Adverse social conditions make people vulnerable to poor health, and poor health makes people even more vulnerable to adverse social conditions. This cycle of vulnerability drives health disparities in the United States: Low-income individuals and racial/ethnic minorities are disproportionately affected by a range of acute and chronic medical conditions such as asthma, diabetes and hypertension, and suffer worse health outcomes. In urban centers like Philadelphia, there is significant overlap between these two populations, resulting in concentration of risk in medically underserved communities.
Data have also shown that health and the quality of health care are a function of not only access to health care, but also of social determinants—including socioeconomic status, race/ethnicity and the physical structure of communities—that directly and indirectly affect the health and well-being of individuals and communities. The social and material needs that correlate with the social determinants are intended to be met by government and public programs designed to increase access to food, housing, income, utilities and insurance. Unfortunately, safety-net programs have become so complex as to be inaccessible to those who need them and are inconsistently implemented and enforced.
At the same time, our nation’s current legal system does have the capacity to meet the civil legal needs of low-income people. A low-income household has, on average, between one and three unmet civil legal needs. However, 80 percent of these problems go unaddressed by a legal aid organization or pro bono attorney. Many people do not recognize their problem as a legal one or seek legal services. And despite an almost 20 percent increase in the number of legal aid attorneys between 2002 and 2007, there is only an estimated 1 legal aid attorney for every 6,415 low-income individuals..
Traditional law and health care treat the problems of poor health and adverse social conditions in isolation; however, breaking this cycle of vulnerability is more likely if the professions marshal their collective resources to improve both health and social well-being. Medical-legal partnerships (MLPs) bring the legal community together with health systems and health providers to harness the power of two disciplines toward the improvement of individual and community health and well-being. MLPs integrate lawyers into the healthcare setting to reduce barriers to health care and help patients navigate the complex legal systems that often hold solutions to problems associated with many social determinants of health.
MLP|Philadelphia, a partnership between the Legal Clinic for the Disabled and the Family Practice & Counseling Network (FPCN), is the first MLP in the nation to integrate legal services into a nurse-managed healthcare setting. FPCN serves over 13,000 of Philadelphia’s most vulnerable individuals each year, the significant majority of whom have multiple coexisting social and legal problems. Nurse practitioners provide high-quality, comprehensive primary care and are able to diagnose and treat illnesses as well as prescribe medications to treat acute and chronic illnesses. FPCN takes a holistic approach to care and also offers its patients behavioral, dental and prenatal services. A lawyer has been added as an integral part of this interdisciplinary healthcare team to provide more comprehensive patient care and reduce health disparities.
Introduction: An MLP Case Study
For 35 years, Maxine Riche of Council Bluffs, Iowa, guided nursing home patients through their daily routines of getting up, getting dressed, eating and bathing. It was tough work, but she kept going even as her own health deteriorated. Maxine broke multiple bones on the job and developed a long list of chronic health problems: osteoporosis, arthritis, carpal tunnel syndrome, a sore back and neck pain. Being a nurse’s aide was the only job she knew, but in 2006, after coming down with a serious illness and breaking her hand, Maxine was forced to stop working entirely.
With no new income, Maxine couldn’t afford to keep paying her insurance. Six months after Maxine’s insurance expired, a fire destroyed her home. For close to two years, she slept in shelters, at friends’ homes or in her car. Maxine applied for Social Security Disability pay, but after a year-long waiting period, her application and subsequent appeal were both denied. With no home, no salary and no way to work, Maxine didn’t know where to turn.
Fortunately, her healthcare provider did. Linda Garcia at the Council Bluffs Community Health Center referred her to Iowa Legal Aid. Attorney Chris Kerbawy took on the case, and he and Linda got to work. The Social Security Administration (SSA) had denied Maxine’s application because it believed she was healthy enough to do “light work” jobs. But when her provider examined Maxine, she saw that Maxine was in no shape to exert the 20 pounds of force that categorize “light work.” In a letter to the SSA, her provider documented Maxine’s medical issues and confirmed that her health prevented her from doing “light work.”
When the Iowa Legal Aid team submitted the provider’s letter, the SSA quickly approved Maxine’s application. Maxine started receiving more than $800 a month in disability pay. To cover the months when her application had been pending, the SSA also paid her a back benefit of $18,000. The new income made an enormous difference for Maxine, but her attorney wanted to make sure she had insurance to cover her healthcare expenses as well. Once Maxine was approved for Social Security disability benefits, she became automatically enrolled in Medicaid. She is now dually enrolled in Medicaid and Medicare, which together provide comprehensive medical coverage.
