Many low- and moderate-income individuals and families have at least one unmet legal need (for example, unsafe housing conditions, lack of access to food and/or income support, lack of access to health care), which, if left unaddressed, can have harmful consequences on health. Eighty unique medical-legal partnership programs, serving over 180 clinics and hospitals nationwide, seek to combine the strengths of medical and legal professionals to address patients' legal needs before they become crises. Each partnership is adapted to serve the specific needs of its own patient base.
This article describes innovative, residency-based medical-legal partnership educational experiences in pediatrics, internal medicine, and family medicine at 3 different sites (Boston, Massachusetts; Newark, New Jersey; and Tucson, Arizona). This article addresses how these 3 programs have been designed to meet the Accreditation Council for Graduate Medical Education's 6 competencies, along with suggested methods for evaluating the effectiveness of these programs. Training is a core component of medical-legal partnership, and most medical-legal partnerships have developed curricula for resident education in a variety of formats, including noon conferences, grand rounds, poverty simulations and day-long special sessions.
Medical-legal partnerships combine the skill sets of medical professionals and lawyers to teach social determinants of health by training residents and attending physicians to identify and help address unmet legal needs. Medical-legal partnership doctors and lawyers treat health disparities and improve patient health and well-being by ensuring that public programs, regulations, and laws created to benefit health and improve access to health care are implemented and enforced.
Social determinants—including income, education, access to health care, and conditions of work, housing, and neighborhood—greatly influence health and mortality.1 Less than 15% of preventable mortality is attributed to medical care alone.2 While the impact of social determinants is readily acknowledged by health care providers for vulnerable populations, addressing these needs remains a challenge. The social and material needs that correlate with the social determinants are intended to be met by public and government programs and laws designed to increase access to food, subsidized housing programs, utility assistance, disability assistance, and health insurance programs. Unfortunately, such public programs and laws are inconsistently implemented, resulting in persistent poverty and its concomitant health effects.3 Given that these programs, benefits, and protections are governed by laws, legal assistance for patients can address legal needs—such as access to food subsidies, housing conditions, or income benefits to improve health.
Frequently, the number and type of unmet legal needs a patient has is associated with income levels and varies from urban to rural areas.4 Nationally, 47% of low-income and 52% of moderate-income households have at least 1 unmet legal need, and 14% of low-income households have 3 or more unmet legal needs.5 A more in-depth study6 performed in 9 states found low-income households had an average of 1 to 3 unmet legal needs. In all 9 states, fewer than 1 in 5 legal problems experienced by low-income people are addressed with help from a private or legal aid lawyer, leaving most problems unmet or unresolved.
Medical-legal partnerships (MLPs) are designed to improve health by bringing legal services to the health care setting to increase the number of legal needs addressed. As part of the MLP model, lawyers educate medical students, residents, and other health care professionals to screen, diagnose, and refer patients with legal needs to legal services as part of their medical care plan. This paper has 2 goals: first, to introduce MLPs as an important collaboration designed to address legal needs as part of health care delivery; and second, to discuss how MLPs can be a new and practical curricular element of residency education to address the general competencies through service, training, and systems advocacy.
What Is a Medical-Legal Partnership?
Medical-legal partnerships, first developed at Boston Medical Center in the Department of Pediatrics in 1993, combine the skill sets of medical professionals and lawyers to treat and teach social determinants of health.3 The principal goal of MLPs is to ensure that public programs and laws that impact the health of vulnerable populations are consistently implemented and rigorously enforced.7
The medical-legal partnership model has 3 core components: direct service for patients and families, training for health care staff, and joint medical-legal systems advocacy. First, lawyers and physicians partner on-site in health care settings to ensure timely access to legal assistance when needed. Second, to detect legal needs, lawyers and doctors train all health care staff, including medical students, residents, nurses, social workers, and practicing physicians, how to screen for legal needs. Third, lawyers and doctors may collaborate to effect change to social policies and laws that result in system-wide solutions to improve health. For the past 8 years, the MLP model has spread across the United States and Canada. In 2006, the National Center for Medical-Legal Partnership8 was founded to help foster new MLP sites. In 2008, there were over 80 MLP programs serving over 160 hospitals and health centers. Although MLPs started in pediatrics, programs have rapidly emerged in internal medicine, family medicine, and subspecialties such as oncology, infectious disease, and geriatrics.
The impact of addressing a patient's legal needs is now beginning to be examined. A recent survey9 of adult patients with cancer identified 30 medically related legal needs that could be sorted into 4 domains: health care, estate, finances, and employment. Subjects reported that medical-legal needs had a significant impact on their quality of life across all the domains, with unmet health care–related needs having the greatest impact. A different survey10 of cancer patients who had received legal assistance showed positive results: 75% of patients interviewed said legal assistance reduced stress, 50% reported that receipt of legal assistance had a positive effect on their family or loved ones, 45% said legal assistance positively affected their financial situation, and 30% reported that legal assistance helped them maintain their treatment regimen.
