Medical-legal Partnerships Research Articles

A Qualitative Analysis of a Primary Care Medical-Legal Partnership: Impact, Barriers, and Facilitators.

Certain health-related risk factors require legal interventions. Medical-legal partnerships (MLPs) are collaborations between clinics and lawyers that address these health-harming legal needs (HHLNs) and have been shown to improve health and reduce utilization. The objective of this study is to explore the impact, barriers, and facilitators of MLP implementation in primary care clinics. A qualitative design using a semistructured interview assessed the perceived impact, barriers, and facilitators of an MLP, among clinicians, clinic and MLP staff, and clinic patients. Open AI software (otter.ai) was used to transcribe interviews, and NVivo was used to code the data. Braun & Clarke's framework was used to identify themes and subthemes. Sixteen (n = 16) participants were included in this study. Most respondents were women (81%) and white (56%). Four respondents were clinic staff, and 4 were MLP staff while 8 were clinic patients. Several primary themes emerged including: Patients experienced legal issues that were pernicious, pervasive, and complex; through trusting relationships, the MLP was able to improve health and resolve legal issues, for some; mistrust, communication gaps, and inconsistent staffing limited the impact of the MLP; and, the MLP identified coordination and communication strategies to enhance trust and amplify its impact. HHLNs can have a significant, negative impact on the physical and mental health of patients. Respondents perceived that MLPs improved health and resolved these needs, for some. Despite perceived successes, integration between the clinical and legal organizations was elusive.

Social Needs Screening Via Electronic Tablet in Pediatric Primary Care.

(1) Assess whether health-related social needs (HRSN)/caregiver mental health concerns (CMHC) disclosure rates differ when screening questions are administered on paper versus electronic tablet. (2) Evaluate whether changes in need identification alters referral rates to social work and our medical-legal partnership (MLP). We conducted a retrospective review of HRSN/CMHC screening in publicly insured patients 0-18 years presenting for well-child visits in three primary care practices. Our primary outcome was HRSN/CMHC disclosure rate, comparing the proportion of positive HRSN/CMHC screens during the 11 months before and after screening modality change. Generalized estimating equations and interrupted time series (ITS) were used to assess changes over time. Mediation analyses assessed the indirect effect of HRSN/CMHC disclosure during the electronic screening period on changes in referrals to social work/MLP. A total of 16,151 patients had paper-based HRSN/CMHC screens; 13,019 patients had electronic screens. Overall, 11% of paper-based screens identified ≥1 need, compared to 26% of electronic screens (p<0.001). All three practices saw an increase in disclosure rate after transition from paper to electronic screening (odds ratio [OR] range 1.54 to 4.24). Using ITS, two of three practices had significantly increased odds of need disclosure with electronic screens compared to paper (OR 3.0, 95% confidence interval [CI] 2.5, 3.6; and OR 1.7, 95%CI 1.2, 2.4). Increased HRSN/CMHC disclosure rates from transitioning to electronic screening mediated increased referrals to social work/MLP. Electronic screening was associated with an increased HRSN/CMHC disclosure rate compared to paper, which led to increased referrals to social work/MLP.

Can Medical-Legal Partnerships Do More to Advance Reproductive Justice After Dobbs?

The medical-legal partnership (MLP) and reproductive justice (RJ) movements both seek to solve complex problems, serve diverse populations with intersectional challenges, and resolve community conditions that impact people's ability to reach their highest health potential. Yet MLPs have been overlooked as a strategy to advance reproductive health and justice. MLP has distinct advantages for advancing RJ, and many MLPs might already be doing RJ work without referring to it by name. By intentionally adopting an RJ strategy and explicitly addressing the unmet social and legal needs that limit people's ability to plan their reproductive futures, MLPs can better serve their clients and contribute to the movement to combat reproductive oppression.

Why MLP Legal Care Should Be Financed as Health Care.

Medical-legal partnership (MLP) integrates the unique expertise of lawyers into collaborative clinical environments. MLP teams meet the needs of individual patients while also detecting structural problems at the root of health inequities and advancing solutions at the institutional, community, and system levels. Yet MLPs today operate in limited settings and survive on scant budgets. Expanding their impact requires secure funding. Financing MLPs as health care can do the following: (1) help address inequity at the point of care; (2) enable expert diagnosis and treatment of nonmedical drivers of health; (3) enhance team-based practice in health care organizations; (4) offer another way for clinicians to participate in advocacy; and (5) bolster a broader movement to increase access to justice.

