The staff at Legal Services of North Dakota (LSND) struggled for years to balance intake procedures with providing quality legal representation for low-income, disadvantaged and elderly populations across North Dakota.

To fix that, LSND streamlined applications through a centralized intake system that transformed its work.

LSND is a recipient of the Bush Foundation’s Bush Prize for Community Innovation.

Too often in small towns across rural North Dakota, lawyers like Rich LeMay work with clients who assume heir hometown bank won’t make a mistake. That faith isn’t always merited. When the bank gets it wrong, Rich makes sure the institution doesn’t take advantage of the trust North Dakotans have put in it. Then there are times when Rich finds himself in the role of teacher when he comes up against people who interpret the law incorrectly. After a call from a creditor in early 2017, a local bank in Minot seized a couple’s account and froze their assets. The creditor claimed the wife, who is on social security, owed money for past medical debts. The problem? Under a recent federal law protecting social security, the bank couldn’t legally hold the couple’s money. Instead, it needed to go through a process to determine how much money in the account was safe from creditors.

Rich, the executive director at LSND, led an exemption with the bank, explaining the many ways the law protected the couple’s money. Despite that, nothing changed after a week.

“The fact that [the bank] hasn’t done anything is unsettling because the law clearly says what it’s supposed to do,” Rich says. “If you’re living on a cash basis and all of a sudden your money is gone, I don’t know what people would do if we weren’t here.”

If LSND didn’t get involved, ultimately the bank would seize the money and give it to creditors. In situations like this, LSND is often the only option for low-income or rural residents who might otherwise lose out when they don’t know their rights. In small towns where clients typically know their bankers personally, it can be hard to question established institutions you expect to follow the law and not make mistakes. When that does happen, though, LSND gives North Dakota residents the knowledge and confidence they need to stick up for themselves.

Rich could always list three things about his clients: their name, their legal challenge and the next step he should take on their case.

Every week, he composed a handwritten list of his cases to stay on top of the workload. When his secretary typed up the list one week, he was shocked to find it ran 10 pages long. A normal caseload for an attorney is about 65 cases. He had 150.

For the first time, the attorney found himself breaking tradition—he couldn’t name all of his clients anymore. The stress kept Rich awake at night. He had to know more about the people who needed his help. So, he got out of bed, got dressed and drove back to work in the dark.

“I didn’t think we were being efficient and serving as many people as we could,” says Rich, who started working for LSND’s Minot office in 1989. “There needed to be something different.”

For years, LSND struggled to find the balance between its application process and providing clients with legal services. Its intake system was disorganized, spread out between several offices and required people to visit an office in person. Each branch opened at a different time to accept applications. Frustrated clients struggled to access LSND’s services, and staff wasted time flipping between intake and caseloads.

After complaints from applicants and local agencies that referred clients to LSND, Rich rigged together a temporary phone system to take applications. With it, he hoped to get in front of the demand he anticipated after the Grand Forks flood hit the area in the spring of 1997. Within two weeks, his team got a couple phones up and running. After six weeks, they received nearly 600 calls from people applying for legal aid. The following year, Rich’s team expanded its operation and developed an official central phone intake system. The success from the year before made it easier to convince other LSND offices to embrace the change. The new system was one of the first of its kind in the country, with all calls funneled through the Minot office. A few years later, LSND added a web application so clients could apply 24 hours a day. With both pieces in place, LSND doubled the amount of applications it processed each year from 4,000 to 8,000.

 

Dedicated intake specialists got faster at sorting through applicants who qualified for services and sussing out the reasons they called. In turn, this freed up significantly more time for attorneys to take on bigger caseloads.

“Sometimes people aren’t always good at explaining things to us, so if we’re cognizant of what’s happening we can help them fill in the gaps in their story,” says Rich.

To promote the new system, LSND identified organizations that served the same clients. Staff mailed information outlining the changes, or they presented at their annual meetings to increase awareness for LSND’s new intake format. The online application spurred an outpouring of support from social workers and caseworkers who could now easily fill out an application with a client in 15 minutes. For North Dakotans who struggled to drive to one of LSND’s offices, the new system was a breakthrough.

