Medical-legal partnerships
Medical-legal partnerships (MLPs) integrate legal services into health care settings, such as hospitals, public health departments, and behavioral health facilities1, 2. Health care providers refer patients to on-site legal assistance, which can include legal aid attorneys, private practice lawyers operating on a pro bono basis, and law professors and students3. Patients are typically screened for legal needs in waiting rooms4, 5, 6; electronic health records (EHRs) may also prompt providers to screen for legal needs7. When needs are identified, legal providers work with health care providers and patients to address concerns related to housing, food and utilities assistance, and social services. Social workers, often located on-site, can also provide guidance4, 5, 6. Some MLPs focus on specific patient populations or conditions such as pregnant women, patients with asthma, or patients with low incomes1. MLPs can be funded by hospitals or health care systems, health foundations, federal legal aid, law schools or firms, or state governments3.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Improved access to legal services
Improved health outcomes
Improved well-being
Reduced stress
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Improved access to social services
Increased enrollment in social services
Improved economic security
Increased housing stability
Improved housing quality
What does the research say about effectiveness?
There is some evidence that medical-legal partnerships (MLPs) improve access to legal services4, 8, 9, 10, patient health outcomes4, 8, and well-being9, 11, 12, 13, 14, and reduce stress4. Additional evidence is needed to confirm effects8.
Early intervention to address legal problems contributes to improved health outcomes4, 8, 11, 13, 14, 15, including mental health4, 16. MLPs can improve short-term and long-term health, in part by reducing stress and improving patient adherence to required medical treatment4. MLPs can also improve patient well-being and increase appropriate use of health care services8. MLPs have been shown to improve health and well-being for children and families11, 13. For children with asthma, MLPs may reduce emergency department visits and hospitalizations17. MLP participants report reduced stress11, 12 and improved well-being11, 12.
MLPs can remove barriers to health care for families with low incomes by addressing cost and insurance concerns and increasing access to preventive care9, 13 and vaccinations9. MLPs may also improve treatment compliance2, 18.
MLPs have been shown to increase access to stable, affordable housing10 for populations including veterans16, families of children with sickle cell disease19, and families of children with asthma17. By screening for energy insecurity8, 10 and issuing certificates of medical need, MLPs can prevent utilities shut-offs and increase energy security, particularly for families with vulnerable children20. A Buffalo, NY-based study of a MLP that serves cancer patients receiving palliative care suggests MLPs can also secure emergency funding from the Low Income Home Energy Assistance Program (LIHEAP) to alleviate heating costs21. MLPs may also improve housing quality by providing legal support for patients’ efforts to reduce home environmental risks such as pests, mold, and other allergens22, 23.
MLPs can increase access to social services and supports2, 13, 15, 17, 19, including social security benefits, family law services, end of life guidance15, 21, and Medicaid15, 18. MLPs can also increase access to education, employment2, 17, 19, and Supplemental Nutrition Assistance Program (SNAP) benefits19, 21. MLPs have been shown to increase access to legal services for disadvantaged populations4, including patients experiencing homelessness24, families with low incomes9, cancer patients21, and families of children with chronic health conditions such as sickle cell disease19 and asthma17.
MLPs have been shown to increase patients’ comfort engaging with legal services10 and can reduce the need for litigation by addressing legal issues through administrative or informal processes16.
Experts suggest that MLPs include social workers on-site to connect patients to social services and supports and to better address disparities in the social determinants of health5. Programs may be more effective if providers use screening prompts in electronic health records (EHRs) to discuss legal issues and access form letters to connect to additional services25. Small budgets, reliance on volunteers with constrained time, and difficulty getting appropriate reimbursements for health care appointments can be challenges to sustainable MLP programs26. Including MLP training in medical residency programs may increase providers’ understanding and use of MLPs3, 27; training health care providers and staff to identify health-harming legal needs is a routine component of MLPs2, 28.
Evaluations of MLPs have shown that health care providers and lawyers working together can advance health equity for vulnerable community residents1. By addressing upstream systematic legal and social issues that affect population health, MLPs may also result in policy changes28, 29. Experts suggest that screening patients for legal issues become a standard practice in patient care26.
Studies of MLPs in New York City, Atlanta, and rural Illinois have shown positive returns on investment3, 14, 15, 17. MLPs may improve reimbursement for hospital services and contribute to health care system improvements18.
How could this strategy impact health disparities? This strategy is rated likely to decrease disparities.
Implementation Examples
As of January 2019, there are medical-legal partnerships (MLPs) in 333 health organizations across 46 states30. The National Center for Medical-Legal Partnership (NCMLP) provides research and technical assistance to organizations interested in creating MLPs and offers a handbook with MLP evaluation guidelines30, 31. NCMLP and the American Bar Association each maintain lists of partners participating in MLPs across the nation32, 33.
