Delivery of Care

When change happens at the speed of trust

An exit interview with Samantha Morton, CEO of MLPB, who is leaving her position after a decade of legal advocacy for better health outcomes

Image courtesy of MLPB

Samantha Morton, CEO, of MLPB.

By Richard Asinof
Posted 5/23/22
Samantha Morton, outgoing CEO of MLPB, a legal advocacy nonprofit focused on developing human-centered communities of care, shares her thoughts about how legal advocacy has evolved as a tool to improve health outcomes.
What are the opportunities for the R.I. Attorney General’s office to engage with MLPB in Rhode Island to develop a collaborative approach to how the attorney General can better serve Rhode Islanders as a public health advocate? What are the opportunities for communities to wrest control of the future testing processes around COVID-19, particularly around public schools? When will the R.I. General Assembly act to increase Medicaid reimbursement rates? What is the value of prevention as a factor of return on investment in health care cost equations?
The state of Rhode Island is now facing a number of problematic federal consent decrees in regard to health care, all of which involve the need to allocate more money – around developmental disabilities, and around the state’s failure to provide services and supports for thousands of children with disabilities. During a time of great abundance when it comes to the state budget, the apparent unwillingness by the state to invest the necessary funds to correct the budget deficiencies seems to be related to a question of stigma – somehow, disabled children and teenagers are not judged “worthy” enough of expending the necessary resources for care.
A similar kind of discriminatory attitude also seems to apply to the failure by the state to raise the low reimbursement rates for Medicaid – as if Medicaid members are somehow not worthy of the expenditures – even though more than one-third of all Rhode Islanders are receiving Medicaid health benefits. That same dynamic applies to the way that Medicaid rates for long-term services and support for residents of nursing homes have been cut over the last decade.

PROVIDENCE – All too often, the focus on transitions in leadership when talking about health care delivery systems is limited to reporting on the corporate rites of passage. For example, Arthur Sampson was recently chosen to serve as the interim leader to replace outgoing President and CEO Dr. Timothy Babineau at Lifespan, the state’s largest health system.

Babineau is departing after his failure to secure the proposed merger with Care New England, the state’s second largest health system, when the deal to consolidate the two entities was rejected by R.I. Attorney General Peter Neronha. [See link below to ConvergenceRI story, “Getting to no.”]

Sampson most recently had served as the president of Miriam Hospital, and before that, he had led Newport Hospital for 24 years; in total, Sampson had toiled as a top executive within Lifespan’s system for 35 years. Translated, he is a corporate insider.

“Arthur is an agile and strong leader who works well with individuals at all levels of the organization,” wrote Lifespan board Chairman Lawrence A. Aubin, Sr., in a message to Lifespan employees, as reported by The Boston Globe. In the message, Aubin promised that a national search for a new president and CEO would be launched in the coming weeks.

What got left out of the story about Sampson’s interim appointment was that Lifespan appears to be a health system in distress, in the midst of a serious workforce crisis as well as a growing lack of care delivery resources.

Last week, the Emergency Department at Hasbro Children’s Hospital, one of the member hospitals in Lifespan’s health system, was reporting the highest score possible, 200 out of 200, from the National Emergency Department Overcrowding Scale, according to The Boston Globe. On average, each day, some two dozen patients were waiting for up to seven hours in the emergency room, many of whom were waiting  for inpatient behavioral health services, according to The Boston Globe.

Symptoms of distress
The overcrowding of the emergency room and the ongoing workforce crisis are symptoms of a health system in distress, much like elevated blood pressure readings and a spike in body temperature and difficulties in breathing would be viewed as troublesome symptoms in a patient.

Treating the corporate transition at Lifespan as somehow removed from the ongoing crisis in health care delivery is a kind of cognitive dissonance; it ignores the flashing red “engine warning sign” on the dashboard about what is wrong with hospitals.

In contrast, a different kind of corporate transition is taking place at MLPB, a nonprofit agency dedicated to working on improving health outcomes through legal advocacy, focused on upstream problem-solving strategies in health care. [MLPB is the next generation evolution of Medical Legal Partnership Boston; the work has often involved building collaborative partnerships in Rhode Island and in Massachusetts.]