“Providing more access to the client population meant we were finding more people we needed to help,” says Rich. “People who never got to us any other way were getting access to us.”

With a smaller and more centralized group of staff handling the influx of applications, LSND started to proactively identify trends among its clients. A few months after the Bakken oil boom took off, intake specialists noticed a significant uptick in the number of housing cases pouring into the system. Seeing that spike allowed LSND to get out ahead of the problem. Rich and his team approached the Otto Bremer Foundation for funding to take on the housing crisis months before newspapers started reporting about the lodging issues plaguing western North Dakota.

In 2016, LSND launched a Medical-Legal Partnership (MLP) with Legal Services of Northwest Minnesota and Family Health Care (FHC), a primary care clinic in Fargo, North Dakota.

About 300 MLPs exist around the country, but North Dakota has never seen a legal team like this before. “It’s the way it should work,” says Adele Page, an attorney and deputy director at LSND’s Fargo office. “Legal services try to improve people’s lives. The healthcare community does the exact same thing, so holding hands makes a lot of sense. Being able to put our information together to help people is a more holistic way of solving problems.”

On either side of law school, Adele worked as a registered nurse, and then as a public health nurse in Washington, DC. She says study after study shows that access to physicians and healthcare treatments only account for 30 to 40 percent of a person’s health. The other 60 to 70 percent of a patient’s well-being is affected by the social determinants of health—things like a safe living environment, legal status, family stability or income supports. Each of these factors contributes to how healthy a person is overall, but to improve that kind of well-being, Adele and her team needed to get Fargo’s Family Health Care clinic on board with its vision.

“You need buy-in at more than just the executive or board level,” Adele says. “It has to be across all the people who touch patients.”

That meant the licensed practical nurses, nurse practitioners and pharmacists. To build those relationships, LSND hosted meetings at the clinic to educate staff around the goals of the new partnership. LSND explained it wasn’t there to help patients sue the clinic, but rather to find ways to use the law to make them healthier. That happens a number of ways: attorneys may prevent someone from unfairly losing housing vouchers or being evicted, they could help someone file a domestic violence protection order or make sure a parent is receiving child care support. The buy-in from the clinic started to take hold when LSND made inroads with the side of the clinic dedicated to serving the homeless. “When we started talking about the social determinants of health, they got it immediately,” says Adele. “They see it first-hand every day.”

The MLP also zeroed in on forging relationships with interpreters at the clinic to build trust among the large percentage of FHC patients who are refugees or immigrants from countries like Bhutan, Ethiopia and Liberia. The interpreters, who collectively speak 20 different languages, act as connectors and trusted advisors between patients from their cultural communities and attorneys at the MLP.

In meetings with clinic staff, LSND focused on improving its communication to bridge the industry gaps that divide healthcare and legal providers. Instead of using the word “client,” LSND adopted the more commonly used clinic word “patient.” Adele also continues to look for ways to make it clear to FHC staff that the MLP can add value to their patients’ lives. “We need to collect data to establish that we’re making a difference,” Adele says. “The medical world is very data-driven and evidence-based. We need to meet that model.”

Once LSND finds the resources, it hopes to convert that data into dollar amounts to show the medical community how the MLP saves the Fargo clinic money. Every year, FHC spends about $2 million to cover sliding fee discounts and uncompensated care for patients who are uninsured or have little income. Adele expects to reduce this amount by ensuring those patients have access to income supports, stable housing and Medicaid so they can put more money toward the care they receive. Adele also plans to track whether patients start visiting the clinic more regularly, if they bring their children in for routine vaccinations and if they follow staff instructions better once they leave the doctor’s office.

“If people have stable housing and benefits, they’re more likely to do a better job at keeping their health stable, too,” Adele says.

Take patients with diabetes who need to keep their insulin cool. If they live somewhere without access to a refrigerator, then following through on a doctor’s orders to keep that medication cold becomes increasingly difficult. For Adele, it comes down to showing the connections between these kinds of situations and how attorneys can positively influence those outcomes. While legal aid might not always seem like the obvious first step to protect or improve people’s lives, LSND continues to find creative ways to put the law to work for North Dakotans.

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