Medical-legal Partnerships Research Articles

How medical-legal partnerships help address the social determinants of mental health

Conditions related to where you are born, live, learn, work, and age—the social determinants of health—account for more than half of overall health and well-being. Problems in these areas include food insecurity, unsafe and unaffordable housing, family violence and instability, employment discrimination, inadequate education, and lack of access to health insurance and care. Such problems negatively affect physical and mental health and contribute to the health disparities that disproportionately impact low-income and marginalized communities of color. Housing instability and homelessness, for example, can increase the risk of chronic illness, infectious disease, and death, and also have a profound impact on mental health, creating or exacerbating psychological distress, anxiety, and depression. Research indicates that even years after an eviction, mothers are more likely to be depressed and report feeling increased material hardship and parental stress. Many underlying social determinants of health implicate or raise legal issues that require advocacy to overcome. One patient might skip critical medical or psychiatric appointments because he is unaware of his legal rights in the workplace and is afraid of losing his job if he misses work. Another may suffer from severe depression even with significant counseling and medication management because of anxiety and stress associated with overwhelming debt or the threat of imminent family violence. Such “health-harming legal needs” create barriers to achieving good health and are major contributors to health disparities. Although nurses and other healthcare providers understand the significant impact social determinants have on health, they do not always draw connections between those determinants and the legal issues they raise. Nor do they generally think of law as a tool that can be prescribed to improve a patient's health and well-being. Medical Legal Partnership (MLP) is an innovative healthcare model that fills that gap by bringing doctors, nurses, and other health professionals together with lawyers to address unmet legal needs that negatively impact health and well-being.

Thinking Outside the Silos: Information Sharing in Medical–Legal Partnerships

Medical–legal partnerships (MLPs) allow providers to address patients’ health-harming legal needs through partnerships with lawyers. MLPs are most successful in addressing the complex needs of vulnerable populations when clinicians, social workers, and other care team members regularly communicate with the MLP lawyer. Privacy laws and professional rules of conduct governing patient/client confidentiality, however, potentially hinder this exchange of patient-client information. MLP attorneys may be reluctant to share relevant information about a client with the medical partner for fear that doing so would breach client confidentiality or result in an ill-advised waiver of attorney–client privilege. Similarly, privacy concerns may lead providers to limit MLP attorneys’ access to patients’ medical information. Drawing on the real-world experiences of MLP professionals, this article explores whether legal and ethical obligations impede the sharing of patient-client information between MLPs’ medical and legal partners. Our research indicates that at present patient/client confidentiality rules generally do not pose a significant barrier to doing so. However, current legal and professional standards may frustrate emerging advanced care coordination models that pair MLPs with care teams that comprehensively address a broad range of social, economic, and behavioral health needs. We therefore recommend continued monitoring and discussion of the issue.

215 Understanding and Improving Population Health from the Emergency Department Through Medical-Legal Partnerships

215 Understanding and Improving Population Health from the Emergency Department Through Medical-Legal Partnerships

A Systematic Review of Medical-Legal Partnerships Serving Immigrant Communities in the United States.

The medical-legal partnership addresses social and political determinants of health. Yet, relatively little is known about best practices for these two service providers collaborating to deliver integrated services, particularly to im/migrant communities. To investigate evaluations of existing medical-legal partnerships in order to understand how they function together, what they provide, and how they define and deliver equitable, integrated care. We searched five databases (PubMed, Medline, Web of Science, HeinOnline, and Nexus Uni) using search terms related to “medical-legal partnerships”, “migrants”, and “United States”. We systematically evaluated ten themes related to how medical and legal teams interacted, were situated, organized, and who they served. Articles were published in English between 2010 and 2019; required discussion about a direct partnership between medical and legal professionals; and focused on providing clinical care and legal services to im/migrant populations. Eighteen articles met our inclusion criteria. The most common form of partnership was a model in which legal clinics make regular referrals to medical clinics, although the reverse was also common. Most services were not co-located. Partnerships often engaged in advocacy work, provided translation services, and referred clients to non-medical providers and legal services. This review demonstrates the benefits of a legal-medical partnership, such as enhancing documentation and care for im/migrants and facilitating a greater attention to political determinants of health. Yet, this review demonstrates that, despite the increasing salience of such partnership, few have written up their lessons learned and best practices.Electronic supplementary materialThe online version of this article (10.1007/s10903-020-01088-1) contains supplementary material, which is available to authorized users.

