Medical-legal partnerships: 11 years' experience of providing acute legal advice for critically ill patients and their families

Integration of medical legal services into a hospital-based violence intervention program: A survey and interview-based provider needs assessment

BACKGROUND

Violent injury among trauma surgery patients is strongly associated with exposure to harmful social determinants of health and negative long-term health outcomes. Medical-legal partnerships in other settings successfully provide patients with legal services to address similar health-harming legal needs and may offer a promising model for the care of violently injured patients.

STUDY DESIGN

An electronic survey tool was distributed to clinicians and staff affiliated with the hospital-based violence intervention program at a single urban level one trauma center. Semistructured follow-up interviews were conducted with participants, and interviews were coded using thematic analysis and grounded theory.

RESULTS

Participants reported many health-harming legal needs among their violently injured patients. The most commonly identified needs were: health insurance denials (62.5%); difficulty accessing crime victims compensation funds (56.3%); trouble accessing official documents (50%); and problems with non-SSDI public benefits (50%). Participants reported inconsistent methods for learning about and responding to patients' health-harming legal needs. The most common barriers to addressing these needs included the following: lack of awareness that a lawyer could help with the issue (68.8%); prioritization of other needs (68.8%); previous negative legal experiences (62.5%); and cost (62.5%). Identified needs encompass issues traditionally addressed by MLPs as well as more novel challenges faced by violent injury survivors.

CONCLUSION

This survey and interview-based study identifies complex health-harming legal needs present among violently injured trauma surgery patients. Medical-legal partnerships specially designed for the setting of violent injury appear well-suited to meet these needs, potentially reducing risk of violent reinjury, long-term negative health outcomes, and health care system costs.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

US Medical-Legal Partnerships to Address Health-Harming Legal Needs: Closing the Health Injustice Gap

The medical-legal partnership (MLP) model is emerging across the USA as a powerful tool to address the adverse social conditions underlying health injustice. MLPs embed legal experts into healthcare teams to address health-harming legal needs with civil legal remedies. We conducted a narrative review of peer-reviewed articles published between 2007 and 2022 to characterize the structure and impacts of US MLPs on patients, providers, and healthcare systems. We found that MLPs largely serve vulnerable patient populations by integrating legal experts into community-based clinical settings or children's hospitals, although patient populations and settings varied widely. In most models, healthcare providers were trained to screen patients for legal needs and refer them to legal experts. MLPs provided a wide range of services, such as assistance accessing public benefits (e.g., Social Security, Medicaid, cash assistance) and legal representation for immigration and family law matters. Patients and their families also benefited from increased knowledge about legal rights and systems. Though the evidence base remains nascent, available studies show MLPs to be associated with greater access to care, fewer hospitalizations, and improved physical and mental health outcomes. Medical and legal providers who were engaged in MLPs reported interdisciplinary learning, and healthcare systems often experienced high returns on investment through cost savings and increased Medicaid reimbursement. Many MLPs also conducted advocacy and education to effect broader policy changes related to population health and social needs. To optimize the MLP model, more rigorous research, systematic implementation practices, evaluation metrics, and sustainable funding mechanisms are recommended. Broader integration of MLPs into healthcare systems could help address root causes of health inequity among historically marginalized populations in the USA.

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.

A review of the effectiveness and experiences of welfare advice services co-located in health settings: A critical narrative systematic review

We conducted a narrative systematic review to assess the health, social and financial impacts of co-located welfare services in the UK and to explore the effectiveness of and facilitators and barriers to successful implementation of these services, in order to guide future policy and practice. We searched Medline, EMBASE and other literature sources, from January 2010 to November 2020, for literature examining the impact of co-located welfare services in the UK on any outcome. The review identified 14 studies employing a range of study designs, including: one non-randomised controlled trial; one pilot randomised controlled trial; one before-and-after-study; three qualitative studies; and eight case studies. A theory of change model, developed a priori, was used as an analytical framework against which to map the evidence on how the services work, why and for whom. All studies demonstrated improved financial security for participants, generating an average of £27 of social, economic and environmental return per £1 invested. Some studies reported improved mental health for individuals accessing services. Several studies attributed subjective improvements in physical health to the service addressing key social determinants of health. Benefits to the health service were also demonstrated through reduced workload for healthcare professionals. Key components of a successful service included co-production during service development and ongoing enhanced multi-disciplinary collaboration. Overall, this review demonstrates improved financial security for participants and for the first time models the wider health and welfare benefits for participants and for health service from these services. However, given the generally poor scientific quality of the studies, care must be taken in drawing firm conclusions. There remains a need for more high quality research, using experimental methods and larger sample sizes, to further build upon this evidence base and to measure the strength of the proposed theoretical pathways in this area.

Conceptualizing interprofessional working - when a lawyer joins the healthcare mix

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.