The work of Iowa Legal Aid also brought thousands of dollars in Medicaid payments to the hospitals and clinics where Maxine was treated while her application for Social Security and Medicaid was pending. Since starting to bill Medicaid for Maxine’s treatment, the Council Bluffs Community Health Center and the Jennie Edmonson Hospital have already been paid more than $7,000 for previously uncompensated care, and could still receive thousands more.
Maxine has recently moved into a new home.
The Problem: Health Inequalities and the Cycle of Vulnerability
Adverse social conditions make people vulnerable to poor health, and poor health makes people even more vulnerable to adverse social conditions. This vicious cycle of vulnerability often consigns our nation’s most disadvantaged households to a lifetime of poverty and other negative consequences (Parker, Greer, and Zuckerman 1988). The result is health inequalities determined by socioeconomic status and race/ethnicity for health markers and outcomes across a range of acute and chronic conditions. Health disparities are magnified in Philadelphia and other urban centers where the significant overlap between these two populations has led to concentration of risk in medically and legally underserved communities.
Social Determinants of Health
Not every illness has a purely biological remedy. An illness caused by an individual or a family being forced to choose between food and heat in winter months will not be prevented or treated with a prescription or a vaccination. Similarly, someone with asthma will never breathe symptom-free, no matter how much medication is administered, if he or she visits a community health center but then returns to mold-infested housing, as thousands do. Poverty creates health risks that in turn perpetuate poverty.
Many studies and reports show the extent to which vulnerable populations in the United States suffer from health disparities (Robert Wood Johnson Foundation 2009; Williams et al. 2008; World Health Organization 2008). Specifically, these studies have documented that low-income populations and racial/ethnic minorities are disproportionately affected by chronic and acute medical conditions such as asthma, cancer, diabetes and hypertension, and suffer worse health outcomes and mortality rates. There is significant overlap between these two populations, especially in urban centers, where people often suffer from coexisting medical and social problems (Fiscella and Epstein 2008) even as they are medically underserved.
Data have also shown that health and the quality of healthcare are a function of not only access to health care, but also of social determinants—including socioeconomic status, race/ethnicity, the physical structure of communities, conditions of work, housing, education, and personal stability and safety (Paul et al. 2009). Social determinants directly and indirectly affect the health, health care and wellness of individuals and communities. In fact, these factors are the primary influence on health at the population level and have downstream effects on the progression and severity of disease (Burris, Kawachi, and Sarat 2002; Williams et al. 2008). For example, less than 15 percent of preventable mortality is attributable to medical care alone (Paul et al. 2009).
The social and material needs that correlate with the social determinants are intended to be met by government and public programs and laws designed to increase access to food, subsidized housing programs, utility assistance, disability assistance and health insurance programs. Unfortunately, safety-net programs have become so complex that many parts of these programs are rendered effectively inaccessible to those they are designed to help. Public programs and laws are also inconsistently implemented, resulting in persistent poverty and its concomitant effects. The current economic downturn and increased unemployment has put millions more at risk for serious health consequences while straining these government programs (Retkin, Brandfield, and Hoppin 2009).
Healthcare providers serving low-income communities see firsthand the impact of social determinants on their patients. The challenge is to find interventions that address these needs by improving outcomes and reducing health disparities.
Poverty and the Justice Gap
One in six households in the United States is currently living in poverty. In all, there are 20.5 million households living on less than $28,000 per year. The recession and worsening unemployment have deepened the overall level of poverty and disproportionately affected already disadvantaged groups. Pennsylvania is one of seven states that had increases in the number and percentage of people in poverty between 2007 and 2008, to over 1.4 million people (U.S. Census Bureau, American Community Surveys 2009).
Low-income households are plagued by legal problems that our nation’s current legal system does not hear about or have the capacity to resolve. A study by the Legal Services Corporation (2009), Documenting the Justice Gap in America: The Current Unmet Civil Legal Needs of Low-Income Americans found striking results: On average, a low-income household has one to three unmet legal needs. However, in-depth studies conducted in nine states revealed that 80 percent of these problems went unaddressed by a legal aid organization or the private bar. Further, despite an almost 20 percent increase in the number of legal aid attorneys between 2002 and 2007, the most recent year for which statistics are available, there has been little change in the ratio of legal aid lawyers to low-income population. There is an estimated 1 legal aid attorney for every 6,415 low-income individuals.