Medical-Legal Partnerships: Supporting the Legal Needs of Women in Their Perinatal Care [16F

INTRODUCTION: Medical-legal partnership (MLP) aims to address the numerous social determinants of health. In July 2018 we added an MLP service for pregnant and postpartum women in an underserved safety net hospital in Los Angeles County. Here, we examine the prevalence of legal needs ascertained by self-administered legal needs assessments and the conversion rate of referrals to legal cases. METHODS: The MLP service was implemented as part of the continuum of clinical care. Referrals are tracked as part of case management. Review of self-administered screenings provided our referral screen-positive rates. Of those clients referred, a case conversion rate was calculated when legal cases were generated. RESULTS: Legal needs were identified in the following areas: family law (27%), employment (25%), housing (11%), and immigration (11%). A 72% screen positive rate (79 of 110) was found when clinic staff (provider, nursing, or social worker) directly referred to the MLP. Legal advice was often provided to those who screened positive (64%). Conversion rates were also high with 58% of those referred for formal legal action resulting in open cases (46 of 79 referred). CONCLUSION: Legal needs, such as assistance with employment law for pregnancy related disability accommodations, may have direct impacts on perinatal outcomes. Incorporating the MLP in resource-limited clinical settings can be achieved by including stakeholders in its development. The high conversion rate of referrals to cases illustrates the ability of the medical staff and patients to effectively identify legal needs and then partner with legal aid groups to address these concerns.

Reducing the Justice Gap and Improving Health through Medical–Legal Partnerships

A recent study by the Legal Services Corporation reported that 71% of low-income U.S. households experienced at least one civil legal problem in 2017 and that 86% of these needs went unresolved. In this article, we examine the potential for medical–legal partnerships (MLPs) to address this “justice gap.” We draw on qualitative interviews, conducted with 20 parents and guardians in one pediatric MLP, to identify barriers to legal access and examine how the MLP model may uniquely address these barriers. Our data suggest that MLPs can (1) identify legal needs and create awareness of legal rights among individuals who would not have sought legal services; (2) create an access point for legal services; (3) improve access to legal advice and brief intervention; (4) support ongoing relationships between patients and lawyers that allow for the timely identification of subsequent legal needs; (5) foster trust and confidence in the legal system; and (6) address affordability concerns. These findings suggest that by improving access to justice, MLPs can address critical social and legal determinants of health and, ultimately, advance health equity.

Special Education Disparities Are Social Determinants of Health: A Role For Medical-Legal Partnerships.

Education is a key social determinant of health. The federal Individuals with Disabilities Education Act (IDEA) purportedly affords children the right to a free and appropriate education. Yet, racial, ethnic, and economic disparities exist regarding appropriate identification and classification of children with needs for special education, and access to services. This article first highlights gaps and disparities in special educational services, and their structural linkage to poverty. The second section describe the first years of a medical-legal collaboration between a University Center of Excellence in Developmental Disabilities (UCEDD) and Fordham University, focused on special education. The collaboration's interdisciplinary training activities increased practical knowledge for law students and UCEDD clinicians. A legal clinic for UCEDD families enabled Fordham students to apply their skills. Because social determinants of health often lie beyond the medical domain, interdisciplinary collaborations are needed to remediate them.

An Interprofessional Approach to Teaching Advocacy Skills: Lessons from an Academic Medical-Legal Partnership

Medical students and educators recognize that preparing the next generation of health leaders to address seemingly intractable problems like health disparities should include advocacy training. Opportunities to acquire the knowledge and skills needed to effectively advocate at the policy level to promote systems-, community-, and population-level solutions are a critical component of such training. But formal advocacy training programs that develop and measure such skills are scarce. Even less common are interprofessional advocacy training programs that include legal and policy experts to help medical students learn such skills. This 2016–2017 pilot study started with a legislative advocacy training program for preclinical medical students that was designed to prepare them to meet with Capitol Hill representatives about a health justice issue. The pilot assessed the impact of adding an interprofessional education (IPE) dimension to the program, which in this case involved engaging law faculty and students to help the medical students understand and navigate the federal legislative process and prepare for their meetings. Results from the pilot suggest that adding law and policy experts to advocacy-focused training programs can improve medical students’ advocacy knowledge and skills and increase their professional identity as advocates.

