Legal needs of patients attending an urban family practice in Hamilton, Ontario, Canada: an observational study of a legal health clinic

Abstract

Background Individuals living in poverty often visit their primary care physician for health problems resulting from unmet legal needs. Providing legal services for those in need may therefore improve health outcomes. Poverty is a social determinant of health. Impoverished areas tend to have poor health outcomes, with higher rates of mental illness, chronic disease, and comorbidity. This study reports on a medical-legal collaboration delivered in a healthcare setting between health professionals and lawyers as a novel way to approach the inaccessibility of legal services for those in need. Methods In this observational study, patients aged 18 or older were either approached or referred to complete a screening tool to identify areas of concern. Patients deemed to have a legal problem were offered an appointment at the Legal Health Clinic, where lawyers provided legal advice, referrals, and services for patients of the physicians. Fisher’s exact test was used to compare populations. Binary logistic regression was used to determine the factors predicting booking an appointment with the clinic. Results Eighty-four percent (n = 648) of the 770 patients screened had unmet legal needs and could benefit from the intervention, with an average of 3.44 (SD = 3.42) legal needs per patient screened. Patients with legal needs had significantly higher odds of attending the Legal Health Clinic if they were an ethnicity that was not white (OR = 2.48; 95% CI 1.14–5.39), did not have Canadian citizenship (OR = 4.40; 95% CI 1.48–13.07), had housing insecurity (OR = 3.33; 95% CI 1.53–7.24), and had difficulty performing their usual activities (OR = 2.83; 95% CI 1.08–7.43). As a result of the clinic consultations, 58.0% (n = 40) were referred to either Legal Aid Ontario or Hamilton Community Legal Clinic, 21.74% (n = 15) were referred to a private lawyer; one case was taken on by the clinic lawyer. Conclusion The Legal Health Clinic was found to fulfill unmet legal needs which were abundant in this urban family practice. This has important implications for the future health of patients and clinical practice. Utilizing a Legal Health Clinic could translate into improved health outcomes for patients by helping overcome barriers in accessing legal services and addressing social causes of adverse health outcomes.

Workforce Models to Screen for and Address Patients’ Unmet Social Needs in the Clinic Setting: A Scoping Review

“…To describe the structure of workforce models performing these activities, studies were first sorted by mode of administration used for screening. We found 37 studies used self-administered screening with patients, 29,30,32,34,41,42-46,48,52-54,56,59,61,62,64-66, 68,69,71-73,75-77,79,80-84,86,87 24 studies used clinician-administered screening, [26][27][28]31,33,[35][36][37][38][39][40]47,[49][50][51]57,60,63,74,78,85,[88][89][90] 3 studies used both, 55,58,70 and 1 study did not mention the mode screening administration 67 (Figure 2). We then categorized the workforce associated with each screening administration type and the roles who responded to identified needs.…”

“…[26][27][28]31,33,[49][50][51]57,60,63,74,78,85,88 In the 8 models using medical providers or residents, they either (1) assisted patients directly through community resource referrals, 38,39 (2) provided community resource referrals with an option to escalate to a social worker or an on-site medical legal partnership, 36,37,47,90 or (3) directly referred patients to social work or the onsite medical legal partnership without providing community resource information themselves. 35,89 In the 15 models that used social care staff or non-physician clinical staff to administer screenings, the same worker who conducted the screening was the same worker to provide initial assistance to patients, 31,36,40,41,44,55,56,58,61,67 with 2 studies allowing for additional follow-up from separate student volunteers. 78,88 Hybrid models.…”

“…Three studies described using both selfadministered and clinician-administered screening. 55,58,70 For example, in 1 model, front desk staff provided paper 31 Safety-net urgent care clinic 27 Adults with depression 31 Community health center 30,31 Women with depression 32 Women's health clinic 32 Multi-setting 26,28 Difference-indifference/quasiexperimental Urban 34 Academic primary care clinic 34 Adults 34 Not mentioned 33 Integrated health system 33 Adults with predicted high utilization 33 Pre-post with control Urban [35][36][37] Academic primary care clinic 35- 60 Elderly Hispanic adults 57 Community health center/ federally qualified health center 40,45,46,61,68,69 Pregnant women 40 Black women 49,50 Women with depression 71 Academic-federally qualified health center 39,57,62,66 Multiple populations 45,55 Unspecified primary care clinic 64,67 Not mentioned 41,60,63 Multi-primary care setting 49,50,55,58 Quality improvem...…”

“…28,[35][36][37][38]42,47,49,50,61,70,74,86,[88][89][90] Of note, 37 studies did not explicitly report how staff were trained to implement the program. 27,[32][33][34]40,41,43,45,[51][52][53][54][55][56]58,59,[62][63][64][65][66][67][68][69]71,73,[76][77][78][79][80][81][82][83][84][85]87…”

“…-41,44-48,52,55,58,61,62,64,66,69,70,72,73,75-77,79,83,84,86,87,89,90 21 included the social care workforce, including paid and volunteer staff,[26][27][28]31,33,40,43,[49][50][51]53,57,60,63,72,74,78,80,82,85,88 7 included research staff,29,30,32,65,67,68,71 and 6 did not mention the specific type of worker 34,42,54,56,59,81. For assistance-related activities, 39 studies included the traditional healthcare workforce,29,30,[35][36][37][38][39][40][41][42][43][44][45][46][47][48]…”