Medical-Legal Partnerships and Residency Education
Training health care providers to detect and refer legal needs is a key component of the MLP model. The model is universal and adaptable, and MLP curricula, which describe physician roles in advocating for housing and government benefits, have been incorporated into 29 residency programs nationwide. This includes pediatrics programs (69%), family medicine programs (14%), internal medicine programs (7%) and programs in other specialties (10%). Twenty-five medical schools participate in MLPs, with 17% having a dedicated MLP course and 20% offering MLP electives. Four partnerships have created joint medical- and law-student courses.
Training curricula across the MLP network are developed locally, depending on the legal needs of the patient populations served by the program. The broad, common topics can be taught using the mnemonic I-HELP, indicating Income supports (eg, health insurance, food stamps, disability benefits), Housing (eg, affordability, conditions, and utility access), Employment/Education, Legal status (immigration), and Personal stability (includes advanced-care directives, domestic violence, and guardianship issues).8,11,12
The patient populations served in residency clinics of academic medical centers typically have a disproportionate share of complicated medical and psychosocial issues.13 Residents, especially those without multidisciplinary resources, may be overwhelmed by some patients presenting with multiple serious medical problems, in addition to poverty, illiteracy, and substance abuse.13 Training residents to identify, triage, and manage the common social factors that negatively impact health is logical, practical, readily definable, and can be evaluated in the language of the general competencies.
Three residency-based MLP curricula are described in 3 specialties: pediatrics, internal medicine, and family medicine. Each description focuses on selected educational experiences but does not list all educational activities. Table 1 presents a more-detailed list of examples of educational experiences across MLP sites that have been used to meet the competencies, as well as tools from the Accreditation Council for Graduate Medical Education (ACGME) outcomes toolbox14 that can be used to measure progress on meeting these competencies. The description of each program includes educational curriculum developed and delivered by doctors and lawyers and how the sessions, experiences, and simulations are also used to address the competencies. Table 2 further details how all 3 core components of the MLP model—direct service, training, and systems advocacy—further meet the core competencies.
Tucson Family Advocacy Program (Family Medicine)
The Tucson Family Advocacy Program (TFAP) is a multidisciplinary partnership of health care providers and lawyers working together to improve the health and well-being of low-income patients. Attorneys with TFAP provide free legal assistance to low-income patients and families referred by health care providers in a wide range of civil matters affecting health, including health insurance access and coverage, disability benefits, housing conditions, advance directives, and domestic violence.
Located on-site in a family medicine residency clinic, TFAP also teaches health care providers about legal issues that impact health and ways they can become more-effective advocates for their patients. Residents are trained to recognize common legal needs of low-income patients through both individual consultations with attorneys and periodic seminars in all years of resident training. Health care providers had over 300 individual consultations with TFAP attorneys in 2008 on legal issues impacting health, including rights to safe housing and disability benefits and completing public-benefit related medical forms for their patients. Seminars are copresented by a faculty physician and lawyer and include focused history taking to screen for legal issues impacting health, physicians' roles in supporting disability determinations, and how to increase insurance coverage for prescribed medical services and procedures through effective documentation of medical necessity.
The ability to effectively screen for legal needs and work as part of an interdisciplinary team that includes lawyers becomes part of each resident's repertoire by the end of their training. By training providers to better screen legal needs, 86% of patients referred to TFAP last year who had not previously sought legal help for their problems discussed their concerns with their health care provider. This statistic supports a fundamental principle of MLPs: providing legal services and education in a trusted health care setting is an effective way to identify and help patients access the benefits and services they need, and are entitled to receive, for health and well-being. Through this active participation as part of a multidisciplinary team, residents also acquire vital skills in all 6 required ACGME competencies (table 1).
Legal Assistance to Medical Patients (Internal Medicine)
The Legal Assistance to Medical Patients (LAMP) program is a collaboration between Legal Services of New Jersey and Newark Beth Israel Medical Center medical and pediatric residency programs. In its first year, the LAMP program received 175 referrals leading to 100 active cases, and by July 1, 2009, the referral rate had doubled. The most common issues were disability-related income supports, Medicaid and other public benefits, housing, family law, immigration, and guardianship.
During development of the LAMP program, 114 residents responded to a survey regarding their knowledge of and attitudes about legal issues among their patients. While 57% felt it was likely that “free access to an attorney can help patients” in their practice, only 33% felt “comfortable raising and discussing legal issues” with them. Follow-up survey data are currently being analyzed, but preliminary data indicate that a year into the LAMP program's presence, 72% felt it was likely that “free access to an attorney can help patients,” and now 55% felt “comfortable raising and discussing legal issues” with them. This attitudinal change, if translated into clinical behavior, represents substantive growth in systems-based practice. Additionally, many residents commented on the value in knowing that they have this resource available for their patients.