The Washington Medical-Legal Partnership is an example of a long-standing MLP; it has provided direct legal assistance to 2,200 individuals and trained 2,000 health care providers and social workers in legal advocacy since its establishment in 200834. Medical-Legal Partnership Boston is another MLP that provides training, coaching, and technical assistance to interested organizations35. UF Health Senior Medical-Legal Partnership, a partnership between University of Florida Health and Three Rivers Legal Services, Inc., offers confidential free legal assistance to low income senior patients residing in 17 counties in North Central Florida36.
Implementation Resources
NCMLP Handbook - National Center for Medical-Legal Partnership (NCMLP). National Center for Medical-Legal Partnership performance measures handbook. Social Interventions Research & Evaluation Network (SIREN). University of California San Francisco (UCSF); 2016.
NCMLP-Regenstein 2017 - Regenstein M, Trott J, Williamson A. The state of the medical-legal partnership field: Findings from the 2016 National Center for Medical-Legal Partnership surveys. Washington, D.C.: National Center for Medical-Legal Partnership. Milken Institute School of Public Health, George Washington University; 2017.
Child HeLP - Cincinnati Child Health-Law Partnership (Child HeLP). Cincinnati Children’s Hospital Medical Center and the Legal Aid Society of Greater Cincinnati.
NCMLP-Utilities - National Center for Medical-Legal Partnership (NCMLP). MLP in action: a utilities case study: What happened when the heat went off? An MLP patients-to-policy story. Washington, D.C.: Milken Institute School of Public Health, George Washington University; 2018.
NCMLP-Marple 2015 - Marple K. Framing legal care as health care: A guide to help civil legal aid practitioners message their work to health care audiences. Washington, D.C.: National Center for Medical-Legal Partnership. Milken Institute School of Public Health, George Washington University; 2015.
Footnotes
* Journal subscription may be required for access.
1 Regenstein 2018 - Regenstein M, Trott J, Williamson A, Theiss J. Addressing social determinants of health through medical-legal partnerships. Health Affairs. 2018;37(3):378-385.
2 NCMLP-Regenstein 2017 - Regenstein M, Trott J, Williamson A. The state of the medical-legal partnership field: Findings from the 2016 National Center for Medical-Legal Partnership surveys. Washington, D.C.: National Center for Medical-Legal Partnership. Milken Institute School of Public Health, George Washington University; 2017.
3 Tobin Tyler 2016 - Tobin Tyler E, Teitelbaum J. Training the 21st-century health care team: Maximizing interprofessional education through medical-legal partnership. Academic Medicine. 2016;91(6):761-765.
4 Speldewinde 2015 - Speldewinde CA, Parsons I. Medical-legal partnerships: The role of mental health providers and legal authorities in the development of a coordinated approach to supporting mental health clients’ legal needs in regional and rural settings. Rural and Remote Health. 2015;15(4):1-11.
5 Colvin 2012 - Colvin JD, Nelson B, Cronin K. Integrating social workers into medical-legal partnerships: Comprehensive problem solving for patients. Social Work. 2012;57(4):333-341.
6 Cohen 2010 - Cohen E, Fullerton DF, Retkin R, et al. Medical-legal partnership: Collaborating with lawyers to identify and address health disparities. Journal of General Internal Medicine. 2010;25(Suppl 2):136-139.
7 Sandel 2010 - Sandel M, Baeder A, Bradman A, et al. Housing interventions and control of health-related chemical agents: A review of the evidence. Journal of Public Health Management and Practice. 2010;16(5 Suppl):S24-33.
8 Martinez 2017 - Martinez O, Boles J, Muñoz-Laboy M, et al. Bridging health disparity gaps through the use of medical legal partnerships in patient care: A systematic review. The Journal of Law, Medicine & Ethics. 2017;45(2):260-273.
9 Sege 2015 - 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.
10 Hernandez 2016 - Hernández D. “Extra oomph:” addressing housing disparities through Medical Legal Partnership interventions. Housing Studies. 2016;31(7):871-890.
11 Rosen Valverde 2018 - Rosen Valverde JN, Backstrand J, Hills L, Tanuos H. Medical-legal partnership impact on parents’ perceived stress: A pilot study. Behavioral Medicine. June 2018.
12 Ryan 2012a - Ryan AM, Kutob RM, Suther E, Hansen M, Sandel M. Pilot study of impact of medical-legal partnership services on patients’ perceived stress and wellbeing. Journal of Health Care for the Poor and Underserved. 2012;23(4):1536-1546.
13 Weintraub 2010 - Weintraub D, Rodgers MA, Botcheva L, et al. Pilot study of medical-legal partnership to address social and legal needs of patients. Journal of Health Care for the Poor and Underserved. 2010;21(2 Suppl):157-168.
