Medical-legal Partnerships Research Articles

INTRODUCTION: Medical-Legal Partnerships: Equity, Evolution, and Evaluation.

The COVID-19 pandemic laid bare systemic inequities shaped by social determinants of health (SDoH). Public health agencies, legislators, health systems, and community organizations took notice, and there is currently unprecedented interest in identifying and implementing programs to address SDoH. This special issue focuses on the role of medical-legal partnerships (MLPs) in addressing SDoH and racial and social inequities, as well as the need to support these efforts with evidence-based research, data, and meaningful partnerships and funding.

A New Kind of Academic MLP: Addressing Clients' Criminal Legal Needs to Promote Health Justice and Reduce Mass Incarceration.

This article describes a new type of medical-legal partnership (MLP) that targets the health and justice concerns of people enmeshed in the U.S criminal justice system: a partnership between clinicians who care for people with criminal system involvement and public defenders. This partnership offers an opportunity to not only improve patient health outcomes but also to facilitate less punitive court dispositions, such as jointly advocating for community-based rehabilitation andtreatment rather than incarceration.

Leveraging Academic-Medical Legal Partnerships to Advance Health Justice.

Unmet legal needs contribute to housing, income, and food insecurity, along with other conditions that harm health and drive health inequity. Addressing health injustice requires new tools for the next generations of lawyers, doctors, and other healthcare professionals. An interprofessional group of co-authors argue that law and medical schools and other university partners should develop and cultivate Academic Medical-Legal Partnerships (A-MLPs), which are uniquely positioned to leverage service, education, and research resources, to advance health justice.

Camden Coalition Medical-Legal Partnership: Year One Analysis of Civil + Criminal MLP Model in Addiction Medicine Setting.

In 2022, the Camden Coalition Medical-Legal Partnership began providing civil and criminal legal services to substance use disorder patients at Cooper University Health Care's Center for Healing. This paper discusses early findings from the program's first year on the efficacy of the provision of criminal-legal representation, which is uncommon among MLPs and critical for this patient population. The paper concludes with takeaways for other programs providing legal services in an addiction medicine setting.

AN INNOVATIVE MEDICAL LEGAL PARTNERSHIP TO SERVE COMMUNITY-DWELLING OLDER ADULTS

Abstract 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.

Integrating legal services to improve behavioral health, a challenge met from a different angle.

The United States' current healthcare delivery system is not prepared to address the expanding behavioral health (BH) crisis without treatment of upstream social determinants that contribute to downstream BH exacerbations. Medical Legal Partnerships (MLP) utilize lessons from integrated BH to create efficiencies, augment the reach of the current BH workforce, network community resources, and likely provide BH prevention at the family unit. Payment policy changes are needed, however, to provide sustainable access to these services. The current surge of federal and state funding for BH care needs may provide the policy window necessary to sustainably fund MLP lawyers as a novel, high-impact, professional on the integrated healthcare team. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Medical-legal partnerships can mitigate climate health impacts on the underserved.

To the Editor: Climate change has been referred to as a “wicked problem par excellence” because it constitutes a “series of linked problems that cannot be solved (or even diagnosed) in isolation.”1 Furthermore, climate impacts those least able to adapt, disproportionately affecting “the most vulnerable, including among children, older populations, ethnic minorities, poorer communities, and those with underlying health problems.”2 Clinicians must be willing to work with allies outside of the medical arena to address climate change with a health equity lens. We, a family physician, and a legal aid lawyer in Florida, believe that Medical-Legal Partnerships (MLPs) represent an underappreciated model for successful cross-disciplinary collaboration that can mitigate climate impacts on underserved populations. We call for more clinicians concerned about climate change to consider working with MLPs, and for more interdisciplinary research3 into MLPs and their ability to deliver meaningful improvements in climate resiliency. Climate effects on health can be exacerbated by inequality, such as increased precipitation contributing to incidence of mould in substandard housing that worsens a child’s asthma.4 Landlords may ignore the requests from low-income tenants to fix leaky pipes that cause the mould, rendering the child sicker and missing school more frequently. Many patients including immigrant populations5 may be unaware of their legal rights to have housing and sanitary codes be enforced and can benefit from a lawyer to advocate on their behalf. Other examples of climate vulnerabilities include unsafe working conditions or substandard educational environments.

