Table 2 Characteristics of Medical Legal Partnership programs

Klein, 2014 [14]

Pediatric residents (N = 47)

Co-located MLP within a hospital based pediatric primary care center in Cincinnati Children’s Hospital partnered with the Legal Aid Society of Greater Cincinnati.

Delivery of a social determinants of health video curriculum by a multidisciplinary team (medical and legal experts). The curriculum featured clinical vignettes to highlight the importance of screening interventions targeting social determinants of health.

Non-randomized, controlled study

Compared residents who received the video intervention to residents who did not (control)

Surveys of patients and parents pre/post 6 month intervention

Outcomes assessed:

1) Confidence in screening and intervening on behalf of SDH

2) Rates of referrals to MLP

3) Rates of referral for infant formula distribution for those who were food insecure

24 residents received the intervention, 23 residents received a standard curriculum (control)

The intervention group was

1) More confident screening for housing, benefits and educational issues

2) More likely to screen for domestic violence and depression

3) Refer patients for formula distribution when food insecurity was found.

5

Klein, 2011 [15]

Pediatric interns (N = 38)

Co-located MLP within a hospital based pediatric primary care center in Cincinnati Children’s Hospital partnered with the Legal Aid Society of Greater Cincinnati.

Delivery of a mandatory 2 week intern advocacy curriculum that incorporated a focus on the social determinants of health including shadowing social workers, guided tours of community organizations such as food banks and lectures taught by multidisciplinary experts (medical and legal) including topics such as the rationale behind MLPs, as well as technical and legal aspects of public benefits, housing and education.

Non-randomized, mixed methods study

Compared interns who received the curricular intervention to the prior year interns who did not (control); Also assessed for pre/post change in the intervention group

Outcomes assessed:

1) Knowledge surrounding benefits, housing and education

2) Attitude/Comfort assessing patients social needs

3) Documentation of social determinants in the EHR

4) Practice: referral rate to the MLP program

20 interns received the intervention, 18 interns received a standard curriculum (control).

For both the pre/post comparison within the intervention group AND the intervention compared to control group, the intervention group:

1) More knowledgeable about benefits, housing and education

2) More comfortable discussing poverty issues; more likely to share information about relevant community resources; More likely to ask patients about social determinants including safe/stable housing and food insecurity

The intervention group when compared to the control group was:

3) More likely to document issues related to benefits, housing and food insecurity

4) Had a trend toward increased referral rate to the onsite MLP (4% versus 2.9%, P = 0.13)

5

O’Toole, 2012 [16]

Pediatric and combined internal medicine/pediatrics residents (N = 40)

Continuity clinics at 3 different sites that had varying levels of social service and legal supports within Cincinnati Children’s Hospital Center – ranging from a clinic with an onsite MLP with 2 lawyers, a paralegal as well as 3 full time social workers, to a clinic with no legal support and limited access to a social worker

None

Cross-sectional comparative survey of resident’s confidence and practice patterns identifying and addressing SDH

Comparison between residents who had their continuity at different clinical sites stratified by the level of legal and social work support.

Studied outcomes in residents at different clinical sites included differences in knowledge, attitudes and practice related to social determinants of health in their primary care practice.

When compared to residents who had their continuity clinic in a setting without co-located MLP, residents with access to co-located MLP:

1) Had increased confidence in their knowledge of benefits and food insecurity

2) Were more likely to ask patients about their housing, WIC (women infant and children program), public benefits and food insecurity

3) Spent a greater amount of time discussing social history with their patients

3

Pettignano, 2017 [17]

3rd year medical students (N = 100)

MLP with Children’s Healthcare of Atlanta, Morehouse School of Medicine, the Atlanta Legal Aid Society and the Georgia State University College of Law

Delivery of a curriculum designed to educate students about MLPs and the ways in which they could collaborate with other professionals to address social determinants of health in their patients / clients

Pre/Post intervention study analyzing impact of 3 different cohorts of medical students over 3 years.