After a decade of leadership, MLPB’s CEO, Samantha Morton, is leaving her position, moving on to her next challenge. Among the partnerships that MLPB has developed under Morton’s leadership have been with the Care Transformation Collaborative and its ongoing initiatives with community health workers, and with the R.I. Life Index, a data survey of Rhode Islanders conducted annually with Blue Cross and Blue Shield of Rhode Island and the School of Public Health at Brown University, now gathering data for its fourth annual edition.

MLPB describes its work as follows: “At the household level, [our] capacity-building support disrupts the trajectory of a social, economic or environmental need into a legal and health crisis.” Translated, the agency’s focus is on preventing crises. At the population level, MLPB’s work “cultivates communities of care as partners in system and policy change.” Translated, the agency recognizes the importance of community participation in supporting systemic change.

The art of convergence
ConvergenceRI has covered the work being done by MLPB on a number of occasions, impressed by the organization’s ability to bring different community voices to the table to strategize about health care as a place-based enterprise.

For instance, ConvergenceRI reported on MLPB’s spring breakfast held in May of 2018 at the Warren Alpert Medical School at Brown University. [See link below to ConvergenceRI story, “In search of a common language about disruptive health innovation in RI.”]

With her announced departure, it seemed like a good time to try  to capture Morton’s perspective on the changing health landscape in the region – and the role that legal advocacy can play in changing the equation. Here is the ConvergenceRI interview with Samantha Morton, CEO of MLPB:

ConvergenceRI: How has the health care landscape changed, in your opinion, in the last 10 years?
MORTON: The momentum toward value over volume – exemplified by the accountable care transformation and global payment environment – is changing the conversation about what really makes up health and well-being, and who needs to be around the table to even begin to achieve greater health equity.

It has been exciting, for instance, to see new space created for important experts like community health workers join care teams in greater numbers in recent years.

What remains unclear is whether we will see “values over volume” in our lifetime. While values remain hotly contested nationally and locally, the health care community has an important opportunity to commit not only to patient-centered care, but to human-centered care.

Just as one’s ZIP code correlates to health status and life expectancy, it also correlates to barriers to justice in our society. The care delivery lens needs to account for the law and policy environment that governs people’s day-to-day lives.

While law can feel like an invisible presence to many, that perception is a mark of privilege. For too many people, zoning laws, law enforcement abuses of power and immigration policy are key “structural drivers of health” [sometimes called “social determinants of health”] and certainly not invisible in their lives.

ConvergenceRI: What have been the greatest successes by MLPB in advocating for health through justice?
MORTON: We’ve pioneered an important strategy that can expand the pool of legal problem-solving partners available to people: what we call team-facing legal partnering.

This capacity-building strategy recognizes that while some legal problem-solving can only be performed by licensed attorneys, care team members – many of whom develop relationships of trust with the people they serve – have a powerful role to play in offering legal information and rights education to their patients.

Not only does this advance prevention as opposed to crisis management, but it also helps to democratize access to justice by inviting more stakeholders to bridge the access-to-justice gap.

This is particularly critical in Rhode Island, which ranks 51st nationally on “self-representation” infrastructure – meaning the tools that people can lean on when trying to navigate court processes successfully without a lawyer.

Refining this strategy has had important ripple effects over the last decade.

• Nationally, MLPB has participated in a number of research studies [DULCE (Developmental Understanding and Legal Collaboration for Everyone), Housing Rx] that are growing the evidence base for legal problem-solving as an important element of care. In DULCE’s case, that approach is now in various stages of planning/implementation in 9 states, including Rhode Island,

• Regionally, MLPB expanded team-facing legal partnering operations to the Ocean State in 2017, thanks to a thoughtful planning process with colleagues from RIMLP and the R.I. Center for Law & Public Policy.

• And finally, within Rhode Island specifically, our partnership with the Care Transformation Collaborative-RI and its Community Health Teams was so impactful that MLPB is now supporting statewide training of community health workers [CHWs] as part of the R.I. Department of Health’s recent Centers for Disease Control and Prevention grant award [“CHWs for COVID Response and Resilient Communities”].

This is a real honor for us, and it speaks volumes about the centrality of law and policy to community health work.

ConvergenceRI: What have been the shortcomings – or perhaps a better way to phrase the question – the places where more work is required?
MORTON: Good grief, there is so much work to do! The health justice chasm is oceanic. And I think about this question a lot because new organizational leadership may bring exciting new vision.

