The Impact of the UTHealth Medical Legal Partnership on Utilization and Health Harming Legal Needs
Winston Liaw, MD, MPH(1); Angela Stotts, PhD (2); Thomas Northrup, PhD(2); Alvin Chen(2); Robert Suchting, PhD(3); Christine Bakos-Block, PhD, LCSW(2); Christian Pineda(4); Alissa Chen, MD(5); Asra Waliuddin, MD(2); Dongni Yang, MD, PhD(2); and Thomas Murphy, MD(2)
1) Department of Health Systems and Population Health Sciences, University of Houston College of Medicine; Houston, Texas | 2) Department of Family and Community Medicine, University of Texas Health Science Center at Houston; Houston, Texas | 3) Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston; Houston, Texas | 4) Lone Star Legal Aid; Houston, Texas | 5) Yale School of Medicine; New Haven, Connecticut
Addressing social determinants of health (SDH) is a critical strategy for lowering costs, improving patient experience, and improving population health.(1,2) A vast body of literature connects SDHs to undesirable health outcomes,(1,3-8) leading to calls for tighter integration between public health and family medicine.(2)
One intervention that links family medicine with public health is the medical legal partnership (MLP), which addresses health-harming legal needs (HHLNs) by embedding lawyers in clinics.(9) These needs disproportionately affect low-income households, which average between one and three legal problems.(10) The evidence base to assess MLPs is growing,(9,11) and one pediatric randomized controlled trial found that access to legal services reduced emergency department (ED) visits.(12)
In collaboration with Lone Star Legal Aid, a legal services non-profit organization, the University of Texas Health Science Center at Houston (UTHealth) launched an MLP in 2018. This study assesses whether access to the MLP was associated with lower urgent care, ED, and hospital visits compared to individuals without access. In addition, we describe the HHLNs identified and services provided by the MLP.
Overview: In this cohort study, three clinics had access to the MLP. A fourth did not and served as the control.
Participants and Eligibility Criteria: We recruited adults aged 18 or older, who were English- or Spanish-speaking, had valid email addresses, and screened positive for HHLNs.
Setting and Recruitment: UTHealth is affiliated with 18 community-based, outpatient clinics. The three MLP clinics include family physicians, and average nearly 17,000 visits annually. The control clinic averages 15,000 visits annually. Staff offered patients with appointments a legal needs screening tool.(13)
Study Course: Screening started on April 16, 2018 at the intervention clinics and on July 17, 2018 at the control clinic. Six months after a positive screen, we sent an email survey. Survey responders were entered into a raffle for a $100 gift card.
Outcomes: We used the following to measure utilization and HHLNs.
HHLN Screening: Given the lack of a universally-accepted HHLN screening tool, we collaborated with researchers and legal professionals to develop one. During this process, we consulted with other MLPs and the National Center for Medical-Legal Partnership and incorporated elements from existing instruments.(14-16) When needed, we obtained permission.(17,18) The screening tool is 23 items and encompasses legal issues, including income, insurance, safety, guardianship, housing, and food.
Utilization: Via email, participants recorded the number of urgent care, ED, or hospital visits over two time intervals: 1) from six months before screening to the time of screening, 2) from the time of screening to six months after screening (Figure 1).
HHLNs Identified and Legal Services Provided: Using data from Lone Star Legal Aid, we tracked the referrals to, the HHLNs identified by, and the legal services provided by the MLP from April 16, 2018 to February 1, 2019. Individuals can have multiple cases, and each case refers to a unique legal concern. The legal professionals grouped referrals into four categories: Open, Closed, Pending, and Rejected. “Open” cases were actively managed legal issues. “Closed” meant that the problem had been resolved or assistance had been completed. “Pending” indicated that the client was completing enrollment paperwork. “Rejected” indicated that the MLP was unable to accept the referral. Applicants were most commonly rejected for not responding to communication. Due to Lone Star Legal Aid’s funding model, the MLP could not enroll clients earning more than 200% of the federal poverty level and could not accept cases pertaining to immigration, personal injury, or medical malpractice. The MLP identified legal issues using an intake form and interview and tracked legal benefits to clients using a categorization system developed by the National Center for Access to Justice.(19)
Covariates: We collected age, gender, race or ethnicity, and language through EHR extraction.
Intervention: Those screening positive were referred to the MLP, which consisted of a lawyer and paralegal. The MLP was physically offsite, and staff communicated with clients face-to-face or over the phone. All services were free.
