Presenters:
• Sarah Hooper, JD, UC San Francisco/UC Hastings Consortium on Law, Science and Health Policy
• Mahala Schlagman, MD, Assistant Professor of Medicine, University of Rochester Medical Center (URMC)
• Rebecca Russo, JD, Staff Attorney, Legal Assistance of Western NY (LawNY)
Presentation Recording:
Summary:
Sarah Hooper gave a brief description of the Medical Legal Partnership model (MLPs). The goal of MLPs is to improve patient health by addressing social determinants of health. MLPs promote interdisciplinary training. Lawyers train MDs to help them identify legal issues and refer patients to MLP projects for free legal assistance. Legal help can be rendered in the clinic setting or in patients’ homes.
The model represents a practice change for healthcare professionals and for attorneys. Some MLPs are in hospitals; some are in clinics. The medical and legal disciplines collaborate in advocacy. What makes MLPs different from referrals into the community is that civil legal attorneys generally first see cases when they are in crisis. That makes it more difficult to address, and the impact may be much more severe, especially for a vulnerable population like older adults. The model emphasizes prevention rather than waiting for a crisis. If they can identify and intervene in problems early on, there is a better chance of preserving health, which is the ultimate goal of the MLP model. In the past ten years, MLP participants have become more attuned to the concept of social determinants of health and of health equity.
There is growing literature and research into the benefits of MLPs.* An estimated 75K patients have benefited thus far and 15K healthcare professional have been trained in MLP projects. MLP services have shown to lower stress, reduce hospitalizations, and increase access to key benefits. Sarah cited one study (2016 observational study involving 140 veterans) in which health benefits were noted following the introduction of MLP services. An interesting observation was that health metrics improved even before the legal issues were resolved; evidently the expectation that issues were being addressed was enough to bring about relief. The longer legal services were involved, the better the outcomes. In another 2015 study, a reduction in hospital readmission rates was found among patients enrolled in the MLP.
There are approximately 350 MLPs in the US but only 6 are older adult specific. Among all MLPs, about 30% of clients are older adults; the low number of older adult programs may indicate that MLPs are not focusing on the needs of older adults even though the health and legal needs of older adults are priorities in the Older Americans Act. Surveys have found that 56% of low-income older adults had a civil legal need; 10% had at least six civic legal needs but 86% overall received inadequate or no legal help.
Sarah’s program works in UCSF Health Center; the project has four attorneys and eight student interns per semester. Elder abuse and exploitation are common issues they see in an older adult caseload. The student interns learn from the geriatricians and from patients; in the process they learn to be advocates as well. Sarah Hooper has been involved in MLP work since 2008; the collaboration with UCSF Hastings started in 2012.
The program is law school-based. They also work at a VA Medical Center. They have been trying to define what an MLP for older adults looks like. Sarah and colleagues published a paper in the Health Affairs journal on common health-related legal needs of older adults. Examples include falls risk and housing advocacy, long term care advocacy, cognitive decline and decision-making assessment, and advance care planning. Elder abuse and neglect are also issues that the MLP is always on alert for. They use the “I-HELP” model to identity patient needs. Training students in elder law is part of the MLP mission. They learn about how to be good advocates and about elder law. They learn from clients and from geriatricians which is something law students don’t get in law school. The legal interns also learn how to identify elder abuse and early signs of MCI. They are also involved in a HRSA-sponsored GWEP grant project to build capacity.
They are scaling the MLP model statewide. The state of CA has given Sarah Hooper’s project a grant to develop a statewide MLP dementia care aware collaborative. This is associated with the CA Master Plan on Aging and MediCal support for cognitive health screenings. The project connects the screenings to referrals for legal help for advance care planning. Training is a huge part of the project.
Lawyers and students engage in a lot of advocacy. They meet with clients in facilities but also in their homes with MDs and social workers. The MLP is involved in changing practice at the VA hospital in San Francisco. The team helps VA staff “unpack” the legal issues in complex medical cases.
