Why pediatricians need lawyers to keep children healthy

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.

Reducing asthma exacerbations in vulnerable children through a medical-legal partnership

BACKGROUND

Asthma health disparities are widely recognized, with worse outcomes in children from low income families. In a Medical-Legal Partnership (MLP), an attorney is embedded in a healthcare setting to address social determinants of health. We studied whether an MLP could impact asthma exacerbation rates in a vulnerable urban population at an academic children's hospital.

METHODS

The study population comprised children with asthma who were referred to the MLP between 2013 and 2017. We compared healthcare utilization for asthma exacerbations managed in primary care, emergency department and inpatient settings in the year before and year after MLP intervention.

RESULTS

98 children with asthma were included in the study. The mean total encounters per person per year decreased from 1.16 to 0.66 (relative reduction 44.2%, p < 0.01). The largest effect was on hospitalizations, with a reduction from 0.33 to 0.10 hospitalizations per patient per year (relative reduction 69.7%, p < 0.01). Encounters for asthma exacerbations in the primary care office and emergency department also decreased but these changes did not meet statistical significance.

CONCLUSION

In a pediatric population with asthma, an MLP intervention was associated with a significant reduction in asthma exacerbation encounters and hospitalizations comparing the year before and after MLP intervention. Further studies are needed to better understand which interventions are most effective, and for which patient groups MLP referral would be particularly useful. MLPs may be an important way to reduce health disparities in patients with asthma and other chronic illnesses.

Towards emplaced understandings of risk: How caregivers of children with asthma identify and manage asthma-related risk across different places

In the United States, pediatric asthma is distributed geographically across lines of racialized segregation. We draw on emplacement, or the theory that embodied experiences and the material world are mutually informed, to situate such geographic trends within the narratives of 41 caregivers of children with asthma. Results suggest that caregivers identified and managed asthma-related risk with regard to the relational and structural conditions of three categories of locations: (1) houses, (2) neighborhoods, and (3) schools and other childhood institutions. Within each type of location, caregivers used emplaced knowledge and emplaced caregiving tactics to respond to asthma-related risk. Based on our findings, we identify critical intervention topics that are consistent with families' everyday lived experiences of place.

Developing an innovative medical ethics and law curriculum-constructing a situation-based, interdisciplinary, court-based learning course: a mixed methods study

BACKGROUND

Traditional lecture-based medical ethics and law courses deliver knowledge but may not improve students' learning motivation. To bridge this theory-to-practice gap and facilitate students' learning effectiveness, we applied situated-learning theory to design an interdisciplinary court-based learning (CBL) component within the curriculum. Our study aimed to investigate students' learning feedbacks and propose a creative course design.

METHODS

A total of 135 fourth-year medical students participated in this course. The CBL component included 1 h of introduction, 1 h of court attendance, and 2 h of interdisciplinary discussion with senior physicians, judges, and prosecutors. After the class, we conducted a survey using a mixed-methods approach to gauge students' perceptions of engagement, performance, and satisfaction.

RESULTS

A total of 97 questionnaires were received (72% response rate). Over 70% of respondents were satisfied and felt that the class was useful except for role-playing activities (60%). More than 60% reported a better understanding of the practical applications of medical law. Approximately half (54%) reported less anxiety about medical disputes. 73% reported that the lecture provided awareness of potential medical disputes, and most respondents expressed an interest in medical law courses after the court visit (78%). 80% of the respondents were able to display empathy and apply mediation skills. Qualitative analyses showed that students demonstrated new knowledge, including recognizing the significance of the medical profession, distinguishing the importance of physician-patient communication, having confidence in the fairness of the justice system, and being willing to increase their legal knowledge.

CONCLUSIONS

CBL curriculum increases students' learning motivation in strengthening medical professionalism and medical law, develops students' empathy for patients and communication skills, as well as builds up students' trust in the justice system. This novel course design can be applied to teach medical ethics and law.

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 37.9 percent 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.

Towards Racial Justice: The Role of Medical-Legal Partnerships

Medical-legal partnerships (MLPs) integrate knowledge and practices from law and health care in pursuit of health equity. However, the MLP movement has not reached its full potential to address racial health inequities, in part because its original framing was not explicitly race conscious.

Situating household management of children's asthma in the context of social, economic, and environmental injustice

BACKGROUND

Structural determinants of health are social, economic, and environmental forces that generate unequal opportunities for resources and unequally distribute exposure to risk. For example, economic constraint, racial discrimination and segregation, and environmental injustice shape population-level asthma prevalence and severity. Structural determinants are especially relevant to consider in clinical settings because they affect everyday household asthma management.

OBJECTIVE

To examine how structural determinants shape everyday household management of pediatric asthma and offer a framework for providers to understand asthma management in social context.

DESIGN

Qualitative interviews of caregivers for children with asthma.

PARTICIPANTS

Participants included 41 caregivers in two U.S. cities: St. Louis, Missouri (n = 25) and Gainesville, Florida (n = 16). Most caregivers were women (83%), Black (73%) and/or had low socioeconomic status (SES; 78%). Caregivers cared for children with asthma aged 0-4 (32%), 5-11 (68%) and 12-17 (54%).

