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Keeping the Heat on for Children’s Health: A

Successful Medical–Legal Partnership Initiative
to Prevent Utility Shutoffs...

Article in Journal of Health Care for the Poor and Underserved · August 2015
DOI: 10.1353/hpu.2015.0074 · Source: PubMed

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Journal of Health Care for the Poor and Underserved, Volume 26, Number
3, August 2015, pp. 676-685 (Article)

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BRIEF COMMENTARY

Keeping the Heat on for Children’s Health:

A Successful Medical–Legal Partnership Initiative
to Prevent Utility Shutoffs in Vulnerable Children
Daniel R. Taylor, DO
Bruce A. Bernstein, PhD
Eileen Carroll, JD
Elizabeth Oquendo, JD
Linda Peyton, JD
Lee M. Pachter, DO

Abstract: Objective. Energy insecurity may result in adverse consequences for children’s
health, particularly for children with special health needs or chronic health conditions. We
aimed to determine whether a multimodal intervention addressing energy insecurity within
the framework of a medical–legal partnership (MLP) resulted in an increase in the provision
of certifications of medical need for utility coverage in an inner city academic primary care
practice. Methods. Working within a medical–legal partnership, we standardized criteria
for providers approving medical need utility certification requests. We compared prior-year
utility certification requests and approvals (pre-intervention) with the intervention year for
families who reported energy insecurity on a waiting-room screening questionnaire. Results.
Between the first and second years of the study, certification of medical need approvals
increased by 65%, preventing utility shut-offs for 396 more families with vulnerable chil-
dren. Conclusions. Energy insecurity can be screened for and addressed in a busy urban
practice, potentially improving the wellbeing of vulnerable children.
Key words: Certification of medical need, energy insecurity, medical–legal partnership,
poverty.

C hildhood poverty has reached epidemic proportions in the United States, with
more than 23% of all children younger than 18 years old and 26% of those
younger than three years old living in poverty.1 Poverty in childhood is one of the
most recognizable risk factors for a lifelong trajectory of poor developmental, social,

DANIEL R. TAYLOR, BRUCE A. BERNSTEIN, and LEE M. PACHTER are affiliated with the Sec‑
tion of General Pediatrics, Department of Pediatrics, St. Christopher’s Hospital for Children, and the
Department of Pediatrics, Drexel University College of Medicine. EILEEN CARROLL, ELIZABETH
OQUENDO, and LINDA PEYTON are affiliated with the Legal Clinic for the Disabled, Philadelphia, Pa.
Daniel R. Taylor is the corresponding author and can be reached at Drexel University College of Medicine,
Director of Community Pediatrics and Child Advocacy, St. Christopher’s Hospital for Children, 3601 A
Street, Philadelphia, PA 19134; by fax at (215) 427‑6014; and by email at Daniel.Taylor@drexelmed.edu.
The authors have indicated that they have no financial relationships relevant to this article to disclose.

© Meharry Medical College Journal of Health Care for the Poor and Underserved 26 (2015): 676–685.
 Taylor, Bernstein, Carroll, Oquendo, Peyton, and Pachter 677