Sarah’s team has published findings in the New England Journal of Medicine. It turns out that a “rights focused approach” is consistent with cost containment in the facility. They have also tried to find other ways to scale their approach. The “Care Ecosystem Model” is being tested in LA, MN and other states. They train interdisciplinary care teams (pharmacist, SW and nurse and patient navigators) to identify issues early and make referrals. The model has improved the quality of life for patients, reduced ER visits and reduced caregiver burden and depression. They have also developed a suite of tools for the public (Prepare for Your Care). They are working on a similar tool that will support financial planning in dementia.
Although there have been no major studies on MLP outcomes to date, legal aid in general has been shown to improve access to housing and long-term care and planning, especially for those who don’t have easy access to legal services. Reaching people through their healthcare providers helps people who would not otherwise access legal services.
Rebecca Russo, who staffs the Finger Lakes Legal Care (FLCC) program at LawNY and Mahala Schlagman, who directs the Medical Legal Partnership at URM, discussed two MLP projects. Rebecca is an attorney with LawNY (Legal Assistance of Western New York). They started by describing a case they served of a man in his 50s with a TBI. He visited the clinic frequently; also had a history of chronic depression. He was isolated in the community and had ongoing complaints related to social challenges. He attributed his depression to financial insecurity. He was referred by his healthcare practitioners to the FLCC MLP. The MLP was able to help him obtain financial benefits which resulted in financial stability for the first time in a long time. He reported this new condition allowed him to think about the future. He started participating in social activities. Rebecca and Mahala cited this case as an example of a successful outcome in their program. He needed a linkage, a warm handoff, which made all the difference for him. He said, “I’ve spent most of my life trying to survive; I have to figure out what to do with myself now.”
Rebecca and Mahala compared the two MLP programs currently in operation in Rochester which are projects of LawNY and operating in two major health systems. One, in the Rochester Regional Health system, was initiated in 2012.
This was a small pilot project. They had a small table in the Cancer Clinic with a sign that said “Free Lawyer.” Over time it grew throughout the whole hospital system. The RRH project started externally. LawNY approached RRH and asked to work together; it took a while to get buy in and access. There is no central coordinating team. On the other hand, in the URMC case, Mahala contacted LawNY and asked for help with her patients who needed legal assistance.
There are advantages for both. In the RRH case, the project was grant funded but is now funded by the hospital. LawNY has been able to make relationships throughout the hospital system. In the URMC case, MLP at URMC is driven from within the medical center. There was a long ramp up for the URMC project which was launched in 2019 through Medicaid Redesign funding originating in the hospital. They are still in a pilot phase. They see patients in two different sites with 36,000 potential clients. The project has been integrated into the Electronic Medical Record.
As they collect client stories, they spot themes and identify what is important to patients. The issues they identify have the potential to influence what they do in the medical institution as well as up the chain to county and national policy makers. MLPs support advocacy at the system level with the patient at the center of the advocacy effort.
Benefits, including health insurance, is a major focus of their legal work and advocacy. Housing issues (especially during the past two years of the pandemic) have been prevalent. They track financial outcomes. The projects show significant financial outcomes including increases in monthly income, lump sum payments and health debts discharged for MLP patients.
The RRH project surveys patients at intake for self-reported health outcomes and again at case closure and six months post closure. There is statistically significant improvement as the result of legal intervention; however, there is a return to baseline after 6 months. The results may argue for sustained legal assistance, an “attorney on contract.”
Native English speakers report that they are healthier at intake than non-native English speakers. The gap narrows with intervention. Other benefits of the program include getting patients enrolled in insurance plans and recovering revenue from fixing problems with the coordination of benefits and obtaining proper billing information.
Mahala showed in a PPT slide how the PLM is integrated in the patient EMR in URM Internal Medicine. The project is also made part of the residency program.
Financial eligibility. The program screens to determine if patients can afford private attorneys; if so, they refer them out. Grant funding allows them some flexibility. NYC’s MLPs rely primarily on hospital funding. Locally (in Rochester) there is discussion about roles, what is the role of hospitals in social determinants of health, of the community, of a lawyer? What is the role of a doctor when someone is suffering but she can’t give them a pill to make them better?
