Mixing healthcare and legal services is often viewed as mixing oil and water, but healthcare providers are finding that legal problems can hinder patients from achieving optimal health. The National Center for Medical Legal Partnership is spearheading an effort to link patients with health-impacting legal problems with legal resources. Here in Minnesota, the Upper Midwest Healthcare Legal Partnership Learning Collaborative promotes collaboration between healthcare and legal service providers in Minnesota to improve health and reduces overall healthcare costs. Their 2nd annual meeting was held earlier this month in St. Paul, highlighting several clinics’ pioneer efforts to impact their health.
Importance of team care. Facilitating communication among healthcare professionals is hard enough, but how do you bring in legal service providers into the mix? They will have different language and bring different interventions, and healthcare documentation doesn’t necessarily support those interventions. Healthcare Legal Partnerships (HLPs) in Minnesota and Medical Legal Partnerships (MLPs) in another 40 states are exploring the healthcare environment to see how to make this work. Clinics with vulnerable populations are leading the way by screening for health-harming legal needs or, more broadly, social determinants of health that can be impacted with legal services. The approach varies from setting to setting, with some screening all patients and some screening specific populations (such as with a diagnosis of cancer or a clinic for low income patients). There are also a variety of workers used as well as several ways to complete a referral.
Measuring outcomes. To make funding more reliable and services routinely available, data must be available to measure outcomes for defined problems. Today, these measurements are subjective, but consensus is building around ways to measure whether legal interventions and outcomes impact health outcomes. Today, pilots are going to funders with “anecdotes plus data to back them up” but look to the future when outcomes clearly justify funding. Some legal aid case management systems are receiving health information from EHRs, and some clinics are documenting directly in EHRs, but either way, metrics and outcomes are still being developed.
With the recognition that social determinants of health drive health outcomes in vulnerable populations, using legal services to address them can make a big difference in the health of individual patients. These pilots are also beginning to show that using HLPs/MLPs are associated with greater use of low cost services, lower use of high cost services and a net reduction in overall healthcare expenditures. In one case, a patient’s father could not get their landlord to replace the carpet in the family’s apartment that was causing his son’s asthma attacks. The clinic’s lawyer, however, was able to do so within a few days of calling the landlord, resulting in fewer clinic visits because the son’s asthma was controlled.
A Minnesota example: CentraCare in St. Cloud, Minnesota. CentraCare is a not-for-profit health system that provides comprehensive, high quality care to people throughout central Minnesota. They have partnered with Mid-Minnesota Legal Aid to provide needed health-related legal services to patients, first at a family medicine clinic, and later at 4 of their regional hospitals. They have identified benefits for both patients and clinicians. Patients previously labeled “non-compliant” with prescribed treatment plans have more services to address problems and create solutions. As patient and caregiver workload is reduced, the barriers to managing complex care are reduced. In addition, legal support for patients has substantially reduced clinician burden – enough so that it is now part of their clinician retention strategy.
A less obvious example: Northern Dental Access Center in Bemidji, Minnesota. This non-profit, community agency is operated by a consortium of community stakeholders who share a commitment to assuring access to oral health by children and families in northern Minnesota. They provide dental care with wrap-around services to create a “dental home” modeled after primary care and behavioral health care homes. Executive director Jeanne Edevold Larson uses data to show impact and improve quality of outcomes. They spend more than $50,000 per year on data analytics, and that has proven to be worth it by improving ways to show not only legal outcomes but also how legal outcomes impact health outcomes. Although analyses are now subjective, with time they will become more objective to enable better reporting that funders need to continue their support.
Legal services for all patients. Although vulnerable populations have more health issues related to social determinants, all patients may be at risk for significant health-harming legal issues. For example, cancer patients are often financially ruined by cancer treatment, which led to the establishment of Cancer Legal Care 10 years ago. Patients facing other serious, life-altering diseases or end-of-life planning also benefit from legal services that optimizes their health care experiences. Although clinicians may be aware of a patient’s legal issues, they do not know how to address them or refer to appropriate resources. These pilots are showing that adding legal expertise to health teams improves outcomes, reduces costs and reduces the impact of poor social determinants of health for all populations. The next steps are to (1) improve documentation and communication for these new team members and (2) establish regular ways to finance their services, whether it’s through direct patient billing, part of bundled payments for specific populations or payment through separate funds, such as grants. As these programs begin to quantify and report clinical and financial benefits, ways to fund and facilitate these services will follow.