Implementing the Partnership Assessment Tool for Health to Assess and Strengthen Cross-sector Partnerships: Lessons from a Federally Qualified Health Center.

La Clínica del Pueblo (LCDP), a federally qualified health center that serves the low-income, Latino/a/x community in D.C., used the Partnership Assessment Tool for Health (PATH) to assess two cross-sector partnerships: a medical-legal partnership with a legal services agency and a five-year partnership with FRESHFARM focused on alleviating food insecurity.

386 Common Health-Harming Legal Needs of Patients Seeking Care in the Emergency Department: Support for Emergency Department-Based Medical-Legal Partnerships

An individual’s health and health outcomes are intimately linked to social and environmental factors. Addressing these underlying factors can positively impact the health of an individual and community. Medical-Legal Partnerships (MLPs) have been shown to positively impact health outcomes and target social determinants of health (SDoH) by providing referrals to legal partners to address health harming legal needs that, if unmet, can lead to adverse health outcomes. MLPs are associated with decreased emergency department (ED) visits, decreased hospitalizations, improved health outcomes, increased routine primary care visits, and are significant cost savings to health systems.

Medical-Legal Partnerships Facilitate Patient-Provider Cost of Care Conversations: A Multisite Qualitative Study in the U.S.

This study examines the impact of medical-legal partnerships on facilitating and managing outcomes of patient-provider cost of care conversations. We conducted 96 semi-structured interviews with 18 patients and 78 medical-legal partnership personnel from 10 states between March and November of 2020. The presence of legal staff helped strengthen interdisciplinary collaborations and build confidence among providers around addressing health-harming legal needs through effective cost of care conversations. Medical-legal partnerships with well-established provider training opportunities reported effective cost of care conversations, improved patient outcomes, and increased return on investment for health systems. Lack of time, knowledge, and training were identified as barriers to clinicians engaging in cost of care conversations. Positive patient outcomes included improved access to public benefits, health benefits, financial benefits, special education services, stable housing, and food. Medical-legal partnerships facilitate effective patient-provider cost of care conversations that improve patients’ medical, legal, and social service outcomes.

Better Together: A Descriptive Analysis of a Medical-Legal Partnership in Western North Carolina.

BACKGROUND The medical-legal partnership (MLP) is an innovative and proven-effective approach to addressing health-harming social needs that have legal remedies (e.g., housing concerns, intimate partner violence). Yet, few MLPs exist within outpatient primary care practices and in rural settings.METHODS We describe the impact of an MLP between Pisgah Legal Services and the Mountain Area Health Education Center, which serves rural North Carolina counties, over a 24-month period.RESULTS Overall, 629 cases were referred to the MLP. Three hundred seventy cases were opened and investigated by a lawyer. Three hundred sixty-four cases were closed (i.e., a resolution was reached), yielding 808 outcomes, with an average of 2.2 outcomes per case. Domestic violence/family law and housing were the main socio-legal concerns addressed by the MLP. Eighty-six (24%) of cases included at least 1 representation outcome; the success rate in representation cases was 90%.LIMITATIONS We did not examine the impact of the MLP on patient health outcomes, nor did we have comparative outcomes data for similar individuals with unmet social needs but who did not receive MLP services.CONCLUSIONS The MLP was successful in helping to address multiple social needs faced by patients that contribute to worse health status and outcomes. Monetary benefits to patients were $309,902 plus an additional $174,733 from tax returns and the Earned Income Tax Credit. The MLP lawyer provided education and training to support clinicians, learners, and community organizations. These data highlight the benefits of collaboration between health professionals and lawyers in advancing equity by addressing unmet social needs.

Legal Needs, Health, and Health Care Utilization Among Patients Participating in the Delaware Medical Legal Partnership.

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.

Improving Access to Legal Gender Affirmation for Transgender Women Involved in the Criminal-Legal System.

Transgender women of color experience interlocking systems of oppression rooted in racism and transphobia, which fuel economic vulnerability and overrepresentation in the criminal-legal system. Legal gender affirmation, which refers to changing one's name and gender marker on official documents, has the potential to mitigate these issues by improving access to employment, housing, education, health care, and social services. These services are particularly important for transgender women of color with criminal records, a history of incarceration, or other legal infractions; however, 23 states have policies that restrict access to legal gender affirmation for these individuals. Alongside eliminating restrictive policies to obtain legal gender affirmation, medical-legal partnerships in these states may address recidivism and health inequities among transgender women of color.