educational, and health and wellness outcomes, as well as an inability to care for oneself
without governmental assistance in later life.2 These statistics are some of the worst of
all developed nations; the United States ranked 34th of 35 countries surveyed by the
United Nations Children’s Fund in 2007.3
One way in which poverty exerts its devastating effects is by exposing the develop-
ing child to toxic stressors in the external environment that become internalized and
produce deleterious effects on multiple body systems, including neuronal, endocrine,
immunologic, and cardiovascular, as well as genomic systems.4 Toxic stress is the extreme,
frequent, or extended activation of the stress response, without the buffering presence
of a supportive adult.5 The external environment includes both material and nonmate-
rial factors. Nonmaterial factors include single parenting, interpersonal violence, child
abuse and neglect, parental distress and mental illness, and lack of cognitive stimulation
for the child by overwhelmed parents. Material stressors may include issues such as
housing instability, food insecurity, transportation issues, lack of health insurance, and
energy insecurity which is defined as “lacking consistent access to enough of the kinds
of energy needed for a healthy and safe life in a particular geographic location.”6[p. e870]
Studies have shown that these material stressors increase hospitalizations in children,
increase reports by parents that their children are in fair or poor health, and increase
reports by parents of significant developmental concerns.7 Studies have also shown that
the more significant the cumulative material hardships, the more likely children are to
be less well and at risk of developmental delays.
A considerable material stressor for families living in poverty is energy insecurity.
Another definition of energy insecurity is living in a household that has experienced
at least one of the following conditions within the previous year:
• a threatened utility shut-off or refusal to deliver heating fuel,
• an actual utility shut-off or refused delivery of heating fuel,
• an unheated or uncooled day because of inability to pay utility bills, and/or
• use of a cooking stove as a source of heat8
With energy prices skyrocketing, unemployment still at high levels, and the consumer
price index rising more than wages, more families are becoming energy insecure.9,10
In a large study in our pediatric emergency department at St. Christopher’s Hospital
for Children in Philadelphia, 31% of families surveyed faced energy insecurity.10 This
problem does not occur in isolation. In this same study many families also reported
housing insecurity (40%) and food insecurity (24%),11 and many felt forced to choose
between “heating or eating.”
Energy insecurity can be analyzed through the Home Energy Affordability Gap,
which is the difference between affordable (6% of gross household income) and actual
energy bills. In the United States, the energy gap rose 168% between 2002 and 2011.12
In Pennsylvania, the gap jumped more than 250% during the same period, with the
average household in Philadelphia sustaining over $2000 a year in shortfalls.11 The
poorer one is, the heavier the home energy burden becomes, and the more likely the
household will have to make tough choices that could affect children’s health.
Inadequate external temperature regulation has the potential to adversely affect
children’s health. Children have evolved to function best in an environment that is
678 Keeping the Heat on for Children’s Health

neither too cold nor too hot. Adults can tolerate fluctuations in temperatures better
than children, particularly young children.12
Numerous studies have shown the harmful medical effects of energy insecurity on
children. Children living in energy-insecure households are more likely to be consid-
ered by their parents to be in fair or poor health, compared with children living in
energy-secure homes.6 Children in energy-insecure households are more likely to be
hospitalized,6 are more likely to be less than the 5th percentile weight for age,6 and are
at greater risk for nutritional growth delay.13 These children are also at risk for devel-
opmental delays as their rapidly developing brains are exposed to the harmful effects
of temperature instability, food insecurity, and stress hormones.10
Inadequate environmental temperature control can also exacerbate problems for
children with special health care needs and chronic conditions. Energy insecurity may
be particularly problematic for children with cold-sensitive conditions such as asthma
and eczema.14,15 Cold weather is also a known risk factor for vaso-occlusive pain crises
in children with sickle cell disease.16 Infants are also more likely to have central apnea
in extremely cold environmental conditions.17
Energy insecurity also increases the risk of serious unintentional injury. Children in
energy-insecure homes are more likely to be exposed to the deleterious effects of carbon
monoxide from space heaters.18,19 Fire risk is increased as families use their stoves to
heat their homes or to light darkened rooms.20 Other children die or sustain serious
injuries falling from windows as families let in the cool night air on hot summer days,
while lacking electricity for a fan or air conditioner.
At St. Christopher’s Hospital for Children, the outpatient practice serves more than
26,000 children, 85% of whom are on Medicaid. The racial/ethnic distribution of the
practice is 45% Latino, 40% African American, 5% White, and 5% Asian. The outpatient
general pediatric practice has 18 attending physicians, five nurse practitioners and 76
pediatric residents. In the fall of 2011 our team started a medical–legal partnership
(MLP)—the PhilaKids MLP (see www.medical-legalpartnership.org for details on MLPs
throughout the country) and one of our first objectives was to standardize provider
review of utility certifications to screen families for potential utility insecurity and to
increase the number of approved certifications.
The objective of this study was to determine whether a multimodal intervention to
screen families for energy insecurity within the MLP framework resulted in an increase
in the provision of certifications of medical need (COMN) for utility coverage in an
inner city academic primary care practice. These certificates, requested by families
struggling to pay their utility bills in full, help protect vulnerable families from utili-
ties shutoffs and in most states require a physician to certify that a child has a medical
condition that will worsen without energy, either gas or electric and sometimes water.
In our study we compared prior-year utility certification requests and approvals
(pre-intervention) with the post intervention year.

