Medical-legal partnerships (MLPs) promote interdisciplinary interventions that seek to combine both medical and legal expertise to address health-related social needs (HRSNs). Such needs include housing quality and stability, public benefits assistance, and employment instability. Usually housed within healthcare settings, MLPs are now a well-recognized model of care delivery. While their origins and subsequent evolution have been thoroughly explored elsewhere, much of the literature on MLPs has thus far focused on their intrinsic interprofessional educational value. Increasingly, studies are seeking to build an evidence base evaluating links between MLPs and meaningful, measurable health outcomes. An important feature of the recent study by Partono et al. is its aim to associate certain characteristics of MLPs to outcomes experienced by patients with HIV (PWH), a population that has not received systematic attention in the MLP literature.
Partono et al. report the findings of a mixed-methods study that incorporated quantitative and qualitative measures in a cross-sectional survey of clinicians, administrators, and other specialists working within or integrated with MLPs in the United States. The survey was administered only to those organizations primarily caring for PWH. Outcome variables were selected to correspond to both clinically-relevant measures (i.e., suppressed viral load and percentage of patients who were retained in care) as well as organizationally-relevant measures (i.e., number of colocated on-site services available, referral numbers, type of healthcare organization linked to MLP). The survey also included opportunities for qualitative responses to open-ended questions.Reference Partono 1 The work of Partono et al. provides important advances in our understanding of the impact of MLPs on a variety of outcomes. In what follows, we review recent scholarship that has generated an evidence base for MLP performance in relation to clinical and cost (value) outcomes.
MLP and Clinical and Cost Outcomes
The literature now includes a significant evidence base for evaluating the efficacy of MLPs across at least three domains — clinical outcomes, cost improvements, and system-level outcomes. Perhaps most intuitively, a wealth of evidence has directly revealed the ability of MLPs to affect several clinically-relevant measures. For example, a recent scoping review revealed that the MLP intervention is associated with improved cognitive development and physical health in pediatric populations.Reference Shchetinina 2 Another review suggested effects on clinical outcome measures such as hospitalization rates across mental and physical health conditions.Reference Johnson 3 These individual, or patient, level effects can be significant; a recent study performed by one of us (AB) concluded that low-income children referred to an MLP were 37.9% less likely to experience hospitalizations than those not referred to the MLP.Reference Beck 4 Indeed, MLPs have been noted as a particularly potent intervention for addressing HRSNs and related social determinants.Reference Pettignano 5
A separate strand of scholarship has suggested that evidence-gathering for MLPs should be broadened to assess the role of MLPs in advancing cost, or value, metrics. A longitudinal study by Teufel et al. demonstrated that a rural MLP increased healthcare recovery dollars by 319%. This study went on to detail other financial impacts for its participants, including recouped social security benefits and more robust end-of-life guidance (increased use of power of attorney or will).Reference Teufel 6 MLPs can also directly reduce expenditures of hospital systems by reducing the need for forms of high-acuity care. MLPs can do this by decreasing costly acute care and increasing uptake of preventive care; this may be particularly striking in care of chronic conditions, from asthma to HIV.Reference Henize and Beck 7 Still others have demonstrated an ability by MLPs to have impacts that are not strictly centered on the healthcare system but rather effects across a broadened conception of a health-promoting system that stretches across settings.
MLP Organization and Operation
Partono et al. demonstrate that the site of care provision matters — MLPs integrated with community-based healthcare organizations (CBOs) are more associated with improved outcomes than those MLPs integrated with hospital systems. Moreover, colocation of legal and support services at the point of care has been associated with a range of quality metrics, such as greater appointment adherence and a greater reduction in viral load among PWH in the Partono et al. study. 8
Colocation may promote coalitional dynamics in meaningful, impactful ways. Bhandary-Alexander and Shek argue, for example, that MLPs serve as crucial coalition-building institutions that allow patients and healthcare actors to “bootstrap” their efforts to achieve policy change — this may be particularly true when partners are situated in close physical and operational proximity to one another. Others have suggested — based on qualitative evidence — that the relationship between the “M” and “L” in MLP can be made more explicit by clearly articulating shared goals of the partnership.Reference Friley 9 And while MLPs largely operate within academic medical centers, certain forms of legal aid may be particularly impactful when integrated into a diverse array of care delivery systems.Reference Sonik 10 For instance, some now advocate for legal supports to be available across a range of CBOs.Reference Ezer 11
Future Directions
Further measurement and evaluation of the breadth of MLP impacts may be warranted. Bhatnagar et al. suggest that MLP evaluation can be refocused to enhance broader systemic health outcomes. 12 Furthermore, MLPs can enrich healthcare systems’ collection of important contextual information about HRSNs that may guide clinical management. 13 Still others suggest that given MLP’s significant effects on the health system at large, they should be more readily integrated into financing schemes.Reference Sage and Warren 14 The Partono et al. study is part of the growing MLP evidence base focused on evaluating the performance and effects of this intervention on outcomes of value to medical teams, legal teams, and patients and families.
Disclosures
The authors have nothing to disclose.
