1 THE IMPACT OF THE UTHEALTH MEDICAL LEGAL PARTNERSHIP ON UTILIZATION AND HEALTH HARMING LEGAL NEEDS FUNDER: WINSTON LIAW, MD MPH ANGELA STOTTS, PhD TEXAS ACADEMY OF FAMILY THOMAS NORTHRUP, PhD PHYSICIANS FOUNDATION ALVIN CHEN ROBERT SUCHTING, PhD CHRISTINE BAKOS‐BLOCK, PhD, LCSW CHRSITIAN PINEDA ALISSA CHEN ASRA WALIUDDIN, MD DONGNI YANG, MD, PhD THOMAS MURPHY, MD
2 Background • Vast literature connects unmet social needs to undesirable health outcomes • Calls for tighter integration between public health and primary care to address these social determinants of health (SDOH) • Medical legal partnership (MLP) • Embeds lawyers into clinics • Address health‐harming legal needs • Low‐income households average between 1 and 3 legal problems • Over 300 nationally • Evaluated in a randomized controlled trial (pediatric population) WHO Commission on Social Determinants of Health, World Health Organization, eds. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health: Commission on Social Determinants of Health Final Report . Geneva, Switzerland: World Health Organization, Commission on Social Determinants of Health; 2008. Institute of Medicine C on IP. Primary Care and Public Health: Exploring Integration to Improve Population Health . Washington (DC): National Academy Press; 2012. Sege R, Preer G, Morton SJ, et al. Medical‐Legal Strategies to Improve Infant Health Care: A Randomized Trial. Pediatrics . 2015;136(1):97‐106. doi:10.1542/peds.2014‐2955.
3 Model for How Health‐harming Legal Needs (HHLNs) Affect Health UTHealth launched a medical legal partnership (April, 2018) ↓ Basic needs for survival Unsafe housing Wrongly denied social Depression Stress security Wrongly denied food Economic strain stamps Housing subsidies Legal problems Limited self‐care Guardianship issues Inefficient utilization interfering with affecting access to care ↓ Quality of life employment Access to care
4 Objectives • Assess whether access to the MLP was associated with lower urgent care, emergency department, and hospital visits compared to individuals without access • Describe the HHLNs identified and services provided by the MLP
5 Methods • Design: Cohort study • Setting: • MLP access: 3 community‐based primary care clinics • MLP staff contacted patients via telephone to assess and address their legal issues • No MLP access: 1 community‐based primary care clinic • Participants: • 18 or older • Patients with an appointment were offered screening • Screened positive for HHLN • Valid email address
6 Methods • Developed a screening instrument • Literature review • Existing screening tools • Assess the most common health‐harming legal needs • National Center for Medical‐Legal Partnership • Screening tools used at other MLPs • Existing social need screening tools • I‐HELP (National Center for Medical‐Legal Partnership) • PRAPARE (National Association of Community Health Centers) • Accountable Health Communities screening tool • Collaborated with the university’s legal counsel and non‐profit legal services partner (Lone Star Legal Aid) Billioux A, Verlander K, Anthony S, Alley D. Standardized Screening for Health‐Related Social Needs in Clinical Settings. Accountable Health Communities Screen Tool Discuss Pap . 2017:2017.
7 Methods 6 months 6 months Date of prior to after screening • Measures screening screening • Utilization: Email survey responses Post‐screening Pre‐screening • Respondents were entered into a $100 raffle 6‐month • Urgent care, emergency department, hospital visits follow up survey emailed • Legal issues and legal benefits: • Screening instrument responses • Lone Star Legal Aid • April 16, 2018 to February 1, 2019 • Demographic variables (age, gender, race / ethnicity, language): Electronic Health Record • Analyses • Descriptive statistics and bivariate analyses, by MLP access • Chi‐square to test associations for categorical variables • Poisson regression was used to model whether MLP access was associated with reduced utilization, controlling for the pre‐screening count
Email Responders, by Demographics 8 Intervention Control N % N % p‐value Number of Respondents 124 86 Number of Individuals Receiving the Survey 437 474 Response Rate 28.4% 18.1% Gender Female 80 64.5% 57 66.3% 0.8 Age 18‐44 75 60.5% 35 40.7% 0.01 45‐64 41 33.1% 37 43.0% 65 or older 8 6.5% 14 16.3% Race / Ethnicity Black 75 60.5% 53 61.6% 0.9 Hispanic or Latino 18 14.5% 14 16.3% White 14 11.3% 9 10.5% Asian 1 0.8% 0 0.0% Other 14 11.3% 9 10.5% Not Answered 2 1.6% 1 1.2% Language English 107 86.3% 81 94.2% 0.3 Spanish 3 2.4% 1 1.2% Arabic 2 1.6% 0 0.0% Other 3 2.4% 0 0.0% Unknown 9 7.3% 4 4.7%
9 Mean Pre and Post Urgent Care, Emergency Department, and Hospital Visits in Intervention and Control Clinics Intervention Control Mean SE Mean SE Urgent Care Total 5.06 0.19 4.48 0.19 Pre‐screening 2.90 0.13 2.38 0.13 Post‐screening 2.15 0.11 2.09 0.13 Emergency Department Total 3.69 0.11 2.26 0.11 Pre‐screening 1.98 0.08 1.19 0.09 Post‐screening 1.72 0.07 1.07 0.08 Hospital Visits Total 1.33 0.09 2.34 0.11 Pre‐screening 0.61 0.06 1.19 0.09 Post‐screening 0.72 0.06 1.15 0.08
Mean Pre and Post Urgent Care, Emergency Department, 10 and Hospital Visits in Intervention and Control Clinics URGENT CARE EMERGENCY DEPARTMENT HOSPITAL Having access to the MLP was not Having access to the MLP was related Having access to the MLP was related related to change in # UC visits to a 58% increase in # ER visits relative to a 41% decrease in # hospital visits relative to those with no MLP access. to those with no MLP access. relative to those with no MLP access. Rate Ratio (RR) = 1.004, p = 0.963. Rate Ratio (RR) = 1.581, p < 0.001. Rate Ratio (RR) = 0.592, p < 0.001.