Methods
The mutimodal strategies for this intervention included trainings, development of a
MLP screener, and development of consensus criteria for COMN approvals.
 Taylor, Bernstein, Carroll, Oquendo, Peyton, and Pachter 679

In September 2011 our group of 18 attending physicians as well as five of our nurse
practitioners underwent intensive group trainings during mandatory staff meetings by
experts in the legal field, including our MLP attorneys, on the effects of energy inse-
curity on families, as well as on the laws surrounding utility certifications. An outside
legal expert in utility law from our local legal services agency met with our group as
well and addressed concerns that the providers had. Some concerns included the idea
of personal responsibility for outstanding utility bills; enabling continued debt forgive-
ness; and assumptions of faulty budgetary priorities of our families requesting COMN
were some of the recurring themes that were discussed. Shut-off protection by health
care providers ensures continued access to heat and electricity but does not erase the
family’s utility debt, which was a common misconception among providers. These
laws vary by state but most utility companies accept a utility COMN to delay shut offs.
Ultimately our group met on three separate occasions to agree upon and finalize the
COMN criteria and protocol.
Our practice also developed a 14-question MLP screener to be used to screen
families in the waiting room for legal issues that can affect the health and wellbeing
of children (available from the authors upon request). Questions cover income and
insurance supports, housing and utilities, education, legal status, and personal family
safety and stability. Both internal as well as external resources were identified to help
families with any of the positive screens. For example, if a parent identified domestic
violence as an issue, we referred to our hospital based domestic violence counselor to
help that family member. If health insurance issues were identified, the provider offered
a listing of community resources to help with health insurance as well as referral to
our social worker. The questionnaire also includes the following validated energy-
insecurity question:5 “Have you received a shut-off notice from any utility in the past
30 days?” as a screen.
In September 2011, our practice also agreed upon and developed standardized medi-
cal criteria for which home energy insecurity could cause specific untoward effects for
the children living in that home (Box 1). These criteria were developed as a group after
review of existing research on the effects of energy insecurity on children as well as by
group consensus with each medical condition. All providers in our practice agreed to use
these criteria and a policy was developed whereby medical providers would approve a
COMN if the child listed on the COMN met any of the criteria. We also collaboratively,
with our legal partners, developed a COMN that met our state utility regulations and
whose wording was acceptable to all providers who would approve a COMN.
Families who request a COMN (whether the provider approves or declines) or screen
positive for energy insecurity on the waiting-room questionnaire receive a packet of
information on community resources such as the low-income energy assistance pro-
gram (LIHEAP), utility services emergency funds, weatherization, Federal Emergency
Management Administration (FEMA) grants, and how to prevent utility shutoffs, as well
as information about free budgeting and financial counseling services. We also offer all
families who request a COMN an opportunity to speak with one of our social workers.
All COMNs are documented in a centralized log book by our executive secretary and
includes the name of the child, what type of utility request the family has made, and
whether the request was approved or declined. For this study we reviewed and totaled
680 Keeping the Heat on for Children’s Health

Box 1.
UTILITY MEDICAL CERTIFICATION CONDITIONS
1. All asthmatics
2. All children under 2 years of age (temperature instability and risk of serious
long-term adverse effects of utility insecurity)
3. OTHER CHRONIC Medical conditions such as:
Heart disease on cardiac medications
Diabetics
Immunodeficiency/and or on chronic immunosuppressive
Oncology Conditions
Sickle Cell Disease
4. Failure to Thrive (due to the documented decrease in weight during colder
months of children in utility insecure homes)
5. Special needs patients
6. Acute conditions that lead to temporary disabilities (for example pneumonia)

** If any child is far behind in their follow-up visits or health maintenance visits, give the chart
and utility form to social work, who will coordinate with scheduling to get an appointment
through a provider within a few days (depending on individual circumstances and potential
for immediate shut off) before signing the form.

the utility certifications between September, 2010, and August, 2012, and tabulated the
percentage that were approved and declined using Microsoft Excel spreadsheets. The
change in percent of approved requests following standardizing criteria and implement-
ing the screening questionnaire was evaluated with a chi square test.
The Drexel University Institutional Review Board approved our study.

