individual representation and doing that individual casework, which is in my opinion, what makes this effort so exciting and so impactful both for individuals, the hospital system and the community. We really are serving the community through the Bowdoin Street Health Center. A lot of people there are seeking primary and preventative care, so making sure that people are able to not only get that primary and preventative care that they need, but also specialty care if needed to ensure that people are in the right coverage and can therefore access. There are also a group of patients who are complex care patients who are quote-unquote stuck in the hospital, often because of immigration-related barriers. And for some of those patients, we can get access to better health insurance and therefore a much better care scenario for them and often for their families as well. And of course, actually this last bullet point should say navigating legal barriers and also ethical boundaries with our patients and clients. That's all I have for you here. You can go to my last slide, it's really about questions, which we can answer at the end. Very happy to talk more about it. Thank you, David. Thank you, Nancy and everybody. Awesome. Thank you, Andrew. So as Kelsey said at the beginning, we're gonna kind of take a step backwards, like a higher level from what BIDMC is doing now with HLA and I'm gonna invite Sarah and Yoni Sarah-Sarrasoff to talk about other models that work and the work that they're doing with medical legal partnerships and other sort of health law clinic sort of work. Sarah, why don't you take us away? Thanks. Thank you, David. And thank you all for coming. It's nice to see some familiar names and faces in this Zoom. I'm also gonna apologize at the outset. I have to leave a little bit early so I might miss some of the Q and A. And if I might ask the host to put my email in the chat, I would be happy to take questions that way. So you can advance my first slide and advance my second slide, you know who I am. Thank you. So I wanted to start by just orienting folks to some of the medical legal partnership work that I have done now over the past almost 20 years, actually. And it started in 2004. I was a recent graduate of law school and I received a fellowship in order to create and launch what we called a health law collaborative, the passageway health law collaborative, which was a collaboration between the Legal Services Center in Jamaica Plain, the Brigham and Women's Hospital, Faulkner Hospital and some area health centers. And this was a collaboration really focused on serving clients who are survivors of domestic violence. And what I learned in the work among the many things that have already been surfaced and I won't repeat them in my brief five minute remarks. But what I learned also was in addition to the kind of preventive benefits of an MLP, sometimes often in the case of DV, I would say, the health law collaboration allowed me to reach clients who never would have made their way to my door as a lawyer. These were survivors who for a variety of logistical reasons, financial reasons, related to fear and safety could never have come to my office and sought the care of an attorney. The only way to access these clients was in partnership with their domestic violence advocates in a safe undisclosed location within that hospital system. So that experience, and I did that work for about five years, really changed the way that I viewed, really formed the way that I viewed my role as a lawyer, I was a new lawyer. And it has really shaped the way that I do my work now in the health law clinic at Suffolk University Law School. I should take a minute to say for those who may not be lawyers or have gone to law school, the clinical programs at law schools are kind of like the internships and residencies that medical students go through. So in their final year of law school, my students are embedded in my clinic. They get special authority from our Supreme Judicial Court to represent low-income clients under the close supervision of an attorney. In my clinic, that's me. And so the students are providing a lot of the direct legal services under my supervision. So doing that work really shaped my thinking about both my role as an educator, but also as a lawyer and I'll get into that in a second. What I wanted to add to the conversation though is that since leaving the passageway health law collaborative in 2010, which I should say I'm very proud to note is still going strong these almost 20 years later. I have continued to engage in this work although at a level less formal than the passageway health law collaborative. So I have over the years had relationships, for example, with the Freedom Trail Clinic that deals with patients with schizophrenia. I have worked and continue to work with the PACT team, for example, at Boston Children's Hospital. And these are not formal MLPs, but I very much consider them in the same vein. When Ellen spoke about that pizza pie, I think what makes an MLP is not necessarily the level of formality, but in part as the mindset of the providers and the attorneys and the openness to collaboration and deep work together. And that interdisciplinary perspective, I think is the nugget or the foundation of this work. And there's a lot of cultural work that has to happen between the lawyers and the attorneys actually, I'm sorry, the lawyers and the doctors and the providers to build the trust and to build that mutual respect. And when you have that piece in place, then that pizza pie, that wedge can grow from just a referral stream, which is sort of one level of care to that, to the systemic work, the trainings and