APPROACH

We carried out narrative interviews with caregivers using an adapted McGill Illness Narrative Interview and using qualitative analysis techniques (e.g. inductive and deductive coding, constant comparison).

KEY RESULTS

Caregivers highlighted three ways that structural determinants complicated asthma management at home: 1) housing situations, 2) competing household illnesses and issues, and 3) multi-household care.

CONCLUSIONS

By connecting social, economic, and environmental injustices to the everyday circumstances of asthma management, our study can help providers understand how social contexts challenge asthma management and can open conversations about barriers to adherence and strategies for supporting asthma management at home. We offer recommendations for medical system reform, clinical interactions, and policy advocacy.

Prescribing Physical, Occupational, and Speech Therapy Services for Children With Disabilities

Pediatric health care providers are frequently responsible for prescribing physical, occupational, and speech therapies and monitoring therapeutic progress for children with temporary or permanent disabilities in their practices. This clinical report will provide pediatricians and other pediatric health care providers with information about how best to manage the therapeutic needs of their patients in the medical home by reviewing the International Classification of Functioning, Disability and Health; describing the general goals of habilitative and rehabilitative therapies; delineating the types, locations, and benefits of therapy services; and detailing how to write a therapy prescription and include therapists in the medical home neighborhood.

Reducing Racial Inequities in Health: Using What We Already Know to Take Action

This paper provides an overview of the scientific evidence pointing to critically needed steps to reduce racial inequities in health. First, it argues that communities of opportunity should be developed to minimize some of the adverse impacts of systemic racism. These are communities that provide early childhood development resources, implement policies to reduce childhood poverty, provide work and income support opportunities for adults, and ensure healthy housing and neighborhood conditions. Second, the healthcare system needs new emphases on ensuring access to high quality care for all, strengthening preventive health care approaches, addressing patients’ social needs as part of healthcare delivery, and diversifying the healthcare work force to more closely reflect the demographic composition of the patient population. Finally, new research is needed to identify the optimal strategies to build political will and support to address social inequities in health. This will include initiatives to raise awareness levels of the pervasiveness of inequities in health, build empathy and support for addressing inequities, enhance the capacity of individuals and communities to actively participate in intervention efforts and implement large scale efforts to reduce racial prejudice, ideologies, and stereotypes in the larger culture that undergird policy preferences that initiate and sustain inequities.

Improving the Care of Youth With Type 1 Diabetes With a Novel Medical-Legal Community Intervention: The Diabetes Community Care Ambassador Program

Purpose The purpose of this study was to examine the feasibility and efficacy of the Diabetes Community Care Ambassador (DCCA) Program, a novel medical-legal community intervention designed to support high-risk youth with type 1 diabetes. Methods Study eligibility criteria: ages 3-19 years, A1C ≥8.5% (≥69 mmol/mol) and/or recent diabetic ketoacidosis hospitalization, type 1 diabetes duration ≥1 year, and English- or Spanish-speaking. Eighty-nine youth and their caregivers participated in the 9- to 12-month intervention, which included diabetes education and support through 3 home visits, 1 to 2 school visits, and phone support from a lay health worker, as well as legal support from a medical-legal partnership attorney. Feasibility was assessed; change in A1C was compared in a linear mixed model. Results Of the 89 DCCA Program participants, 80% completed the program, with the majority of participants rating their DCCA favorably. Sixty-two percent reported ≥1 unmet legal need, of whom 29% accepted legal counsel. Youth enrolled in the DCCA Program demonstrated an improvement in glycemic control as their mean A1C decreased from 9.71% (83 mmol/mol) at the start of the program to 9.40% (79 mmol/mol) at the end of the intervention period ( P = .03). Participants with public health insurance experienced the greatest differential A1C reduction (9.79% to 9.11%, 83 mmol/mol to 76 mmol/mol). Conclusions The DCCA Program represents a promising intervention for improving care of high-risk youth with type 1 diabetes. A significant proportion of caregivers of youth reported having an unmet legal need. Participants remained highly engaged and demonstrated improved glycemic control, particularly youth with public health insurance.

Quality Health Care for Homeless Children: Achieving the AAP Recommendations for Care of Homeless Children and Youth

BACKGROUND

We assessed whether and how health care organizations serving homeless pediatric patients meet recommendations issued by the American Academy of Pediatrics (AAP).

METHODS

We conducted a web-based survey of Health Care for the Homeless (HCH) Program grantees serving children.

RESULTS

Of 169 grantees, 77 (46%) responded. All organizations reported connecting patients to specialty services. Nearly all reported screening for homelessness (90%), facilitating Medicaid enrollment (90%), connecting patients to benefits (94%), addressing underlying causes of homelessness (83%), assisting with transportation (83%), and knowing about the causes of homelessness (76%). Fewer reported integrating comprehensive care into acute visits (61%) or having medical-legal partnerships (57%). Federally qualified health center status was associated with meeting more recommendations. We described barriers and facilitators to meeting recommendations.

