By one estimate, the number of deaths attributable to the social determinants of health including low education, racial segregation, low social support, individual-level poverty, and income inequality is comparable to the number of deaths attributable to the leading bio-medical causes of death in the United states including myocardial infarction, cerebrovascular disease, and lung cancer . According to the landmark 2017 Justice Gap Report, low income households are especially impacted by legal barriers, with 71% of low income households having at least one civil legal problem and 41% of low-income households estimated to have civil legal needs associated with health care . Fewer than one in five legal problems experienced by low income individuals are addressed with the help of an attorney who understands how to successfully navigate the legal system , and many vulnerable patients cannot ascertain their legal needs . Some of these legal needs such as access to appropriately maintained housing, adequate food, and even applying for state funded insurance such as Medicaid can improve health. To address these health harming legal needs, Medical Legal Partnerships (MLPs), pioneered in the 1990 s, recruit the capacities of clinicians and lawyers to directly address legal-barriers to health  and more than 300 hospitals around the United States have adopted an MLP program .
Most described MLPs in the United States are based in a health care clinic (either primary care or specialty care) and patients are screened by either a physician or a member of the staff in the clinic during a routine clinic visit. Positive screens trigger detailed interviews through which the patient’s specific health harming legal situation is understood as that requiring the intervention of a legal professional. Limitations of time, training, and human resources may cause health care organizations to inadequately identify and address patients’ health harming legal needs. As many as 79% of health care organizations in the United States with an MLP reported screening for health harming legal needs among the social determinants of health. However, because the time and resources required to screen, assess, and refer legal needs are substantial, only 30% screened the general population “all of the time,” and only 63% of health care partners used a formal screening protocol .
Some programs utilize medical assistants or social workers to screen patients for health harming legal needs, but medical assistants in these models also juggle competing responsibilities  and many Licensed Clinical Social Workers spend an increasing amount of time on mental health counseling and less time on tasks associated with helping patients obtain social services and resources to assist patients with their medical needs . Other programs have tried to integrate screening for health harming legal needs in the electronic medical record , or incorporate self-screening as part of the pre-visit check-in . Care coordinators or navigators were used to conduct screening for health harming legal needs in the Whitman-Walker Health system  but only in a focused group of LGBTQ and HIV-positive communities utilizing a federally qualified health center.
Screening for health harming legal needs may be effectively conducted by care coordinators, whose cost-effectiveness in various areas is supported by recent studies [11, 12]. As care coordinators are not a part of the clinic staff they do not have the same time constraints as clinical staff or clinicians. This allowed us to add the patient service of screening and referral to the MLP without adding new responsibilities to primary and specialty care clinics that were already strained for time and resources. The use of care coordinators to screen, assess, and refer a general population of a safety-net population for legal services has not been described previously in literature. The goal of the study was to demonstrate that referrals from care coordinators screening patients outside of the clinic are comparable to referrals from clinical staff. We also evaluated outcomes using legal case status, patient self-reported health, general well-being of patient and family, and return on investment compared to previous studies.
Medical legal Partnership at cook county health
Cook County Health (CCH) is a public healthcare system serving about 300,000 patients each year in 2 hospitals, 15 community health centers, and correctional health services in Cook County Jail and the Cook County Juvenile Temporary Detention Center. In any given year, approximately a third of CCH patients are uninsured and another third are Medicaid insured. CCH also administers CountyCare, the largest Medicaid managed care plan for Cook County Medicaid beneficiaries, with more than 330,000 members in 2018. To further the organization’s service mission and identify potential policy changes to decrease health disparities, an MLP was established and implemented in March 2017 through a partnership of Cook County Health, Legal Aid Chicago (formerly Legal Assistance Foundation (LAF)), and the Chicago Department of Public Health. Legal Aid Chicago is a civil legal services organization, providing bi-lingual (English/Spanish) non-criminal legal services to people living in poverty and other vulnerable populations. Initial funding for the partnership was provided through the BUILD Health Challenge Grant, which comes from a collaboration of private foundations seeking to improve coordination between community-based organizations, health systems, and local public health departments.
The MLP targeted various high-risk populations assigned to CCH’s complex care program for patients with profile similar to the highest utilizers of public entitlement programs . Patients in the complex care program were assigned to a care coordinator. In addition to patients of the complex care program, care coordinators screened for the healthcare needs of approximately 4000 patients from May 2017 to August 2018 in Chicago’s Central Bond Court located on the premises of Cook County Jail prior to detainees’ court hearing. Finally, patients admitted to the hospital and seen in the emergency department represented some of the most medically vulnerable population screened by care coordinators.
Care coordinators are nurses, social workers, and community health workers who work directly with patients and are familiar with patient’s medical conditions, psychosocial circumstances, living environment, history, values and readiness for self-care management  in order to identify barriers to health and help patients overcome those barriers. Care coordinators interact with patients inside and outside health care facilities to identify how their disease impacts their social and emotional health, and how their distinct situations impact the overall health of the patient. They help patients coordinate care between primary care, specialty care and ancillary services (wound care, physical therapy, etc.) with the goal of reducing complications from chronic medical conditions. At CCH care coordinators screen patients for health and social needs using a standardized health risk screening tool which includes self-reported health care needs, social determinants including food, housing, and personal safety and assist patients with coordinating appointments and transportation.
Legal Aid Chicago worked closely with the care coordination team and provided continual and regular training to educate the care coordinators about what health harming legal needs are, how to identify them, which legal issues can be addressed through a high intensity legal intervention, and which issues are appropriate for self-advocacy. Between March 2017 and August 2018, 22 training sessions were held. Training used a mnemonic that identifies common social determinants of health known as I-HELP . IHELP stands for Income, Housing, Education & Employment, Legal Status, Personal and Family Stability. All categories of IHELP were covered during the training sessions, but public benefits were identified as the highest need that could be addressed by this partnership.
Care coordinators were not given a script or specific questions to use for screening for health harming legal needs, but were given training about how to identify health harming legal needs during their regular patient interactions. Care coordinators were equipped to manage common social needs such as provision of information and referrals to social services. When care coordinators elicited health harming legal needs beyond their scope, they discussed the availability of legal resource with the patient, obtained permission to make a referral, and referred patients to Legal Aid Chicago through a warm handoff. Care coordinators were encouraged to consult with the project attorney if there was a question as to whether a patient’s issue was appropriate for a referral in order to ensure the quality of referrals through regular feedback. Commonly surfaced legal issues that were not appropriate for extended representation provided insight for where self-advocacy materials would be valuable for care coordinators to share directly with patients.
To effect the warm handoff, care coordinators communicated directly with the staff attorney providing a brief description of patients’ needs and their contact information. Legal Aid Chicago staff made at least 3 attempts to contact the patient; if those efforts were unsuccessful a letter was sent to the patient with information on how they can connect with the attorney directly if the legal issue persisted. After successful contact with the patient, the staff attorney performed an intake interview to determine the nature of the legal issue, ensure that no legal conflicts of interest existed, and develop their recommended course of action. Recommendations provided by the staff attorney after reviewing the case include: direct legal services provided by the staff attorney, referral to an internal legal specialty practice group, advice on self-advocacy measures, or referral to an outside agency. Once the case was closed, and permission from the client obtained, information about the outcome of the case was relayed back to the care coordinator who made the initial referral. This closed-loop provided continual reinforcement and refinement of the care coordinators knowledge of how to identify and refer health harming legal needs.