Medical-legal partnerships: An integrated approach to advance health equity and improve health outcomes for people living with HIV.

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.

#21 High Caregiver Adverse Childhood Experiences are Associated with Influenza and COVID-19 Vaccination Acceptance in One Pediatric Primary Care Site

BackgroundVaccine hesitancy is complex, ranging from safety concerns to decisions built atop disinformation and medical mistrust. Though distrust towards healthcare providers has been described in those with adverse childhood experiences (ACEs), studies have not assessed for links between caregiver ACEs and pediatric vaccine refusal. We sought to determine the association between caregiver ACEs and caregiver decisions to immunize their child with influenza and COVID-19 vaccines.MethodThis was a cross-sectional study of caregivers of patients >6 months at one pediatric primary care center. Caregivers completed a 19-question survey to determine ACE score, influenza vaccine acceptance and beliefs (adapted from a CDC-validated survey), and intention to accept the COVID-19 vaccine for their children. Demographic characteristics, social risk factors (e.g. housing and food insecurity), social work notes or medical legal partnership referrals within 3 days of a clinic visit, and vaccination data of the children present with each caregiver were extracted from the electronic medical record. Statistical analyses included chi-square tests for categorical variables and t-tests for age. The chi-square test was used to determine the association between caregiver ACEs (high versus low) and demographic, social risk factors and vaccination acceptance, and the two-sample t-test was used to test for differences in child age.ResultsA total of 234 caregivers participated, representing 276 patients (mean age of 5.9 years, 52% male). Of participating caregivers, 24% (n = 56) had high ACEs (score ≥ 4) and 38% (n = 88) accepted influenza vaccination for their child in 2021. Of those with high ACEs, 51% accepted influenza vaccination for their child compared to 34% with low ACEs (p = 0.03). Those with high ACEs also had more positive attitudes toward influenza vaccine safety and efficacy (p=0.01). Intention to vaccinate children with COVID-19 vaccine also varied by caregiver ACE score (high ACEs: 40%; low ACEs: 24%; p=0.03). Insurance type, a positive social risk screen, and social work consult were not associated with ACEs (Table 1).ConclusionInfluenza vaccination rates and intention to vaccinate children with the COVID-19 vaccine differed between caregivers with high and low ACEs – those with more ACEs were more likely to vaccinate. Further studies assessing the role of caregiver ACEs on vaccine decision-making is warranted.

The Case for Integrating Medical-Legal Partnerships Into Trauma Care.

Medical-legal needs are health-harming adverse social conditions with a legal remedy. Medical-legal partnerships in primary care settings have been proposed to address these needs for at-risk patients already seeking medical care. Our hypothesis is that trauma patients represent a unique population that may be more likely to have baseline medical-legal needs. A trauma-specific medical-legal needs survey was developed. Adult trauma patients who were able to give consent and were admitted to our urban Level I hospital were surveyed. Medical-legal needs were tabulated from the surveys. Those patients in the top decile of medical-legal needs were categorized as having a High Burden of medical-legal needs. Multivariate logistic regression was used to identify those independent risk factors for having a High Burden of medical-legal needs. A total of 566 participants completed the survey (78.2% response rate). The mean number of medical-legal needs for our population was 2.5 (SD=3.1). 73% of our respondents had at least one medical-legal need. The most common needs were Housing (n=229, 40%) and Education/Employment (n=223, 39%). Older age (aOR=3.01, 95% CI 1.2-8.1, P=0.02), being separated or divorced (aOR=4.25, 95% CI 1.2-14.0, P=0.02), self perceived poor health (aOR=8.4, 95% CI 2.61-26.86, P<0.001), penetrating mechanism of injury (aOR=2.52, 95% CI 1.22-5.2, P=0.01), and having been admitted to the hospital for a longer period of time (aOR=5.48, 95% CI 1.55-19.4, P=0.008) were all independently associated with a High Burden of medical-legal needs. Trauma patients have a high baseline burden of medical-legal needs. Medical-legal partnerships embedded in trauma teams may offer an innovative strategy to help address long-term health outcomes in a highly vulnerable population that would not otherwise have contact with the healthcare system.

