An Innovative Approach to Medical-Legal Partnership: Unauthorized Practice of Law Reform as a Civil Justice Pathway in Patient Care

Medical Legal Partnerships: A Key Strategy for Addressing Social Determinants of Health

Medical Legal Partnerships (MLPs) offer a structural integrated intervention that could facilitate improvements in medical and psychosocial outcomes among people living with HIV (PLWH). Through legal aid, MLPs can ensure that patients are able to access HIV services in a culturally sensitive environment. We conducted organizational-level qualitative research rooted in grounded theory, consisting of key informant interviews with MLP providers (n = 19) and members of the Scientific Collaborative Board (SCB; n = 4), site visits to agencies with MLPs (n = 3), and meetings (n = 4) with members of the SCB. Four common themes were identified: (1) availability and accessibility of legal and social services support suggest improvements in health outcomes for PLWH; (2) observations and experiences reveal that MLPs have a positive impact on PLWH; (3) 3 intersecting continua of care exist within MLPs: HIV care continuum; legal continuum of care; and social services continuum; and (4) engagement in care through an MLP increases patient engagement and community participation. The MLP approach as a structural intervention has the potential to alleviate barriers to HIV/AIDS treatment and care and thus dramatically improve health outcomes among PLWH.

Medical-legal partnerships (MLPs) bring together medical professionals and lawyers to address social causes of health disparities, including access to adequate food, housing and income. Eighty-one MLPs offer legal services for patients whose basic needs are not being met. Besides providing legal help to patients and working on policy advocacy, MLPs educate residents (29 residency programs), health care providers (160 clinics and hospitals) and medical students (25 medical schools) about how social conditions affect health and screening for unmet basic needs, and how these needs can often be impacted by enforcing federal and state laws. These curricula include medical school courses, noon conferences, advocacy electives and CME courses. Four example programs are described in this paper. Established MLPs have changed knowledge (MLP | Boston-97% reported screening for two unmet needs), attitudes (Stanford reported reduced concern about making patients "nervous" with legal questions from 38% to 21%) and behavior (NY LegalHealth reported increasing resident referrals from 15% to 54%) after trainings. One developing MLP found doctors experienced difficulty addressing social issues (NJ LAMP-67% of residents felt uncomfortable). MLPs train residents, students and other health care providers to tackle socially caused health disparities.

Trauma patients are particularly vulnerable to the impact of preexisting social and legal determinants of health postinjury. Trauma patients have a wide range of legal needs, including housing, employment, debt, insurance coverage, and access to federal and state benefits. Legal support could provide vital assistance to address the social determinants of health for injured patients. Medical legal partnerships (MLPs) embed legal professionals within health care teams to improve health by addressing legal needs that affect health. Medical legal partnerships have a successful track record in oncology, human immunodeficiency virus/acquired immune deficiency syndrome, and pediatrics, but have been little used in trauma. We conducted a scoping review to describe the role of MLPs and their potential to improve health outcomes for patients with traumatic injuries. We found that MLPs use legal remedies to address a variety of social and structural conditions that could affect patient health across several patient populations, such as children with asthma and patients with cancer. Legal intervention can assist patients in obtaining stable and healthy housing, employment opportunities, debt relief, access to public benefits, and immigration assistance. Medical legal partnership structure varies across institutions. In some, MLP lawyers are employed directly by a health care institution. In others, MLPs function as partnerships between a health system and an external legal organization. Medical legal partnerships have been found to reduce hospital readmissions, increase treatment utilization by patients, decrease patient stress levels, and benefit health systems financially. This scoping review outlines the potential of MLPs to improve outcomes for injured patients. Establishing trauma-focused MLPs could be a feasible intervention for trauma centers around the country seeking to improve health outcomes and reduce disparities for injured patients.

Medical-legal partnerships (MLPs) are innovative, promising models that integrate legal service providers and medical professionals to prevent, detect, and address legal, social, and economic needs arising from social inequities that may negatively impact health. The COVID-19 pandemic impacted health care systems across the United States. MLP workflows and legal services were also interrupted by COVID-19 infection prevention and control measures such as no-visitor policies, social distancing, and the cancellation of non-emergent or routine health care services. We sought to describe the impact of COVID-19 on legal services provided by an MLP by exploring case types and services provided prior to the COVID-19 pandemic and during the pandemic. This is an examination of MLP services provided at a Midwestern academic medical center comparing data from three years prior to the pandemic (2017-2019) to three years during the pandemic (2020-2022). The MLP is a collaboration between the University of Nebraska Medical Center/Nebraska Medicine (an academic medical center) and Legal Aid of Nebraska and Iowa Legal Aid (legal service providers). Case data was drawn from individuals who were MLP patient-clients between 2017 and 2022. The main outcome measures were the number of cases and categories and types of legal services provided by the MLP. Consistent across time, we found that on average 494 cases were closed each year. Consumer/finance cases decreased significantly from pre-COVID-19 to during the pandemic, while family cases increased significantly during the pandemic. Cases related to income maintenance increased across time. Through the COVID-19 pandemic experience and understanding the case mix, MLPs and health care champions can be better prepared to understand some of the challenges that may occur and changes that may be necessary to better serve patient-clients during a public health emergency.