14 Atkins 2014 - Atkins D, Heller SM, DeBartolo E, Sandel M. Medical-legal partnership and healthy start: Integrating civil legal aid services into public health advocacy. Journal of Legal Medicine. 2014;35(1):195-209.
15 Teufel 2012 - Teufel JA, Werner D, Goffinet D, et al. Rural medical-legal partnership and advocacy: A three-year follow-up study. Journal of Health Care for the Poor and Underserved. 2012;23(2):705-714.
16 Tsai 2017 - Tsai J, Middleton M, Villegas J, et al. Medical-legal partnerships at Veterans Affairs medical centers improved housing and psychosocial outcomes for vets. Health Affairs. 2017;36(12):2195-2203.
17 Pettignano 2013 - Pettignano R, Bliss LR, Caley SB, McLaren S. Can access to a medical-legal partnership benefit patients with asthma who live in an urban community? Journal of Health Care for the Poor and Underserved. 2013;24(2):706-717.
18 Pettignano 2012 - Pettignano R, Caley SB, McLaren S. The health law partnership: Adding a lawyer to the health care team reduces system costs and improves provider satisfaction. Journal of Public Health Management and Practice. 2012;18(4):E1-E3.
19 Pettignano 2011 - Pettignano R, Caley SB, Bliss LR. Medical-legal partnership: Impact on patients with sickle cell disease. Pediatrics. 2011;128(6):e1482-e1488.
20 Taylor 2015 - Taylor DR, Bernstein BA, Carroll E, Oquendo E, Pachter LM. Keeping the heat on for children’s health: A successful medical-legal partnership initiative to prevent utility shutoffs in vulnerable children. Journal of Health Care for the Poor and Underserved. 2015;26(3):676-685.
21 Rodabaugh 2010 - Rodabaugh KJ, Hammond M, Myszka D, Sandel M. A medical-legal partnership as a component of a palliative care model. Journal of Palliative Medicine. 2010;13(1):15-18.
22 Beck 2012 - Beck AF, Klein MD, Schaffzin JK, et al. Identifying and treating a substandard housing cluster using a medical-legal partnership. Pediatrics. 2012;130(5):831-838.
23 O’Sullivan 2012 - O'Sullivan MM, Brandfield J, Hoskote SS, et al. Environmental improvements brought by the legal interventions in the homes of poorly controlled inner-city adult asthmatic patients: A proof-of-concept study. Journal of Asthma. 2012;49(9):911-917.
24 Tsai 2017a - Tsai J, Jenkins D, Lawton E. Civil legal services and medical-legal partnerships needed by the homeless population: A national survey. American Journal of Public Health. 2017;107(3):398-401.
25 Sandel 2010a - Sandel M, Hansen M, Kahn R, et al. Medical-legal partnerships: Transforming primary care by addressing the legal needs of vulnerable populations. Health Affairs. 2010;29(9):1697-1705.
26 Theiss 2017 - Theiss J, Regenstein M. Facing the need: Screening practices for the social determinants of health. The Journal of Law, Medicine & Ethics. 2017;45(3):431-441.
27 Paul 2017 - Paul EG, Curran M, Tobin Tyler E. The medical-legal partnership approach to teaching social determinants of health and structural competency in residency programs. Academic Medicine. 2017;92(3):292-298.
28 Tobin Tyler 2017 - Tyler ET. Medical-legal partnership in primary care: Moving upstream in the clinic. American Journal of Lifestyle Medicine. 2017;XX(X):1-10.
29 NCMLP-Theiss 2016 - Theiss J, Sandel M, Teitelbaum J, Marple K. Applying the medicallegal partnership approach to population health, pain points and payment reform. Washington, D.C.: National Center for Medical-Legal Partnership. Milken Institute School of Public Health, George Washington University; 2016.
30 NCMLP - National Center for Medical-Legal Partnership (NCMLP). Washington, D.C.: Milken Institute School of Public Health, George Washington University.
31 NCMLP Handbook - National Center for Medical-Legal Partnership (NCMLP). National Center for Medical-Legal Partnership performance measures handbook. Social Interventions Research & Evaluation Network (SIREN). University of California San Francisco (UCSF); 2016.
32 NCMLP-Partnerships - National Center for Medical-Legal Partnership (NCMLP). Partnerships across the U.S. Washington, D.C.: Milken Institute School of Public Health, George Washington University; 2018.
33 ABA-MLP - American Bar Association (ABA). Medical-legal partnerships pro-bono project.
34 WA MLP - Washington Medical-Legal Partnership (WA MLP). Working towards better health through legal advocacy.
35 MLPB - Medical-Legal Partnership Boston (MLPB).
36 UF Health-MLP - UF Health Senior Medical-Legal Partnership. University of Florida Health and Three Rivers Legal Services, Inc.
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