Examining the impact of medical legal partnerships in improving outcomes on the HIV care continuum: rationale, design and methods

BackgroundOver the past two decades, we have seen a nationwide increase in the use of medical-legal partnerships (MLPs) to address health disparities affecting vulnerable populations. These partnerships increase medical teams’ capacity to address social and environmental threats to patients’ health, such as unsafe housing conditions, through partnership with legal professionals. Despite expansions in the use of MLP care models in health care settings, the health outcomes efficacy of MLPs has yet to be examined, particularly for complex chronic conditions such as HIV.MethodsThis on-going mixed-methods study utilizes institutional case study and intervention mapping methodologies to develop an HIV-specific medical legal partnership logic model. Up-to-date, the organizational qualitative data has been collected. The next steps of this study consists of: (1) recruitment of 100 MLP providers through a national survey of clinics, community-based organizations, and hospitals; (2) in-depth interviewing of 50 dyads of MLP service providers and clients living with HIV to gauge the potential large-scale impact of legal partnerships on addressing the unmet needs of this population; and, (3) the development of an MLP intervention model to improve HIV care continuum outcomes using intervention mapping.DiscussionThe proposed study is highly significant because it targets a vulnerable population, PLWHA, and consists of formative and developmental work to investigate the impact of MLPs on health, legal, and psychosocial outcomes within this population. MLPs offer an integrated approach to healthcare delivery that seems promising for meeting the needs of PLWHA, but has yet to be rigorously assessed within this population.

IMPACT OF GERIATRIC INTERPROFESSIONAL TRAINING ON ADVANCE CARE PLANNING IN GERIATRIC PRIMARY CARE

Currently, an important measure of Advance Care Planning (ACP), Advance Health Care Directives (AHCD) documentation rate, is at 33% for older adults in the United States. To address this disparity, geriatric faculty in an academic geriatric primary care practice aimed to train geriatrics fellows and other interprofessional (IP) learners to engage patients in ACP. As part of a Geriatric Workforce Enhancement Program funded by the Health Resources and Services Administration, geriatrics faculty and the Medical Legal Partnership for Seniors based at University of California Hastings College of Law provided ACP training to fellows and IP learners, including social work interns. In practice, the fellows and social work interns collaborated to incorporate ACP into patient visits and follow-up telephone calls. To monitor ACP progress, research staff reviewed patients’ electronic health records and performed descriptive analysis of the data. In 21 months, 4 geriatrics fellows built a panel of 59 patients who on average had 3 office visits and 7 telephone calls per person. Prior to clinic enrollment, 12 (20.3%) patients had preexisting AHCD, and 47 lacked AHCD documentation. After ACP intervention, 42 of 47 patients without AHCD documentation engaged in ACP discussion. Of those who engaged in ACP discussion, 24 completed AHCD, raising AHCD completion rate to 61%, or 36 patients in the panel of 59. ACP is a complex process that benefits from skilled communication among interprofessional providers and patients. Findings underscore the potential advantages of IP training and engaging patients in ACP discussion in an academic primary care setting.

4.6 YEAR ONE OUTCOMES FROM A COMMUNITY-BASED MEDICAL-LEGAL PARTNERSHIP TO DISRUPT THE SCHOOL-TO-PRISON PIPELINE

Medical-legal partnerships (MLPs) integrate legal advocacy and medical care to mitigate factors disproportionately affecting underserved populations. For children with mental health conditions, academic and behavioral issues are common stressors requiring additional supports typically facilitated by individualized education programs (IEPs). Disciplinary action resulting from inadequately addressed emotional and learning issues in school feeds the school-to-prison pipeline. In the first known initiative of its kind, an MLP integrating mental health services with educational legal advocacy onsite within a community mental health clinic provides participants coordinated legal advocacy, neuropsychological testing, and parental support and legal rights orientation. This study provides the initial outcomes for this unique MLP.