How Should We Measure Effectiveness of Medical-Legal Partnerships?

Medical-legal partnerships (MLPs) try to mitigate health inequity by uniting legal and health professionals to respond to legal determinants of patients' health. While there is a long tradition of "patients-to-policy" work in MLPs, the current empirical evidence base has evaluated MLP effectiveness by assessing benefits to individual patients, clinicians, and hospital and legal systems. This article calls for future research to measure how community power, which includes shifting power to impacted communities to develop and lead equity-focused agendas, is built as both a process and an outcome of MLPs.

How Should MLP Clinicians and Attorneys Help Veterans Secure Disability Benefits When Health Records Documentation Is Insufficient?

This case commentary considers unique features of medical-legal partnerships (MLPs) in the Veterans Health Administration that may potentially mediate and minimize ethical tensions that may arise in MLP collaborations involving diagnosing and documenting disability.

Medical-Legal Partnerships and the Future of Health Care.

Medical-Legal Partnerships and the Future of Health Care.

Mental health as the cornerstone of effective medical-legal partnerships for asylum-seekers: The terra firma model.

Challenges and traumas faced by asylum-seekers before, during, and after migration are compounded by the stressors of the asylum-seeking process, potentially compromising mental health (MH). Poor MH outcomes, in turn, complicate asylum-seekers' capacity to navigate the asylum-seeking legal process (e.g., hindering an individual's ability to provide an organized statement of their premigration experiences). Medical-legal partnerships are models of care that address legal problems as social determinants of health. However, when implementing medical-legal partnerships for asylum-seekers, standard definitions focusing on physical health do not appropriately capture the crucial role of MH services. Since 2013, the Terra Firma Program has provided services for asylum-seekers in the South Bronx, New York, by integrating MH, medical, and legal services along with enrichment activities, and concrete services. The present paper describes the benefits of this approach to working with asylum-seekers; highlights the importance of the MH component, including MH staff's dual therapist-evaluator role as a trauma-informed and ethical vehicle to support clients' asylum cases; and advocates for these partnerships to be recognized as MH-medical-legal partnerships. Drawing from Terra Firma's experience with over 800 asylum-seekers, the authors provide a framework for addressing asylum-seekers' needs through MH-medical-legal partnerships. Terra Firma's work with asylum-seeking children and families provides evidence in support of the establishment of MH-medical-legal partnerships and highlights the importance of the MH component in addressing asylum-seekers' legal needs. MH-medical-legal partnerships are proposed as effective models for working with asylum-seekers, with potential benefits to MH, physical health, and legal outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

How Is Access to Legal Resources and Advocacy Foundational to Health Justice?

Health justice as a movement incorporates research about how to more effectively leverage law, policy, and institutions to dismantle inequitable power distributions and accompanying patterns of marginalization that are root causes of health inequity. Legal advocacy is key to health justice because it addresses patients' health-harming legal needs in housing, public benefits, employment, education, immigration, domestic violence, and other areas of law. In medical-legal partnerships, lawyers and clinicians are uniquely positioned to jointly identify and remove legal barriers to patients' health, advocate for structural reform, and build community power.

How Should a Medical-Legal Partnership Address Unique Needs of People With Criminal Legal System Involvement?

Medical-legal partnerships (MLPs) are well suited to address health-harming legal needs associated with the collateral consequences of mass incarceration in the United States, such as those that limit access to food, housing, employment, and family reunification postrelease. MLP innovations seek to expand the current model to address patients' criminal, as well as postrelease, civil legal needs by including community health workers and some patients as legal partners and creating coalitions to promote local and state policy change. Overall, this article explains how these MLP innovations can support rights of people returning to communities after incarceration and can be leveraged to mitigate criminal legal system involvement.

AMA Code of Medical Ethics’ Opinions Related to Medical-Legal Partnerships

AMA <i>Code of Medical Ethics</i>’ Opinions Related to Medical-Legal Partnerships

What Should Clinicians in Organizations Without Established MLP Programs Do When Their Patients Need Lawyers to Meet Their Health Needs?

Undocumented people in the United States face innumerable legal and structural barriers to health and health care services, including for kidney failure. Their experiences vary across states and regions due to wide variation in insurance coverage and unreliable access to health-promoting resources, including medical-legal partnerships. This commentary on a case canvasses key policy about structural and legal determinants of health for undocumented persons.

