Romney, Martha, RN,MS,JD,MPH

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Medical-Legal Partnerships as a Value-Add to Patient-Centered medical Homes

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Vol. 24, No. 4 |  FALL 2011GUEST EDITORIAL  Two innovative models of healthcare delivery focused on increasing access to care and improving quality have been independently gaining traction: the patient-centered medical home (PCMH) and the medical-legal partnership (MLP).  Both models aim to improve health outcomes for patients and families, but approach it from differing and complementary perspectives. PCMHs establish networks of care and support around a primary point of care. MLPs provide free legal advice, advocacy and services to low-income and underserved populations to address social determinants that have a negative impact on health.1 In these challenging economic times, it is imperative to identify innovative models of care which can potentially help to improve outcomes and reduce costs. Integrating MLPs into PCMHs may allow us derive value by leveraging the synergies to effectively meet these goals.  PCMHs and MLPs operate on similar principles: incorporating a ‘whole-person’ approach; improving the well-being and quality of life for individuals, families and communities; employing preventive measures and proactively addressing needs; and establishing collaborative networks to provide coordinated services and expand safety nets for those in need. The federal government and healthcare experts have identifi ed the PCMH as a model to engage and empower patients, coordinate, track and integrate care, effi ciently manage chronic illnesses, reduce unnecessary and duplicative care and, in turn, reduce costs while improving outcomes.2,3 The federal government has invested in PCMHs through the Patient Protection and Affordable Care Act2 and by funding demonstration projects which integrate the PCMH model in federally qualifi ed health centers (FQHCs) and advanced primary care practice settings.4 Medical-Legal Partnerships (MLP) were initially created in 1993 by Dr. Barry Zuckerman, a pediatrician at Boston Medical Center.1 Although healthcare providers have traditionally referred patients to local legal service agencies, these organizations lack suffi cient fi nancial and personnel resources to meet the needs of those eligible for services. According to a recent report by the Legal Services Corporation, for every individual who receives services, someone is turned away.5 With the current economic crisis and high unemployment, the need for these services seems likely to increase.   What distinguishes MLPs from traditional legal service organizations are the relationships established between legal and healthcare staff involved in providing services, training, advocacy and evaluation. The MLP concept has been endorsed by the American Medical Association and the American Bar Association.6 While there is no uniform MLP model, there are several common attributes: •   Formal collaborations between healthcare institutions and legal organizations;  •   A preventive approach, focused on identifying and responding to legal needs that have an impact on health;•   Interdisciplinary training of healthcare providers, social workers, attorneys and students;•   Interdisciplinary collaboration to support services and expand advocacy efforts on behalf of patients and families;•   Collaboration among attorneys and Health Care Providers (HCP) to: -  Provide template forms with appropriate language to support applications for benefi ts and services; -  Participate in meetings and hearings to support social, educational and environmental changes that improve communities; -  Advocate for social, legislative and policy changes to improve the lives and health of their communities.1, 6, 7The eligible populations, spectrum of legal services and models of delivery vary based upon community need, legal staffi ng and experience, contractual agreements with the respective health systems and funding. MLPs provide legal services to underserved populations in both urban and rural areas, generally in FQHCs, community clinics and hospital settings. MLPs work with a variety of patient populations, underserved populations (citizens who are homeless, have physical or mental disabilities, veterans and refugees) and health care practices. MLP attorneys primarily address issues around access to public benefi ts and services, including Social Security, environmental and housing, landlord-tenant, family, domestic violence, education, employment, disability and other consumer and civil rights matters. Legal matters not supported by the MLP are referred to local legal clinics or attorneys.In 2010, the US Department of Health and Human Services’ Health Resources and Services Administration (HRSA) awarded three demonstration grants to incorporate MLPs in Healthy Start programs. Based upon the value of MLPs in healthcare settings, HRSA recognized the benefi ts of extending the model for attorneys partnering with social and outreach workers to reduce infant mortality and to improve perinatal outcomes in underserved populations.8  In 2010, more than 30,000 individuals and families received legal assistance from 85 MLPs affi liated with over 200 health centers, community and federally-qualifi ed health clinics and hospitals in 38 states. 