The health care delivery system in the United States has begun to turn a corner, heading away from a system focused on the expensive and inefficient treatment of individuals at their sickest to one that emphasizes prevention, integration, interprofessional collaboration, and the health of populations. For too long, society has ignored the extent to which social determinants of health (SDH)—the conditions in which people live, learn, work, and play—are inextricably woven into and affect individual and population health. As the U.S. health care system rapidly evolves, many analysts, policy makers, and health care providers have paid more attention to SDH’s effects, and begun to develop and adopt innovative methods of care that extend beyond medicine to include social, legal, and other community-based supports.
These same forces—national health reform, health care delivery systems transformation, and growing recognition of the significance of SDH—have led to renewed calls for changing the way that physicians are trained and have accelerated medical education curricular reforms. In particular, the next generation of physicians will be expected to deliver care that meets “the triple aim” of improving the quality of patient care and population health outcomes while reducing costs.1 As a result, medical educators are increasingly focused on preparing future physicians and other providers to practice patient-centered, team-based care that is more responsive to the multiple factors that influence health outcomes and costs. This Perspective describes one such innovative method of team-based care and examines the opportunities for its integration into medical education: medical–legal partnership (MLP).
MLP is an approach to health care delivery that embeds civil* (as opposed to criminal) legal services2—whether in the form of legal aid attorneys, private-practice lawyers serving on a pro bono basis, or law professors and students working in clinical programs—into the spectrum of health care services provided to low-income or otherwise vulnerable patients and communities.†3 The power of the MLP approach is twofold: first, its focus is “upstream,” which refers to the structural and systemic nature of social and legal problems that affect population health; second, its cross-disciplinary and interprofessional nature combines existing medical and legal resources to effectively and sustainably reduce health-harming legal needs among low-income and other vulnerable populations.3,4
Since the first MLP in 1993, the model’s growth was slow but steady for the first decade or so: By 2005, nearly 75 health care institutions housed an MLP. In 2006, the National Center for Medical–Legal Partnership (NCMLP) was developed; its creation both reflected the need for an infrastructure to support MLP research, best practices, and scaling and also resulted in a wave of new partnerships. For example, after nearly a decade of providing technical assistance, NCMLP designed a toolkit to guide health and legal professionals through the process of building strong, sustainable MLPs that reflect the populations they serve. (The toolkit is available to download at the NCMLP’s Web site: http://www.medical-legalpartnership.org.) Today, more than 276 U.S. hospitals and health centers house an MLP, serving a range of diverse population, including children, those who are disabled, the elderly, rural populations, veterans, refugees, homeless individuals, and more.
Funding for MLPs is derived from a variety of health, legal, and other sources: community benefit dollars, direct hospital or health center support, health foundation grants, federal legal aid funding, law school support, law firms, legal bar foundations, fellowship programs, state governments, and private philanthropy. According to several studies, this funding results in significant returns on the investment; for example, one study found that an MLP targeting the needs of cancer patients generated nearly $1 million by resolving previously denied benefit claims.5 Another study of a rural MLP in Illinois demonstrates a 319% return on the original investment of $116,250 over a three-year period.6 Although beyond the scope of this Perspective, there are many other examples.7
The MLP approach is built on the understanding that SDH often manifest in the form of legal needs (e.g., assistance with housing code violations, food insecurity, public health insurance applications, domestic violence remediation, and many others), and that attorneys have the requisite training and expertise to address these needs. Indeed, one in six Americans—more than 50 million people—live in poverty, and every single one of those individuals has some sort of civil legal problem,8 many of which can be linked to health. The MLP model further recognizes that social determinants that contribute to poor individual and population health require both system and policy change. By working together and advocating for public policies that improve population health, health care and legal professionals can transform institutional approaches to health care and work to prevent health-harming social and legal needs.