DISCUSSION

Health care organizations serving homeless children largely meet AAP recommendations, but integrating comprehensive care into acute visits remains an area for improvement. Disseminating best practices may support guideline adherence.

Burden of socio-legal concerns among vulnerable patients seeking cancer care services at an urban safety-net hospital: a cross-sectional survey

Background

Social and economic conditions that affect one’s ability to satisfy life’s most basic needs such as lack of affordable housing, restricted access to education and employment, or inadequate income are increasingly well-documented barriers to optimal health. The burden of these challenges among vulnerable patients accessing cancer care services is unknown.

Methods

We conducted a cross-sectional survey of patients presenting for ambulatory cancer care services (screening and treatment) at an urban safety-net hospital to assess socio-legal concerns (social problems related to meeting life’s basic needs supported by public policy or programming and potentially remedied through legal advocacy/action).

Results

Among 104 respondents, 80 (77 %) reported concerns with one or more socio-legal needs in the past month, with a mean of 5.75 concerns per participant. The most common socio-legal concerns related to income supports, housing, and employment/education.

Conclusion

Our findings support the need for innovations in cancer care delivery to address socio-legal concerns of a vulnerable patient population.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1443-1) contains supplementary material, which is available to authorized users.

"Extra Oomph:" Addressing Housing Disparities through Medical Legal Partnership Interventions

Low-income households face common and chronic housing problems that have known health risks and legal remedies. The Medical Legal Partnership (MLP) program presents a unique opportunity to address housing problems and improve patient health through legal assistance offered in clinical settings. Drawn from in-depth interviews with 72 patients, this study investigated the outcomes of MLP interventions and compares results to similarly disadvantaged participants with no access to MLP services. Results indicate that participants in the MLP group were more likely to achieve adequate, affordable and stable housing than those in the comparison group. Study findings suggest that providing access to legal services in the healthcare setting can effectively address widespread health disparities rooted in problematic housing. Implications for policy and scalability are discussed with the conclusion that MLPs can shift professionals' consciousness as they work to improve housing and health trajectories for indigent groups using legal approaches.

Identifying Social Determinants of Health and Legal Needs for Children With Special Health Care Needs

Children with special health care needs (CSHCN) require comprehensive care with high levels of community and government assistance. Medical-legal partnerships may be particularly suited to address needs for this population. To explore this, we conducted in-depth telephone interviews of families of CSHCN cared for in the primary care practice of our tertiary care children's hospital. The majority of the sample (N = 46) had been late on housing payments and 17% of homeowners had been threatened with foreclosure. Families frequently reported denial of public benefits. Approximately 10% had executed advance planning documents such as guardianship plans for the children or wills for the parents. A minority of families had sought help from community agencies or lawyers. Less than one third had ever discussed any of the issues with health care providers, but two thirds were likely or very likely to in the future. CSHCN may especially benefit from the social support of a medical-legal partnership.

Caregiver Opinion of In-Hospital Screening for Unmet Social Needs by Pediatric Residents

OBJECTIVE

Child health is strongly influenced by social determinants. Little is known about the opinions of primary caregivers regarding the physicians' role in addressing social needs. Our objective was to examine caregivers' opinions about that role and any associations between those opinions, previous exposure to screening for needs by pediatric residents, and socioeconomic status (SES).

METHODS

Cross-sectional survey study of caregivers of hospitalized children. The survey collected information on caregiver opinion regarding their ability to ask physicians for help with social needs, whether physicians know how to help with those needs, and whether physicians should ask about social needs. The chi square test was used to identify associations between caregiver opinions, prior screening by a resident at admission, and SES (determined by census tract median household income).

RESULTS

Surveys were completed by 143 caregivers (79% participation). Most respondents agreed that they could ask their physician for help (54.5%), that their physician knows how to help (64.3%), and that physicians should ask about social needs (71.3%). Previously screened caregivers had more favorable opinions about asking for help (76.2% vs 45.5%, P < .01), whether their physician knows how to help (81.0% vs 57.4%, P = .02), and physician screening for unmet needs (85.7% vs 65.3%, P = .03). There were no SES differences in opinion.

CONCLUSIONS

Caregivers have favorable opinions of the physician's role in addressing the social determinants of health, especially after being screened. Physicians should be confident in the acceptability of screening families for social needs.

Two-Generation Pediatric Care: A Modest Proposal

To reduce inequities in child health, we need to reduce the gap between what we know and what we do. We must challenge our practices and traditions, develop new solutions and have the strength and courage to change how we practice. Based on my experience that the best way to help children is to help their parents, and the best way to reach parents is through their children, I propose a new frame of a 2-generation approach that focuses not only on the child but also on the parents and their relationship to guide our innovation and target improvements. Pediatricians' knowledge and empathy for families is a special base to use new strategies to test ideas on a small number of families with minimal time and cost. Examples from our work includes the following: (1) identify and refer parents with mental health conditions and lack of effective contraception, (2) develop more effective approaches to explain illness and disease to parents, and (3) educate parents about the impact of social relations from infancy on; love can amplify and stress can impair brain and child development. I encourage clinicians to think about what should be changed and more importantly to be excited and brave enough to take the first steps to design and test an idea.