Social and structural determinants of health (SSDoH), including legal challenges related to housing, employment, and public benefits, often obstruct HIV care adherence and viral suppression. Medical-Legal Partnerships (MLPs) have emerged as a promising structural intervention to mitigate these barriers but are underutilized in HIV service settings. This feasibility and acceptability trial evaluated the impact of an MLP intervention compared to treatment-as-usual (TAU) among people with HIV (PWH) in Philadelphia, Pennsylvania. Two matched service organizations were randomized to MLP or TAU. The MLP included interdisciplinary training, standardized legal screening by peer navigators, and integration of legal services from a legal aid organization. A total of 202 participants were enrolled using a multi-pronged recruitment strategy that included venue-based outreach, online recruitment methods, and peer referrals. Kaplan-Meier survival analyses and logistic regressions assessed the time to viral suppression and likelihood of achieving undetectable viral load at 3 and 6 months. Participants in the MLP site achieved undetectable viral load faster than those in the TAU site in both conservative and robust survival analyses. At 3-month follow-up, MLP participants were significantly more likely to achieve viral suppression (OR = 2.42, 95% CI: 1.06, 5.49, p = .03). Although the 6-month odds ratio was reduced (OR = 2.28, 95% CI: 0.79, 6.57), it did not reach statistical significance. Findings suggest that MLPs can accelerate viral suppression among PWH by addressing health-harming legal needs. This study supports the integration of legal services into HIV care as a promising strategy to improve outcomes and reduce disparities.

To assess reach and identify facilitators of and barriers to the implementation of housing-focused medical-legal partnerships (MLPs) within a large healthcare system. In 2021, Kaiser Permanente (KP) launched the Health, Housing, and Justice (HHJ) Initiative to embed MLPs within five medical centers across four states. KP invested in the capacity of five publicly funded legal aid providers to collaborate with healthcare teams and focus on housing stability. This paper summarizes findings from a mixed-methods implementation evaluation conducted from 2021 to 2023 on staff and system capacity, operational facilitators and barriers, and lessons learned. Data sources included key informant interviews with healthcare and legal staff, surveys of social workers and care navigators, and administrative data on 857 legal referrals made by medical staff in 2022-2023 for housing-related legal support. Implementation characteristics and the rate of referrals varied across each of the six sites engaged in the multisite MLP. Attorneys reported that the MLP enabled access to legal resources for clients who typically would not have access. Most cases (82%) were addressed with fewer than 5 h of attorney time. Key implementation facilitators included clinical champions in the partnering medical team, staff training with a focus on knowledge of housing-related legal issues and MLP referral criteria, and existing social screening processes. Key implementation barriers were associated with information sharing, orienting legal partners to a complex medical system, and mismatches in service delivery areas between KP and the legal aid organizations. Embedding MLPs upstream in healthcare systems can enable access to legal resources for underserved clients. Attention to key implementation factors can support the spread of MLPs within other large healthcare systems.

402 Background: Engagement with legal teams after a cancer diagnosis —medical-legal partnerships—can identify, prevent, and resolve health-harming legal needs (HHLNs), such as housing instability, employment concerns, medical debt, etc. Cancer Legal Care (CLC) is a nonprofit providing free legal services to persons affected by cancer in Minnesota. Methods: We conducted a single-arm, mixed-methods pilot study to assess the feasibility and acceptability of delivering legal support, and preliminary efficacy in addressing HHLNs to 20 adults with advanced stage colorectal cancer. CLC staff conducted an initial screening visit and provided structured as well as personalized legal support over the 6-month study period. These services encompassed a wide range of topics such as employment rights, insurance coverage or claims denial, eligibility for Social Security disability, and estate planning. We collected patient-reported outcomes (assessing comfort with health-related tasks, financial toxicity, stress, coping, and self-esteem) at baseline, 3, and 6 months and conducted end-of-study interviews to explore participant experiences. Results: Of the 20 participants enrolled, the median age was 52 years, 12 (60%) were male, 12 (60%) had full or part-time employment, and 8 (40%) had a household annual income of < $25,000. Two patients were withdrawn due to death related to rapid disease progression. The study met pre-defined feasibility (90% of participants completing initial legal checkup visit, 90% remaining engaged at 3 months, 80% received at least 1 legal service) and acceptability (81% of participants recommended the intervention to others) benchmarks. For the 18 participants completing the initial visit, the visit lasted a median of 45 minutes, and 61% had self-identified HHLNs. Using a standard issue-spotting checklist, CLC attorneys identified additional HHLNs for 72% of participants, with a median of 3 total HHLNs per participant. The percentage of participants with moderate/severe financial hardship was high at baseline (70%) and decreased marginally to 63% at 6 months. Measures of stress, coping, and self-esteem remained relatively unchanged. Over the study period, participants expressed greater comfort with tasks such as addressing unexplained bills, guardianship planning, and ensuring insurance coverage. Participants endorsed high satisfaction with interpersonal relationships with CLC staff, felt empowered and supported, and suggested including their care partners in future work. Conclusions: Proactive legal care to address HHLNs through a medical-legal partnership was feasible, acceptable, and valued by patients with advanced colorectal cancer. Despite no requirement for baseline legal need, HHLNs were prevalent and addressable. This work provides essential data on the population, intervention, and outcomes to focus on in future studies assessing medical-legal partnerships. Clinical trial information: NCT06475664 .