What Are Epidemiological Foundations for Integrating Legal Services Into Health Care Settings?

Medical-legal partnerships vary widely in how they are structured and use data to inform service delivery. Epidemiological data on certain chronic conditions' prevalence, the incidence of potentially preventable morbidity, and health-harming legal factors also influence approaches to care. This article draws on a pediatric example of how data-driven medical care complements data-driven legal care. This article also considers medical and public health ethical frameworks to guide protected information sharing, promote optimal service delivery, and achieve the best possible medical-legal outcomes.

Medical-Legal Partnerships: a promising approach for addressing health-harming legal needs among people with HIV.

People with HIV (PWH), particularly those at the intersection of sexual and gender identities, face enduring obstacles to accessing HIV care, including structural stigma, structural racism and discrimination, housing instability, and limited access to health insurance. To address these challenges, Medical-Legal Partnerships (MLPs) in HIV care offer an innovative approach that integrates medical and legal services. By targeting health-harming legal needs (HHLN), MLPs aim to enhance the HIV care continuum outcomes for PWH. This study examines the benefits and challenges of MLPs within organizations serving PWH through the social-ecological model. MLP providers (n=111) identified organizational-level challenges such as funding limitations, resource integration issues, and staffing constraints. MLPs demonstrated numerous benefits, including patient impact and benefits, comprehensive service provision, enhanced staff support and capacity, and potential for policy influence. These results underscore the feasibility of MLPs while offering valuable insights into their efficacy and challenges, guiding the implementation of MLPs to address health-harming legal needs, including discrimination, and thereby improving HIV care outcomes.

An Institutional Approach to Equity and Improvement in Child Health Outcomes.

Pediatric health inequities are pervasive. Approaches by health care institutions to address inequities often, and increasingly, focus on social needs screening without linked, robust responses. Even when actions in pursuit of health equity do occur within health care institutions, efforts occur in isolation from each other, standing in the way of cross-learning and innovation. Learning network methods hold promise when institutions are confronted with complex, multidimensional challenges. Equity-oriented learning networks may therefore accelerate action to address complex factors that contribute to inequitable pediatric health outcomes, enabling rapid learning along the way. We established an institutional Health Equity Network (HEN) in pursuit of excellent and equitable health outcomes for children and adolescents in our region. The HEN supports action teams seeking to eliminate pediatric health inequities in their clinical settings. Teams deploy targeted interventions to meet patients’ and families’ needs, addressing both medical and social factors affecting health and wellbeing. The primary, shared HEN measure is the equity gap in hospitalization rates between Black patients and all other patients. The HEN currently has 10 action teams and promotes rapid learning and scaling of interventions via monthly “action period calls” and “solutions labs” focused on successes, challenges, and potential common solutions (eg, scaling of existing medical-legal partnership to subspecialty clinics). In this Advocacy Case Study, we detail the design, implementation, and early outcomes from the HEN, our equity-oriented learning network.

Partnering With Immigrant Patients and Families to Move Beyond Cultural Competence: A Role for Clinicians and Health Care Organizations

The delivery of culturally competent health care is recognized as critical to providing quality, equitable care for marginalized groups. This includes immigrant patients and families who experience significant barriers to health care and poor health outcomes. However, operationalization of cultural competence challenges health care delivery. Complementary concepts have also emerged such as cultural humility, cultural safety, and structural competence, recognizing the need for multi-level approaches involving patients, families, clinicians, health care organizations, the larger community, and policymakers. In this review, we define cultural competency and related frameworks and their applicability to immigrant patients and families. The evolution in terminology reflects an increasingly more comprehensive approach to understanding culture as multidimensional and shaped by social and structural factors. We then highlight strategies at each level, focusing on clinicians and organizations to leverage loci of control most directly within clinicians’ reach. Community-level strategies include community engagement (ie, vis-à-vis community health workers or community advisory boards) for clinical and research practice. Organization-level strategies include “immigrant-friendly,” or “immigration-informed” policies aimed at reducing immigration-related stressors, like limiting cooperation with immigration enforcement agencies or developing medical-legal partnerships to assist with patients’ legal needs. Lastly, policy-level strategies seek to change local and federal policies to address needs beyond health care (eg, education, housing, other social services), taking a “Health in All” policies approach that articulates health considerations into policymaking across sectors. Finally, we conclude with suggestions for future directions that center the experiences of immigrants, with the ultimate goal of sustainably meeting the complex needs of immigrant patients and families.