This is a larger debate for healthcare and society in the future. MLPs represent in some ways a return to traditional medicine in which there wasn’t a lot of treatment but a lot of social support.
*For more on the impact of Medical/Legal partnerships, go to Studies on Medica/Legal Partnerships.
The model represents a practice change for healthcare professionals and for attorneys. Some MLPs are in hospitals; some are in clinics. The medical and legal disciplines collaborate in advocacy. What makes MLPs different from referrals into the community is that civil legal attorneys generally first see cases when they are in crisis. That makes it more difficult to address, and the impact may be much more severe, especially for a vulnerable population like older adults. The model emphasizes prevention rather than waiting for a crisis. If they can identify and intervene in problems early on, there is a better chance of preserving health, which is the ultimate goal of the MLP model. In the past ten years, MLP participants have become more attuned to the concept of social determinants of health and of health equity.
There is growing literature and research into the benefits of MLPs.* An estimated 75K patients have benefited thus far and 15K healthcare professional have been trained in MLP projects. MLP services have shown to lower stress, reduce hospitalizations, and increase access to key benefits. Sarah cited one study (2016 observational study involving 140 veterans) in which health benefits were noted following the introduction of MLP services. An interesting observation was that health metrics improved even before the legal issues were resolved; evidently the expectation that issues were being addressed was enough to bring about relief. The longer legal services were involved, the better the outcomes. In another 2015 study, a reduction in hospital readmission rates was found among patients enrolled in the MLP.
There are approximately 350 MLPs in the US but only 6 are older adult specific. Among all MLPs, about 30% of clients are older adults; the low number of older adult programs may indicate that MLPs are not focusing on the needs of older adults even though the health and legal needs of older adults are priorities in the Older Americans Act. Surveys have found that 56% of low-income older adults had a civil legal need; 10% had at least six civic legal needs but 86% overall received inadequate or no legal help.
Sarah’s program works in UCSF Health Center; the project has four attorneys and eight student interns per semester. Elder abuse and exploitation are common issues they see in an older adult caseload. The student interns learn from the geriatricians and from patients; in the process they learn to be advocates as well. Sarah Hooper has been involved in MLP work since 2008; the collaboration with UCSF Hastings started in 2012.
The program is law school-based. They also work at a VA Medical Center. They have been trying to define what an MLP for older adults looks like. Sarah and colleagues published a paper in the Health Affairs journal on common health-related legal needs of older adults. Examples include falls risk and housing advocacy, long term care advocacy, cognitive decline and decision-making assessment, and advance care planning. Elder abuse and neglect are also issues that the MLP is always on alert for. They use the “I-HELP” model to identity patient needs. Training students in elder law is part of the MLP mission. They learn about how to be good advocates and about elder law. They learn from clients and from geriatricians which is something law students don’t get in law school. The legal interns also learn how to identify elder abuse and early signs of MCI. They are also involved in a HRSA-sponsored GWEP grant project to build capacity.
They are scaling the MLP model statewide. The state of CA has given Sarah Hooper’s project a grant to develop a statewide MLP dementia care aware collaborative. This is associated with the CA Master Plan on Aging and MediCal support for cognitive health screenings. The project connects the screenings to referrals for legal help for advance care planning. Training is a huge part of the project.
Lawyers and students engage in a lot of advocacy. They meet with clients in facilities but also in their homes with MDs and social workers. The MLP is involved in changing practice at the VA hospital in San Francisco. The team helps VA staff “unpack” the legal issues in complex medical cases.
Sarah’s team has published findings in the New England Journal of Medicine. It turns out that a “rights focused approach” is consistent with cost containment in the facility. They have also tried to find other ways to scale their approach. The “Care Ecosystem Model” is being tested in LA, MN and other states. They train interdisciplinary care teams (pharmacist, SW and nurse and patient navigators) to identify issues early and make referrals. The model has improved the quality of life for patients, reduced ER visits and reduced caregiver burden and depression. They have also developed a suite of tools for the public (Prepare for Your Care). They are working on a similar tool that will support financial planning in dementia.