There are other significant barriers to low-income households accessing needed assistance with legal problems, including the fact that individuals may not identify their problem as a “legal” issue or realize that there might be a legal solution. In seven of the state studies analyzed by the Legal Services Corporation, many respondents indicated, as their primary reason for not seeking legal services, a belief that there was no solution or that their particular problem “was not a legal problem, it’s just the way things are” (Legal Services Corporation 2007). Those same studies observed that even among people who identified a legal problem there seemed to be a low awareness of available legal services and their eligibility for such services. Even assuming that potential clients are aware of both the problem and their eligibility, legal services organizations are often geographically dislocated from the communities they serve, and transportation may be difficult or too expensive. Finally, there is, among many low-income individuals, a general mistrust of the legal community.
The Solution: Medical Legal Partnership--Integrating Legal Services into the Healthcare Setting to Break the Cycle of Vulnerability
The Solution: Medical-Legal Partnership—Integrating Legal Services into the Healthcare Setting to Break the Cycle of Vulnerability
Legal needs can be defined as any set of circumstances involving rights and responsibilities recognized by law or regulation (Washington State Supreme Court 2003). Material hardships associated with poverty include utility shut-offs and housing evictions. These problems constitute legal needs that are barriers to good health.
Traditional law and health care treat the problems of poor health and adverse social conditions in isolation; breaking this cycle of vulnerability is more likely if the professions marshal their collective resources to improve both health and social well-being. Across the United States, healthcare providers who serve low-income individuals and families are turning to a new type of specialist to keep patients healthy and safe: lawyers who practice poverty law.
Medical-legal partnerships (MLPs) bring the legal community (in the form of legal aid organizations, law schools, private bar, and other legal entities) together with health systems and health providers (such as hospitals, clinics, community health centers, medical schools, and public health agencies) to harness the power of two disciplines toward the improvement of individual and community health and well-being. MLPs integrate lawyers into the healthcare setting to reduce barriers to health care and help patients navigate the complex legal systems that often hold solutions to problems associated with many social determinants of health—for example, income supports for hungry families, utility shut-off protection during cold winter months, and mold removal from the home of asthmatics. MLPs are emerging as a key strategy to provide more comprehensive patient-centered care and decrease health disparities.
Opportunity for Change through Social Determinants
A social determinants framework assumes a broad definition of health. However, there is certainly no broad consensus about what health is or how it should be defined and measured. For example, it has been defined by the presence or absence of pain, disease, or physical or mental defect (Mold 1995). Terms used to describe one’s state of health according to this view include well, normal, symptomatic, disabled, diseased and ill (Patrick, Bush, and Chen 1973). In contrast, the World Health Organization in 1948 defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (cited in World Health Organization 2008).
The wide range of views on the subject suggests that there are many opportunities for multidisciplinary partnerships designed to better understand what makes some individuals or populations sick and others not (Burris, Kawachi, and Sarat 2002; Rose 1985). Larger systemic issues as well as circumstances of daily living can be grouped in different ways to better describe and understand a particular disease. For example, one study has suggested the following groupings as applied to obesity: (1) fundamental factors (race-based or socio-economic segregation), (2) intermediate factors (stressful life conditions, the material environment, access to information), (3) proximate factors (physiologic responses to stress, dietary practices, physical activity), and (4) outcomes (body weight, fitness, diabetes) (Shultz et al. 2005). This breakdown illustrates how a broad conceptualization of health reveals multiple factors potentially influencing health and possible links between them. Further, it implicates numerous academic and practical disciplines that could help to uncover and explain these links and create interventions that affect individual and population health outcomes and reduce health inequities.
Williams et al. (2008) have written that although most health problems occur well before individuals encounter medical care, the complex and varied nature of health inequities requires interventions within as well as outside of the healthcare system. The MLP is one within-system intervention that can reduce disparities both at the level of the individual, by affecting the progression and severity of disease, and potentially at the population level, by combating “upstream” factors that may reduce the overall incidence of disease. Indeed, MLP has the potential to bridge the community and the healthcare system by creating “early warning systems” in healthcare settings for failed policies that adversely impact vulnerable populations.
The MLP Operating Model Brings Partners Together to Improve the Lives of the Most Vulnerable
An MLP provides legal advice and assistance to patients and works toward internal process improvements in health care and law and external system change using the following steps (see figure):
- Legal advice and assistance: Healthcare providers see vulnerable patients on a regular basis in the clinical setting. As a result of trainings provided by their local MLPs, they are able to identify patients whose social stressors may be ameliorated or resolved by legal intervention. Healthcare providers refer patients in need of legal advice and assistance to attorneys at their affiliated MLPs.
- Internal process improvement in health care and law: From seeing repeated legal needs in a diverse patient population, MLP staff is able to identify patterns of need and develop the necessary tools, techniques and approaches to resolve these chronic problems. Many MLPs have begun to develop letter templates and screening tools to increase the efficiency and quality of the solutions front-line healthcare providers can use to address their patients’ legal needs in the clinical setting.