A Road Map to Address the Social Determinants of Health Through Community Collaboration

Economic, environmental, and psychosocial needs are common and wide-ranging among families cared for in primary care settings. Still, pediatric care delivery models are not set up to systematically address these fundamental risks to health. We offer a roadmap to help structure primary care approaches to these needs through the development of comprehensive and effective collaborations between the primary care setting and community partners. We use Maslow's Hierarchy of Needs as a well-recognized conceptual model to organize, prioritize, and determine appropriate interventions that can be adapted to both small and large practices. Specifically, collaborations with community organizations expert in addressing issues commonly encountered in primary care centers can be designed and executed in a phased manner: (1) build the case for action through a family-centered risk assessment, (2) organize and prioritize risks and interventions, (3) develop and sustain interventions, and (4) operationalize interventions in the clinical setting. This phased approach to collaboration also includes shared vision, codeveloped plans for implementation and evaluation, resource alignment, joint reflection and adaptation, and shared decisions regarding next steps. Training, electronic health record integration, refinement by using quality improvement methods, and innovative use of clinical space are important components that may be useful in a variety of clinical settings. Successful examples highlight how clinical-community partnerships can help to systematically address a hierarchy of needs for children and families. Pediatricians and community partners can collaborate to improve the well-being of at-risk children by leveraging their respective strengths and shared vision for healthy families.

Building a Health Care Legal Partnership Learning Collaborative

Many Americans need both health care and legal interventions to maximize their opportunities for health. Medical-legal partnerships (MLPs), also known as health care legal partnerships (HLPs), bring the power of law to health care to reduce barriers and negative social determinants of health. The two terms--HLP and MLP--are used interchangeably in this article. Growing research shows that these partnerships can improve care, improve health, enhance interprofessional collaboration, and improve the financial status of patients and providers. HLPs take many forms, depending on their settings and resources. A health care legal partnership learning collaborative that brings leaders of diverse HLPs together to share experiences and best practices can help expand this effective model and enhance its potential for collective impact in improving population health.

Use of colocated multidisciplinary services to address family psychosocial needs at an urban pediatric primary care clinic

OBJECTIVE

To examine associations between use of on-site multidisciplinary services at a pediatric primary care clinic, perceptions of the clinic, and health care utilization.

STUDY DESIGN

Eighty caregivers were interviewed during clinic visits assessing on-site service use, satisfaction, and perception of the clinic as a medical home. Acute care, emergency department, and well-child visit data were abstracted from children's medical records. Student's t test and multivariate regression were used to examine associations between service use, satisfaction, and health care utilization.

RESULTS

Use of ≥3 clinic services was associated with improved satisfaction (Client Satisfaction Questionnaire-8 mean: 31.8 vs 31.0, P < .05), stronger perception of the clinic as a medical home (Parents' Perception of Primary Care mean: 97.6 vs 93.4, P < .01), and increased missed well-child care visits (mean: 0.49 vs 0.20, P < .05).

CONCLUSIONS

On-site service use was associated with improved caregiver satisfaction but decreased well-child visit adherence. Caregivers using support services may face barriers to accessing preventive care.

Forging a pediatric primary care-community partnership to support food-insecure families

BACKGROUND AND OBJECTIVES

Academic primary care clinics often care for children from underserved populations affected by food insecurity. Clinical-community collaborations could help mitigate such risk. We sought to design, implement, refine, and evaluate Keeping Infants Nourished and Developing (KIND), a collaborative intervention focused on food-insecure families with infants.

METHODS

Pediatricians and community collaborators codeveloped processes to link food-insecure families with infants to supplementary infant formula, educational materials, and clinic and community resources. Intervention evaluation was done prospectively by using time-series analysis and descriptive statistics to characterize and enumerate those served by KIND during its first 2 years. Analyses assessed demographic, clinical, and social risk outcomes, including completion of preventive services and referral to social work or our medical-legal partnership. Comparisons were made between those receiving and not receiving KIND by using χ2 statistics.

RESULTS

During the 2-year study period, 1042 families with infants received KIND. Recipients were more likely than nonrecipients to have completed a lead test and developmental screen (both P < .001), and they were more likely to have received a full set of well-infant visits by 14 months (42.0% vs. 28.7%; P < .0001). Those receiving KIND also were significantly more likely to have been referred to social work (29.2% vs. 17.6%; P < .0001) or the medical-legal partnership (14.8% vs. 5.7%; P < .0001). Weight-for-length at 9 months did not statistically differ between groups.

CONCLUSIONS

A clinical-community collaborative enabled pediatric providers to address influential social determinants of health. This food insecurity-focused intervention was associated with improved preventive care outcomes for the infants served.