the partnerships, the work on systemic problems and so on. So you can advance my slide deck here. So I wanted to speak about what brings me to this work, both as a lawyer and then as a law school professor. So as a lawyer, I, like you all, am aware of the social determinants of health, but one thing I thought this audience might not think about or might not think about in the same way or what I almost like to call the health determinants of justice, right? Which is to say, it isn't just that MLPs help lawyers serve patients better, but providers help lawyers serve clients better. So I have, I'll give you two examples of this kind of dynamic. The first is an example of a client I'll call Tommy, who came to me with severe mental health issues and that had gone for many years untreated, as well as many physical issues and he was homeless on and off. And Tommy had sparked a really meaningful relationship with a provider at a local area health center and for the first time was getting mental health and then he needed it. And I worked for three years because this is the length of these cases to get him social security disability benefits, which I finally did, which allowed him to become housed, it allowed him to finally get the, you know, to pay his copays and get the medication he needed and all of the things that you all know. And then he lost the relationship with that provider because the provider left as happens often and he never really found a link with another person who he could relate to, who looked like him, who listened to his story in the same way. And, you know, two years later, he called me and he had, because he had become untreated, he had become, he had been affected, he had then gotten arrested, he had been incarcerated and he'd lost the benefits that we spent three years working together to get. And so that's an example of what I mean about the fact that just as legal services can further health outcomes, really good healthcare is what stabilizes the legal outcomes that lawyers get for their clients. The next piece is that it just makes our work easier, when we, as a lawyer, when I am working on a case, when I can call a provider and get that evidence I need, that I have the David I need, the access to the medical records, it just makes my work easier, just as it makes your work easier. So I just, I just wanted to add that this is a benefit in both directions. Next level, please. So then why bring this into an educational setting or a law clinical setting? So I thought I would just mention there are many reasons, but in a law school, my job, while it is to serve my clients certainly, is to train and educate my students and to help them form professional identities as lawyers. And in my collaborations in particular with teaching hospitals, I have really come to appreciate that shared mission, right? You all who are parts of teaching hospitals are doing the same thing with your medical students. And some of the most fun and interesting and rewarding collaborations over the years have been between medical students and my law students who have taught one another. I've had medical students come in and teach my students about mental health issues. We've gone in and taught them about the legal systems. For example, the legal systems definitions of capacity. And we've had conversations about how that differs from medical definitions of capacity and lots of rich exchanges. And so I just think that the learning that can happen is really special when you combine an illegal educational institution and a medical educational institution. But also, I think there's an opportunity to change the culture of both of our professions. When you teach young lawyers, maybe not just young, but new lawyers, that physicians, providers, nurses, caregivers can be their allies in this work and have value to add. Likewise, when you teach young physicians, doctors, nurses, so on, that lawyers may have value to add. I think it can help bridge that cultural gap that I spoke about and really change the next generation of care delivery. I know that sounds spooky, but I definitely have, I drink that Kool-Aid. I believe that. I also think there are these collaborations, particularly with law schools, open up opportunities for systemic and creative thinking. That's one of the luxuries I have as a member of a law faculty, is I am in an environment where that kind of creative thinking is encouraged and quite frankly, I have time to do it. And so, although less and less, I find. But I think there is an opportunity for some system levels thinking in these collaborations. That's quite unique. Another point I wanted to make is that I think, and I'm a big believer in the social determinants of health and addressing them, but I think sometimes there can be an externalization that happens, which is to say that I think on the medical side, and forgive me if I'm being bold for making this suggestion, but there can be sometimes a feeling like that wasn't our fault. It's somebody else's issue that is causing this outcome. It's their housing, it's the lack of benefits. It's something out there. It's not something we're doing. And likewise, I told you about the client, right? My first reaction was I didn't do it. That wasn't my fault as an attorney. I did my job as an attorney. It was that system. And I think one of the things that can happen as we align our missions here is we can kind of put away some of that externalization and begin to think about interdisciplinary collaboration as a path forward. I think I've said enough, I was gonna talk a little bit about the political determinants of health, but I think I'm at my five minutes. So if folks have questions, I