Medical-Legal Partnership Model Is Growing — Including in EDs

August 19th, 2024

By Stacey Kusterbeck

Medical-legal partnerships (MLPs), which embed legal experts into healthcare teams, can result in benefits for patients, healthcare providers, and hospitals. “MLPs are about changing the culture in both the medical and the legal settings, so that each side sees the relationship between the services they provide and a healthy life,” says Abbe R. Gluck, JD, the Alfred M. Rankin professor of law and the founding faculty director of the Solomon Center for Health Law and Policy at Yale Law School.

“MLPs bring lawyers into healthcare settings and convince populations that normally would not seek legal services that lawyers are there for them too,” adds Gluck.

However, implementing an MLP poses significant logistical challenges. At the University of Chicago Medicine Trauma Center, clinicians were in the process of implementing an MLP and needed specifics on the “nuts and bolts” of doing so. “We were looking for some really tangible answers regarding staffing, training, and how to structure an MLP,” says Elizabeth Tung, MD, MS, a researcher and practicing internist in the Section of General Internal Medicine at the University of Chicago.

Prior review articles on MLPs described outcomes but did not give a clear picture of how MLPs were put together. This led Tung and colleagues to review articles from 2007 to 2022 on MLPs.¹ The researchers learned that while MLPs mainly occur in outpatient clinic settings or in children’s hospitals, they’re being added to other healthcare settings. “The first MLP was implemented in a pediatric clinic. But today, MLPs are also in mobile vans, emergency departments, and trauma centers, among other settings,” says Tung. Other key findings:

• MLPs provide a wide variety of services, including helping patients to access Medicaid and legal representation for family law or immigration matters.
• MLPs are linked to better physical and mental health outcomes and fewer hospitalizations.
• Healthcare systems see cost savings and increased Medicaid reimbursement.

The team’s review of how existing MLPs were built helped them to move forward with their own. In 2022, UChicago Medicine Trauma Center implemented its MLP, working with Legal Aid Chicago.² Two full-time lawyers work at the trauma center, providing legal help for patients recovering from violent injuries. “The majority of trauma patients had been denied public benefits in the past, even when they qualified for benefits,” reports Tung.

Clinicians ask patients at intake if they need, want, or have been denied benefits for the 10 most common public benefits with which legal aid attorneys can help. One or two days later, legal experts meet with the patient at the bedside.

“The legal expert guides the patients through a complicated system and advocates for them when doors are slammed in their face,” says Tung.

One patient had been denied disability after a firearm injury. Social workers tried to help the patient obtain the benefits at that time but were unsuccessful. After a second firearm injury, the patient was enrolled in the MLP program. Legal experts worked with the patient to obtain disability benefits, which allowed the patient to find stable housing and treatment for post-traumatic stress disorder.

“MLPs look very different from one setting to the next. It’s important to adapt the model for the specific needs of a given patient population,” observes Tung. At UChicago Medicine Trauma Center, public benefits and housing are the biggest needs. In a different setting, the biggest needs might be related to legal status or family stability. “It’s important to get a sense of the patients being served. You might start with a public benefits attorney but find that you need an immigration attorney on the team,” says Tung.

At Yale New Haven Hospital, clinicians implemented an MLP in 2014 after a palliative care physician repeatedly called Gluck seeking legal help for patients. Patients at the end of life were facing a variety of very stressful situations. Some needed to make arrangements for their children; others were struggling with how to manage debt. “After a series of recommending attorneys for one-off emergency representations, the situation impressed on us that there was a need to do something more permanent and more stable,” reports Gluck. Since Gluck’s arrival at Yale in 2012, the Law School (together with Yale New Haven Hospital, Yale School of Medicine, and the Center for Children’s Advocacy) has launched eight MLPS in different settings.³ The Yale MLPs serve undocumented immigrants; persons returning from incarceration; and pediatric, oncology, and geriatric patients, among others.

Some medical departments have begun screening patients for social determinants of health, even without MLPs in place. However, providers may identify urgent needs without anyone to refer the patient to. “That can be a stressful situation for doctors, and makes the doctors feel that they are falling down at their obligation to help the patient,” says Gluck. This situation commonly occurs in the emergency department (ED) setting. “Finding a way to integrate MLP referrals into the ED is a big challenge — but one certainly worth addressing,” says Gluck. Here are some unique considerations for EDs implementing MLPs:

ED patients may be more reluctant than patients in other settings to speak with attorneys.

Many patients are uncomfortable talking to lawyers in general. One role of the MLP is to build trust with lawyers by having the introduction made by the patient’s physician. “But the ED is sometimes different,” says Gluck. “Some ED visits result from trauma, which may make it harder for the clinicians to establish enough trust to allow the connection to the lawyer to be made.”

Typically, MLPs have established hours when patients are seen and lawyers are present.

Since the ED never closes, it is unlikely the MLP could be staffed continually by social workers and lawyers. Therefore, the ED has to work out how to integrate the MLP with the nonstop nature of the ED’s operations. “These challenges can be overcome. It just requires, potentially, more effort than an MLP in an outpatient clinic would,” says Gluck.

One approach is for EDs to simply refer patients to the MLP lawyers after the ED visit. However, patients will not always follow up. At Yale, some MLPs were initially referral-based, with patients given contact information for legal services. Many never reached out to the lawyers.

“The beauty of an in-house MLP is that everyone is already there. It’s very meaningful for the patient to meet the lawyer in the medical setting before going home. The difficulty of a referral is that you have to bring them back,” explains Gluck. While an ED with a referral-based MLP could be successful, it would take some planning to ensure patients follow up. “Scheduling a legal consultation at the same time and in the same place as the follow-up medical appointment might help,” suggests Gluck.

Complex legal needs can’t be addressed during the ED visit.

In inpatient settings or other less urgent settings, the lawyer can meet with the patient over a timeframe of days or weeks. The ED visit may last just a few hours. “At Yale, in our palliative MLP, we’ve done some meaningful turnaround projects for patients who we have met very shortly before their death,” reports Gluck. “So it’s possible to address some of the patient’s needs in a short timeframe. But it’s challenging.”

REFERENCES

1. Johnson DY, Asay S, Keegan G, et al. US medical-legal partnerships to address health-harming legal needs: Closing the health injustice gap. J Gen Intern Med 2024;39:1204-1213.
2. The University of Chicago. Legal Care in Violence Recovery. https://www.recoverylegal.uchicago.edu
3. Benfer EA, Gluck AR, Kraschel KL. Medical-legal partnership: Lessons from five diverse MLPs in New Haven, Connecticut. J Law Med Ethics 2018;46:602-609.