Impact of a medical-legal partnership program on readmissions to a family medicine inpatient service

Abstract

Background: The Centers for Medicare and Medicaid Services (CMS) value-based reimbursement prioritizes health outcomes and population health in a way that emphasizes social determinants of health, access disparities, and prevention. Unmet legal assistance needs are an area of considerable interest because it can impact access to healthcare services and can be a social determinant of health. Medical-Legal Partnerships (MLP) are tools to link patients with unmet legal needs with lawyers and other legal services. The goal of these programs is to address legal issues that complicate the life and healthcare of patients. With the hypothesis that unmet legal needs were a risk factor for poor health outcomes, we studied the impact of unmet legal needs on the readmission rate to the SIU Family and Community Medicine inpatient service at Memorial Medical Center in Springfield, Illinois. Methods: All adult patients discharged between January 2016 and March 2018 were retrospectively studied to determine if the need for legal services was a significant predictor of all-cause hospital readmission within 30 days of discharge. Patients in need of legal services were identified using an interview-based screening tool and were referred to an HRSA-grant funded MLP. The impact of unmet needs for legal services was compared to validated risk factors for hospital readmissions such as the LACE index and HOSPITAL score. Results: Data from 2500 hospital discharges from the SIU FCM service were analyzed. The overall readmission rate was 27%. Univariate analysis showed patients who were readmitted were older (57 vs 53 years, p < 0.001), had longer hospital stays (4.69 vs 4.17 days, p < 0.014), had higher Charlson Comorbidity Index values (2.31 vs 1.57, p < 0.001), HOSPITAL scores (4.79 vs. 3.14, p < 0.001), LACE index values (10.13 vs. 8.33, p < 0.001) and were more likely to need legal services (12% vs. 3%, p < 0.001). Multivariate analysis showed the HOSPITAL score (OR 2.12, p<0.001), LACE index (OR 1.16, p<0.001), Charlson Comorbidity Index (OR 0.70, p<0.001), hospital length of stay (OR 0.85, p<0.001), congestive heart failure (OR 2.10, p<0.001), COPD (OR 1.85, p<0.001), diabetes with complications (OR 1.88, p<0.001), and a need for legal services (OR 2.21, p<0.001) to be independent predictors of an increased risk of hospital readmission. Conclusion: Unmet legal needs identified in this study via an interview-based screening tool appear to be an independent risk factor for hospital readmission. The predicted risk of readmission (OR 2.21) compares favorably with validated HOSPITAL score (OR 2.12) and LACE index (OR 1.16) readmission risk assessment tools. These findings suggest that the presence of unaddressed legal issues may be a modifiable non-medical risk factor for hospital readmission. Further study of the impact of MLP programs on hospital readmission is necessary to clarify the implications of this social determinant of health on a critical value-based care measurement.

What Medical-Legal Partnerships can do for Trauma Patients and Trauma Care

“…A small body of research on the impact of MLPs shows significant improvements on hospital readmissions, patient stress levels, and financial impact for both patients and health care institutions when MLPs intervene. One study showed a 91% reduction in ED visits and hospital readmissions for asthma after having a medical-legal intervention and over 91% of these patients also dropped in asthmatic severity by two or more classes 17 . Another study, looking at stress in cancer patients, found that those that used MLP services had a 75% reduction in stress and 30% increase in treatment score 18 .…”

“…Medical legal partnerships could help with the legal needs of trauma patients and have successfully done so in other populations, including pediatrics, veterans affairs, obstetrics, and people living with HIV/AIDS. 12,15,17,25 Existing MLPs currently address housing, immigration, employment, discrimination, rehab treatment, benefits, and insurance, all of which are or might be existing legal needs in trauma patient populations. The most common legal needs currently being addressed by MLPs can be found in Figure 1.…”

“…One study showed a 91% reduction in ED visits and hospital readmissions for asthma after having a medical-legal intervention and over 91% of these patients also dropped in asthmatic severity by two or more classes. 17 Another study, looking at stress in cancer patients, found that those that used MLP services had a 75% reduction in stress and 30% increase in treatment score. 18 The mean perceived stress scale score decreased by 8.1 points and wellbeing scores increased by 1.8 points due to "less concern regarding legal issues that were addressed adding legal form letters to electronic health records to help low-income patients rectify substandard housing conditions."…”

Free legal aid in hospitals for persons with mental illness: Is it helpful? An Indian prospective study

“…Legal issues in PwMI are not uncommon as emphasized earlier. [ 4 10 ] Hence, the clinicians need to exercise sensitivity during assessment and evaluation to consider legal issues as a prospective factor in the patient’s treatment and recovery plan. As most of the patients benefitted from the interventions of the LAC, we have preliminary evidence to suggest that they are helpful.…”