- External system change: MLPs unite the health and legal professions into one powerful voice to pursue systemic changes in government, policies, procedures and laws. By leveraging legal expertise in systemic advocacy with the credible perspective and evidence offered by the healthcare provider, MLPs are increasingly able to develop prevention-oriented systemic changes that spring from their unique positioning within the healthcare system.
Additionally, MLPs have been endorsed by the American Academy of Pediatrics and the American Bar Association (the ABA has also developed an in-house national MLP Support Center). The Agency for Healthcare Research and Quality featured the National Center for Medical-Legal Partnership in an Innovations Profile, and the Center for Law and Social Policy held out MLP as an approach that could transform the civil legal aid system (Houseman 2009).
Medical-Legal Partnership | Philadelphia
MLP|Philadelphia, a partnership between the Legal Clinic for the Disabled (LCD) and the Family Practice & Counseling Network (FPCN), is the first MLP in the nation to integrate legal services into a nurse-managed healthcare setting. Since 1990, LCD has partnered with Magee Rehabilitation Hospital to provide free legal services to people with physical disabilities to help them overcome legal obstacles that would otherwise affect their health, independence and safety. The project is funded by the Independence Foundation, a nonprofit investor that supports organizations providing services to people who do not ordinarily have access to them and emphasizes both public interest law and nurse-managed health care. MLP|Philadelphia brings these two initiatives together to form an innovative approach to patient care.
FPCN serves over 13,000 patients per year. The significant majority of these patients are among the almost 25 percent of Philadelphians living below the poverty line. This means that almost a quarter of the people living in the city—and most of FPCN’s patients—are more likely to have poor health outcomes and less likely to have access to and receive medical care than more affluent residents (Bailey et al. 2009). Specifically, the average FPCN patient is disproportionately affected by chronic and acute medical conditions such as asthma, cancer, diabetes and hypertension, and suffers worse health outcomes and mortality rates. According to the nonprofit Public Health Management Corporation (2008), 13.7 percent of adults in Philadelphia are without a regular source of health care.
The partnership is located in southwest Philadelphia at the Health Annex, one of three safety-net health centers within FPCN where nurse practitioners provide high-quality, comprehensive primary care and are able to diagnose and treat illnesses as well as prescribe medications to treat acute and chronic illnesses. The patient mix includes 37 percent with Medicaid and 46 percent who are uninsured (Bailey et al. 2009). FPCN providers apply a holistic model to make sure the complete picture of a patient’s care is addressed, including behavioral, dental, prenatal and gynecological health services. FPCN founder Donna Torrisi, a national leader in the development of nurse-managed health care, in partnership with LCD, has expanded the wide range of services available to patients by adding a lawyer as an integral part of the healthcare team.
Integrating legal services into the nurse-managed healthcare setting makes sense: As noted earlier, the average household served by FPCN is likely to have multiple coexisting medical and social problems. Virtually all legal needs for this population are directly or proximally related to health status (Zuckerman et al. 2008). An LCD staff attorney is on-site at the Health Annex two days per week to meet with patients referred by healthcare providers or social work staff. The attorney provides brief advice, options counseling, representation or further referral for a range of civil legal issues, including protection from abuse, Supplemental Security Income (SSI), Social Security Disability Insurance, Medical Assistance, housing, and child custody/support.
The attorney is also available for consultations with providers about general legal issues or a particular individual or family’s legal problem. This is an important aspect of the partnership because some people with an identified legal problem may not be ready for or interested in a referral. It is a way to “meet the patient where they are” while empowering providers with tools to better understand the full range of a patient’s needs. For example, a nurse practitioner recently had questions about SSI benefits for a patient who is partially blind and aging, and has a past history of drug and alcohol abuse. The patient had for years been receiving SSI benefits through a representative payee because of his substance abuse problems and inability to manage his own benefits. At the time of the consultation, however, he had been sober for over six months and reported that his payee was refusing to provide for his necessities such as food, clothes and toiletries and was apparently misappropriating his benefits for personal use. The attorney was able to explain the process of requesting a change in representative payee and discuss how the provider could be involved with the process.
The LCD attorney, who is also a master’s-trained social worker, facilitates trainings for front-line healthcare providers on the connection between the law, social determinants and health. One example is domestic violence. Patients and their families often suffer a range of destabilizing behaviors—physical, economic, sexual or mental/emotional abuse—that are proven to raise stress, lower quality of life, and increase non-adherence to treatment regimen and missed medical appointments. Recent trainings covered the fundamentals of identifying and assessing different types of domestic violence and possible legal responses. A common case is a patient who is economically dependent on her abuser and who does not have the financial resources to flee with her children. Providers are trained to recognize red flags and then refer the patient for legal services such as accessing available income supports (food stamps, disability benefits, public assistance) or navigating the child custody/support process. Over time, this iterative process will raise provider awareness of the issue and empower them with tools to address the problem while providing more comprehensive patient-centered care.
