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Research ArticleOriginal Research

Medical-Legal Partnership Effects on Mental Health, Health Care Use, and Quality of Life in Primary Care: A Randomized Clinical Trial

Winston Liaw, Thomas F. Northrup, Angela L. Stotts, Christine Bakos-Block, Robert Suchting, Alvin Chen, Abigail Hernandez, Lisandra Finzetto, Charles Green and Thomas Murphy
The Journal of the American Board of Family Medicine April 2023, jabfm.2022.220349R1; DOI: https://doi.org/10.3122/jabfm.2022.220349R1
Winston Liaw
From the Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Texas (WL); Department of Family & Community Medicine, University of Texas Health Science Center at Houston, McGovern Medical School (TFN, ALS, TM); School of Biomedical Informatics, University of Texas Health Science Center at Houston (CBB); Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston (RS); University of Texas Health Science Center at Houston, McGovern Medical School, (AC); Department of Medicine, University of Texas Health Science Center at Houston (AH); Department of Counseling, Wake Forest University, Winston-Salem, North Carolina (LF); Department of Pediatrics, University of Texas Health Science Center at Houston (CG).
MD, MPH
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Thomas F. Northrup
From the Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Texas (WL); Department of Family & Community Medicine, University of Texas Health Science Center at Houston, McGovern Medical School (TFN, ALS, TM); School of Biomedical Informatics, University of Texas Health Science Center at Houston (CBB); Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston (RS); University of Texas Health Science Center at Houston, McGovern Medical School, (AC); Department of Medicine, University of Texas Health Science Center at Houston (AH); Department of Counseling, Wake Forest University, Winston-Salem, North Carolina (LF); Department of Pediatrics, University of Texas Health Science Center at Houston (CG).
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Angela L. Stotts
From the Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Texas (WL); Department of Family & Community Medicine, University of Texas Health Science Center at Houston, McGovern Medical School (TFN, ALS, TM); School of Biomedical Informatics, University of Texas Health Science Center at Houston (CBB); Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston (RS); University of Texas Health Science Center at Houston, McGovern Medical School, (AC); Department of Medicine, University of Texas Health Science Center at Houston (AH); Department of Counseling, Wake Forest University, Winston-Salem, North Carolina (LF); Department of Pediatrics, University of Texas Health Science Center at Houston (CG).
PhD
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Christine Bakos-Block
From the Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Texas (WL); Department of Family & Community Medicine, University of Texas Health Science Center at Houston, McGovern Medical School (TFN, ALS, TM); School of Biomedical Informatics, University of Texas Health Science Center at Houston (CBB); Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston (RS); University of Texas Health Science Center at Houston, McGovern Medical School, (AC); Department of Medicine, University of Texas Health Science Center at Houston (AH); Department of Counseling, Wake Forest University, Winston-Salem, North Carolina (LF); Department of Pediatrics, University of Texas Health Science Center at Houston (CG).
PhD, LCSW
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Robert Suchting
From the Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Texas (WL); Department of Family & Community Medicine, University of Texas Health Science Center at Houston, McGovern Medical School (TFN, ALS, TM); School of Biomedical Informatics, University of Texas Health Science Center at Houston (CBB); Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston (RS); University of Texas Health Science Center at Houston, McGovern Medical School, (AC); Department of Medicine, University of Texas Health Science Center at Houston (AH); Department of Counseling, Wake Forest University, Winston-Salem, North Carolina (LF); Department of Pediatrics, University of Texas Health Science Center at Houston (CG).
PhD
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Alvin Chen
From the Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Texas (WL); Department of Family & Community Medicine, University of Texas Health Science Center at Houston, McGovern Medical School (TFN, ALS, TM); School of Biomedical Informatics, University of Texas Health Science Center at Houston (CBB); Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston (RS); University of Texas Health Science Center at Houston, McGovern Medical School, (AC); Department of Medicine, University of Texas Health Science Center at Houston (AH); Department of Counseling, Wake Forest University, Winston-Salem, North Carolina (LF); Department of Pediatrics, University of Texas Health Science Center at Houston (CG).
BS
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Abigail Hernandez
From the Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Texas (WL); Department of Family & Community Medicine, University of Texas Health Science Center at Houston, McGovern Medical School (TFN, ALS, TM); School of Biomedical Informatics, University of Texas Health Science Center at Houston (CBB); Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston (RS); University of Texas Health Science Center at Houston, McGovern Medical School, (AC); Department of Medicine, University of Texas Health Science Center at Houston (AH); Department of Counseling, Wake Forest University, Winston-Salem, North Carolina (LF); Department of Pediatrics, University of Texas Health Science Center at Houston (CG).
BS
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Lisandra Finzetto
From the Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Texas (WL); Department of Family & Community Medicine, University of Texas Health Science Center at Houston, McGovern Medical School (TFN, ALS, TM); School of Biomedical Informatics, University of Texas Health Science Center at Houston (CBB); Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston (RS); University of Texas Health Science Center at Houston, McGovern Medical School, (AC); Department of Medicine, University of Texas Health Science Center at Houston (AH); Department of Counseling, Wake Forest University, Winston-Salem, North Carolina (LF); Department of Pediatrics, University of Texas Health Science Center at Houston (CG).
BA
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Charles Green
From the Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Texas (WL); Department of Family & Community Medicine, University of Texas Health Science Center at Houston, McGovern Medical School (TFN, ALS, TM); School of Biomedical Informatics, University of Texas Health Science Center at Houston (CBB); Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston (RS); University of Texas Health Science Center at Houston, McGovern Medical School, (AC); Department of Medicine, University of Texas Health Science Center at Houston (AH); Department of Counseling, Wake Forest University, Winston-Salem, North Carolina (LF); Department of Pediatrics, University of Texas Health Science Center at Houston (CG).
PhD
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Thomas Murphy
From the Department of Health Systems and Population Health Sciences, University of Houston Tilman J. Fertitta Family College of Medicine, Texas (WL); Department of Family & Community Medicine, University of Texas Health Science Center at Houston, McGovern Medical School (TFN, ALS, TM); School of Biomedical Informatics, University of Texas Health Science Center at Houston (CBB); Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston (RS); University of Texas Health Science Center at Houston, McGovern Medical School, (AC); Department of Medicine, University of Texas Health Science Center at Houston (AH); Department of Counseling, Wake Forest University, Winston-Salem, North Carolina (LF); Department of Pediatrics, University of Texas Health Science Center at Houston (CG).
MD
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Article Figures & Data

