Article Figures & Data
Figures
- Figure 1.
Impact, barriers, and facilitators of the medical-legal partnership.
Tables
Characteristic # (%) Gender Woman 13 (81.3%) Man 2 (12.5%) Transgender 1 (6.3%) Race White 9 (56.3%) Black or African American 6 (37.5%) Other 1 (6.3%) Ethnicity Hispanic, Latino/a, or Spanish origin 6 (37.5%) Age 18 to 24 1 (6.3%) 25 to 34 6 (37.5%) 35 to 49 4 (25.0%) 50 to 64 2 (12.5%) 65 and older 3 (18.8%) Professional Role Clinician or staff 4 (25.0%) Attorney or paralegal 4 (25.0%) Patient 8 (50.0%) *Due to the small cell sizes, we chose not to report gender, race, ethnicity, and age, by professional role.
Themes Sub-themes Additional Quotes (Representative quotes are listed under results) The impact of health-harming legal needs on health Patients experienced legal issues that were pernicious, pervasive, and complex Because they affected basic needs for survival, legal issues led to worse physical and mental health “What I'm trying to do is get to a safe place. [W]hen I get to a safe place, my body reboots…the challenge has been trying to find that safe place and with my [apartment] that my mom gives me, there's always some type of chemicals…[R]ight now I'm sleeping in my car because when I go in the apartment…my throat, my chest, my nose everything burns.” (Patient)
“Because it allows things to go deeper, that connection with the topics of medical health and…legal issues that can actually affect your health…I didn't [know] it was affecting me…it wasn't until this opportunity came…[I]t…opened my eyes…This is really more serious than I thought it was.” (Patient)Patients were not only dealing with their own issues but were also affected by the legal issues of friends and family members “she [the patient’s mother] needs help fixing her house up…she owes a lot [of] taxes on the house. And therefore it's hard for her to get somebody to help her fix the house because of the tax… [Her house has] been messed up [since Hurricane] Harvey. And…it's got mold in it. [So] she can't live in there. So she's staying with me…and we've been hoping and praying [for] somebody to help us” (Patient) For some, health-harming legal needs accumulated and persisted “One thing that we've noticed is that a lot of…legal aid clients…come back….” (Attorney or paralegal) The impact of the MLP Through trusting relationships, the MLP was able to improve health and resolve legal issues, for some Addressing health-harming legal needs can help patients get the medical care they need and improve their physical and mental health “I had been in and out of the hospital several times…I was talking to my doctor about it…And that's when he referred me so I was willing to try anything, because I was already looking for an attorney. But I was having so much trouble trying to find the [right] type of attorney that I needed. And so it I'd been looking for like a month and everybody was just like…[it was a] giant case. So I guess they didn't want to take it. Like I [said], I'm glad the person took it who did because he has been doing a phenomenal job” (Patient)
“it was a difficult appeal case against [a health insurance company]…I did not even expect to get the outcome that we got for the client and she was just overjoyed…that experience sticks out because it was to provide care for her minor son.” (Attorney or paralegal)The MLP addressed a broad range of legal issues related to poverty “We're kind of generalists…Whereas other parts of [the legal services organization]…we have all specialized units…[W]hen you're working in the MLP…you get cases that can be anything from a housing issue, like mold in an apartment to a social security disability denial appeal…to a guardianship proceeding.” (Attorney or paralegal) When they were able to connect with patients, the legal professionals served as advocates and gave patients hope “it also gave…a sense of hope. [The patients] actually matter to somebody…[the patients] have somebody in their corner fighting for them as well.” (Attorney or paralegal)
“It made me feel like somebody cared…Some of the other attorneys who I've talked to…they were nowhere near as thorough. And I believe once…my apartment started acting crazy, then they probably would have [given] up on it. So I appreciate them sticking by and doing what they're doing.” (Patient)Barriers to implementation Mistrust, communication gaps, and inconsistent staffing limited the impact of the MLP Some clients did not trust the MLP due to a lack of follow-up or information, which contributed to suspicion and disappointment “if a patient has a question about [the MLP], and [the clinic staff is] not…excited about it…I think that that could deter a client…And also, sometimes they will complete the form because they do need legal help. And so we'll have our intake person call them to begin the process. And they will be like, Oh, I had no idea what this was that I filled out…And then…we got to…deal with the distrust because like, Oh, how did you get my information? I don't remember filling this out.” (Attorney or paralegal)
