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Bridging Health Disparities in HIV/AIDS through the Use of Medical Legal PartnershipsOmar Martinez, JD, MPH, MSAssistant ProfessorTemple University School of Social Work

Meka Anyamele, MD, MPHPostdoctoral Research FellowColumbia University

Systematic Review: MLP ModelIntroduction: Health Disparities and Legal Needs Affecting Vulnerable PopulationsMethodsResultsLimitationsDiscussionOutline

Introduction

Medical-legal partnerships (MLPs) have been established in 273 healthcare institutions in 36 states in the U.S. Healthcare delivery model that integrates legal assistance as a vital component of healthcare

MLPs are built on three key beliefs: 1) the social, economic and political context in which people live has a fundamental impact on health; 2) social determinants of health often manifest in the form of legal needs; and 3) attorneys have the special tools and skills to address these needs.

Introduction

Health disparities continue to increase among those most vulnerable:Four in five physicians say patients social needs are as important to address as their medical conditions (RWJF, 2015). 85% of primary care providers and pediatricians reported that unmet social and legal needs, such as access to nutritious food, reliable transportation, and adequate housing, lead directly to worse health for all Americans (RWJF, 2015).80% of physicians lack confidence in their capacity to address such needs, and reported that this impeded their ability to provide quality care (RWJF, 2015).

Health disparities in HIV/AIDSAlthough Black Americans represent only 12% of the U.S. population, they accounted for 44% of new HIV infections and an 44% of people living with HIV in 2010. Male-to-male sexual contact accounted for half (51%) of new HIV infections among Blacks. A similar trend holds for Latinos, who represented 16% of the U.S. population but accounted for 21% of new HIV infections and 19% of people living with HIV in 2010. Male-to-male sexual contact accounted for 68% of new HIV infections among Latinos.

Introduction

People living with HIVIn a recent study of people living with HIV/AIDS in Los Angeles County, 98% of participants reported having one or more legal needs within the last year, ranging from health care access to public benefits (Williams Institute, 2015).31% of study participants reported experiencing HIV-based discrimination in employment, housing and/or health care settings.

Aim of the Systematic ReviewWe aimed to collect and synthesize contemporary scholarly knowledge regarding the impact of MLPs on patient welfare and community health disparities. We further aimed to speculate regarding the potential for MLPs to address the needs of HIV-affected populations.

Methods

We conducted our review in accordance with the Preferred Reporting Items for Systematic Review and Metal-Analyses (PRISMA) guidelines.

Methods

Methods

The final 13 articles were subjected to intensive qualitative analysis, based on the overarching concerns of the systematic review: assessing the potential for MLPs to reduce health disparities in vulnerable populations, and speculating and/or identifying empirical data regarding the potential for MLPs to specifically address the needs of HIV-affected populations.Table 2. Studies Examining the impact of MLPs in addressing Health Disparities, 19932015Authors YearTitleJournalLocationSample SizeTarget PopulationMethodologyMain FindingsBeck, et al.2012Identifying and treating a substandard housing cluster using a medical-legal partnership.PediatricsCincinnati, OH16 units, housing 45 childrenFamilies with children, specifically those living in substandard housing conditionsFamilies screened for substandard housing during outpatient primary care, MLP referrals made as appropriate. Researchers presented the outcomes of MLP intervention.Sixteen families screened for substandard housing; outcome data available for 14. Pest infestation and water damage were the most common issues. After MLP intervention, major repairs were completed in at least 10 homes.Fleishman, et al.2006The attorney as the newest member of the cancer treatment team.Journal Of Clinical OncologyNew York, NY3 patientsCancer patientsPresentation of three in-depth case studies for patients who received MLP services.Patients received effective interventions in regards to end-of-life, financial, and workplace related issues.

Results: MLP Overview

Overall structure of MLPsSome MLPs were limited to attorneys and primary care staff such as physicians, whereas others relied heavily on social workers to screen and support patients/clients. Some MLPs made use of waiting rooms for initial screenings, whereas others incorporated legal and other social determinants of health (SDH) assessments into standardized medical histories.