would certainly invite them. Post conference, you can email me. Thank you. Thanks, Sarah. Yeah, we'll see if there's time to come back to this concept of the political determinants of health in our comment section. Yoni, last, but certainly not least, if you wanna tell us a little bit about the work you're doing. Yeah, when David, thanks, David, when he introduced Sarah and I, he described it as taking a step back. And I'm not sure that Sarah's comments were a step back in quality, but mine may be. Thank you for having me a pleasure to speak as was mentioned, a partner at Ropes and Gray. And my practice is actually focused on private equity fundraising and funds-related work. Also, by the way, hi, Hannah, on funds-related work. But we have a really strong partnership, medical-legal partnership between Ropes and Gray at the Dorchester House and also another program with children's. And so I'm one of the partners that helps oversee that program. So I thought it would be helpful to come give an example of a law firm, a for-profit law firm that is engaged in this work and what our partnership looks like. So the primary prong of the partnership is with the Dorchester House. As Kelsey said in the introduction, it's a community health center, multi-service clinic. They have, in addition to medical facilities, they have social workers and food pantries and lots of other services. And in 2008, 2009, a former Ropes and Gray partner, Michelle Gavin, in collaboration with the National Organization, the medical-legal partnership, Boston, launched this initiative for us to work as the exclusive provider with Dorchester House for them to refer legal cases to us. And the idea was really what everyone's been talking about this whole time to help bridge the gap between medical issues and legal needs for patients at the Dorchester House and clinicians and hospital staff were trained to help screen for these legal issues when administering care. And then when they detect an issue to sort of point that in our direction, David and others talked a bit about how patients don't always know how to access the care, sort of to what Sarah said, some of them wouldn't know to access the care and wouldn't have talked to anyone at all. A lot of the people we speak with did not realize that they have a cause of action of any sort to move forward that they have a legal problem. And so it's really critical for us that we are, for the patients overall that we have an opportunity to be with them in the room, to be sort of with them in the room through our representatives when they're getting medical care. We established a further relationship with Boston Children's Hospital in 2014 when Michelle left where she became counsel at Boston Children's Hospital. So that was helpful. But sort of as Sarah alluded to in that they also work with Boston Children's, it's not an exclusive relationship with Boston's Children's. We're on a panel and we're one of a number of panels, a number of legal service providers who decide whether to take cases or not. I believe we're the most active panelists though, which we're happy about. I thought maybe I could talk a little bit about like why does ropes do this? I think for some of the other participants like Andrew or Sarah, they're more typically thought of as good people. And so it makes natural sense to why they wanna do it. But corporate attorneys care too. I think that the firm overall, as David said, it's the right thing to do. It's a moral imperative given our position of privilege to be giving back generally. We also care about the broader health of our community and we're a very firmly Boston present firm and we care about the health of Boston more broadly. And then from a bit of a selfish perspective, it really helps our attorneys. It helps us develop skills, especially for more junior attorneys, it really helps them cut their teeth, so to speak on helping someone where it's a win-win. They're helping someone who wouldn't have help otherwise and they're getting an opportunity to develop some legal skills. Sometimes in an area of law, they don't otherwise get a chance to practice in. And it also helps the attorneys here feel engaged and good about being at work. Like we also care about feeling good about work and not that I don't love my paying clients, but it's a different sense of pride in serving as a resource to something like the Dorchester house or those in need in the community. Just to give a sense of scope, so in 2022, so last year, 171 timekeepers at Robson Gray worked on Dorchester house matters. Nearly 1,300 attorneys at the firm overall committed at least 20 plus pro bono hours, which is our target. And so we're very focused on this as a whole. And as part of that, actually we give billable hours. So for those of you who are not attorneys, the metric by which lawyers are somewhat measured internally is their billable hours and how many hours you've done in a year. And so that can put some pressure because time is a pretty valuable commodity. And so to sort of emphasize the value of pro bono work at the firm, attorneys all get billable hour credit for time spent on pro bono matters, even though the firm doesn't actually collect money from that. And also we're just very proud and we make clear that we have an internal info net where we publish all very successful cases on pro bono matters. And we have people present at practice group meetings, even if they're not related to the practice group, because it's an important part of what we do. Along with the Volunteer Lawyers Project, VLP, which is one of our partner organizations that serves as really great external mentors to us, we've received more than 1,000 