“if they would have sent me a letter telling me [someone will call] at this hour…Because at [that] time…this phone belonged to my sister because she borrowed mine, [because hers needed a charger], she dropped it and broke mine…So this phone does not take messages, because she doesn't remember the code…I just look at missed calls…And I was very disappointed because I feel like…they say [they’ll help] you.” (Patient)The MLP had a difficult time getting in touch with patients, particularly those who did not speak English “I [should have] kept up with it…that's…my fault…They contacted me. They [sent] me a letter and I should've…answered the phone call…I should've answered the letter…So, I mean, they did their part…I didn't do my part” (Patient)
“We'll get the referral and try to contact them as soon as possible. A lot of times…we won't get a response…We call at least two to three times, and then we also send them a letter…We'll email them…So establishing that contact so that we actually can have an attorney, client relationship is a huge barrier.” (Attorney or paralegal)A lack of buy-in and education at the individual staff and organizational leadership levels affected engagement “at first there was more of a kind of like standoffish cold shoulder…here's…the referrals you handle it” (Attorney or paralegal)
“one of the clinics…was hesitant…the clinic staff wasn't willing to…provide assistance. [They] were there like…we're already screening the clients for you.” (Attorney or paralegal)Because of the number of people involved, coordination between legal and medical staff was challenging “[There is] some challenge…being virtual…key players not being available when needed…for example…the legal counsel. And that person may not always be available whenever we're trying to make a decision, but we need their input to make a decision…it can linger on for weeks or months” (Attorney or paralegal)
“you're gonna [face] a lot of administrative…hurdles…you're working with so many…cooks in the kitchen that you…have to really break down barriers, make time to look at processes and collaborate.” (Attorney or paralegal)Laws governing medical and legal data affected the flow of information “with the MLP…there's a lot of more…red tape. There's a lot of…data that [they need] to collect on the health care end, that we don't have to collect on our end at [the legal services organization]. And so I just noticed that sometimes it's kind of hard for me and my team at [the legal services organization] to understand why is this form needed? Why is this information being gathered?” (Attorney or paralegal)
“[Clinics] have obligations under HIPAA…that…prohibits what we do. And so when you've got four different sets of legal counsel…it's difficult to create processes and procedures to manage that flow of information that work for all parties…How are we getting the referrals? Are you guys sending them in a way that's HIPAA compliant, but are we able to access them?” (Attorney or paralegal)Referrals and staff capacity varied, and when referrals exceeded capacity, bottlenecks emerged “So I was out for nine months. I just came back…in October. And we got new staff. So right now the challenge is just kind of figuring out what…the right balance is…how to divvy up…the tasks between myself and the other paralegal.” (Attorney or paralegal)
“the numbers [of referrals] go up and down….[Ultimately, we hope that] we could get that more steady trickle of referrals versus…how it is now [where] some weeks we'll have five [and] some weeks we'll have 20…it just kind of is inconsistent.” (Attorney or paralegal)Facilitators of implementation The MLP identified coordination and communication strategies to enhance trust and amplify its impact Language resources addressed communication gaps “I also tried to make sure that we used qualified interpreters. We…have access to…language line so we can get interpreters for any call….so making sure that the interpreters were available, that I used them in a way that wasn't…condescending or arduous…I called the interpreter first and then had them conference her…really just taking those extra steps and precautions to…get through to the client…And thankfully [the patient] did work with us. We were able to get her a positive outcome.” (Attorney or paralegal) Co-location and predictable office hours expedited the intake process “[W]henever the client was screened…they knew [the legal services organization was] going to be here on Fridays…Do you want to go in and just speak with [the legal services organization] and come in on Friday?…It was a lot easier than…trying to call them…once…twice, three times a week…I had them actually just coming into the clinic and…talking with us…even if it was…5, 10, 15 minutes…it…made the referral process a lot easier…, which is one of the main reasons why…we made those office hours once a week…there wasn't a lot of wait time towards the end.” (Attorney or paralegal)