Geographic Location and Target PopulationAll 13 studies were conducted in the United States, and 12 of them focused on MLPs located in major urban centers such as Atlanta, GA and Boston, MA; only one assessed the implementation and impact of MLP services in rural communities. Broadly speaking, MLPs target low-income populations. As is often the case with legal advocacy services, interventions were typically available for families with incomes below 200% of the federal poverty line. Beyond this emphasis on low socioeconomic status, many MLPs (and assessments of MLPs) focused specifically on families with children. Only one study focused explicitly on adults; an additional two seemed primarily geared towards adult populations.

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Results: MLP Impact

Identifying and Addressing Legal NeedsSeveral studies provided data regarding the need for legal interventions. Within its first three years, Child HeLP in Cincinnati, OH identified 1,614 patients with unmet legal needs. Housing and public benefits were the most common issues. This led to 1,945 MLP interventions, approximately 90% of which had positive legal outcomes.A rural MLP in Southern Illinois provided services for 825 patients over a 7-year period, resulting in 259 successful outcomes in court /mediation, the provision of advice and referrals for 450 cases, and the relief of nearly $4,000,000 in health care debt.

Addressing Health DisparitiesOnly four studies directly addressed the impact of MLPs on patient health, and three of these had samples of fewer than 70 patients.Assessment of Project Dulce was the most rigorous (see next slide).An assessment of 12 asthmatic adults in NYC documented declines in ER visits, hospital admissions, patient need for systemic steroids, and clinical asthma severity.An assessment in Tucson, AZ with 67 participants found improvements in patient stress and overall personal wellbeing.

Results: Evaluation Approaches

Assessment StrategiesGreater attention towards legal outcomes than the ultimate impact of MLP intervention on patient and community health.Only 4 of the 13 studies provided rigorous investigations that incorporated pre- and post-test data for a sample of patient-clients. The most rigorous was a RCT for Project DULCE in Boston, MA, which provides support for families with newborns.330 families participated (163 control, 167 intervention). Control families received an infant safety intervention; intervention families were assigned a Family Specialist who provided support for 6 months, including MLP referrals. At 6 months after infants birth, intervention families were more up to date on immunizations and care visits, and used emergency services less frequently; however, these effects disappeared at the12 month follow-up.

Theoretical FoundationsNone of the articles included in this review provided a guiding theoretical framework concerning the development, implementation, or evaluation of MLPs. A previous publication on Project DULCE drew on a risk and protective framework, which compels providers to consider patients strengths and other resources in addition to the factors that threaten their wellbeing..

MLP Elements and Constructs

MLP Model to Address Health Disparities in HIV/AIDS

Limitations

Although we used a thorough search strategy, we were invariably constrained by search terms; therefore, we may have inadvertently overlooked some MLP programs.

Our search was limited to two languages and two major databases. Therefore, we did not look at reports or studies published at web sites of major international organizations or policy centers. It is possible that MLP program descriptions and evaluations may be available in other languages or on other Web sites.

The decision to exclude reports or studies published at web sites or gray literature such as conference proceedings or institutional publications results from our strict inclusion criteria to include peer-reviewed articles.

Discussion

Our results speak to the potential impact of MLPs in addressing health and legal needs and open important new venues for longitudinal research to better capture the efficacy and impact of MLPs.

The findings from this review point to the urgent need to test the efficacy of MLPs through rigorous designs. Developing adequate scales and instruments to measure impact of MLPs remains particularly difficult.

We recognize that alternatives to randomized controlled trials are necessary to fully understand the impact of MLP while taking into consideration the real-life conditions in low-income countries. Therefore, a stepped-wedge randomized trial design might be a suitable mechanism to explore and evaluate the efficacy of MLPs. By the end of the study, all participants will have received the intervention, although the order in which participants receive the intervention is determined at random.

The medical and legal service providers should have a framework of shared understanding concerning patient confidentiality issues, compliance with HIPAA, proper identification of the client, safeguarding the attorney-client privilege, and other legal and ethical issues that arise in medical-legal collaborations.

Thank You!

To live is to know. It is to feel the joy of lifes forces coursing through ones veins. To survive AIDS is to feel the joy of escape, and the elation of continued life. It is also to bear the duty to speak, and the responsibility to bear witness.

Justice Edwin Cameron Acting Justice in South Africas highest court Constitutional Court Contact:Omar Martineztug29454@temple.edu Meka Anyamelecanyamele@gmail.com