Research, policy and practice in the field of interprofessional collaboration have focused on how medical, nursing, allied health and social care practitioners work together to positively impact patient care. This paper extends conceptual thinking about interprofessional practice by focusing on lawyers as part of the interprofessional mix. This attention is prompted by medical–legal partnerships (MLPs), a service model by which lawyers join health care settings to assist patients with unmet, and often health-harming, legal needs. MLPs are present in around 450 hospitals and other health care sites across the United States and the model has spread to other countries, including Australia, the United Kingdom and Canada. However, enthusiasm for the MLP model is not yet matched by good evidence on how, when and for whom the model works. Interprofessional scholars contend that imprecise terminology and poor conceptualization of interprofessional arrangements hinder high-quality research and evaluation. In response to their critiques, this paper formulates a stepwise conceptual framework to guide the design, implementation and study of interprofessional arrangements that connect health, social care and legal practitioners. This framework draws on findings from national surveys of MLP initiatives in several countries and adapts several key conceptual frameworks that have been developed from systematic reviews of interprofessional working in primary health care. These conceptual frameworks are valuable because they promote clarity about different modes of interprofessional working and characterize the factors at macro (policy, funding), meso (organizational) and micro (practitioner, patient) levels that help or hinder professionals from different disciplines in working together. The paper considers factors at these three levels that require particular attention when lawyers join health care settings and proposes questions for future research in this emerging area.

Medical-legal partnerships (MLP)—collaborations between legal professionals and health care providers that help patients address health-harming civil legal problems, such as safe housing and access to veterans benefits—have been implemented at several Veterans Affairs (VA) medical centers to serve low-income veterans with mental illness or other health conditions. First, we describe the MLP framework and give an overview of the current state of MLPs at VA facilities (VA MLPs). Second, we discuss how VA MLPs help veterans address common legal problems that can affect health and well-being. Third, we provide windows into the inner workings of four VA MLP sites in Maine, California, and New York that serve different segments of the veteran population—homeless, women, and senior veterans—at different types of VA healthcare sites, like VA medical centers and Vet Centers. Fourth, we present data on the characteristics of veterans that participate in MLPs and on the health benefits that flow from this interdisciplinary service model. We conclude by discussing funding mechanisms for VA MLPs, including recent congressional momentum for federal government funding for VA MLPs, and the need for additional data gathering and outcome measurement to further assess and refine this innovative service model.

PURPOSEEngagement with legal teams after a cancer diagnosis—medical-legal partnerships (MLPs)—can identify, prevent, and resolve health-harming legal needs (HHLNs). Cancer Legal Care (CLC) is a nonprofit providing free legal services to persons affected by cancer in Minnesota. We sought to conduct a pilot study of delivering proactive and free legal support through CLC.METHODSWe conducted a single-arm, mixed-methods pilot study to assess the feasibility and acceptability of delivering legal support, and preliminary efficacy in addressing HHLNs to 20 adults with advanced-stage colorectal cancer. CLC staff conducted an initial screening visit, crafted an individualized plan, and provided structured as well as personalized legal support over the 6-month study period. We collected patient-reported outcomes (assessing comfort with health-related tasks, financial toxicity, stress, coping, and self-esteem) at baseline, 3 months, and 6 months, and conducted end-of-study interviews to explore participant experiences.RESULTSThe study met predefined feasibility (90% of participants completed initial screening visit, 90% remained engaged, 80% completed the study) and acceptability (81% of participants recommended the intervention to others) benchmarks. The initial legal checkup visit lasted a median of 45 minutes, 61% self-identified HHLNs, and CLC attorneys identified additional HHLNs for 72%, with median 3 HHLNs per participant. On the basis of participant preference, 100% of visits were virtual, with attorneys spending a median 3.5 hours per participant, often also supporting individuals with administrative burdens and providing emotional support. After the 6-month study period, participants expressed greater comfort with tasks such as addressing unexplained bills, guardianship planning, and ensuring insurance coverage compared with baseline. Participants noted very high satisfaction with the interpersonal relationships with CLC staff, felt empowered and supported, and suggested including informal care partners in future work.CONCLUSIONProactive legal care to address HHLNs through a MLP was feasible, acceptable, and valued by patients. Despite no requirement for baseline legal need, HHLNs were prevalent and addressable. This work underscores the importance of further study on how interdisciplinary teams can best deliver sociolegal care to persons with cancer.