I see three significant challenges – opportunities – in this work over the next few years:

• Challenging the health care ecosystem to expand their government relations lenses to include priorities like affordable housing expansion that are fundamental to human health, well being, and dignity.

We don’t need more data demonstrating the links between unstable, unhealthy housing and poor health outcomes; rather, systems with tremendous political and strategic capital could consider energetically supporting broader policy change efforts that are consistent with population health improvement imperatives – a significant step beyond the current “screen and refer” framework. This is starting to happen around the country in promising ways.

• Challenging the public interest law community to (a) welcome allied colleagues – like community health workers – more intentionally as collaborators in the march toward health justice in our society; and (b) embracing role differentiation among different legal community actors as a key transparency and trust-building step with people and communities.

Conflicts of interest can and do arise when the same organization/lawyer that provides direct legal representation to a patient delivers other kinds of funded services to the clinic/system that treats that patient.

Errors and bad acts do happen, and these conflicts of interest will only grow as health care teams take on greater responsibility for promoting people’s social, economic and environmental health.

We are gratified to see Integra Community Care Network modeling this kind of “legal partnering village” by engaging both MLPB and the R.I. Center for Justice to play distinct but complementary roles in a partnership with them.

• Challenging ourselves – organizationally and individually – to make sure we are grounding the work in specific, data-driven and community-driven health equity and race equity goals. Integrating law and policy expertise within care planning is path-breaking innovation, but the integration itself is not the ultimate goal – it’s a strategy that should catalyze health justice reforms at both the household level and the population level.

ConvergenceRI: How do you think that the “leaked” opinion about the U.S. Supreme Court has changed the legal advocacy landscape moving forward?
MORTON: One of the barriers to justice in the U.S. is the density and complexity of law itself. Most of us can’t confidently explain how a bill becomes a law. And most laws and policies are not written for regular people -- yet it shouldn’t require a law degree to decipher the principles and rules that govern our society.

Over the last several years, there has been some exciting momentum around deeper civic education – citizens and neighbors learning more about how their federal, state, and local governments work. The release of the draft Supreme Court opinion ‘lifted the hood’ a bit on a process that has been somewhat mysterious – what these deliberations are like.

This event may prompt more people to ask important questions about how power is stewarded, exercised, and checked in our country’s judicial system.

ConvergenceRI: What are the best, most effective methods to advocate on behalf of patients, using legal tools?
MORTON: In MLPB’s experience, it takes a combination of capacity-building tools to meaningfully fill a team’s social care “toolbox.” Training is an important foundation, but team members need the opportunity to reinforce and apply that learning in their problem-solving partnerships with the people they serve.

One way we reinforce that learning is to integrate our staff into standing interdisciplinary team meetings [care planning settings] so that we can contribute continuous law and policy education to that setting.

We’ve seen this be particularly valued over the last 5+ years, given whiplash-inducing changes to immigration policy [like the chilling effect of the threatened public charge rule modification] and the evolving eviction moratoria at state and national levels.

Ultimately, though, advocacy is most effective when our learning from capacity-building partnerships is translated into recommendations for system-level and policy-level change.

ConvergenceRI: Can you place the work of health equity zones in the context of how they are changing the conversation around health outcomes?
MORTON: Circling back to ZIP code as a structural driver of health, we need look no further than the April 2022 HEZ Update to see that the conversation is changing in exciting ways.

This update spotlights, among other things, men as allies in combating domestic violence; anti-racism and reproductive health; reducing youth homelessness; and public parks as community wellness hubs. Now this is a community health- and health justice- oriented dialogue.

ConvergenceRI: Moving forward, what are the most important lessons from the efforts to combat the coronavirus pandemic, when it comes to racial justice?
MORTON: This question is tied to lessons from the pandemic, but on reflection – and thanks to recent conversations with First 5 Orange County collaborators Ana Page and Andrew Montejo – I think the answer is universal: trust is fundamental and in short supply.

Many systems have caused harm to, and therefore generated understandable distrust among, many people they ostensibly exist to serve. This means that pursuit of racial justice is happening amid a landscape of deep, long-standing and frankly earned distrust.

A reminder from my colleague Rosanna Batista of East Boston Social Centers is ringing in my ears: “Change happens at the speed of trust.” To grow both trust and trusted messengers in racial justice contexts, I think we must deeply invest in truth, justice and reconciliation processes locally, regionally and nationally..

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