Results
In the first year of the study, 294 families of 2,573 surveyed (11.4%), responded posi-
tively regarding energy insecurity, making energy the third most identified unmet need
after health insurance and food resources (Figure 1). Almost 10% of families attend-
ing for health maintenance visits filled out the MLP screener out of 27,000 total office
visits during that time. The MLP screener for this study was only provided to parents
in our resident continuity clinic that represents 50% of all health maintenance visits
at our institution.
Requests for utility medical certifications came directly from the family or by iden-
tification of energy insecurity from a positive screen through the survey. For the year
starting September 2010, 450 utility medical certifications were requested, of which only
52% were approved and signed by the health care provider. For the year ending August,
2012, 846 utility medical certifications were requested and 86% were approved (Figure
2). The 34% increase is statistically significant (Χ2 = 175.5, p < .0001) and represents a
67% improvement (34%/52%) in the acceptance rate.
Figure 1. Responses to a waiting-room social-determinants-of-health questionnaire (Nov 2010–Oct 2012, N = 2,573).
682 Keeping the Heat on for Children’s Health

Figure 2. Increases in approvals of certification of medical need requests over 2 years

following our multi-modal intervention.

Roughly the same number of office visits occurred during both time periods, sup-
porting the effectiveness of our intervention. Furthermore, there were no significant
variations in weather between the two study periods.²¹ This allowed 396 more families
to submit medical certifications to the utility company, representing an increase of
approvals by 65% (χ2 = 156.7, p< .0001) (Figure 2).

Discussion
Energy insecurity is one of several potentially remediable adverse material circumstances
that can affect the wellbeing of children. It rarely occurs in isolation. In our first year’s
experience with our MLP screener (Figure 1), 33% of families had more than two unmet
legal needs that had the potential to affect the health and/or safety of their children.
Our results demonstrate that our multimodal intervention to screen families for
energy insecurity within the MLP framework did result in a substantial increase in the
provision of certifications of medical need (COMN) for utility coverage. The implica-
tions of these results are that hundreds of families were protected from the potentially
damaging effects of utility shut-offs by our simple, reproducible intervention.
Our intervention also brought to light for providers in our practice, the adverse
health implications of energy insecurity as well as other material stressors on the families
we serve, as well as empowering providers to help families meet a basic critical need.
Lastly, it reaffirmed for us that screening for social determinants of health is a crucial
part of routine pediatric care.
National programs are available to help families with energy insecurity, including
the Department of Health and Human Services Office of Community Service (http://
 Taylor, Bernstein, Carroll, Oquendo, Peyton, and Pachter 683

www.acf.hhs.gov/programs/ocs/programs/liheap). Many communities have local pro-

grams to help families suffering from energy insecurity as well. Forty seven states offer
some form of utility shut-off protection, a guarantee of uninterrupted utility access for
vulnerable individuals and families. ²²
One limitation of this study is that different pediatric practices (and the providers
who work within them) may have criteria for approval of COMN different from ours.
Many practices also do not have a MLP screener like ours and may fail to identify
families who are unaware of the protection that may be available to their families to
prevent utility shut-offs. Additionally, this study was conducted over only one year’s
time; results may vary in subsequent years. Yet, between September 2012 and October
2013, we recorded 878 further requests and an approval rate of 89%, suggesting that
one year after the study, the project has not only been sustained but is growing.
This study also had a particular, mostly Medicaid, population as well as a specific
geography (northeastern United States) so results might not be generalizable to other
pediatric practices. Lastly, we have no data confirming that when a family obtains an
approved COMN, their children’s health or wellbeing improves. Future studies will
need to address this question. Although energy insecurity is one of many material
stressors for families, our results suggest that it can be screened for and addressed in
a busy urban practice, with a few simple reproducible steps.

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