referrals for intakes for the MLP program since the program's inception and we've helped more than 425 patient families. We have, ropes alone has undertaken roughly 645 matters under the Dorchester House Initiative and we remain optimistic about continuing to do that. We, I think one of the earlier slides covered the type of things you can work on, you typically see, those are matters we see also. So we do income insurance, social security, SSDI, that kind of stuff. We do education work, helping people with who might need help getting an IEP for a child or the like. We help with immigration and legal status issues, housing and utilities, family and personal stability matters. So really a wide range of issues and we have lots of success stories that if we had more time, I'd go into in detail, but lots of opportunities where we've helped families get asylum or escape abusive unsafe environments or obtain medical, or sorry, obtain housing help. One of the cases I like to, one of the frequent incidences that I like to talk about as an example of where a client might come in for a medical issue and not realize they have a legal issue is a lot of times we see patients come in with asthma or with children with asthma related problems. And very often that's because there's unremediated mold in their housing unit and they've sometimes attempted to talk to the landlord about it, sometimes not, but they don't understand that they have certain rights as a tenant in Massachusetts. And so they're kindly pointed in our direction. And then we're, as I mentioned earlier, we're lucky to have a bunch of really excellent external mentors and partner organizations and we feel really tied in with them. So I mentioned VLP already, but we work with PAIR, the Greater Boston Legal Services, DeNovo, and we work with them. They provide subject matter expertise for us to help supplement our knowledge. As I said, not all of our lawyers, almost all of our lawyers are not specifically trained in these immigration or housing matters. We're fortunate often to have people who did spend some time working on those matters at one of these organizations, let's say, before they joined the firm, but it really gives us an opportunity to have expertise and to share trainings. We offer trainings with them, they offer trainings with us and it's really a great partnership. And then we do, with VLP in particular, we host a weekly intake meeting where VLP does the intake and we have conversations with them about which matters to work on. So it really is another way for us to connect to the broader legal community as well, which we really greatly enjoy. Scott there. Well, thank you so much, Yoni. Thank you, Sarah. Thank you all of you for this incredible deep dive into the story of the MLP with BID and C&HLA and then also broadening out. We're gonna turn over to Ellen for some reflections before we take questions from the audience, but I'll just say MLP is really it's incredible evidence-based intervention to address the social drivers of health and justice for individual patients and populations. And if we're asking, why isn't it the norm? Why, despite it being in 48 states, not in every single health organization yet, until a regulation requires it, each new MLP is going to be born of some kind of organization level choice to pursue it. And that's really the bread and butter of organizational ethics and it's why we're bringing you this example, although it is just one example, right? That's key. So let me invite Ellen in for some reflections as you've listened to the presentation today. Great, thanks so much, Kelsey. I really appreciate that introduction, right? Because it is a choice of organizations to adopt this. There are no regulations mandating medical legal partnership activity, but as Nancy referenced in terms of just, you know, social screening requirements in Massachusetts, there is a mandate and emerging mandate around social needs screening. And so then you start to think about what are our choices in terms of how we meet that mandate and to do it effectively, right? So I do think that the quote unquote requirements are you can interpret them in different ways, right? And permission as well as requirements is what I would say. Because for example, and I know a number of you are coming out of a federally qualified health center work in different ways, including Nancy and Yanni, you're at an FQHC and some of the other participants here. It's almost 10 years now since HRSA, which is the federal entity responsible, clarified that their Title 330 funding could be used to support legal partners who are engaged in medical legal partnership activities at FQHCs, right? So that was an enormous success, but we still don't see 100% participation from the FQHCs around the country. And why is that? And I think David really appreciate how you have laid out and each of the speakers have laid out what are some of the challenges, right? It really does require vision and leadership at different levels, right? Not just at the top, but leadership within whatever entity you're charged with leading, especially in major health systems. So that need for vision and leadership has not gone away. And just because as David, you were talking about and heard from Sarah and others, just because it seems like a good idea and everybody's in favor of it and it benefits patients and maybe it even benefits the health system financially as well as sort of spiritually, right? And from a community benefit perspective, it still is going to require, I think an intentional effort, an intentional campaign, if you will. And so I think it's important to acknowledge that. Maybe we can shorten the