Survey regarding the perceived benefits of an MLP and the importance of inter-professional practice as well as assesses subjects confidence regarding their ability to identify and address social determinants of health in their patients

After the intervention, students were more likely to:

1) Appreciate that social determinants such as access to public benefits, can impact the health of low-income patients

2) Screen patients for socioeconomic and legal issues related to income, education, family law, health insurance, public benefits, and supplemental security income / disability.

3) Refer patients to a legal resource when facing a patient with socioeconomic or environmental issues that may affect health

4

Cohen et al., 2010 [13]

Medical residents (N = 143) at three clinics participated in this study. LegalHealth, a division of New York Legal Assistance has weekly co-located MLP clinics at 16 different hospitals and clinics.

Interns (N = 76) in the primary care internal medicine program participated in this study. MLP Boston has co-located clinics at Boston Medical Center and six community health centers.

Pediatric interns (N = 19) participated in this study.

Peninsula Family Advocacy Program is a collaboration between Lucile Packard Children’s Hospital at Stanford, Ravenswood Family Health Center in East Palo Alto, San Mateo Medical Center and the Legal Aid Society of San Mateo County.

(This paper also describes the Legal Assistance to Medical Patients program partnering with Beth Israel Medical Center pediatric and medicine residency programs, but does not describe the impact of MLP educational initiatives)

Didactic sessions through grand rounds presentations such as “Bring advocacy to patients,” and one to one teaching sessions on topics such as income supports

Multiple components including a poverty simulation session, and physician advocacy training which includes touring community resources and didactic sessions relevant to social determinants of health as well as clinical exposures with vulnerable populations

Multiple components including an interdisciplinary course “medical-legal issues in children’s health,” and separate didactic sessions on topics such as “Immigrants and the health care system” and “your patient and the workplace,” as well as one on one sessions for a range of topics including legal status (e.g. immigration) and personal stability (e.g. advanced directives, guardianship)

Pre/Post intervention surveys surrounding knowledge, attitudes and practice in MLP

Evaluations limited to surveys after the interventions and informal qualitative feedback

Evaluations limited to surveys after the interventions and informal qualitative feedback

After completing the interventions, residents were:

1) More likely to believe it is the responsibility of the physician to help patients find free legal services when needed

2) Have increased knowledge regarding how to assist patients seeking public benefits

3) More likely to refer patients to legal services

4) More likely to assist patients with obtaining government benefits and obtaining safe housing

After completing these programs:

1) 97% of participants reported they could screen for two unmet social needs

2) 74% strongly agreed and 21% somewhat agreed that they better understood poverty and the majority felt that “the experience has helped me better understand how poverty can affect health”

Qualitative feedback included “I feel more encouraged in my ability as an MD to make changes”

Interns attitudes towards legal screening for needs improved, as few providers reported concerns about making patients “nervous” with legal questions

Qualitative feedback included “this course does a whole lot to empower students to effective action and advocacy” and “seeing how lawyers prioritize components of a patient case differently than physicians gave me a new perspective on how I might approach a patient.”

3

Pettit, 2019 [18]

Family medicine interns (N = 39)

Tucson Family Advocacy Program MLP within the University of Arizona Department of Family and Community Medicine

A multidisciplinary (MLP director and medical director of primary care clinic) led advance care planning training program which included didactics and direct observations of residents conducting advance care planning discussions

Pre/Post intervention surveys related to residents comfort performing advanced care planning discussions

MLP director ratings of residents during direct observations of residents conducting advanced care planning (scored according to ACGME milestone ratings during shadowed patient encounters).

Interns’ advanced care planning discussions with patients improved after receiving the intervention – During the first year of the program, residents were almost all rated as ACGME level 1 “beginner” or 2 “novice” and by the 3rd observed session, residents were all rated at least a ACGME level 3 “developing” which is the expected level for a 2nd or 3rd year resident.

Residents also reported increased comfort leading advanced care planning discussions.

3