Medical-Legal Partnership | Boston (Pediatrics)
Medical-Legal Partnership | Boston12 at Boston Medical Center is the founding site of the national MLP Network. Established in the Department of Pediatrics in 1993, it serves more than 1500 patients annually. Medical-Legal Partnership | Boston teaches residents, students, and health care providers in pediatrics, internal medicine, geriatrics, oncology, infectious disease, and family medicine. It is most heavily integrated in the pediatrics residency, delivering a regular monthly series of noon conferences and preclinic conferences and annual grand rounds. MLP | Boston frequently incubates innovative curricula for the national MLP Network; two examples of such innovations are described below.
During resident orientation at the Boston Combined Residency in Pediatrics (BCRP), MLP | Boston facilitates a 2-hour poverty simulation for 35 interns. The poverty simulation is a curriculum developed by the Missouri Association for Community Action15 that educates participants about the day-to-day realities of life with little money and an abundance of stress. During four 15-minute sessions, participants assume new roles and life situations representing 4 weeks in the life of a low-income family. Activities include paying bills, buying food, and working. This is followed by a reflection session to discuss the meaning and relevance of the experience to medical practice. Nineteen residents evaluated this exercise after participating in 2008; 74% strongly agreed and 21% somewhat agreed that the experience helped them understand poverty. All participants agreed with the statement that “This experience has helped me better understand how poverty can affect health” (42% strongly, 58% somewhat).
Medical-Legal Partnership | Boston has designed the Primary Care Advocacy Block for interns in the BCRP since 2004, and in 2009 it helped design and implement the Leadership in Advocacy Block, a 4-week course required of Boston University primary care training program interns in internal medicine. These two advocacy blocks have 4 components:
Clinical experiences with vulnerable populations, including homeless, transgendered, and methadone-dependent patients
Didactic sessions focused on the legislative process, media advocacy, and physicians' role in advocacy at the individual and system-wide levels
Community exposures such as tours of homeless shelters, urban neighborhoods, housing court, and the State House
Project work to address a health disparity in the vulnerable population of their choice, such as methadone treatment in prison, access to alternative medicine, and the role of physicians in palliative care.
Poverty simulations and advocacy blocks expose trainees to the multiple governmental, health care, and social systems in which their patients participate and the limitations of these systems in meeting patients' needs. They also foster residents' understanding of and sensitivity toward the vulnerable populations they serve.
Medical-legal partnership education programs are spreading throughout the country and garnering increasing attention. Through MLP curricula, residents, faculty, medical students, and other providers learn not only to screen, triage, and diagnose but also to refer patients to lawyers as part of the health care team. Working with frontline health care staff, MLP lawyers can “treat” or resolve complicated issues and can teach physicians and trainees how integral legal assistance is to patient health. This new curricular approach of engaging an MLP can be central in teaching the most challenging competencies, systems-based practice and professionalism,16 and is uniquely applicable to each of the 6 general competencies (tables 1 and 2).
Ensuring that residents are adequately prepared to practice medicine in an increasingly socially and legally complex environment is pivotal. The widespread prevalence of health-harming social determinants among low-income patients underscores the importance of implementing MLPs to address these basic needs. However, beyond providing critical legal assistance for vulnerable patients, the MLP model also teaches important knowledge and a new skill set to residents as they form their medical identities. Residents who have been trained to understand a range of public systems and recognize legal needs of their patients will be better prepared to practice medicine in continually changing health care delivery systems, especially in primary care settings.
Medical-legal partnership models also complement the patient- and family-centered medical home movement, whose principles include whole person orientation and coordinated care.17 The contributions of MLPs to experiential learning for residents is substantial. By modeling advocacy and communications skills in a variety of systems settings for residents, legal partners can support residency programs in meeting competency requirements. At the same time, lawyers can join health care staff in comprehensively addressing patients' health, material, social, and legal needs. From pediatrics to geriatrics, medical-legal partnerships are bringing new strategies for training professional, team-oriented, excellent physician advocates for the 21st century.
Edward Paul, MD, is an Associate Professor of Family and Community Medicine, University of Arizona at Tucson; Danya Fortess Fullerton, BA, is a Research Associate at the National Center for Medical-Legal Partnership, Boston Medical Center; Ellen Cohen, MD, is Program Director and Vice Chair for Education at the Department of Medicine, Newark Beth Israel Medical Center; Ellen Lawton, JD, is Executive Director at the National Center for Medical-Legal Partnership, Boston Medical Center; Anne Ryan, JD, is Director at the Tucson Family Advocacy Program; and Megan Sandel, MD, MPH, is Medical Director at the National Center for Medical-Legal Partnership, Boston University School of Medicine.