Although there have been no major studies on MLP outcomes to date, legal aid in general has been shown to improve access to housing and long-term care and planning, especially for those who don’t have easy access to legal services. Reaching people through their healthcare providers helps people who would not otherwise access legal services.
Rebecca Russo, who staffs the Finger Lakes Legal Care (FLCC) program at LawNY and Mahala Schlagman, who directs the Medical Legal Partnership at URM, discussed two MLP projects. Rebecca is an attorney with LawNY (Legal Assistance of Western New York). They started by describing a case they served of a man in his 50s with a TBI. He visited the clinic frequently; also had a history of chronic depression. He was isolated in the community and had ongoing complaints related to social challenges. He attributed his depression to financial insecurity. He was referred by his healthcare practitioners to the FLCC MLP. The MLP was able to help him obtain financial benefits which resulted in financial stability for the first time in a long time. He reported this new condition allowed him to think about the future. He started participating in social activities. Rebecca and Mahala cited this case as an example of a successful outcome in their program. He needed a linkage, a warm handoff, which made all the difference for him. He said, “I’ve spent most of my life trying to survive; I have to figure out what to do with myself now.”
Rebecca and Mahala compared the two MLP programs currently in operation in Rochester which are projects of LawNY and operating in two major health systems. One, in the Rochester Regional Health system, was initiated in 2012.
This was a small pilot project. They had a small table in the Cancer Clinic with a sign that said “Free Lawyer.” Over time it grew throughout the whole hospital system. The RRH project started externally. LawNY approached RRH and asked to work together; it took a while to get buy in and access. There is no central coordinating team. On the other hand, in the URMC case, Mahala contacted LawNY and asked for help with her patients who needed legal assistance.
There are advantages for both. In the RRH case, the project was grant funded but is now funded by the hospital. LawNY has been able to make relationships throughout the hospital system. In the URMC case, MLP at URMC is driven from within the medical center. There was a long ramp up for the URMC project which was launched in 2019 through Medicaid Redesign funding originating in the hospital. They are still in a pilot phase. They see patients in two different sites with 36,000 potential clients. The project has been integrated into the Electronic Medical Record.
As they collect client stories, they spot themes and identify what is important to patients. The issues they identify have the potential to influence what they do in the medical institution as well as up the chain to county and national policy makers. MLPs support advocacy at the system level with the patient at the center of the advocacy effort.
Benefits, including health insurance, is a major focus of their legal work and advocacy. Housing issues (especially during the past two years of the pandemic) have been prevalent. They track financial outcomes. The projects show significant financial outcomes including increases in monthly income, lump sum payments and health debts discharged for MLP patients.
The RRH project surveys patients at intake for self-reported health outcomes and again at case closure and six months post closure. There is statistically significant improvement as the result of legal intervention; however, there is a return to baseline after 6 months. The results may argue for sustained legal assistance, an “attorney on contract.”
Native English speakers report that they are healthier at intake than non-native English speakers. The gap narrows with intervention. Other benefits of the program include getting patients enrolled in insurance plans and recovering revenue from fixing problems with the coordination of benefits and obtaining proper billing information.
Mahala showed in a PPT slide how the PLM is integrated in the patient EMR in URM Internal Medicine. The project is also made part of the residency program.
Financial eligibility. The program screens to determine if patients can afford private attorneys; if so, they refer them out. Grant funding allows them some flexibility. NYC’s MLPs rely primarily on hospital funding. Locally (in Rochester) there is discussion about roles, what is the role of hospitals in social determinants of health, of the community, of a lawyer? What is the role of a doctor when someone is suffering but she can’t give them a pill to make them better?
This is a larger debate for healthcare and society in the future. MLPs represent in some ways a return to traditional medicine in which there wasn’t a lot of treatment but a lot of social support.
*For more on the impact of Medical/Legal partnerships, go to Studies on Medica/Legal Partnerships.