Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnerships

Martin J, Martin A, Schultz C, Sandel M
Publication Year: 2015
Patient Need Addressed: Behavioral health, Chronic Conditions
Population Focus: Complex care
Intervention Type: Best practices, Staff design and care management
Type of Literature: Grey

Mr. Jackson (not his real name) is a 42-year old man who was hospitalized three times in a seven-month period at Lancaster General Hospital in Pennsylvania. These hospitalizations were due to complications from chronic obstructive pulmonary disease, morbid obesity, depression, chronic kidney disease, and lower extremity non-healing ulcers. He was depressed and concerned that he was not able to move beyond the revolving door of frequent inpatient admissions.

Mr. Jackson was also incurring a large debt due to copays and uncovered services and medications. But his problems were not just medical. He was having legal problems getting enrolled in Medicaid, and his Social Security benefits were being unlawfully garnished. After his last hospitalization, he was so distraught that he did not leave his house for six weeks.
Mr. Jackson represents one of the most fundamental problems we face in medicine today — controlling cost among the highest users of our healthcare system. We often call these individuals “super-utilizers,” but that term only defines one truth about their interaction with the healthcare delivery system. While high use leads to higher costs and poorer quality outcomes, it is often driven by psychosocial, financial, and societal barriers to care and points to a lack of coordination between healthcare, social service, and civil legal aid infrastructure.

A “patient-centered” approach is at the heart of many successful programs attempting to address the needs of super-utilizers. Between September 2011 and September 2012, Lancaster General Health conducted a pilot super-utilizer project that embedded lawyers within an inter-professional care team. The goal was to see what effect integrating civil legal aid services into the care of high-using patients like Mr. Jackson would have on healthcare use, cost, and fulfilling the promise of patient-centered care.

Insights Results

Overview of model/article

  • Lancaster established a pilot to address super-utilizers by using the Camden Coalition model and also embedding a lawyer into the practice to address patients’ civil legal problems
  • During the pilot year, 55 patients were enrolled in the super-utilizer project. Of those, 52 (95%) had 2 or more civil legal problems impacting their healthcare use. The most common were housing (e.g., evictions), access to public benefits (e.g., appeals), and domestic violence
  • The pilot care team developed a survey that asked about 26 financial, economic, and environmental barriers to health, and the survey was administered to all pilot patients via an interview with the care manager
  • Legal care can include consultations with the healthcare team, full legal representation, changes to clinic policies, and state, local, or federal advocacy. However, only about 16% of cases required direct legal care, while all others could be addressed with the lawyer supporting the case management team
  • Participating lawyers received MLP training at Lancaster General Hospital in how social workers observe and document observations

    Key takeaways/implications

    • The pilot became an official program at Lancaster General Health called Care Connections; However, funding sources to continue beyond the initial grant period were not secured
    • Going forward, it will be important for institutions to build MLPs into outcomes based reimbursement and global payments and develop clear metrics to capture civil legal problems