Legal services: a necessary component of patient navigation

OBJECTIVES

Access to legal advocacy is an essential tool to help cancer patients and survivors through the continuum of care. This article examines delivery models that can seamlessly integrate into patient navigation programs.

DATA SOURCES

Technical reports, books, journal articles, and Web sites.

CONCLUSION

Psychosocial obstacles are common barriers of low-income individuals facing a cancer diagnosis. Legal solutions can help to minimize these obstacles, yet patients rarely have access to these services. Training patient navigators to appropriately screen for legal issues and collaborate with attorneys can be used to help prevent, rather than just react to, legal issues by addressing them as a part of a treatment plan.

IMPLICATIONS FOR NURSING PRACTICE

Attorneys working with patient navigators, particularly nurse navigators, can impact oncology nursing practice by providing an innovative collaboration that is consistent with emerging trends in patient-centered treatment.

Social service barriers delay care among women with abnormal cancer screening

BACKGROUND

Inequity in cancer outcomes for minorities and vulnerable populations has been linked to delays in cancer care that arise from barriers to accessing care. Social service barriers represent those obstacles related to meeting life's most basic needs, like housing and income, which are often supported by public policy, regulation and services.

OBJECTIVE

To examine the association between social service barriers and timely diagnostic resolution after a cancer screening abnormality.

DESIGN

Secondary analysis of the intervention arm of Boston Patient Navigation Research Program (2007-2008) conducted across six urban community health centers. Subjects with no barriers, other barriers, and social service barriers were compared on their time to diagnostic resolution.

SUBJECTS

Women ≥ 18 years of age with a breast or cervical cancer screening abnormality.

MAIN MEASURES

Social service barriers included: income supports, housing and utilities, education and employment, and personal/family stability and safety. Time to event analyses compared across five groups: those with no barriers, one barrier (other), one barrier (social service), two or more barriers (all other), and two or more barriers (at least one social service).

KEY RESULTS

1,481 navigated women; 31 % Hispanic, 27 % Black, 32 % White; 37 % non-English speakers and 28 % had private health insurance. Eighty-eight women (6 %) had social service barriers. Compared to those without social service barriers, those with were more likely to be Hispanic, younger, have public/no health insurance, and have multiple barriers. Those with two or more barriers (at least one social service barrier), had the longest time to resolution compared to the other four groups (aHR resolution < 60 days = 0.27, ≥ 60 days = 0.37).

CONCLUSION

Vulnerable women with multiple barriers, when at least one is a social service barrier, have delays in care despite navigation. The impact of patient navigation may never be fully realized if social service barriers persist without being identified or addressed.

Community household income and resource utilization for common inpatient pediatric conditions

BACKGROUND AND OBJECTIVE

Child health is influenced by biomedical and socioeconomic factors. Few studies have explored the relationship between community-level income and inpatient resource utilization for children. Our objective was to analyze inpatient costs for children hospitalized with common conditions in relation to zip code-based median annual household income (HHI).

METHODS

Retrospective national cohort from 32 freestanding children's hospitals for asthma, diabetes, bronchiolitis and respiratory syncytial virus, pneumonia, and kidney and urinary tract infections. Standardized cost of care for individual hospitalizations and across hospitalizations for the same patient and condition were modeled by using mixed-effects methods, adjusting for severity of illness, age, gender, and race. Main exposure was median annual HHI. Posthoc tests compared adjusted standardized costs for patients from the lowest and highest income groups.

RESULTS

From 116,636 hospitalizations, 4 of 5 conditions had differences at the hospitalization and at the patient level, with lowest-income groups having higher costs. The individual hospitalization level cost differences ranged from $187 (4.1%) to $404 (6.4%). Patient-level cost differences ranged from $310 to $1087 or 6.5% to 15% higher for the lowest-income patients. Higher costs were typically not for laboratory, imaging, or pharmacy costs. In total, patients from lowest income zip codes had $8.4 million more in hospitalization-level costs and $13.6 million more in patient-level costs.

CONCLUSIONS

Lower community-level HHI is associated with higher inpatient costs of care for 4 of 5 common pediatric conditions. These findings highlight the need to consider socioeconomic status in health care system design, delivery, and reimbursement calculations.

Addressing social determinants of health in the adolescent medical home

PURPOSE OF REVIEW

To provide a framework for addressing the social determinants of health (SDH) in the adolescent medical home.

RECENT FINDINGS

There has been recent recognition worldwide that SDH affect health throughout the life-course. Adolescents are a vulnerable population, with health behaviors, access, and outcomes shaped by social and environmental contexts. Medical homes have aimed to reduce the health inequities by facilitating connections with community resources. Interventions have been described in the literature for triaging social needs, connecting patients to resources, and utilizing multidisciplinary team members.

SUMMARY

SDH should be incorporated into the routine adolescent healthcare. Screening tools and referral programs should be developed and evaluated in the adolescent population. Programs utilizing multidisciplinary team members would be effective in reaching adolescents and facilitating connections to resources.