6,8The positive impact of MLPs on healthcare is recognized by patients, HCPs, health systems and government offi cials. Patients have reported satisfaction with attorney-client communications and expressed gratitude for access and support of legal staff to resolve their problems.  Successful legal outcomes include the securing of public benefi ts (eg, medical assistance, social security disability benefi ts and services, educational evaluations Medical-Legal Partnerships as a Value-Add to Patient-Centered Medical HomesContinued on next pageVol. 24, No. 4 |  FALL 2011and placements); remediation of environmental household hazards; resolution of landlord-tenant and public housing disputes; protection of victims of domestic violence; and resolution of custody and guardianship issues.1 MLPs are reporting the financial benefits of legal services provided to their clients and their healthcare partners. In 2010, MLPs collectively recovered $5.3 million for patient-clients and $692,000 for healthcare partners.9 MLPs are demonstrating their value by evaluating return on investment. 10, 11  In Illinois, a full-time partnership reported a 150% ROI of MLP services by tracking Medicaid reimbursement.11 The time has come to invest in incorporating MLPs into PCMH practices.  The potential benefits to improve access and health outcomes, and reduce costs for patients and healthcare systems are great.  The strategy is feasible, with minimal logistical challenges, and healthcare systems that have institutionalized MLPs are reporting returns on their investments. In the current economic environment, considering the actual and anticipated rates of uninsured/under-insured, and the prevalence of chronic illness and stress, integrating MLPs into PCMHs and primary care practices is a meaningful, cost-effective investment. Federal legislators and healthcare systems should be encouraged to invest in this enhanced model of care.  Martha C. Romney Martha C. Romney, RN, MS, JD, MPH is Assistant Professor at JSPH and a Medical-Legal Partnership Program Evaluator. For more information contact martha.romney@jefferson.edu. RefeRences1.    Paul E, Fullerton DF, Cohen E, et al. Medical-legal partnerships: addressing competency needs through lawyers. J Grad Med Ed. 2009;304-309. http://www.jgme.org/doi/pdf/10.4300/JGME-D-09-00016.1. Accessed August 26, 2011.2.    Fields D, Leshen E, Patel K. Driving quality  gains and cost savings through adoption of medical homes. Health Affairs. 2010;(29): 819-826. http://content.healthaffairs.org/content/29/5/819.full.pdf+html. Accessed August 26, 2011.3.    Crabtree BF, Nutting PA, Miller WL, et al. Summary of the national demonstration project and recommendations for the patient-centered medical home. Ann Fam Med. 2010;8(Suppl 1); S80-S90. http://www.annfammed.org/cgi/reprint/8/Suppl_1/S80. Accessed August 26, 2011. 4.    US Department of Health & Human Services. News Release: New Affordable Care Act support to improve care coordination for nearly 200,000 people with Medicare. June 6, 2011. http://www.hhs.gov/news/press/2011pres/06/20110606a.html.  Accessed August 29, 2011.5.    Legal Services Corporation. Documenting the justice gap in America. The current unmet civil legal needs of low-income Americans. September 2009.  http://www.lsc.gov/pdfs/documenting_the_justice_gap_in_america_2009.pdf. Accessed August 26, 2011. 6.    Sandel M, Hansen M, Kahn R, et al. Medical-legal partnerships: transforming primary care by addressing the legal needs of vulnerable populations. Health Affairs. 2010;29(9):1697-1705.  http://content.healthaffairs.org/content/29/9/1697.full. Accessed August 26, 2011. 7.    Fitzgerald J. The future of health care: Medical-Legal Partnership for Health Act. The Boston Health Law Reporter. 2011;6(1):13-15.8.    Maternal and Child Health Bureau, Division of Healthy Start and Perinatal Systems. Supplemental funding announcement.  Promotion advocacy through medical-legal partnership. http://www.medical-legalpartnership.org/sites/default/files/news_story_file/HRSA%20Healthy%20Start%20MLP%20Funding%20Opportunity.pdf. Accessed September 13, 2011.9.    National Center for Medical Legal Partnership. Medical-Legal Partnership: a new standard of care.  2011 MLP Network Site Survey. http://www.medical-legalpartnership.org/mlp-network/network-site-survey.  Accessed August 11, 2011.10.  Teufel J, et. al. Process and impact evaluation of a legal assistance and health care community partnership. Health Promot Pract. 2009;10; 378-385.11.  Knight R. Health care recovery dollars: a sustainable strategy for medical-legal partnerships? White paper-Capacity and sustainability working group. The Medical Legal Partnership for Children at Boston Medical Center.  April 3, 2008:1-20. http://www.medical-legalpartnership.org/sites/default/files/page/Health%20Care%20Recovery%20Dollars%20White%20Paper%20--%202008(3).pdf.  Accessed August 30, 2011.

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Medical-Legal Partnerships as a Value-Add to Patient-Centered medical Homes

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