Medical–Legal Partnerships: How Legal Services can Dramatically Improve Health Outcomes, and the Missed Opportunity to Help Women Seeking Abortions

There are significant health disparities in the United States, with low‐income and minority Americans experiencing higher rates of chronic disease and autoimmune disorders. Research has firmly established that social factors ‐ such as malnutrition, limited access to healthcare, and safe housing ‐ play a critical role in these health disparities. Medical‐Legal Partnerships are a relatively new approach to improving the health of people living in poverty by addressing the root causes of these health‐harming social factors. This article discusses the benefits of Medical‐Legal Partnerships and argues for continued expansion of the model, particularly in pediatricians’ offices, because parents are more likely to seek medical care for their children than themselves. This article further discusses how legal constraints prevent federal funding for Medical‐Legal Partnerships in abortion clinics; this creates a missed opportunity to work with women who are seeking abortions, many of whom face considerable social and economic challenges that could be addressed through legal assistance. This article digs into the legal restrictions that create this missed opportunity and proposes potential solutions to better serve the vulnerable population of abortion‐seeking women.

Medical legal partnerships - a powerful collaboration for change. Clinicians and lawyers working together to prevent lead poisoning in Chicago and beyond.

Pediatricians are trained to not only treat individual children but to work systemically to change environments that contribute to illness or injury. Medical-legal partnerships (MLPs) are a growing model where clinicians and lawyers work together to more effectively address a broad range of social determinants of health. Erie Family Health Center (Erie), a large Federally …

Medical legal partnerships - a powerful collaboration for change. Clinicians and lawyers working together to prevent lead poisoning in Chicago and beyond.

Medical legal partnerships - a powerful collaboration for change. Clinicians and lawyers working together to prevent lead poisoning in Chicago and beyond.

90. STRENGTHENING MEDICAL-LEGAL PARTNERSHIPS: THE ADVOCACY LETTER PROJECT

Many medical problems intersect with legal issues. While medical providers may screen for such social determinants of health, they often lack the time, knowledge, tools and, agency to effectively advocate for their patients. Physicians may refer patients to a social worker or legal aid clinic, but these resources do not have sufficient capacity to address all patient needs. The Advocacy Letter Project worked with the Pediatric Advocacy Clinic (PAC), a legal aid clinic, at the University of Michigan Law School to identify important medical-legal issues and to build capacity among community providers by creating advocacy letter templates and training for their ideal utilization. This project is supported by an AAP CATCH grant. An initial needs assessment survey of providers identified which common medical legal issues are identified during patient visits. We developed advocacy letter templates to address these issues with the help of the PAC. Workshops were given for faculty and residents to optimize utilization of the letters. A reporting mechanism was created to track utilization of these templates within the Electronic Medical Record (EMR). Pre and post implementation provider survey data will be used to monitor provider perception of efficacy and usefulness of the letter templates. EMR review of template utilization will be used to identify frequency of use for each letter type. Preliminary data from the needs assessment suggest a significant need to better intervene on patient's behalf regarding medical legal needs to improve health equity. Letter templates are being created, reviewed by PAC, and implemented in the EMR. Data on frequency of use and post implementation survey data as well as statistical analysis will be available in March. Medical providers often struggle to intervene on legal issues affecting patient's health. Strengthening a medical legal partnership and making patient advocacy letters easily accessible allows physicians to more effectively address their patients’ needs. The next step is increasing access to and utilization of these letter templates in our community.

Building Immigration-Informed, Cross-Sector Coalitions: Findings from the Los Angeles County Health Equity for Immigrants Summit.

In December 2017, the Los Angeles County Office of Immigrant Affairs and Board of Supervisors, alongside local health care and legal providers, convened the Health Equity for Immigrants and Families Summit to advance a vision for immigrant health. We describe the four critical concepts identified by stakeholders to address the varied needs of immigrants in an increasingly anti-immigrant political environment: (1) Recognizing immigration status as a modifiable social determinant of health; (2) Adopting the concept of “Immigration-Informed Care” within health care institutions; (3) Establishing immigration-focused medical-legal partnerships; and (4) Building coordinated systems based on knowledge of local stakeholders, policies, and funding mechanisms.