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    Figure 1.

    CONSORT flow diagram. Abbreviation: MLP, medical-legal partnership.

Tables

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    Table 1.

    Participant Characteristics of a Randomized Controlled Trial Testing a Medical-Legal Partnership Referral, by Total Sample, Randomized Condition, and Whether Participants Received Legal Services

    OverallWaitlist ControlImmediate Referral 
    (n = 159)(n = 80)(n = 79)
    VariableMean (SD)Mean (SD)Mean (SD)P value
    Age52.3 (16.0)50.5 (15.8)54.7 (16.0)0.821
     n (%)n (%)n (%)P value
    Sex   0.140
    Female108 (68%)50 (62%)58 (73%) 
    Male51 (32%)30 (38%)21 (27%) 
    Race   0.849
    African American85 (54%)40 (51%)45 (57%) 
    Hispanic*44 (28%)24 (31%)20 (25%) 
    Other11 (7%)5 (6%)6 (7%) 
    White17 (11%)9 (12%)8 (10%) 
    Ethnicity   0.463
    Hispanic21 (13%)9 (11%)12 (15%) 
    Not Hispanic136 (87%)70 (89%)66 (85%) 
    Language   0.650
    English153 (97%)76 (96%)77 (97%) 
    Spanish5 (3%)3 (3%)2 (2%) 
    VariableOverallNo receiptReceived services 
    (n = 141)(n = 115)(n = 26)
    Mean (SD)Mean (SD)Mean (SD)P value
    Age52.8 (16.2)53.1 (16.8)51.7 (13.3)0.701
     N (%)N (%)N (%)P value
    Sex   0.614
    Female98 (70%)81 (70%)17 (65%) 
    Male43 (30%)34 (30%)9 (35%) 
    Race   0.171
    African American76 (55%)58 (51%)18 (72%) 
    Hispanic*39 (28%)35 (31%)4 (16%) 
    Other8 (5%)8 (7%)0 (0%) 
    White16 (12%)13 (11%)3 (12%) 
    Ethnicity   0.020
    Hispanic20 (14%)20 (18%)0 (0%) 
    Not Hispanic119 (86%)93 (82%)26 (100%) 
    Language   0.333
    English136 (97%)110 (96%)26 (100%) 
    Spanish4 (3%)4 (4%)0 (0%) 
    • ↵*Please note that the race categories were provided by the clinical partner.

    • Abbreviation: SD, standard deviation.

    • View popup
    Table 2.

    Responses to the Health-Harming Legal Needs Screening Instrument by Total Sample and Randomized Condition

