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Improving Maternal Health Outcomes with a Medical-Legal Partnership

State of DelawareMedical-Legal PartnershipPilot Project

DHMIC Annual Summit 2014 Wilmington, DE Presented by Daniel Atkins

Marissa BandRobert Locke

Vikrum VishnubhaktaApril 9, 2014

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Road Map

About Us

Background on Medical-Legal Partnerships Pilot Project

Results

Implications of Medical-Legal Partnerships

Limitations

Next Steps

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About Us

Daniel Atkins, JD; CLASI Attorney

Marissa Band, JD, MPAP; CLASI Attorney

Robert Locke, DO, MPH; Christiana Care Neonatologist

Vikrum Vishnubhakta, MPH, MBA; Forward Consultants

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What Is A Medical-Legal Partnership?

MLP is a healthcare delivery model that integrates legal assistance as a vital component of patient care.

MLP’s 3 key activities transform the delivery of health and legal services andimprove health and well-being for America’s mostvulnerable

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What Is A Medical-Legal Partnership?

Where we work, live, and play…

…determines our health status.

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Unmet Legal Need

Fewer than 1 in 5 low-income persons receive assistance with an unmet civil legal need.

Low-income households experience on average between 1 and 3 unmet civil legal needs per year.

Source: Legal Services Corporation, Documenting the Justice Gap in America: The Current Unmet Civil Legal Needs of Low-Income Americans (September 2009).

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MLP Connection to Health

Improved physical environment.

Increased access to health care.

Increased access to basic necessities.

Decreased stress.

Increased access to educational services.

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MLP Connection to Maternal Child Health

Healthy Start MLPs improve overall health by reducing RISK factors and increasing PROTECTIVE factors through legal intervention and advocacy.

Risk Factors include: Stress Poor Environment Poverty

Protective Factors include: Increasing Access to Care Increasing Education Reuniting Families Coordinating Care

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Anxiety and Stress

Anxiety and Stress during pregnancy have been linked with poor birth outcomes.

– Dole, N., Savitz, D., Hertz-Picciotto, I., Siega-Riz, A., McMahon, M., Buekens, P. (2003). Maternal stress and preterm birth. Am J Epidemiol, 157(1): 14-24.

– Wainstock, T., Anteby, E., Glasser, S., Shoham-Vardi, I., Lerner-Geva, L. (2013). The association between prenatal maternal objective stress, perceived stress, preterm birth, and low birthweight. J Maternal-Fetal and Neonatal Medicine, 26, 10, 973-977

– Hedegaard, M., Henriksen, T., Secher, N., et al. (1996). Do stressful life events affect duration of gestation and risk of preterm delivery? Epidemiol, 7, 339-345.

– Lobel, M., Dunkel-Schetter, C., Scrimshaw, S. (1992). Prenatal maternal stress and prematurity: a prospective study of socioeconomically disadvantaged women. Health Psychol, 11, 32-40.

MLP services as a method to reduce anxiety and stress for expectant mothers with low socioeconomic means (HWHB mothers) experiencing legal and social stressors (housing issues, immigration status, etc.).

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About Pilot Project

HWHB Sites:– Brandywine Women’s Health Associates– Westside Family Healthcare

Enrollees: – Expectant Mothers Experiencing Legal and Social Stressors

Methods:– Needs Assessment – Enrollees Identified– Complete SF-36/PSS (R1)– Receive Services– Complete SF-36/PSS at Follow-Up (R2)

SF-36/PSS Dates: April 1, 2013 - September 6, 2013.

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Description of Tools Used

Short Form 36 (SF-36)– Physical Functioning: Moderate Activities, Walking– Role-Physical: Physically Performing Activities– Bodily Pain: Pain in Performing Activities– General Health: Perception of Health– Vitality: Pep/Life, Energy, Tiredness – Social Functioning: Social Time and Extent– Role-Emotional: Emotional in Performing Activities– Mental Health: Nervous, Peaceful, Happy

Perceived Stress Scale (PSS-4)

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Results

39 Referrals, 26 Enrollees Completed R1 11 Enrollees Completed R1 and R2 Surveys

Age:– Average: 29 Years– Minimum: 21 Years– Maximum: 37 Years

Race/Ethnicity:– Hispanics: 7– White non-Hispanics: 2– Black non-Hispanics: 2

Days Between R1 and R2 Surveys:– Average: 78 Days– Minimum: 26 Days– Maximum: 144 Days

