Medical-Legal Partnership: What is It & How Can I Get Involved?
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1 Medical-Legal Partnership: What is It & How Can I Get Involved? Ellen Lawton, Esq National Center for Medical-Legal Partnership Jeff Martin, MD Lancaster General Hospital July
2 Only 18% of Americans surveyed believe that lawyers contribute a lot to society. Source: Pew Research Study, July 2013
3 Ellen Lawton & Dr. Jack Geiger As we focus on how to build healthier communities over the next 50 years, we must remember that health does not exist in a vacuum separate from wealth, from the laws we write, from the systems we create to protect our citizens, or from the injustices that exist in each of these things.
4 The problems are visible. The solutions are not.
5 AMERICAN BAR ASSOCIATION HEALTH LAW SECTION REPORT TO THE HOUSE OF DELEGATES 2007 RECOMMENDATION RESOLVED, That the American Bar Association encourages lawyers, law firms, legal services agencies, law schools and bar associations to develop medical-legal partnerships with hospitals, community-based health care providers, and social service organizations to help identify and resolve diverse legal issues that affect patients health and well-being.
6 What types of lawyers are there? Public Health Private Practice Attorneys Corporate Attorneys Public Interest/ Gov t Civil legal aid Academics
7 Availability of legal assistance in the U.S. Source: Legal Services Corporation, Documenting the Justice Gap in America: The Current Unmet Civil Legal Needs of Low-Income Americans (September 2009).
8 Integrating civil legal aid as part of quality health care Medical-legal partnership embeds lawyers alongside health care teams to improve both individual and population health.
9 MLPs help patients with I-HELP issues Income & Insurance Legal status Housing & energy Personal & family stability Employment & Education
10 It s a Culture Shift Team Huddle at 7:30am! Team? What team? Prevention is..not a thing None of your beeswax!
11 How MLPs differ from referrals Work onsite and participate in clinical meetings Establish formal screening processes of patients healthharming social needs Share data and communicate about patient-clients Detect and address patterns of systemic need
12 Impact of treating legal problems with MLP People with chronic illnesses are admitted to the hospital less frequently. People more commonly take their medications as prescribed. People report less stress. Less money is spent on health care services for the people who would otherwise frequently go to the hospital. Clinical services are more frequently reimbursed by public and private payers. Read the research on our website.
13 State of the MLP Field Report Coming Soon! survey-report/
14 MLP Health Care Partners by Organization Type Children's Hospital 17% Other 17% General Hospital/ Health System 33% FQHC 33% Notes: n=129. Source: 2016 NCMLP Survey.
15 MLP Legal Partners by Organization Type Law School 20% Other 9% LSC-Funded Legal Aid Organization 40% Non-LSC-Funded Legal Aid Organization 31% Notes: n=103. Source: 2016 NCMLP Survey.
16 Total number of referrals by health care organizations to MLP legal partners in the past year. 23% 30% 28% 12% 9% Notes: n=111. Source: 2016 NCMLP Survey. < >500
17 MLP Legal Partners Median Annual MLP Budget 26% 28% 29% 18% Notes: n=94. Source: 2016 NCMLP Survey. $0 $10,000 - $90,000 $100,000 - $195,000 $200,000 or More
18 Patient-Centered Health Care Model Includes MLP Pilot Medical Legal Partnership Targets High-Need, High-Use Patients Lancaster General Hospital s Pilot Program Embeds Attorney in the Health Care Team Attorney Social workers Nurses Physicians Pharmacists Patientnavigators Psychologists Targets highest utilizing patients 95% of high use patients enrolled in program had 2 or more legal needs Source: Embedding Civil Legal Aid Services in Care for High-Utilizing Patients Using Medical-Legal Partnership ; Health Affairs, April 22, 2015.
19 Overview of Lancaster Medical Legal Partnership 2011 Began in 2011 with LG Superutilizer pilot small foundation grant allowed Lawyer to be part of interdisciplinary team 2013 Superutilizer project became Care Connections 2014 Health Affairs article published data based on Superutilizer pilot 2015 In July, United Way Collective Impact grant established attorney position for 3 years, funds 0.73 FTE initially, now 0.6 FTE. (shortfall made up with fundraising) 2014 United Way grant required at least 3 partners, so funds were also allotted to a community agency which provided financial case management / representative payee services
20 In a study at Lancaster General Health: of high-need, high cost patients had 95% 2-3 unmet legal needs When legal problems were addressed, inpatient and Emergency Department use dropped 50% And overall costs fell by 45% Source: Health Affairs (2015) Jeff Martin, et. al.
21 more than superutilizers
22 Typical Care Connections Patient Usually multiple, chronic, co-morbidities including CAD, CHF, COPD, DM, CKD. With frequent admissions. Often behavioral health (childhood trauma (ACEs), serious mental illness, substance use disorders) Sometimes with intellectual disability Always with social isolation, or significant psychosocial barriers (DV, housing, food insecurity, transportation, financial, etc.) Any combination elevates risk Lancaster County consists of urban, suburban, and extremely rural areas. Patients come from all types of living situations from city rooming houses to trailers in isolated rural settings. Homeless persons may be living in either urban (shelter) or rural environments (campsites, forested areas).