     TotalWaitlist ControlImmediate Referral
     N (%)N (%)N (%)P value
    Does anyone in your household have concerns about?
    Income issues (including disability, supplemental security income, Social Security, debt, medical bills, paying for medications, and Women, Infants, and Children benefits)90 (56.6%)46 (57.5%)44 (55.7%)0.819
    Health insurance coverage or benefits57 (35.8%)27 (33.8%)30 (38.0%)0.579
    Losing a job or being at risk for losing a job over the past 90 days18 (11.3%)9 (11.3%)9 (11.4%)0.977
    Losing transportation or being at risk for losing transportation over the past 90 days29 (18.2%)20 (25.0%)9 (11.4%)0.026
    Education needs that are not being met13 (8.2%)9 (11.3%)4 (5.1%)0.155
    Immigration status13 (8.2%)10 (12.5%)3 (3.8%)0.045
    Personal safety22 (13.8%)11 (13.8%)11 (13.9%)0.975
    Personal injuries (including accidents)20 (12.6%)9 (11.3%)11 (13.9%)0.611
    Custody, guardianship, or child support38 (23.9%)17 (21.3%)21 (26.6%)0.431
    Wills, advance directives, power of attorney, or any other form of end-of-life planning81 (50.9%)41 (51.3%)40 (50.6%)0.938
    What is your housing situation today?
    I do not have housing (I am staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)30 (18.9%)16 (20.0%)14 (17.7%)0.714
    I have housing today, but I am worried about losing housing in the future45 (28.3%)23 (28.8%)22 (27.8%)0.9
    Utilities
    In the past 12 months, the electric, gas, or water company made threats to shut off services in your home45 (28.3%)21 (26.3%)24 (30.4%)0.563
    In the past 12 months, the electric, gas, or water company made threats to shut off services in your home and the utilities are already shut off1 (0.6%)0 (0.0%)1 (1.3%)0.313
    Think about the place you live. Do you have problems with any of the following? (Check all that apply) 
    Bugs37 (23.3%)23 (28.8%)14 (17.7%)0.1
    Mold37 (23.3%)23 (28.8%)14 (17.7%)0.1
    Lead (or chipped) paint or pipes16 (10.1%)6 (7.5%)10 (12.7%)0.28
    Water leaks or plumbing problems45 (28.3%)26 (32.5%)19 (24.1%)0.237
    Neighborhood conditions that affect health13 (8.2%)9 (11.3%)4 (5.1%)0.155
    Oven or stove not working12 (7.5%)7 (8.8%)5 (6.3%)0.563
    No or not working smoke detectors29 (18.2%)17 (21.3%)12 (15.2)0.322
    Inadequate heat or air conditioning24 (15.1%)12 (15.0%)12 (15.2%)0.973
    Food
    Within the past 12 months, you worried that your food would run out before you got money to buy more (Often true)28 (17.6%)15 (18.8%)13 (16.5%)0.714
    Within the past 12 months, you worried that your food would run out before you got money to buy more (Sometimes true)45 (28.3%)23 (28.8%)22 (27.8%)0.9
    Within the past 12 months, the food you bought just didn't last and you didn't have money to get more (Often true)26 (16.4%)16 (20.0%)10 (12.7%)0.211
    Within the past 12 months, the food you bought just didn't last and you didn't have money to get more (Sometimes true)67 (42.1%)35 (43.8%)32 (40.5%)0.679
    Over the past year, have you had…? 
    3 or more emergency room visits45 (28.3%)21 (26.3%)24 (30.4%)0.563
    2 or more hospital stays21 (13.2%)6 (7.5%)15 (19.0%)0.032
    Additional concerns 
    Would like to speak with a lawyer about other legal issues102 (64.2%)50 (62.5%)52 (65.8%)0.662
    Mean (SD)Mean (SD)Mean (SD)P value
    Number of issues6.7 (3.5)7.0 (3.5)6.4 (3.5)0.310
    • Abbreviation: SD, standard deviation.

    • View popup
    Table 3.

    Legal Benefits Provided by the Medical Legal Partnership

    Legal Benefit Provided*# Participants Benefitted (%)
    Wills & Guardianship10 (27.8%)
    Housing9 (25.0%)
    Social Security6 (16.7%)
    Employment & Education4 (11.1%)
    Insurance3 (8.3%)
    Food2 (5.6%)
    Income1 (2.8%)
    Other1 (2.8%)
    • ↵*Includes 4 individuals who were not randomized due to health-harming legal needs that represented an immediate and significant risk. All four had legal issues related to evictions. Furthermore, 6 individuals received more than 1 legal benefit.

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The Journal of the American Board of Family     Medicine: 37 (6)
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Medical-Legal Partnership Effects on Mental Health, Health Care Use, and Quality of Life in Primary Care: A Randomized Clinical Trial
Winston Liaw, Thomas F. Northrup, Angela L. Stotts, Christine Bakos-Block, Robert Suchting, Alvin Chen, Abigail Hernandez, Lisandra Finzetto, Charles Green, Thomas Murphy
The Journal of the American Board of Family Medicine Apr 2023, jabfm.2022.220349R1; DOI: 10.3122/jabfm.2022.220349R1

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Medical-Legal Partnership Effects on Mental Health, Health Care Use, and Quality of Life in Primary Care: A Randomized Clinical Trial
Winston Liaw, Thomas F. Northrup, Angela L. Stotts, Christine Bakos-Block, Robert Suchting, Alvin Chen, Abigail Hernandez, Lisandra Finzetto, Charles Green, Thomas Murphy
The Journal of the American Board of Family Medicine Apr 2023, jabfm.2022.220349R1; DOI: 10.3122/jabfm.2022.220349R1
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