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Results

Physical Health ScalesPhysical Functioning: Xbar = 8.64, p = 0.12Role-Physical: Xbar = 27.27, p = 0.01Bodily Pain: Xbar = 14.09, p = 0.15 General Health: Xbar = -1.36, p = 0.81

Mental Health Scales

Vitality: Xbar = 16.36, p = 0.04Social Functioning: Xbar = 17.05, p = 0.06Role-Emotional: Xbar = 6.06, p = 0.56Mental Health: Xbar = 10.91, p = 0.08

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Results

Physical Health Component: Xbar = 10.17, p = 0.02

Mental Health Component: Xbar = 12.07, p = 0.02

SF-36 Overall: Xbar = 10.93, p = 0.00

Perceived Stress Scale: Xbar = 0.08, p = 0.34

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Results

- Δ No Δ + Δ

Physical Functioning 3 2 6

Role-Physical 0 4 7

Bodily Pain 2 3 6

General Health 7 0 4

Vitality 2 0 9

Social Functioning 1 3 7

Role-Emotional 2 4 5

Mental Health 2 3 6

Perceived Stress 3 2 5

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Valentina was experiencing pregnancy-related discrimination at work - she was not allowed to take snack breaks - and had a significant fear of deportation due to not having legal immigration status.

Maria was fired by her employer/landlord due to her pregnancy. Due to her termination, not only was she no longer bringing home income, her employer/landlord ceased offering her reduced rent.

Camila requested Medical-Legal Partnership Project assistance because she had overdue bills in collections. Camila did not know the status of these bills and wished to learn their status. She was also fearful of their potential impact on her immigration status in the future.

Tamira’s son was awarded temporary SSI benefits. Tamira was fearful of spending the checks for risk of incurring an overpayment. Thus, she was not able to spend the income she needed to support her family without significant anxiety.

Nicole, several months pregnant, discovered when she moved into a house, that there was mold in the basement, a leak from the bathroom into the room below, and the landlord was entering the house without proper notice, among many other problems.

Case Examples

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Results

“Where I am living causes me stress. Just moved in May 1st. House falling apart. Leaking ceiling in dining. Moths and roaches. Basement has 2-3 inches of water. Coughing and sneezing everyday. Broken fridge. Holes in it. Food doesn’t stay fresh longer than 1 week. Continuously buying groceries. Can’t get out front door. Door knob is stuck. No heat and LL says because it’s summertime, he doesn’t have to fix heater. He told me he doesn’t have to fix the basement, because it wasn’t in ad for house as being part of the rental property. Sockets don’t work. When you plug them in, they fall out. I have 3 other children: 5, 7, and 11. They are also coughing and sneezing. It’s just me and my 3 children. Have a written lease for 1 year. I did walk through of house and pointed out some of these things and he said he would fix those things. Even more things were discovered after the move-in. I call him to tell and he never comes to fix. Don’t safe and secure either because he doesn’t give me notice when he comes to visit. 3x he’s walked in when I didn’t have clothes on. I feel like he’s invading my privacy.” – “Nicole”, 6/4/13

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Results

“Your services were a great help. Changed a lot for me confidence wise. You don’t feel like you're by yourself. It helped me a lot getting out of the old place that was terrible, getting help with services.” – “Nicole”, 8/27/13

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Implications

Population Health

ROI

Health Reform and Medical Home

Healthy People Goal– “Development and implementation of policies and preventive

interventions that effectively address these determinants of health can reduce the burden of illness, enhance quality of life, and increase longevity.”

Health Indicators. (2010). Community Action Network. Retrieved from:http://www.caction.org/health/PrescriptionForWellness/CommunityHealth/HealthInd.htm.

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Limitations/Challenges

Non-Responsive Clients Small Cohort (n = 11)– Multiple Attempts to Contact: Calls, Letters by

Culturally/Linguistically Appropriate Staff– Why:

• No Incentive After Services Provided• Changes in Clients’ Address/Phone• After Delivery• Poverty

Relatively Short Project Period– Longer Time for Certain Services (e.g., Immigration)

Lack of Control Group Broad Range of Legal Problems – Link to Health Funding Limits Scope of Service and Program

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Next Steps

Integration of MLP model with MCH home visiting program.

Sustaining funding for continuation of HWHB MLP and expansion statewide.

Use of bilingual legal staff.

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Acknowledgements

HWHB Sites– Brandywine Women’s Health Associates– Westside Family Healthcare

Delaware Healthy Mother and Infant Consortium (DHMIC) Executive Committee

Thank You