Mr. Jackson (not his real name) is a 42-year old man who was hospitalized three times in a seven-month period at Lancaster General Hospital in Pennsylvania. These hospitalizations were due to complications from chronic obstructive pulmonary disease, morbid obesity, depression, chronic kidney disease, and lower extremity non-healing ulcers. He was depressed and concerned that he was not able to move beyond the revolving door of frequent inpatient admissions.
Mr. Jackson was also incurring a large debt due to copays and uncovered services and medications. But his problems were not just medical. He was having legal problems getting enrolled in Medicaid, and his Social Security benefits were being unlawfully garnished. After his last hospitalization, he was so distraught that he did not leave his house for six weeks.
Mr. Jackson represents one of the most fundamental problems we face in medicine today — controlling cost among the highest users of our health care system. We often call these individuals “super-utilizers,” but that term only defines one truth about their interaction with the health care delivery system. While high use leads to higher costs and poorer quality outcomes, it is often driven by psychosocial, financial, and societal barriers to care and points to a lack of coordination between health care, social service, and civil legal aid infrastructure.
A “patient-centered” approach is at the heart of many successful programs attempting to address the needs of super-utilizers. Between September 2011 and September 2012, Lancaster General Health conducted a pilot super-utilizer project that embedded lawyers within an inter-professional care team. The goal was to see what effect integrating civil legal aid services into the care of high-using patients like Mr. Jackson would have on health care use, cost, and fulfilling the promise of patient-centered care.
Lawyers As The New Member Of The Health Care Team
Inspired by the work of Dr. Jeffrey Brenner and the Camden Coalition, Lancaster General Health set up a super-utilizer pilot, but with a twist. In addition to social workers, nurses, physicians, patient navigators, psychologists, and pharmacists, the pilot’s inter-professional team also included a lawyer from MidPenn Legal Services, the non-profit civil legal aid organization that serves South Central Pennsylvania. The lawyer’s time was supported through grant funding from the hospital foundation.
The goal of the pilot was to assess the impact on health care use of addressing patients’ civil legal problems – the social, financial, or environmental problems that require assistance from lawyers to remedy. The lawyer was embedded in the health care team and present during case management discussions to identify specific civil legal problems and to help the team better understand how to address them.
Throughout the pilot, it became clear that high use was often a marker for unaddressed civil legal problems. During the pilot year, 55 patients were enrolled in the super-utilizer project. Of those, 52 (95 percent) had two or more civil legal problems impacting their health care use. The most common were housing (preventing evictions, securing housing subsidies, and improving substandard conditions) and access to public benefits (appealing wrongly denied benefits). Other civil legal problems were related to domestic violence (securing restraining orders), access to care or coverage of health care services, and mental health/incapacity.
The inclusion of a lawyer on the health care team is a key element of the Medical-Legal Partnership (MLP) approach, which integrates the expertise of health care, public health, and civil legal aid professionals to address and prevent civil legal problems that affect health. Medical-Legal Partnership lawyers are experts in civil legal aid, advocating for patients on both an individual and a systemic level, and focusing primarily on a core set of legal domains, frequently referred to by the acronym I-HELP® (signifying income and insurance, housing and utilities, education and employment, legal status, and personal or family stability).
By building the patient-care team’s capacity to handle civil legal problems, MLP’s allow team members to work at the top of their license. When identified in a health care setting, civil legal problems are often detected earlier, enabling the civil legal aid community to prevent these problems before they cascade into crises, achieving better outcomes with fewer resources.
The 55 patients were identified for the Lancaster pilot based on high cost emergency department and inpatient use. The pilot care team developed a survey that asked about 26 financial, economic, and environmental barriers to health, and the survey was administered to all pilot patients via an interview with the care manager. The care manager and civil legal aid lawyer reviewed all the surveys to track civil legal problems.
Patients Can Benefit From Both Direct And Indirect Civil Legal Care
Medical-legal partnerships facilitate the provision of different “doses” of legal care, or the spectrum of interventions that help address health-harming civil legal needs. Legal care can include consultations with health care team members, full legal representation, changes to clinic policies that can more efficiently address problems, and advocacy to change local, state, and federal policies to better prevent civil legal problems. For example, it can be more efficient and effective to share legal resources with a health care team member such as a social worker, who then uses a trusting patient relationship to ensure that the patient can makes the best use of those resources.
Medical-Legal Partnership lawyer trainings at Lancaster General Hospital led to significant changes in how social workers document observations and examples in the medical record. Trainings facilitated a more comprehensive, detailed record for valid Social Security disability claims, as well as a better understanding of the Social Security disability system, standards, timelines, and resources, to discourage inappropriate claims and to respond to patient concerns regarding issues like ability to work part-time while receiving benefits. The MLP lawyer also trained social work and medical staff on the medical certification requirements to help seriously ill patients prevent utility shutoffs, and assisted in developing a standardized certification form.