Considerations for Alternative Decision-Making When Transitioning to Adulthood for Youth With Intellectual and Developmental Disabilities: Policy Statement.

With advances in medical care, more youth with intellectual and/or developmental disabilities (IDD) are transitioning into adulthood. Patient- and family-centered, integrated care is warranted around this time of transition. Support teams (including the youth, caregivers, teachers, and pediatricians) should engage in transition planning, ideally starting between 12 and 14 years of age, to identify and develop resources to support the maturing youth's capacity for independent decision-making. Care teams should consider the varied levels of alternative decision-making support, which may include supported decision-making, medical proxy decision-making, power of attorney, and/or establishment of legal guardianship arrangements, to support the youth's health and well-being optimally. Ultimately, if independent decision-making is not appropriate, the goal for youth with IDD should be the least restrictive alternative, while preserving human rights and human dignity and promoting their autonomy. These considerations review alternative decision-making support, concepts, and legal requirements available for youth with IDD and their care teams. Pediatricians can support youth with IDD and their families in the transition process and decision-making autonomy by actively engaging the youth in care decisions, supporting needs for augmentative communication, fostering their expression of preferences and understanding of care decisions, and linking them to resources such as the medical-legal partnership model.

Designing and Developing a Medical-Legal Partnership to Address Cancer Patients' Health-Harming Legal Needs

Summary: The Georgetown University's Cancer Legal Assistance and Well-being Project launched in 2020 as a medical-legal partnership that works with health care providers at a Washington, D.C. safety-net hospital to treat the health-harming legal needs of historically and intentionally marginalized patients with cancer.

Improving Quality of Life for Patients with Cancer and Legal Involvement: Integrating Medical-Legal Partnerships

Improving Quality of Life for Patients with Cancer and Legal Involvement: Integrating Medical-Legal Partnerships

Abstract P309: Health-Harming Legal Needs Are Associated With Blood Pressure, Quality of Life, and Utilization

Background: Health-harming legal needs (HHLNs) significantly contribute to stress and have been linked to chronic disease burden in low-income populations. Medical-legal partnerships (MLPs) target HHLNs by embedding legal services within clinics. The impact of HHLNs on chronic disease, quality of life, and utilization is uncertain. This study sought to determine whether presence of and the number of HHLNs is associated with high blood pressure, worse quality of life, and higher healthcare utilization rates. Method: This is a cross-sectional study of a MLP program involving a federally qualified health center and non-profit legal services organization. The evaluation included all individuals, 18 years old and above, who received care at the clinic and were screened for HHLNs. All patients were offered HHLN screening (23-items) between March 2021 and December 2022. Blood pressure status was measured by two approaches: 1) the presence of hypertension diagnostic codes or anti-hypertensive medication, 2) the most recent mean arterial pressure (MAP). Quality of life was assessed using the number of unhealthy physical or mental days in a month. Participants reported the number of urgent care, emergency department (ED), and hospital visits over the prior 12 months. Using an available case analysis approach and logistic regression, we assessed the association between the total number and individual HHLNs and the presence of hypertension diagnoses or medications. For MAP, unhealthy days, and utilization, we used linear and negative binomial regression models. Results: Four hundred seventy-five participants completed surveys. Nearly half (198; 41.7%) reported at least one HHLN. There were no differences in HHLN reported across demographic groups. The number of HHLNs was associated with having a diagnosis of or medication for hypertension (OR=1.08, p=0.049) but was not associated with MAP (coeff=0.098, p=0.596). The number of HHLNs was similarly associated with more unhealthy physical (coeff=0.150, p=0.015) and mental days (coeff=0.157, p=0.002). More HHLNs were also associated with higher urgent care (coeff=0.252, p&lt;0.001) and ED utilization (coeff=0.181, p=0.014) but not hospitalizations (coeff=0.099, p=0.150). Hypertension was found to be associated with individual HHLN: income issues, losing health insurance, immigration applications, food insecurity and housing instability (all p&lt;0.05) over other needs. Several more HHLNs were associated with physical and mentally healthy days in past month (all p&lt;0.05). Multiple relationships persisted after controlling for demographics. Conclusions: The number of HHLNs and several specific legal needs are associated with hypertension, higher unhealthy physical and mental days, and higher urgent care and emergency department utilization. In future studies, we will study the longitudinal outcomes of HHLNs that are addressed by the MLP.