“[R]eally incorporate the [MLP into] clinics…not doing [it] every day, but maybe…two or three times out of the week…we saw that sometimes…patients weren't available the days that the [legal services organization] staff was available. So giving them a wider option of…being able to have that [in-person] contact with the legal aid within the clinic would be…beneficial. [O]ne of the biggest [recommendations from] me is actually having…adequate space to…[house the MLP] within the…clinic.” (Attorney or paralegal)Periodic meetings broke down organizational siloes “making sure that the lines of communication are open and having meetings with all necessary parties have really helped…So not having siloed meetings where it's just us and one representative from the clinic that may not be authorized to consent to a change or without general counsel…on the call…[T]hat's the key to effective integration is just making sure that all necessary parties are communicating early [and] often.” (Attorney or paralegal) The reputation of the clinic facilitated patient recruitment “one of…the positives of the actual partnership was…having those established clinics in the communities where we could come in and…piggyback off of their reputation to provide those services and get our organization into the community.” (Attorney or paralegal) Having staff buy-in and a clinic champion improved communication and strengthened coordination “[S]omeone has to be appointed to keeping the forms organized and making sure they're completed…That their [medical record numbers] and stickers are on the forms, because if there's not…they're incomplete. They don't have the full phone number on it. We can't read the patient's name…you can lose time and referrals…if more than four weeks lapse between a patient completing their form in the clinic, and us calling them, they're going to be highly suspicious.” (Attorney or paralegal)
“the social workers or the community workers that were…processing…the referrals…they got invested in the…program…..[B]y them getting invested…calling us up, trying to check up…on the status of their cases, that was one of the beneficial things[.]…[A]ctually building that relationship between…the medical side and the legal side, and…doing our best to work together, to resolve an actual problem [for] the client…was one of the best…improvements we did for the program.” (Attorney or paralegal)Patient education about the MLP reduced uncertainty and confusion “[W]e also created…a reference document that…tells them what happens next. So it's this…infographic flyer…that says,[the clinic] is gonna take this referral form that you completed. And they are going to provide it to [the legal services organization]…And then…[the legal services organization] is going to reach out to you. The call will be coming from a number starting with this, so that they'll recognize the phone number. [T]hen we'll collect your information, [to] make sure you qualify for our services and provide you…[with] free legal assistance…depending on your matter…[N]ow people know…this isn't a spam caller or a bill collector.” (Attorney or paralegal) Sharing lessons across sites disseminated best practices “with our other MLPs, there was also…that learning curve, and because we've already been through [implementation] with them…I'm able to bring [those lessons] to [this MLP]. [T]his has worked and the referrals are consistent over there. We have a great referral process over there…let's try to implement it here.” (Attorney or paralegal) Effective data systems facilitated the timely exchange of information “[We’re using] [a web-based platform] to transmit referral forms, which their legal counsel is comfortable with. And it works so much better from the perspective [of the legal services organization] because [the web-based platform] is easy to use.” (Attorney or paralegal) Attorneys and paralegals Can you describe your experiences working in legal aid? Can you describe your experiences working with the medical-legal partnership? What are the differences between working in the medical-legal partnership and in legal aid, generally? What are the challenges of integrating the medical-legal partnership? How were those barriers addressed (if applicable)? How did you approach patients who were hesitant working with you? How did you build rapport with those patients? What helped patients use legal services? What made it more difficult to connect with patients? What helped the integration of the medical legal partnership? Is there anything else you would like to add? Is there anything else that I did not ask you that you want me to know? Patients Tell me about your first impressions of the medical-legal partnership. What were you thinking when you were asked to complete the medical-legal partnership screening form? What were you thinking when you were approached about participating in the medical-legal partnership? Did you have reservations about participating? (If yes) Can you describe what your hesitation was regarding participation? Can you talk about your willingness to participate? What might have caused you to not want to participate? Can you describe your experience with the medical-legal partnership? How did having access to the medical-legal partnership at your doctor’s office affect you? Is there anything else that I did not ask you about that you want me to know? Clinicians and staff Tell me about your experiences working with this clinic population. What non-medical problems affect your patient’s health and access to healthcare? What was your first impression of the medical-legal partnership? How has that changed since its implementation? What barriers and facilitators affected its integration? What could change or improve its integration? (For clinicians) How has having access to the medical-legal partnership affected your care decisions? (For clinicians) How has knowing about your patients’ legal needs affected your care decisions? How has having access to the medical-legal partnership affected your patients? Is there anything else that I did not ask you about that you want me to know?