MLPs also offer a unique role for lawyers and legal advocacy in individual health care and population health. Although health care providers are most familiar with lawyers in their advisory roles on issues such as physician liability, HIPAA compliance, or bioethics, MLP lawyers serve as advocates for patients, not as counsel to health care institutions. As part of the health care team, they problem-solve alongside physicians, nurses, and social workers to address the social and legal barriers affecting patient and population health. To accommodate this unique role, health care institutions, with MLPs, typically draft comprehensive memoranda of understanding that explicitly spell out the role of the lawyer in serving patients, not the institution, and stipulating that the MLP lawyer will not engage in any action against the health care institution.9
Integration is key: Although each MLP is unique because of the needs and resources of its community and partners, there exists a strong and direct correlation between the level of integration of legal services into health care delivery, the success and sustainability of a partnership, and thus the return on investment to patients, institutions, and communities alike. Increasingly, as the health and legal communities recognize the importance of integration to ameliorating SDH’s negative effects,10 they are turning to the MLP as a unique opportunity to assist individual patients while also detecting structural policy failures through patient patterns and community partnerships.11 For example, pediatricians working with an MLP in Cincinnati mapped the homes of children hospitalized with asthma exacerbations and used those data to drive legal advocacy to enforce the housing code, successfully reducing home-based asthma triggers.12 This approach to individual and population health continues to gain traction, and the federal Patient Protection and Affordable Care Act continues to drive innovations in care delivery models that focus on systems change and interprofessional coordination.13 Perhaps the most important component to further hasten the U.S. health care system’s transformation is providing a structure for the upstream education and training of clinicians around SDH generally and MLP specifically.
MLP and Trends in Medical Education
National reports focused on the development of competencies for undergraduate medical education elucidate clear themes. Medical students should display an understanding of nonbiologic determinants of health, cultural diversity, public health and prevention, and health policy and systems thinking.14 They should develop skills in policy and systems advocacy15 and demonstrate an ability to work in interprofessional teams.16 Similarly, competencies for residency education highlight skills in interprofessional communication as well as demonstration of “an awareness of and responsiveness to the larger context and system of health care as well as the ability to effectively call on resources in the system to provide optimal health care.”17
Below, we describe how educating medical students and residents through the lens of MLP not only meets but also integrates these multiple goals, developing physicians who are knowledgeable and skilled at connecting health care to the broader social, legal, and policy context of patient and population health, as well as effective members of interprofessional teams.
MLP in undergraduate medical education
Expanding interprofessional education to include systems thinking, law, and policy.
Interprofessional education (IPE) in medical school curriculum and programming most recently has focused on providing students with experiences, early in their education, with team-based approaches to health care. The premise of IPE is that high-quality patient-centered health care that is responsive to the larger context of population health improvement is most effectively and efficiently delivered by a comprehensive health care team.16,18 IPE exposes medical students to the values, perspectives, and skills of students and practitioners from other health professions, such as nursing, psychiatry, dentistry, and pharmacology in order to teach them effective collaboration to promote better, more cost-effective health care. Some IPE programs have begun to integrate social work students into their IPE programs to help medical students build skills around identifying patients’ unmet social needs, including how and when to refer patients for help with accessing community resources.19
MLP education fills three gaps in medical school IPE programs, providing students with (1) an understanding of the role that unmet legal needs play in patient health (that may not be addressed by other professionals, including social workers); (2) concrete examples of how systems and policies, both within health care and outside of it, shape not only individual patient but also population health; and (3) the skills to translate the patterns they witness in patient care to policy advocacy for population health improvement.
Integrating MLP into the curriculum.