Medical-Legal Partnerships to Support Continuity of Care for Immigrants Impacted by HIV: Lessons Learned from California.

The United States (US) has experienced a surge of anti-immigrant policies and rhetoric, raising concerns about the influence on health outcomes for immigrants living in the US. We conducted qualitative interviews (n = 20) with health care and social service providers, attorneys, and legal/policy experts in California to understand how agencies were maintaining access to HIV care and prevention for immigrant clients. We conducted a thematic analysis to describe the role of medical-legal partnerships (MLPs) and document best practices. Informants reported high demand for legal services. Referrals were facilitated by case managers, medical providers, and pre-existing relationships between clinics and legal agencies. Informants identified a need for additional funding and further guidance on screening for and supporting patients with legal needs. MLPs have the capacity to create sustainable, efficient, comprehensive structural changes that minimize barriers to HIV prevention and treatment and improve health outcomes among immigrant populations.

The Promise and Failures of Children’s Medicaid and the Role of Medical-Legal Partnerships as Monitors and Advocates

For decades we have known that access to health care and early and preventive diagnosis and treatment can dramatically alter the course of a child’s life. Because of this knowledge, immediately after Congress enacted Medicaid, it created the Early and Periodic Screening, Diagnostic and Treatment, or EPSDT, program for children. EPSDT requires broad holistic and preventive care to correct or ameliorate health defects identified in Medicaid-eligible children. This coverage currently extends to 2 out of 5 children and 48 percent of children with special health care needs. Because of the broad parameters of coverage mandated by EPSDT, eligible children should receive any and all necessary medical care indicated by their health care providers. Tragically, for children like Savannah, a Medicaid-eligible girl with complex medical needs in Michigan who was denied access to the physical therapy, occupational therapy, and speech therapy critical to maintaining the ability to walk, feed herself, and function with some independence, failures in EPSDT implementation has resulted in unmet needs. As states have adopted state plan guidelines and transitioned to privatized Medicaid through contracts with Medicaid managed care organizations in an effort to cut growing costs, coverage gaps for vulnerable children have intensified, leaving parents and providers feeling the desperation of not being able to give their patients and children the care they need. Medical-legal partnerships - interdisciplinary collaborations between health care providers and lawyers - are well suited to monitor EPSDT compliance, engage medical providers in informed patient advocacy, facilitate exchange of information regarding failures in coverage, and hold Medicaid programs accountable to low-income children. This article will review the history of the public health insurance system, outline the current legal mandates and landscape of EPSDT, and discuss the role that medical-legal partnerships can play in ensuring that EPSDT fulfills its purpose.

Greater support and resources needed for cancer survivors returning to work.

Greater support and resources needed for cancer survivors returning to work.

Medical-Legal Partnerships to Enhance Residency Training in Advance Care Planning.

Only about one-third of adult Americans have completed advance directives for end-of-life care, and primary care physicians report that they are not always comfortable discussing advance care planning (ACP) with patients. Current approaches to teaching clinicians about ACP have limited evidence of effectiveness. With the objective of improving residents' comfort and skill discussing ACP with patients, we developed a curriculum that involved clinicians and attorneys working together to teach first-year family medicine residents (R1) about leading ACP discussions with patients. Our curriculum consisted of a 1-hour multimedia training session on ACP followed by a series of direct in-exam room observations. Attorney and/or physician faculty observed residents holding ACP discussions with patients and provided structured feedback to residents about their performance. The initial R1 cohort observed had a series of three direct observations; the subsequent R1 cohort had two direct observations. We developed an evaluation tool with a 5-point developmental scale (beginner, novice, developing, near mastery, mastery) corresponding to the Accreditation Council for Graduate Medical Education's milestone system to score residents' performance. R1 performance improved from the beginner/novice level during the first observed ACP discussion to the novice/developing level during the second or third discussion, representing an increase in competence to that expected of a second- or early third-year resident. Based on our initial experience, using medical-legal partnerships to teach residents about ACP may be more effective than previously reported approaches. Validation of our results with a larger sample is needed.