Socioeconomic Return on Investment
The MLP model was first developed in 1993 at Boston Medical Center as a way to better serve vulnerable patients. In 2009 there were 76 MLPs in 166 health settings (including 76 hospitals and 90 community health centers) across the United States, bringing together 41 legal aid organizations, 23 medical schools, 20 residency programs, 37 law schools and 42 private law firms. Fifty-five of those programs completed the 2009 MLP Network Partnership Site Survey conducted by the National Center for Medical-Legal Partnership. Some highlights of that survey, which reflect only a portion of MLPs’ national accomplishments, show that MLP teams at 137 hospitals and health centers:
- Served nearly 13,000 individuals and families and gave nearly 3,000 legal consultations to front-line healthcare staff.
- Trained almost 8,000 front-line healthcare providers to recognize the connection between unmet legal needs and health.
- Recovered over $5 million in public benefits for vulnerable individuals and families.
- Recovered over $800,000 for hospitals and health centers in Medicaid appeals.
- Received $13 million in in-kind services from pro bono partners.
- Received over $8 million in cash funding from legal, health, foundation, academic and government partners (National Center for Medical-Legal Partnership 2010).
Over the last four years the model has begun to be rigorously evaluated, but there is still much work to be done to document and understand the impact of MLP as we measure the impacts of improving holistic health status. The return on investment in medical-legal partnership can be broadly categorized into four domains: (1) financial return on investment for health partners, (2) systemic impact, (3) impact on patient-clients, and (4) impact on healthcare and legal providers.
Financial Return on Investment for Health Partners
Improving healthcare results and outcomes for low-income patients can also bring financial benefits to healthcare institutions. MLPs may increase healthcare revenue by collecting rejected but eligible insurance claims (from Medicaid and other payers) or by removing barriers to discharge for patients who no longer need to be in the hospital in order to make room for new paying patients.
Healthcare Recovery Dollars: When a hospital or community health center treats an uninsured patient, the hospital will generally remain unpaid for those services unless the patient receives public insurance or some other benefit program. This uncompensated care can result when a patient’s application for insurance is pending at the time services are rendered but is later denied. If, however, a lawyer can help a patient to successfully appeal a Medicaid denial, the healthcare institution can rebill Medicaid and be reimbursed for services provided up to three months prior to the date a patient becomes eligible. Additionally, the newly insured patient can then become a future paying patient (Knight 2008).
Several MLPs have documented the net financial benefits of these healthcare recovery dollars to the healthcare institution. In 2009, MLP programs recovered over $800,000 for hospitals and health centers in Medicaid appeals (National Center for Medical-Legal Partnership 2010). An earlier study documented that the Medicaid Appeals Project, a partnership between Legal Aid of Missouri and Truman Medical Center, netted $2,995,088 in Medicaid payments for services that it had provided to 422 patients (Knight 2008). A recent study of the Health and Law Project in Carbondale, Illinois, found that over a four-year period MLP lawyers assisted 20 clients with Medicaid services that resulted in benefits. These cases resulted in $296,704 in Medicaid-adjusted reimbursements and $1,177,844 in billings. The simple return on investment for the hospital, after an investment of $115,438 in the project over the four-year period, was 149 percent, or $402 per case (Teufel et al. 2009).
Cutting Costs and Reducing Post-Discharge Adverse Events: Hospitals lose revenue each day from patients who no longer need to be in the hospital but are unable to leave because of legal constraints such as mental or physical incapacity or lack of insurance. Additionally, one in five hospital stays is complicated by a post-discharge adverse event such as medical complications, emergency room visits or readmission (Jack et al. 2009). MLPs help connect patients with supports that can facilitate medically appropriate discharge. thereby cutting costs and increasing revenue for the healthcare institution. Legal services could also be part of a comprehensive discharge plan designed to reduce post-discharge adverse events.
Cost control has been a major point in the larger discussion about healthcare reform. The recently passed federal healthcare reform bills seek to “bend” the cost curve by reducing waste, fraud and overuse of medical services. Patients who remain in the hospital past medical need represent both an overuse of the healthcare system and a financial loss to the healthcare institution. The length of a patient’s stay is a significant driver of the cost of hospital care. In fact, the average hospital cost for a patient in a non-federal short-term general or special hospital has been estimated at $1,522 per day (U.S. Census Bureau, Statistical Abstract 2008).