Racism and Health II: A Needed Research Agenda for Effective Interventions

This article reviews the empirical evidence that suggests that there is a solid foundation for more systematic research attention to the ways in which interventions that seek to reduce the multiple dimensions of racism can improve health and reduce disparities in health. First, research reveals that policies and procedures that seek to reduce institutional racism by improving neighborhood and educational quality and enhancing access to additional income, employment opportunities and other desirable resources can improve health. Second, research is reviewed that shows that there is the potential to improve health through interventions that can reduce cultural racism at the societal and individual level. Finally, research is presented that suggests that the adverse consequences of racism on health can be reduced through policies that maximize the health-enhancing capacities of medical care, address the social factors that initiate and sustain risk behaviors and empower individuals and communities to take control of their lives and health. Directions for future research are outlined.

Integrating social workers into medical-legal partnerships: comprehensive problem solving for patients

Medical-legal partnerships (MLPs) integrate legal services into the health care setting to resolve legal issues that have a negative impact on patient health. These partnerships between attorneys and health care professionals have traditionally focused on physicians. Despite early success and expansion of the MLP model, the literature is only beginning to explore the significant role that social workers can play in an MLP's development, process, and success. This article argues that MLPs are greatly enhanced when they seek the active engagement of a health center's social workers. All members of the MLP, however, should be aware of differing ethical and legal obligations in the medical, social work, and legal profession as well as differences in professional cultures that can affect the work of the partnership.

Identifying social risk via a clinical social history embedded in the electronic health record

Although the link between social determinants and health outcomes is well established, the social history remains poorly integrated into clinical care processes. This study's purpose was to determine social risk documentation rates among newborns using a new electronic template. A retrospective review of 639 well-infant visits was performed. The authors determined documentation rates for a standardized social history embedded in the clinic electronic health record. Social history completion rates and prevalence of risks were identified. More than 80% of clinicians documented asking at least 1 of 7 questions (mean = 4.5, SD = 2.9). The most commonly asked question was about "making ends meet," and the least common was about personal safety (79% vs 57%, P < .01). Nearly 30% of caregivers reported at least 1 risk, 11% at least 2 risks. An electronic health record-embedded social history led to documented screening in more than 80% of visits, identifying 30% as having at least 1 social risk.

Resident confidence addressing social history: is it influenced by availability of social and legal resources?

BACKGROUND

Pediatric residency clinics caring for underserved populations are often staffed with varying levels of social and legal resources, though their effects on residents' knowledge and practice have not been studied. Aim To examine the effects of clinic-based social and legal resources on resident knowledge and screening patterns for social determinants of health.

METHODS

A cross-sectional study of residents from 3 continuity clinics with different social and legal resources was performed. Resident surveys assessing their knowledge and screening practices, and direct observation of social history taking was compared.

RESULTS

Forty resident surveys revealed that those from clinics with more social and legal resources had greater confidence in their knowledge, screened more frequently, and spent more time taking social histories as assessed on direct observation.

CONCLUSIONS

Residents who practiced in continuity clinics with increased social and legal resources were more confident in their knowledge and screened for social determinants of health more frequently.

Teaching law in medical schools: first, reflect

Law is now routinely included in the medical school curriculum, often incorporated into bioethics and/or practice of medicine coursework. There seems to lack, however, a systematic understanding of what works in terms of getting across an effective depth and breadth of legal knowledge for medical students - or what such would even look like. Moreover, and more critically, while some literature addresses these what, when, how, and who questions, a more fundamental question is left unanswered: why teach law in medical school? This article suggests a process to reveal a more consensual understanding of this latter question. The author highlights findings and recommendations of some of the leading literature to date related to teaching law in medical schools, and also recent U.K. projects addressing legal teaching in medical schools. Reflecting on these materials and activities, the author suggests that we take a "pause" before we argue for more or different legal topics within the medical curriculum. Before we alter the curricula for more and/or different "law," first, it is critical to have a meaningful, stakeholder-driven, consensus-seeking discussion of the goals of legal education: why do we think it matters that medical students learn about "the law"?

Medical-legal partnership: impact on patients with sickle cell disease

OBJECTIVE

To determine the types of legal problems addressed by the Health Law Partnership (HeLP) and the impact of the legal interventions in pediatric patients with sickle cell disease (SCD) or its variants. We hypothesized that an interdisciplinary team that includes lawyers would positively affect the social determinants of health that affect patients with SCD.

METHODS

The HeLP database was retrospectively queried for all patients with the diagnosis of SCD or 1 of its variants who had been seen by the lawyers of HeLP between April 2004 and September 2010. Data collected in this cohort of patients included income level of the patient/client, the initial presenting problems, any patient/parent/guardian problems identified during the legal checkup, and the type of legal assistance provided. Estimated annualized financial outcomes were calculated.

RESULTS

From April 2004 through September 2010, 71 parents/guardians with 76 children with SCD were referred to the HeLP for legal intervention. Of the 71 parents/guardians, 33 were at <100% of the federal poverty level. There were 106 initial case problems identified in the 71 parents/guardians; 51 of 106 problems were directly related to the child. An additional 93 issues were identified during the legal checkup. Of 106 cases, 99 were closed with 21 resulting in a measurable gain of benefits.