timeframe, right? From seven years to seven months, right? But it is still, we have to acknowledge what that cost is and David, you referenced that, to act as though this was all really just all on the positive side of the ledger is not reality. And addressing social and structural drivers of health and shout out to Laughlin for putting some great resources in the chat. It's gonna cost us. It will cost money. It's gonna cost staff time. It's gonna cost leadership. And so I think approaching it by saying all the benefits, it's all benefits and no downside is not realistic. And instead, we have to challenge ourselves and challenge as you have done, challenge our communities to think differently about some of these problems, right? And I appreciate the questions in the chat, for example, around the epidemic of kids with mental health issues or people with mental health issues in ERs, right? I think it was David Meyer who asked that question in the chat, right? Is there any MLP solution there? And there may well be an MLP solution. It actually may be an uncomfortable MLP solution for the host facility, right? And that's what we see as a possibility and I'm bringing it this forward because this is an organizational ethics group, right? So like the threshold organizational ethical issue that MLP struggled with early on was generals counsel who said, we can't do that. They're gonna come on site, they're gonna sue us. That's the first thing that the legal aid entities are going to do is sue us, right? And over time, I think because of, you know, private attorneys like Robes and Gray, community-based organizations and their strong legal roles, people like David and colleagues who said, it's okay. We can have other kinds of lawyers on board and we'll figure out, you know, roles and responsibilities and the ethics and conflicts. And we're gonna have to continue to do that together, right? And that's really, we're lawyers. We can figure that out. We can help our healthcare partners figure that out. So I'm very confident that we can sort through the thicket of conflicts, but I've never seen complex problems like, you know, a kid who's stuck in the ER waiting for a bed for mental health crisis. I've never seen that be successfully resolved without access to some kind of legal advocacy, right? Like it's really hard to resolve that complex problem. And so I think presuming that, you know, some of these complex, again, not every single problem needs that solution of a lawyer, but some of these problems are deeply complex and they require lots of different providers around the table. I would say my challenge to all of you as you're thinking about medical legal partnership is, and this is something that, you know, has challenged the medical legal partnership field nationally in a lot of different ways is who are the providers, the clinicians that are joining us in this work because the lawyers have, we would not be here were it not for the legal sector. Seeing the value pressing forward, you know, staying on task, David, seven years, right? Trying to think about a pathway, just like shout out. But I think we forget in the legal profession, we forget to bring along our clinician friends and leverage their voice and tap into, and all of the speakers that have shared have talked about, you know, the importance that they've heard from their clinician partners over time, but we need them here in the conversation with us and we need them in their leadership roles to be very articulate about why this is important. I know why as a lawyer, why it's important, but I also think it's important to build those voices on the clinical side because in fact, they're often who get the audience inside of major health systems. And we, and so thinking about the clinician leaders, thinking about our peer navigators, our community specialists, patient navigators, what is their role, how do we explicitly bring them into the work that we're doing together and again, cement the lawyer's role inside of healthcare team responses to social and structural drivers of health, knowing that, you know, it could become uncomfortable at times and that we can manage that. The last thing I'll say is I think that, you know, in my experience of 20 years of medical-legal partnership activity, I think that on the legal aid side in particular, we consistently undervalue, we overpromise and we undervalue. And that is a problem for us because if we're really delivering a $200,000 savings based on, you know, 60 length of stay estimation, if Andy had called me and said, what should I do? I would say, like that's worth a lot of money. Like we have to know our worth in the legal aid community to have a seat at the table, right? So that we can do the work as effectively as we think we need to do it. And then on the healthcare side, you know, Nancy, I really appreciated how you laid out all of the alignments, right? And the drivers that are relevant to being able to fund. And there's a terrific community benefit history of investing in medical-legal partnership. And now we're starting to see as a result of that. We're moving to investment through 1115 waivers, right? That include medical-legal partnership as a feature of the 1115 waiver. And we're moving from that to, I think, really incorporating lawyers as part of the solution around social determinants. For example, in CalAIM, in the new Medicaid transformation that's happening in California, where it really, you can see the highlighted terms about medical-legal partnership activities that impact are embedded in a lot of that language. And then now really the last thing I'll say, because in a little time, and I'll post it in the chat, a major appropriation