Accordingly, a prime consideration for hospital administrators is readying patients for discharge (Cooke 2010). MLP attorneys assist patients and their families with health insurance coverage, income supports, guardianship or powers of attorney that will allow a smooth and timely discharge. Despite the importance of the discharge process, hospital discharge procedures have not been standardized. Legal services could be part of comprehensive discharge planning to support other interventions that may reduce post-discharge adverse events such as emergency room visits or readmission. Studies looking at such interventions have focused on connecting patients with transitional nursing services, increasing access to primary care follow-up, and improving patients’ ability to advocate for themselves after discharge (Jack et al. 2009).
MLPs help implement and enforce laws impacting health. The combined voice of medical and legal partners makes the case for increased access to resources to meet basic needs for low-income families at the federal, state and local levels. One powerful example of systemic change was MLP|Boston’s leadership in changing Massachusetts’s utility shut-off regulatory policy, stipulating that households with children that are unable to pay their utility bills in the winter months must continue to receive utilities without payment if they are able to provide a doctor’s authorization letter.
Impact on Patient-Clients
The impact of addressing a patient’s legal needs is now beginning to be examined. A recent survey of adult patients with cancer identified thirty medically related legal needs that could be sorted into four domains: health care, estate, finances and employment (Zevon et al. 2007). Subjects reported that medical-legal needs had a significant impact on their quality of life across all the domains, with unmet healthcare-related needs having the greatest impact. A different survey (Fleishman et al. 2006) of cancer patients who had received legal assistance showed positive results. Receiving legal assistance was said to reduce stress (in 75% of patients interviewed), have a positive effect on family or loved ones (50%), positively affect the financial situation (45%) and help maintain the treatment regimen (30%).
In April 2008, the National Center for Medical-Legal Partnership and MLP|Boston with Cornell University conducted a qualitative study (Hernandez 2008) to measure the impact of MLP on patient-families. Seventy-two interviews were conducted with patient-families (36 had access to legal services, 36 did not). The study found that MLP patient-families:
- Employed more effective strategies to solve legal problems than they would have otherwise.
- Felt supported while receiving legal assistance.
- Saw improvements in their family’s well-being.
- Were able to assist other families with the knowledge they gained.
Local MLP studies also indicate that medical-legal intervention improves medical conditions by promoting health environments that contribute to decreased severity of asthma (National Center for Medical-Legal Partnership 2006); leads to increased quality of life when patient-clients report increased ability to maintain medical treatment regimens and reduced stress (National Center for Medical-Legal Partnership 2007); and improves patient-client communication about their problems when working with skilled advocates.
MLPs across the United States are currently evaluating the impact on patient-clients using a variety of measures. The 2010 Site Survey by the National Center for Medical-Legal Partnership documented that MLPs are currently gathering the following data on patient-clients using pre- and post-service data: access to legal services; achieving desired results; levels of stress; overall health or well-being; ability to manage disease/illness; ability to comply with treatment plans; understanding of their legal rights; and ability to advocate for self and family.
Impact on Healthcare and Legal Providers
The real innovation of MLP is not that it can provide additional referrals to legal aid attorneys and increase access to legal services for the poor, although these are certainly benefits of the model. MLP is advancing patient health and reducing health disparities by fostering internal process improvement in healthcare systems. One part of the systems change that has begun to be measured is the impact of MLPs—which trained 17,236 health care and legal staff in 2008—on the knowledge, attitudes and behaviors of healthcare providers.
LegalHealth, an MLP in New York, studied the impact of its training on physicians in 2005–2006 and found a definite change in attitude and behavior among participating physicians. They had a greater awareness of their patients’ legal needs, were more likely to make referrals for on-site legal assistance, were better equipped to assist their patients with needed forms and letters, and recognized the importance of their role in resolving their patients’ non-medical needs (National Center for Medical-Legal Partnership 2006).
MLP has also been incorporated into the curriculum at 52 residency programs across the country. The Legal Assistance to Medical Patients (LAMP) program, a partnership between Legal Services of New Jersey and Newark Beth Israel Medical Center, collected data from 114 residents before and after the development of the LAMP program. Preliminary data indicate that one year into their residencies, there has been an increase in the number of residents who felt that it was likely that “free access to an attorney can help patients” (from 57% to 72%) and who felt “comfortable raising and discussing legal issues” with their patients (from 33% to 55%) (Paul et al. 2009). If translated into clinical behavior, these attitudinal changes represent a growth in systems-based practice (one of the six core competencies required by the Accreditation Council of Graduate Medical Education).