CONCLUSIONS

In a cohort of families of children with SCD, incorporating access to legal services as part of the care plan resulted in a positive impact on these patients/parents/guardians. The impact was directly attributable to the intervention of the HeLP.

Training in social determinants of health in primary care: does it change resident behavior?

OBJECTIVE

The aim of this study was to examine the effects of a new social determinants of health curriculum on pediatric interns' attitudes, knowledge, documentation, and clinical practice.

METHODS

A nonrandomized mixed-methods study of an educational intervention conducted over a 1-year period was performed. The 2008-2009 pediatric interns (intervention group) participated in a new social determinants of health curriculum; prior year interns were controls. An anonymous online survey at the end of internship to both groups (post-tests) and the beginning of internship to the intervention group (pretest) assessed attitudes and knowledge. Documentation from the electronic medical record of social history questions was audited during the same 3-month period in successive years. Medical-legal partnership (MLP) referrals from both groups were compared.

RESULTS

Intervention interns (n = 20) were more comfortable discussing issues (100% vs. 71%; P < .01) and felt more knowledgeable regarding issues (100% vs. 64%; P = .005), community resources (94% vs. 29%; P < .001), and housing (39% vs. 6%; P = .04) than control group interns (n = 18). No differences regarding the importance of social hardships or screening for food security or education issues were found. Knowledge was greater in the intervention group post-test in all domains: benefits (72% vs. 52%), housing (48% vs. 21%), and education (52% vs. 33%; P < .001 for all). Intervention interns were more likely to document each issue (benefits 98% vs. 60%, housing 93% vs. 57%, food 74% vs. 56%; P < .001 for all). The intervention group had a slightly higher rate of referral to MLP, although the difference did not reach statistical significance.

CONCLUSION

The educational intervention increased interns' comfort and knowledge of social determinants of health and community resources. Documentation of social questions also increased.

Use of electronic technologies to promote community and personal health for individuals unconnected to health care systems

Ensuring health care services for populations outside the mainstream health care system is challenging for all providers. But developing the health care infrastructure to better serve such unconnected individuals is critical to their health care status, to third-party payers, to overall cost savings in public health, and to reducing health disparities. Our increasingly sophisticated electronic technologies offer promising ways to more effectively engage this difficult to reach group and increase its access to health care resources. This process requires developing not only newer technologies but also collaboration between community leaders and health care providers to bring unconnected individuals into formal health care systems. We present three strategies to reach vulnerable groups, outline benefits and challenges, and provide examples of successful programs.

Recent developments in health care law: partners in innovation

This article reviews recent developments in health care law, focusing on the engagement of law as a partner in health care innovation. The article addresses: the history and contents of recent United States federal law restricting the use of genetic information by insurers and employers; the recent federal policy recommending routine HIV testing; the recent revision of federal policy regarding the funding of human embryonic stem cell research; the history, current status, and need for future attention to advance directives; the recent emergence of medical-legal partnerships and their benefits for patients; the obesity epidemic and its implications for the child's right to health under international conventions.

Linking urban families to community resources in the context of pediatric primary care

INTRODUCTION

Pediatric guidelines emphasize the importance for healthcare providers to view children in the context of family and community, and promote community resources at visits. In 2006, a Family Help Desk (FHD) was established in an urban academic-based clinic in Baltimore, MD to assist healthcare providers in educating families about available community-based resources.

METHODS

A longitudinal cohort pilot study was conducted during a 6-week period in 2007 to evaluate the impact of the FHD in connecting at-risk families to community resources.

RESULTS

Overall, 6% of parents (n=59) who brought their child for a scheduled clinic visit accessed the FHD. Parents had a mean of 1.7 social needs, including after-school programs and childcare (29%), employment (13%), housing (12%), and food (11%). Most parents who utilized the FHD (64%) contacted a community resource or service within 6 months of their clinic visit. Nineteen parents (32%) who utilized the FHD enrolled in community programs.

CONCLUSION

A clinic-based multi-disciplinary model can empower families to connect with community-based resources for basic social needs.

PRACTICE IMPLICATIONS

The Family Help Desk model has great potential for addressing family psychosocial needs, and educating families about community resources within the context of pediatric primary care.

Medical-legal partnership: collaborating with lawyers to identify and address health disparities

INTRODUCTION

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.

SETTING

Eighty-one MLPs offer legal services for patients whose basic needs are not being met.

PROGRAM DESCRIPTION

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.

PROGRAM EVALUATION

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).

DISCUSSION

MLPs train residents, students and other health care providers to tackle socially caused health disparities.

Specialized care of overweight children in community health centers

We have developed a new approach to child obesity that supports the delivery of so-called secondary care-referral-based specialized visits-by primary care teams within community health centers. The Healthy Weight Clinic reorganizes care to provide access to a trained team consisting of a pediatric provider, nutritionist, and case manager during dedicated weight management visits. Our model improves obesity care by promoting local specialization and increasing capacity for specialized care; building multidisciplinary teams within primary care; focusing on health behavior change as a critical determinant of chronic disease outcomes; and using health information technology to promote high-quality care.