that was announced in Congress, a $2 million grant program for medical-legal partnerships. That is a huge milestone, and it should signify to all of our systems, to our communities, to our government partners that this is important, and it's worthy of investment. So I'll stop there, thanks. Thank you so much, Ellen. As often happens when we have such an incredible group of presenters, there is far more to say than any one of us could have imagined. And so we're coming close to the end of our time. What I want to encourage among the audience is because we won't be able to get to all of your questions. If you do have a question, if you would just put it in the chat, we're going to capture the chat so that we're able to respond to those questions to the extent possible. And there have been discussions about bringing a group together to look into making MLPs, more so than norm here locally in Massachusetts and of course beyond. So if you're interested in further discussion on that front, please contact David. I just put his email there and he'll make sure that you get pointed in the right direction. With the last kind of three minutes here, I did want to pose one question for anyone to consider, which is, we put a lot of ethicists in the room today. And this is a Center for Bioethics after all. What is the role of an ethics program in advancing these kinds of partnerships between the clinical and legal side? David, I wondered if maybe you want to start there, but generally, if anyone has thoughts on the ethical issues that they encountered as they were part of this work, we'll have to hear a little bit about that. Well, so I'll just start by saying, I think the ethics program, a well-developed ethics program certainly has a role. The challenge, as we've talked about in this consortium a lot of times, is getting a seat at the table and getting invited into those discussions. But as you saw in my comments, sometimes it's forcing your way into those discussions and telling people why they need to be doing the right thing and giving them the case for doing it. So I think as I've grounded all these arguments in an ethical argument, it's also important to pay attention to the other reasons why an MLP or whatever other initiative makes sense. Thanks, David. And are there ethics issues bubbling around the nascent MLP that you and Andrew or Nancy are thinking about? I have to say it, we know, of course, funding is not unlimited, right? In some respects, in so setting limits and scope and targeting are all things that of course require a little bit of thoughtful engagement. How are you doing on that front? Yeah, I mean, that is definitely one of the challenges because money is finite. I think the other one that kind of came up in the end of the comments was really about how there may be instances where our, what people will perceive as the hospital's interests are not gonna necessarily align with the client, right? Our patient client's interests. And I know there'll be times where Andrew and his team will be doing work where my client will be upset that it's gonna lead to a longer length of stay. But that is part of what we have to accept. And when it turns into the right thing for the patient, that's the most important answer. And so I try and always direct our client to say, what's the right thing for the patient and what's the legal hurdles to doing that or what are the legal ways to ensure that? And sometimes the legal ways to ensure that don't align with what we think we need in the short term, right? In the longterm, the best thing for patients should always be the best thing for a hospital. That's what our job is, right? That's what a health system is aimed to do. And the better we do that, the better we're doing everything. But I know the dollars don't always line up that way. Well, thank you so much. As we're just kind of running out of time, I think that from the perspective of the Organizational Ethics Consortium, you've given us a lot to chew on, both in thinking strategically, right? Within organizations about how to create sustainable structures for positive change and working with internal stakeholders to do that really thoughtfully and then also with external stakeholders. So, chance favors the prepared mind, I suppose, in really putting all of the thinking together so that when the moment comes, it's possible to move it forward. I think that one of the things that we can always keep coming back to is this core feature of organizational ethics, which is really mission discernment and considering how to align positive initiatives, not only with a general ethical rationale, but really embedded for an organization so that the organization can take it on as its own. And this is certainly true, not just for the healthcare providers in the room, but also for the legal services providers who are thinking about the role that they fold in bringing these sorts of services under their fold. So with that, I'm going to thank every single one of our panelists, not by name, but as a group for really bringing this forward and all of the audience for being thoughtful with us together, please do continue to share your questions if you have them in the chat and we'll close the session in just about 20 seconds as we give a little round of applause for all of the speakers today. So thank you all. And we hope to see you back again for our next sessions in the Organizational Ethics Consortium, which will be at the end of April. I think it's April 28th. And then again, mid-May, May 12th, where we'll take up some different topics, which you can follow up on the calendar to learn a little bit more about. Thank you all and have a good afternoon.