MLP Is the Right Model at the Right Time
It seems clear that medical-legal partnership is an emerging best practice in the health and law sectors. Replication and sustainability of the model will depend on the depth of integration of the model into the standard practice of law and medicine for vulnerable populations. Indicators of the trajectory towards MLP as the standard of care include the percentages of federally funded legal aid agencies (29%), federally funded community health centers (5%) and medical and law schools engaged in MLP activities.
As government agencies recognize and start to address the impact and cost of health disparities and reach for innovative solutions, MLP offers a leveraging of two important skill sets that are critical for vulnerable communities. With the recent passage of both the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act, it will be essential to support healthcare systems in optimizing scarce healthcare dollars by ensuring that patients arrive at their doctor’s office with all their basic needs—for food, housing, safety, and access to education and employment—met.
The fervent replication of grassroots MLPs across the country should give way to a meaningful, large-scale demonstration project in multiple healthcare settings, to test the range of impacts that MLPs are detecting at the patient, provider, institutional and community levels. A major federal investment, coupled with strategic investments from health and philanthropy, will support the meaningful, sustainable integration of legal assistance as a core component of quality patient care. At the same time, such investments will help to shift legal resources towards prevention of legal crises, and lead the legal community to think about its work and impact in a framework of innovation and partnership.
Ellen Lawton is executive director of the National Center for Medical-Legal Partnership. She is a 1993 graduate of Northeastern University School of Law and was a Harvard Law School Wasserstein fellow. The National Center for Medical-Legal Partnership supports the expansion, advancement and integration of medical-legal partnership by providing technical assistance to partnership sites, facilitating the MLP Network, promoting leadership in law and medicine and coordinating national research and policy activities related to preventive law, health disparities and the social determinants of health.
Ben Beck-Coon is a staff attorney and Independence Foundation Public Interest Law Fellow with the Legal Clinic for the Disabled, Inc. (LCD). Since 1990, it has been LCD’s mission to provide free, high-quality legal representation to low-income people with physical disabilities in the Philadelphia area to help them overcome legal obstacles that would otherwise affect their health, independence and quality of life.
Abby Fung is a consultant with Root Cause, a research and consulting firm in Cambridge, Massachusetts. She received her BA from Harvard and her MBA from Columbia Business School.
Since 2004, Root Cause has worked extensively with social innovators who demonstrate promising approaches to social problems, social impact investors seeking to make the most of their resources, and public innovators committed to spreading proven solutions.
The authors thank Jeremy Alexander, Special Programs Intern at Legal Clinic for the Disabled, Inc., who contributed research for this article.
Bailey, D.N., K. Taylor, K. Malick, A. L. O’Connell, C. Ridgway, and B. Valdez. (2009). Family Practice and Counseling Network: A Nurse-led Social Innovation Ensuring Access to Primary Care. Philadelphia Social Innovations Journal, Issue 1, Fall. Available at www.philasocialinnovations.org.
Burris, S., I, Kawachi, and A. Sarat. (2002). Integrating Law and Social Epidemiology. Journal of Law, Medicine & Ethics, 30: 510–521.
Cooke, M. (2010). Cost Consciousness in Patient Care—What Is Medical Education’s Responsibility? New England Journal of Medicine, 14: 1253–1255.
Fiscella, K., and R. Epstein. (2008). So Much to Do, So Little Time: Care for the Socially Disadvantaged and the 15-Minute Visit. Archives of Internal Medicine, 168: No. 17 (September 22).
Fleishman, S., R. Retkin, J. Brandfield, and V. Braun. (2006). The Attorney as the Newest Member of the Treatment Team. Journal of Clinical Oncology, 24: 2123–2126.
Hernandez, D. (2008). Legal Needs Study. National Center for Medical-Legal Partnership. Available at http://www.medical-legalpartnership.org/sites/default/files/page/Diana%20Hernandez%20Qualitative%20Summary.pdf.
Houseman, A. (2009, July). Civil Legal Aid in the United States: An Update for 2009. Center for Law and Social Policy. Available atwww.clasp.org/admin/site/publications/files/CIVIL-LEGAL-AID-IN-THE-UNITED-STATES-2.pdf.
Jack, B., V. Chetty, D. Anthony, et al. (2009). A Reengineered Hospital Discharge Program to Decrease Hospitalization. Annals of Internal Medicine, 150, 3: 178–187.
Knight, R. (2008). Health Care Recovery Dollars: A Sustainable Strategy for Medical-Legal Partnerships? National Center for Medical-Legal Partnership. Available at www.medical-legalpartnership.org/resources/white-papers-and-reports.