The Impact of a Pediatric Medical-Legal Partnership on Pediatric Providers: A Qualitative Study.

Context:Unmet legal needs can exacerbate health disparities and contribute to a lack of adherence to treatment plans and medical recommendations for care. Medical legal partnerships (MLPs) are integrated health care and legal aid interventions offered by many health systems in the United States. Although much research has been published regarding the success of MLPs with specific patient groups, there is a gap in literature regarding the nature of MLPs in a more general, at-risk patient population.Objective:We aimed to better understand specific patient characteristics and health outcomes associated with different iHELP legal needs.Design:This is a cross-sectional study of patients who were enrolled in the Delaware MLP (DMLP) from November 2018 to June 2020 (N = 212).Setting:The DMLP is a collaboration between ChristianaCare, a Mid-Atlantic health system, and the Community Legal Aid Society, Inc (CLASI).Participants:Patients must be adults (ie, 18 years or older), below 200% of the federal poverty level (eg, ≤$53 000 for a household of 4 as of 2021), have at least one qualifying legal need, and live in the state.Intervention:The DMLP is designed to address unmet legal needs that fall under a framework called iHELP. iHELP legal domains are income and insurance (i), housing and utilities (H), education and employment (E), legal status (L), and personal and family stability (P).Main Outcome Measures:Outcomes of interest were iHELP legal needs, patient demographics, perceived stress and mental and physical health–related quality of life, comorbidities, and health care utilization.Results:Housing and utilities (46.2%) and income support (41.5%) were the highest reported legal needs. Perceived stress scores were significantly higher for those with income needs (P = .01) as well as those with housing and utilities needs (P = .01).Conclusions:MLP programs offer a value-added service that can address unmet legal needs in vulnerable, at-risk patients.

Medical-legal partnerships (MLP) are a model in which medical and legal practitioners are co-located and work together to support the health and wellbeing of individuals by identifying and resolving legal issues that impact patients' health and wellbeing. The aim of this article is to analyse the benefits of this model, which has proliferated in the USA, and its applicability in the context of rural and remote Australia. This review was undertaken with three research questions in mind: What is an MLP? Is service provision for individuals with mental health concerns being adequately addressed by current service models particularly in the rural context? Are MLPs a service delivery channel that would benefit individuals experiencing mental health issues? The combined searches from all EBSCO Host databases resulted in 462 citations. This search aggregated academic journals, newspapers, book reviews, magazines and trade publications. After several reviews 38 papers were selected for the final review based on their relevance to this review question: How do MLPs support mental health providers and legal service providers in the development of a coordinated approach to supporting mental health clients' legal needs in regional and rural Australia? There is considerable merit in pursuing the development of MLPs in rural and remote Australia particularly as individuals living in rural and remote areas have far fewer opportunities to access support services than those people living in regional and metropolitan locations. MLPS are important channels of service delivery to assist in early invention of legal problems that can exacerbate mental health problems.

According to the Legal Services Corporation, each year, 56% of older adults have at least one civil legal problem yet 87% receive inadequate or no professional legal help for their civil legal problems. Unmet legal needs can have cascading catastrophic effects on the health and well-being of older adults. To address this, we took the innovative approach of creating a Medical-Legal Partnership (MLP) within a community based social service agency on aging. MLPs have been successful by addressing the social determinates of health. However, previous studies have not investigated MLPs aimed at older adults. We used a single arm, pretest-posttest design to investigate the effects and feasibility of providing legal services to community dwelling older adults. The MLP served over 88 clients referred both internally from the agency as well as external partners. The participants had a mean age of 73, (age range 45-98, n=88), were 60% female. African Americans represent 9% of the clients, 7% are Hispanic/Latino and 74% Caucasian. Additionally, 5% were veterans. 52% of clients were at or below the Federal Poverty line at baseline. 50% of clients reported greater financial stability as a result of legal services. 75% reported improved health of between 1 and 3 points on a 5 point likert scale (pre-test=2.75; post-test 3.9 p<.01). This pilot project demonstrates a successful intervention to work across professional silos coordinating lawyers, medical providers and social workers to better meet the legal needs of older adults by creating MLPs in social service agencies to support their well-being.