23 Care Connections clients
24 Navigating Care in Lancaster County Today DPW Pay er LGH-af f iliated phy sicians Care / access programs FQHCs County / community serv ices Collaboration Flow of f unds Claims reimbursement Inf ormal linkages AmeriHealth Mercy Gateway UPMC Unison (UHC) Medical Assistance Medicaid FFS Lancaster County Lebanon County Dauphin County Perry County Cumberland County CABHC (Five County Collaborative) Assertive Community Treatment (ACT) Mobile Psychiatric Nursing FQHC BH Integration Project SouthEast Lancaster FQHC MH / MR / EI Office of Aging Lancaster County Programs Poverty Assistance Drug & Alcohol Commission Treatment for serious mental illness Food stamps, w elfare, etc. Safety net services for the frail elderly Rehab / detox services Aetna Better Health CBHNP Welsh Mountain Medical & Dental Center FQHC Coalition to End Homelessness Housing support and transitional assistance Lancaster Hospital LGMG Heart Group Twin Rose Independent Physicians Lancaster Lancaster General General Health Health Superutilizers Program Healthy Beginnings+ Nurse Family Partnership Geriatric house call Heart failure / high risk clinic HIV Clinic (Ryan White Grant) PCMH NCQA Level 3 Accreditation PACE / LIFE Program Participation Inpatient Psych Emergency Department Urgent Care Outpatient Center / Clinic LG Health Express Additional resources include: psychiatrists for inpatient, social w orkers, palliative care, hospitalists, advanced practice providers, RNs/MAs, etc. h? Member????? Rx assistance programs Transportation programs?? Home care providers Non-LGH MH / BH networks Drug & alcohol outpatient centers Inpatient rehabilitation facilities Employment assistance Support groups for drug & alcohol Other county programs include: Children & Youth Agency, Lancaster County Prison, Adult Probation & Parole Services, Veteran s Affairs Non-LGH healthcare providers Support helplines Low-income energy assistance Community Resources Food banks / stamps / Pharmacies distribution Protective services Counseling and legal services Social rehabilitation Case management Domestic abuse support services Emergency / transitional housing Housing, shelters, missions Child welfare Crisis interventions Support for the disabled
25 Development of Care Connections High Risk Team Home Visits Enablement Data/claims analytics Communication Patient Centered Medical Home Member Enrollment Repatriate Care Connections Team Physician Adv anced Practice Provider (NP) Nav igators (Home-based) Community Health Worker Social worker/ Behavioral Health Chaplain Clinical Support Specialist RN Case manager Clinical pharmacist County Social Serv ices Liaison Legal Services Coordination The core care team is responsible for coordination (gets what is needed, when it is needed, where it is needed) Acute Episodes County & Community Resources Support Serv ices Place of Residence Graduation Assessment At home / institution Transition Plan Dev elopment Virtual care At the Clinic Adv ance Care Planning
26 Care Connections team at morning huddle
27 Care Connections Process
28 Legal Consultation Workflow Daily Huddle Team Consult Enrollment Screen EMR Referral Identification of Legal Issues Data capture: I-HELP, ICD-10 codes Outreach/intake by attorney Legal advice/ representation/referral Team feedback/emr in-basket
29 Legal Partner Access to Electronic Medical Records To function effectively within multidisciplinary complex care team, we have found legal partner needs at a minimum: Read-only access to charts on current patient list Secure messaging capabilities Ability to document can assist in outcomes tracking Make electronic referrals to MLP Record/resolve SDH with ICD-10 codes Very limited documentation of legal assistance within medical record
30 Prevalence of Health Harming Legal Needs at Enrollment 184 PATIENTS
31 Breakdown of Income-related legal needs 107 PATIENTS
32 Breakdown of Housing-related legal needs 43 PATIENTS
33 LESSONS LEARNED: SUSTAINABILITY + LESSONS LEARNED Can we capture social determinants? EMR evolution Defining the benefit Using this work to go after at-risk contracts
34 outpatient + specialty visits pre-mlp data gathered 6/30/15 post-mlp data gathered 12/31/16 VOLUME INCREASES POST MLP OUTPATIENT visits per enrollee % OUTCOMES SPECIALIST visits per enrollee %
35 ED + inpatient utilization OUTCOMES graduated patients 1/31/17 since inception % 350 emergency visits 12 mo. pre-enrollment 18 mo. post-enrollment % 278 inpatient visits 12 mo. pre-enrollment 18 mo. post-enrollment
36 Total cost (based on charges) OUTCOMES COST PRE-ENROLLMENT $28,935,785 COST POST-ENROLLMENT $14,438, graduated patient charges FYD 1/31/17 since inception 9/1/13, 12 month pre vs. 18 mo. post-enrollment 50% cost reduction
37 LESSONS LEARNED: SUSTAINABILITY Accountable Health Communities Model
38 For more information NCMLP National_MLP
39 Questions 39
40 For more information on the ABA Health Law Section medical legal partnership's work group, contact: Clay J. Countryman, Partner Breazeale, Sachse & Wilson, LLP Simeon Carson Director ABA Health Law Section 40
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