Legal Services Corporation. (2009, September). Documenting the Justice Gap in America: The Current Unmet Civil Legal Needs of Low-Income Americans. Available at www.lsc.gov/pdfs/documenting_the_justice_gap_in_america_2009.pdf.
Legal Services Corporation. (2007). Documenting the Justice Gap in America: The Current Unmet Civil Legal Needs of Low-Income Americans. Available at www.lsc.gov/JusticeGap.pdf.
Mold, J. (1995). An Alternative Conceptualization of Health and Health Care: Its Implications for Geriatrics and Gerontology. Educational Gerontology, 21: 85–101.
National Center for Medical-Legal Partnership. (2010). 2009 Site Survey. Available at www.medical-legalpartnership.org/mlp-network/network-site-survey.
National Center for Medical-Legal Partnership, LegalHealth Study. (2007). Effect of Legal Assistance on Asthma. Cited at www.medical-legalpartnership.org/results/research-and-evaluation.
National Center for Medical-Legal Partnership, LegalHealth Study. (2006). Impact of Training on Physician Attitudes and Behavior. Cited at www.medical-legalpartnership.org/results/research-and-evaluation.
Parker, S., S. Greer, and B. Zuckerman. (1988). Double Jeopardy: The Impact of Poverty on Early Childhood Development. Pediatric Clinics of North America, 35(6): 1227–1240.
Patrick, D. L., J. W. Bush, and M. M. Chen. (1973). Toward an Operational Definition of Health. Journal of Health and Social Behavior, 14: 6–23.
Paul, E., D. F. Fullerton, E. Cohen, et al. (2009). Medical-Legal Partnerships: Addressing Competency Needs Through Lawyers. Journal of Graduate Medical Education, December: 304–309.
Public Health Management Corporation. Community Health Data Base. (2008). Southeastern Pennsylvania Household Health Survey. Available at http://www.chdbdata.org/datafindings-details.asp?id=77.
Retkin, R., J. Brandfield, and M. Hoppin. (2009). Medical-Legal Partnerships: A Key Strategy for Mitigating the Negative Health Impacts of the Recession. The Health Lawyer, 22: 29–34.
Robert Wood Johnson Foundation. Commission to Build a Healthier America. (2009). Findings available at www.commissiononhealth.org/WhatDrivesHealth.aspx.
Rose, G. (1985). Sick Individuals and Sick Populations. International Journal of Epidemiology, 14: 32–38.
Shultz, A., S. Peak, A. Odoms-Young, et al. (2005). Healthy Eating and Exercising to Reduce Diabetes: Exploring the Potential of Social Determinants of Health Frameworks Within the Context of Community-Based Participatory Diabetes Prevention. American Journal of Public Health, 95: 645–651.
Teufel, J., S. Brown, W. Thorne, D. M. Goffinet, and L. Clemons. (2009). Process and Impact Evaluation of a Legal Assistance and Health Care Community Partnership. Health Promotion Practice, 10:3, 378–385.
U.S. Census Bureau, American Community Surveys. (2009, September). Poverty: 2007 and 2008 American Community Surveys: American Community Survey Reports. Available at www.census.gov/prod/2009pubs/acsbr08-1.pdf.
U.S. Census Bureau, 2008 Statistical Abstract. (2008). Average Cost to Community Hospitals per Patient: 1980 to 2005. Available at https://www.census.gov/compendia/statab/2008/tables/08s0164.pdf.
Washington State Supreme Court Taskforce on Equal Civil Justice Funding. (2003, September). The Washington State Legal Needs Study Executive Summary. Available at http://www.courts.wa.gov/newsinfo/content/taskforce/legalneedsexecsummary.pdf.
Williams, D., M. Costa, A. Odunlami, and S. Mohammed. (2008). Moving Upstream: How Interventions That Address the Social Determinants of Health Can Improve Health and Reduce Disparities. Journal of Public Health Management Practice, November Supplement: S8–S17.
World Health Organization, Commission on Social Determinants of Health. (2008). Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health.
Preamble to the Constitution of the World Health Organization, 1948. Available at http://www.who.int/about/definition/en/print.html.
Zevon, M.A., S. Schwabish, J. P. Donnelly, and K. J. Rodabaugh. (2007). Medically Related Legal Needs and Quality of Life in Cancer Care: A Structural Analysis. Cancer, 109: 2600–2606.
Zuckerman, B., M. Sandel, E. Lawton, and S. Morton. (2008). Medical-Legal Partnerships: Transforming Health Care. The Lancet, 372: 1615–1617. Available at www.medical-legalpartnership.org/resources/academic-articles#2008.