Improving Health Outcomes in Vulnerable Populations: The Medical-Legal Partnership—Colorado's Experience

Medical-legal partnerships (MLPs) add legal professionals, trained specifically to tackle health-related social needs (HRSN), to the health care team. We evaluated the impact on health outcomes and health care utilization of a MLP housed in a large federally qualified health center in Colorado (MLP-CO). Clients screened for I-HELP (Income, Housing, Employment, Legal status, Personal stability) needs were surveyed at baseline and six months post-enrollment. Reasons for legal aid were legal immigration status (46.5%), income (30.8%), personal/family stability (14.8%), housing (4.8%), and education (1.2%). Overall, 61.4% attributed great/moderate improvements in their health care experience to the MLP-CO. Statistically significant improvements were noted for days with poor physical/mental health, and feelings of stress/worry. There was a reduction in emergency department visits, hospitalization days, and missed appointments, but only the latter was statistically significant. In conclusion, MLPs are a promising innovation to achieve the Institute for Healthcare Improvement's quadruple aim.

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

Medical-Legal Partnerships (MLPs) integrate medical and legal care to address prevalent health-harming legal needs (HHLN) among socioeconomically marginalized populations. MLPs address a diverse array of social determinants of health (SDOH) and have been shown to positively impact children's health. Less is known, however, about how MLPs affect health care providers. MLPs may affect child health by changing clinical practice and provider behavior, and transforming providers' relationships with their patients and patients' families. Examining and understanding how MLPs affect providers is thus critical to elucidating how MLPs may ultimately impact child health. We examined one pediatric MLP at an academic medical center in New Haven, Connecticut. We conducted semi-structured interviews with 20 pediatric providers who had engaged with the MLP and 20 parents/guardians who had interacted with the MLP. We analyzed the qualitative data using inductive coding, primarily drawing upon provider interviews. The MLP affected providers in five major ways. The MLP 1) improved provider awareness of SDOH and HHLN, 2) expanded provider perceptions of their role and responsibilities as clinicians, 3) improved provider efficacy in addressing SDOH and HHLN, 4) empowered providers to engage in systemic advocacy, and 5) improved providers' relationships with patients' families. Our study identifies multiple ways that a pediatric MLP affects providers. Our findings suggest that MLPs can improve patient and population health by equipping providers with the knowledge and tools needed to assist patients with HHLN and SDOH, improving provider-family relationships, and encouraging providers to engage in systemic and institutional advocacy.

Reductions In Hospitalizations Among Children Referred To A Primary Care-Based Medical-Legal Partnership.

Medical-legal partnerships integrate legal advocates into health care settings to address health-related social needs. However, their effect on health outcomes is unclear. This retrospective cohort study examined the effect of referral to a medical-legal partnership on hospitalization rates among urban, low-income children in Greater Cincinnati, Ohio, between 2012 and 2017. We compared 2,203 children referred to a pediatric primary care-based medical-legal partnership with 100 randomly selected control cohorts drawn from 34,235 children seen concurrently but not referred. We found that the median predicted hospitalization rate for children in the year after referral was 37.9percent lower if children received the legal intervention than if they did not. We suspect that this decrease in hospitalizations was driven by the ability of legal advocates to address acute legal needs (for example, threat of eviction and public benefit denial) and, when possible, to confront root causes of ill health (for example, unhealthy housing conditions). Interventions such as those provided through a medical-legal partnership may be important components of integrated, value-based service delivery models.

Increasing LGBTQ+ Access to Legal Services via Medical-Legal Partnerships.

This Note details and proposes a solution to the deficit in access to justice and to care faced by the LGBTQ+ community due to historical and ongoing homophobia and transphobia in both the legal and medical fields. The proposed solution is the integration of medical-legal partnerships ("MLPs") into LGBTQ+ resource organizations. These organizations already serve and have the trust of the queer community, which lowers one barrier to access medical and legal services for the LGBTQ+ community: mistrust and negative past experiences. MLPs are the ideal solution to this problem because they would not only allow LGBTQ+ individuals to access medical and legal services, but to receive holistic services that account for their personal circumstances as well as their physical health. Underlying this premise is the concept of social determinants of health, which are environmental and social factors that create systemic roadblocks to wellness. By creating an integrated MLP, professionals can address these social determinants head on and remedy the underlying causes of poor health. This is especially important for LGBTQ+ people whose minoritized identities often lead them to have multiple negative social determinants of health. The integration of MLPs into LGBTQ+ resource organizations would allow queer individuals to get the care they need-not just physically, but socially and environmentally.