Teaching health law

Our course on social justice and health began as an experiment between Roger Williams University School of Law and the Warren Alpert Medical School of Brown University. As a course for both law and medical students, it broke relatively new ground by focusing on the intersection between law and the social determinants of health and the ways in which lawyers and doctors might partner to address social and health disparities. The course blends professionalism, ethics, and problem-solving by using case studies that raise practical challenges at the intersection of poverty, law, and health. This kind of collaborative, interdisciplinary teaching presents many challenges and rewards, which I discuss in this essay.

How bioethics can enrich medical-legal collaborations

Medical-legal partnerships (MLPs) - collaborative endeavors between health care clinicians and lawyers to more effectively address issues impacting health care - have proliferated over the past decade. The goal of this interdisciplinary approach is to improve the health outcomes and quality of life of patients and families, recognizing the many non-medical influences on health care and thus the value of an interdisciplinary team to enhance health. This article examines the unique, interrelated ethical issues that confront the clinical and legal partners involved in MLPs. We contend that the ethical precepts of the clinical and legal professions should be seen as opportunities, not barriers, to further the interdisciplinary nature of MLPs. The commonalities in ethical approaches represent a potential bridge between legal and health care advocacy for patient/client well-being. Bioethics has a role to play in building and analyzing this bridge: bioethics may serve as a discourse and method to enhance collaboration by highlighting common ethical foundations and refocusing legal and clinical partners on their similar goals of service for patients/clients. This article explores this bridging role of bioethics, through a series of case studies. It concludes with recommendations to strengthen the collaborations.

Social determinants: taking the social context of asthma seriously

Although asthma has emerged as a major contributor to disease and disability among US children, the burden of this disease is unevenly distributed within the population. This article provides a brief overview of social-status variables that predict variations in asthma risks and social exposures, such as stress and violence, that are emerging as important risk factors. The central focus of the article is on the distal social variables that have given rise to unhealthy residential environments in which the risk factors for asthma and other diseases are clustered. Effective initiatives for the prevention and treatment of childhood asthma need to address these nonmedical determinants of the prevalence of asthma.

Towards an integrated service response to the link between legal and health issues

International research that confirms links between health issues and legal needs and the prevalence of non-legal services as the first port of call for assistance with legal problems has reinvigorated interest in providing integrated legal and health services. This article details research that indicates experiencing ‘justiciable events’ (problems for which there is a potential legal remedy) leads to stress, anxiety and deterioration in physical or mental health problems. Health consequences are identified for those that do not obtain appropriate and timely legal assistance. People often experience clusters of legal and non-legal problems that require a range of responses. For those that seek assistance with their justiciable event, most seek this assistance from non-legal sources. Within the legal aid sector, these research findings are considered compelling reasons to integrate legal, health and welfare services. However, the co-ordination and collocation of legal and non-legal services (particularly for disadvantaged communities) is not a straightforward solution. Drawing on the experience of several examples of integrated approaches in legal, health and welfare service delivery including the longstanding arrangements between the West Heidelberg Community Legal Service, which is collocated with Banyule Community Health, a range of challenges facing those agencies wishing to develop relationships to provide integrated legal, health and welfare services are identified.

"You get what you get": unexpected findings about low-income parents' negative experiences with community resources

CONTEXT

Community-based resources are considered a critical part of the American health care system. However, studies evaluating the effectiveness of such resources have not been accompanied by rigorous explorations of the perceptions or experiences of those who use them.

OBJECTIVES

We aimed to understand and classify types of negative perceptions that low-income parents have of community resources. This objective originated from a series of unexpected findings that emerged during the analysis of qualitative data that were initially collected for other purposes.

METHODS

We conducted in-depth qualitative interviews with urban low-income parents. Themes emerged through a grounded theory analysis of coded interview transcripts. Interviews took place in 2 different cities as part of 2 studies with distinct objectives.

RESULTS

We completed 41 interviews. Informants often perceived their interactions with people and organizations as a series of trade-offs, and often perceived important choices as decisions between 2 suboptimal options. Seeking help from community resources was seen in that context. The following specific themes emerged: (1) engaging with services sometimes meant subjecting oneself to requirements perceived as unnecessary and, in the extreme, having to adopt the value systems of others; (2) accepting services was sometimes perceived as a loss of control over one's surroundings, which, in turn, was associated with feelings of sadness, helplessness, or stress; (3) individuals staffing community agencies were sometimes seen as judgmental or intrusive, and when many services were accessed concurrently, information sometimes became overbearing or a source of additional stress; and (4) some services or advice received as part of such services were perceived as unhelpful because they were too generic or formulaic.

CONCLUSIONS

Our data suggest that definable patterns of negative perceptions of community resources may exist among low-income parents. Quantifying these perceptions may help improve the client-centeredness of such organizations and may ultimately help reduce barriers to engagement.