While the movement toward IPE in medical schools has caught fire in the last five years, law students and medical students have come together to learn about the MLP approach for more than a decade. The first formal MLP-focused course was introduced in 2003 at the Alpert Medical School of Brown University as a preclinical elective, teaching medical and law students together about SDH, the role of law and policy in patient and population health, and MLP as a model of team-based health care.20,21 An informal 2014 survey conducted by the NCMLP shows that there are now at least 17 MLP programs with partnering medical schools that include a formal MLP education component for undergraduate medical students.22
MLP is integrated into undergraduate medical education in two ways. First, elective courses offered at medical schools bring together medical and law students, and increasingly, with the movement toward IPE, students from other disciplines as well, most commonly social work, public health, and nursing. Second, elective rotations place medical students on-site with an MLP at a health center or hospital, working directly with attorneys and law students. Some courses bring medical and law students together from the same institution, while others that do not have both schools on the same campus partner across institutions. Law school clinics, in which law students work under the supervision of a licensed attorney faculty member to provide pro bono legal service to low-income clients, have increasingly embraced MLP, partnering with health care institutions to offer students an interdisciplinary legal practice experience focused on improving health in vulnerable populations.23,24
Although MLP courses vary somewhat across curricula, they share common goals and objectives: (1) teach students to identify the social, economic, and environmental determinants of health and the role of law and policy in shaping and addressing those determinants; (2) offer students practice in interprofessional team-based problem solving through case-based learning as well as experiential opportunities at a local MLP; and (3) provide students with skills in systems thinking and policy advocacy strategies intended to improve population health.21 For example, the Stanford University School of Medicine and Stanford Law School offer a joint course for medical and law students in which they learn in the classroom about medical–legal issues affecting child health; jointly conduct interviews with patients at the Lucile Packard Children’s Hospital or a local community health center to identify unmet legal needs affecting a patient’s health; and work on group projects focused on a local or state-level policy issue affecting child health in the community.21
Curricula for MLP courses are generally structured around five domains, where complicated bureaucracies, wrongfully denied benefits, and unenforced laws commonly impact health and require legal assistance. These are usually referred to as I-HELP areas: Income/insurance, Housing and utilities, Education/employment, Legal status (immigration), and Personal/family safety and stability.3 Many courses use the textbook Poverty, Health, and Law: Readings and Cases for Medical–Legal Partnership (2011), which is designed as an accessible text for students from multiple disciplines and offers case studies as well as MLP best practice and “patient to policy” examples.3 Classroom teaching methods include lecture, small- and large-group discussion, case- and team-based learning, as well as service–learning opportunities.
In addition to didactic MLP education, medical schools are increasingly offering elective rotations that allow students to spend time on-site at an MLP program. Because most MLP programs partner legal staff with multiple professionals, including physicians, nurses, and social workers, medical students are exposed to a team model that incorporates legal advocacy as part of a broader patient-centered approach to care. Frequently, rotations are designed in conjunction with a law school clinical program in which medical students work side by side with law students at a clinic or hospital that serves a vulnerable patient population. Medical student experiences vary, but often include participating in meetings with clients being served by the MLP, going on home visits, summarizing medical records for legal cases (such as disability claims), developing trainings for health care staff on medical–legal issues, and/or working on policy-related advocacy projects. For example, the Health Law Partnership at Georgia State University College of Law partners with Morehouse School of Medicine to offer medical students both hands-on experiences working with the MLP as well as interdisciplinary didactic sessions alongside law students.25
By learning how unmet legal needs affect the health of individual patients and engaging in team-based problem solving with attorneys and law students, medical students learn not only about how social determinants affect health but also about how to formulate concrete solutions to patient problems. Through screening for unmet legal needs, they observe systems and policy failures affecting patient health, such as wrongful denial of government assistance, lack of enforcement of the housing code, or inadequate law enforcement and judicial protection for victims of domestic violence. Additionally, students learn through the MLP team model how to leverage partners with the expertise to address unmet social and legal needs so that they can more efficiently and effectively care for their patients.26
Through the process of interprofessional problem solving, students come to understand the roles that each professional on the team plays in addressing SDH and improving patient and population health. For example, a social worker is instrumental in connecting patients with social services, public benefits, and community resources.27 However, the patient may be unable, without the assistance of a lawyer, to effectively challenge a landlord who is unwilling to address asthma-related housing code violations or a government agency that has wrongfully denied a safety net program benefit despite the patient’s eligibility. MLP promotes a model of practice that optimizes each professional’s expertise, and therefore delivers more efficient and cost-effective care.