11 Health‐Harming Legal Need Screening Responses • Intervention Group: • Health insurance coverage: 61% • Personal safety: 58% • Transportation: 57% • Control Group • Income: 62% • Health insurance coverage: 61% • Oven or stove not working: 58%
12 Medical Legal Partnership Case Referrals, Issues, and Benefits N % Total Case Referrals 559 Legal Issues Identified (Open and Closed Cases)* Government Benefits (e.g., social security, food stamps) 52 22.9% Family (e.g., custody, divorce, domestic violence) 47 20.7% Housing (e.g., subsidized housing, landlord) 43 18.9% Estate Planning (e.g., wills and estates) 39 17.2% Health Insurance (e.g., Medicare and Medicaid) 18 7.9% Finances (e.g. bankruptcy, collection, debtor relief) 12 5.3% Employment (e.g., employee rights, wage claims) 12 5.3% Education (e.g., special education) 4 1.8% Legal Benefits Provided (Closed Cases)* Obtained advice and counsel or litigation advocacy services in an income maintenance matter 50 24.3% Obtained advice and counsel on a family matter not involving domestic violence 40 19.4% Obtained advice and counsel, non‐litigation advocacy services, or a decision in a housing matter 39 18.9% Obtained advice and counsel or non‐litigation advocacy services in a health matter 19 9.2% Obtained advice on a miscellaneous matter 19 9.2% Obtained advice and counsel or non‐litigation advocacy services on a consumer/finance matter 12 5.8% Obtained advice and counsel on an employment matter 11 5.3% Obtained a living will, health proxy, or health care power of attorney 8 3.9% Obtained advice and counsel or non‐litigation advocacy services on an education matter 3 1.5% Obtained advice and counsel or non‐litigation advocacy services in an individual rights matter 2 1.0% Obtained advice and counsel on a domestic violence matter 1 0.5% Obtained, preserved or increased spousal support 1 0.5% Obtained, preserved or increased Supplemental Security Income benefits 1 0.5%
13 Conclusions • MLP addresses a wide range of issues • 41% decrease in the number of hospital visits • Needs to be confirmed using more rigorous methods • Average hospital stay is $9,700 • 58% increase in the number of emergency department visits • Due to increase in resources? • Confounders? Pfunter A, Wier LM, Steiner C. Statistical Brief #146: Costs for Hospital Stays in the United States, 2010 .; 2013.
14 Limitations and Next Steps • Limitations • Low response rate • Recall bias • Did not control for baseline health, medical conditions, or insurance status • Next steps • Randomized controlled trial to assess the effectiveness of the MLP • Primary outcome: stress • Additional outcomes: anxiety, depression, quality of life, urgent care / ED / hospital visits, resolution of health‐harming legal needs
A Prescription for Wellness: Exercise Referrals for Patients at a Federally‐Qualified Health Center Presented by Zachary Sartor, MD TAFP Annual Session and Primary Care Summit 2019 Original Research Authors: Kelly R. Ylitalo, PhD; Mariela Gutierrez, BS; Wendy Cox, MPH; Gabriel Benavidez, MPH; Brock Niceler, MD; Jackson O. Griggs, MD
Disclosures • No personal conflicts of interest to disclose. • This project was supported, in part, by the Episcopal Health Foundation and by the National Institute on Aging of the National Institutes of Health. • The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.
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