Control: Social workers were available and received referrals as needed.
Analysis: We calculated descriptive statistics and conducted bivariate analyses by MLP access, using chi-squared tests for categorical variables. Poisson regression was used to model post-period counts for urgent care, ED, and hospital visits as a function of the MLP group while controlling for the pre-period count. Testing did not find evidence that age, sex, or race or ethnicity confounded these relationships.
The Committee for the Protection of Human Subjects approved this protocol through the Quality Improvement Project Registry.
Nine hundred and eleven individuals received email surveys, with 210 responding (response rate of 23%: 28% for the intervention and 18% for the control). Respondents were primarily female, black, and English-speakers (Table 1).
Over the preceding 12 months, the respondents from the intervention group had higher urgent care and ED visits and lower hospital visits (Table 2). These trends were consistent across the pre-screening and post-screening periods.
Poisson regression found that having access to the MLP (relative to no access) was related to a 58% increase in the number of ED visits (Rate Ratio (RR)=1.58, p<0.001), no change in urgent care visits (RR=1.00, p=0.963), and a 41% decrease in the number of hospital visits (RR=0.59, p<0.001) (Figure 2).
The intervention group most commonly reported that health insurance, personal safety, and transportation were concerns (Table 3). In the control, the most common concerns included income, health insurance, and the oven or stove not working.
Four hundred and ninety individuals were referred to the MLP, generating 559 unique cases. Over 40% of the cases were closed, open, or pending (Table 4). Among the open and closed cases, 80% were related to government benefits, family issues, housing, or estate planning. Nearly a quarter of the legal benefits related to maintaining income. The next most common benefits were for family matters and housing matters.
The MLP addressed a wide variety of legal issues, helping its clients obtain Supplemental Security Income, spousal support, housing, education, and insurance. While we did not assess the MLP’s impact on health, there is a theoretical link between these benefits and better health. Improved health may explain our finding that access to the MLP was associated with a 41% decrease in the number of hospitalizations, compared to the control.
Several of our findings differ from MLP studies conducted in pediatric populations. For example, a pediatric MLP reported that 37% of cases were related to housing compared to 19% in our MLP.(11) Our utilization findings also differ. A previous randomized controlled trial concluded that access to pediatric legal services was associated with a reduction in the likelihood of having an ED visit.(12) In contrast, we found an increase in the number of ED visits. Though the factors for this finding remain undetermined, we hypothesize that the increase could be related to having more resources to seek care. Additionally, unmeasured confounders could also account for this increase, including baseline health, insurance status, and co-morbidities. Our finding that the MLP was associated with reduced hospital visits needs to be evaluated using more rigorous studies. If confirmed, however, the MLP could reduce spending in a health care system where one in every three dollars is spent in the hospital and the average cost of a hospitalization is $9,700.(20,21)
These data also highlight areas for improvement, as nearly 60% of the cases were rejected, and several changes could help. For example, a modified screening instrument could improve accuracy. Having the MLP co-located at the clinics could enable warm hand-offs. Tighter integration between the clinic and MLP could allow staff to share salient information. With access to clinic schedules, MLP staff could facilitate in-person communication.
There were numerous limitations. Some did not sign a client release form, allowing the MLP to share legal data with us; therefore, our results do not include all clients. Second, our results are limited by a low response rate, and the results may differ if we had a higher response. Third, the utilization results are subject to recall bias, as respondents were asked to remember events that took place over the span of a year. The results may differ if we used claims data. Finally, because we wanted an appropriate control, our sample consisted of individuals who screened positive. The utilization results may differ if we had sampled those enrolled in the MLP instead.
In conclusion, the UTHealth MLP has provided critical legal services that affect the basic needs for survival and facilitate access to care. The MLP is associated with decreased hospital visits but also increased ED visits. While promising, these findings need to be confirmed in other sites, using more rigorous methods. Hospital and ED visits are two of the outcomes being assessed in the next phase of this project — an MLP randomized controlled trial that started enrolling participants in February of 2019.(22)
Acknowledgements: We would like to thank Adeel Qureshi, Bernice Yau, David Wang, Caj Johansson, Isabelle Zare, Jocelyn Abraham, and Michael Connelly for their assistance with data entry and Casey Goodman and Aaron Tracy for their assistance collecting preliminary data. We would like to thank Sandra Stansberry for her assistance with data extraction and UT Physicians for their assistance with data collection and referrals.
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