MLP in graduate medical education
As the MLP model continues to expand across the United States, many residency programs are situated in hospitals and health centers that have an MLP on-site. Although most MLP programs have been embedded in primary care practices, particularly family medicine, pediatrics, and geriatrics, MLPs are also being incorporated into specialty care such as oncology, psychiatry, and infectious disease, offering training opportunities for residents in these programs as well.28–30 MLP education is delivered by partnering lawyers through residency program curricula—regularly scheduled didactic sessions—as well as during grand rounds and noontime conferences. In addition to specific trainings on legal issues affecting health, MLP lawyers train residents on how to screen for social and legal determinants of health and when to seek consultation from the legal partner or refer a patient to the MLP program for assistance. Similar to undergraduate medical education curricula, residency education often uses the I-HELP topics to structure and demonstrate the connection between unmet legal needs and health.
MLP residency education provides concrete opportunities for residents to practice and demonstrate many of the six Accreditation Council for Graduate Medical Education (ACGME) competencies: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice and improvement.31 Most notably, MLP training and experience helps to meet the ACGME competency in systems-based practice, training residents to identify larger systems-based barriers that affect their patients’ health and locate the appropriate resources to address those barriers.
Challenges and Future Directions
Ethical issues in interprofessional MLP practice
Effectively collaborating across professions is never easy, and it is even more challenging when bringing together the legal and medical professions. There has been extensive discussion in the literature about the ethical challenges that may arise when lawyers and doctors partner on patient cases due to differing professional ethical obligations.9,32 Scholars who have studied these ethical issues conclude that, through careful planning, MLPs can accommodate these differences and allow professional collaboration on most cases.32 In the educational context, these challenges provide an excellent forum for exploration of professional values, ethics, and goals.20 Additionally, as medical educators continue to promote IPE and team-based models of care, MLP education offers a model for exploring the challenges and benefits of collaboration among professionals with different cultures, perspectives, and ethical obligations.
Growth and development
MLP education, like MLP programs, continues to grow organically, often based on the interest and advocacy of individuals convinced of its power. The benefit of this grassroots growth is that programs have committed champions. In the educational context, however, the challenge is that there is little systemic monitoring or evaluation of the educational initiatives. As MLP education continues to grow, particularly in undergraduate medical school programs, the NCMLP, which serves as a clearinghouse for information about the network of MLP sites, can help to disseminate best practices and implement more systemic tracking of curriculum and formal MLP rotations. Additionally, better alignment between medical school IPE programming and MLP educational initiatives will facilitate sharing of curricular and pedagogical approaches (such as classroom and experiential learning), as well as evaluation of program quality and student outcomes.
Evaluation of MLP education
A few studies have measured the impact of MLP residency education on resident knowledge, attitudes, and behavior. A 2011 study found that residents who received MLP education indicated in posttests that they were more comfortable discussing SDH and more knowledgeable about resources. The posttests also showed that residents who received training were more knowledgeable about and more likely to document issues such as public benefits, housing, and education compared with the control group.33 Pre- and posttests conducted after MLP residency training in three New York hospitals also showed changes in attitude about the physician’s responsibility to connect patients to legal services and behavior in referring patients to legal services.34
MLP education in undergraduate medical school programs has primarily been evaluated through qualitative student self-reports on how the curriculum or experience affected their attitudes, knowledge, and expectations regarding future behavior in practice as part of course evaluations. As MLP education continues to grow, there is a need for formal evaluation of student outcomes. To determine the effect of MLP education, measurement of actual change in practice behavior will require more longitudinal studies that track students into residency and then into practice.
There seems to be little disagreement at this point that training the next generation of health care leaders will require a modernized medical curriculum that includes new foci, new partnerships, and new skills attuned to the influence that social determinants play in the health of individuals and populations. A critical component of this revised training is the recognition that unmet legal needs have a negative impact on health. Addressing these needs in turn should translate into a healthier population and a more efficient health care delivery system. By combing the expertise and resources of the health care and legal professions, MLP—both as an education model and care delivery innovation—will play an important role in the 21st-century health system.
*Generally speaking, the primary role of civil legal aid is to promote and effectuate the enforcement of existing laws that protect vulnerable populations. For more information, see Houseman’s 2009 report.2
†For a more in-depth discussion of MLP than can be provided in this Perspective, visit the National Center for Medical–Legal Partnership: http://www.medical-legalpartnership.org/.
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