Many of the civil legal problems identified through the pilot were able to be treated with this kind of indirect legal care where the lawyer relayed legal information and resources to social workers and medical staff. A smaller number of civil legal problems required direct legal care such as advice from a lawyer directly to the patient or full legal representation. A little more than 16 percent of disability-related civil legal problems required direct legal care, while almost 84 percent could be addressed by a lawyer supporting the case management team.
When the super-utilizer team addressed a patient’s civil legal problems, health care use and costs dropped. The pilot data suggest a decrease in both 30-day and seven-day readmission rates among the identified patients. Both inpatient and Emergency Department use dropped upward of 50 percent, and overall costs (as defined by charges) fell by 45 percent.
The Difference For Mr. Jackson
Mr. Jackson was one of the patients enrolled in the Lancaster General pilot. He was given a care navigator, and a social worker visited him in his home to identify the particular barriers that were driving his increased use.
The team discovered Mr. Jackson was eligible for Medicaid, but was only enrolled in Medicare, which immediately helped with some of the non-covered hospital costs for which he was responsible. The lawyer also discovered that he was only receiving half of the Social Security benefits to which he was entitled and that his benefits were being garnished at too high a level, in violation of federal regulations. The team was able to reinstitute the benefits to 95 percent of the original amount.
With civil legal help, Mr. Jackson felt emboldened and more financially able to take better care of his medical conditions. He was evaluated for and had bariatric surgery. He lost over 150 pounds, moved his family into better housing, and is now in the process of looking for full-time employment. He also met his future wife during the group visits at the bariatric surgery center.
As a result of direct civil legal care, both Mr. Jackson and the hospital were able to dramatically reduce the amount spent on his health and health care, and Mr. Jackson has not been back to the hospital since his initial enrollment in the project.
Challenges and Opportunities For Super-Utilizer Medical-Legal Partnerships
In 2013, this pilot super-utilizer project became an official program at Lancaster General Health called Care Connections. However, initial grant funding for the lawyer as part of the team ran out, and a new funding source was not found. Civil legal aid resources are scarce; national studies show that current legal aid organizations have sufficient resources to address only 20 percent of civil legal needs, and federal funding continues to decline.
This means that civil legal aid is focused primarily on addressing emergency needs, like housing evictions, rather than preventive, upstream interventions. Without new funding streams to support additional civil legal aid staff dedicated to projects like this one, civil legal care is unavailable to high-utilizing patients in the preventive, integrated manner that was effective in the Lancaster General Health pilot.
To sustain investment in the legal component of Care Connections and for other health care institutions to develop similar programs, two important things must occur. First, as health care providers move to outcomes-based reimbursement and global payments, they need to develop clear metrics to capture civil legal problems and how embedding civil legal aid helps them reduce avoidable admissions and use of health care services.
Despite rapidly growing awareness of the pervasiveness of civil legal problems for vulnerable populations and their negative effect on health, as well as emerging pilot data detailing the impact that civil legal aid services can have on patient health and well-being, clearly defined health care metrics have not been developed. Second, the civil legal aid community at-large must re-align some of its own priorities using health as an organizing principle and articulate a succinct business case for investment from the health care sector.
Despite the funding challenges, the need for integrated health and legal care is gaining recognition. In fall 2014, the Health Resources and Services Administration released guidance, which clarified that civil legal aid services may be included in the range of enabling services that Federally Qualified Health Centers may provide to meet the primary care needs of their patients.
Improving Health Outcomes
Civil legal barriers to health and well-being—from safe and affordable housing to receipt of appropriate insurance and other public benefits—were incredibly common among super-utilizers in the Lancaster General Health pilot. While not all patients who are assessed and treated for civil legal problems will have the turnaround that Mr. Jackson did, his case highlights how civil legal aid services can dramatically improve health outcomes. Given the reactive, under-resourced nature of civil legal aid agencies across the United States, most of these patients will never get access to civil legal aid; nor will the health care teams that treat them have the benefit of legal expertise and insights.
However, this pilot shows that medical-legal partnership can build on the intent of a super-utilizer program, which is to embed efficiencies within the health care system, reduce costs, and improve health outcomes among the most vulnerable patients. Future studies should analyze super-utilizer teams with and without civil legal aid services to better understand how much civil legal problems contribute to health care use. These data will allow super-utilizer projects to build the business case for legal care based on provider efficiency, improve health and well-being, and lower costs.
Photo caption: From left to right: Katie Schultz (attorney), Wendy Walton (Social Worker), Amber Jerauld (Pharmacist), Mr. Jackson (Client), Adam Wilikofsky (Clinical Psychologist), Jeffrey Martin (physician), and Audrey Martin (LCSW) (Photo provided by Lancaster General Health Superutilizer Project)