Medical–Legal Partnerships to Support Continuity of Care for Immigrants Impacted by HIV: Lessons Learned from California

Abstract

The United States (US) has experienced a surge of anti-immigrant policies and rhetoric, raising concerns about the influence on health outcomes for immigrants living in the US. We conducted qualitative interviews (n = 20) with health care and social service providers, attorneys, and legal/policy experts in California to understand how agencies were maintaining access to HIV care and prevention for immigrant clients. We conducted a thematic analysis to describe the role of medical–legal partnerships (MLPs) and document best practices. Informants reported high demand for legal services. Referrals were facilitated by case managers, medical providers, and pre-existing relationships between clinics and legal agencies. Informants identified a need for additional funding and further guidance on screening for and supporting patients with legal needs. MLPs have the capacity to create sustainable, efficient, comprehensive structural changes that minimize barriers to HIV prevention and treatment and improve health outcomes among immigrant populations.

Introduction

Anti-immigrant policies directly and indirectly impact the health of immigrants [1]. Health and social service providers across the United States (US) have recently observed increased no-show rates among their immigrant patients and reduced enrollment in public assistance programs, in light of a more restrictive era of immigration policy [2]. Similar trends were reported in HIV clinics in California, which is home to the largest number of immigrants [3] and one of the highest prevalences of HIV in the country [4]. Even before the recent changes in immigration policy, studies have found that foreign-born individuals in the US are at heightened risk for HIV infection and late diagnosis [5]. In response to concerns among health and social service providers in California, we conducted qualitative interviews to document best practices for maintaining access to HIV care and prevention services for immigrant communities. In this brief report, we describe the value of medical–legal partnerships (MLPs), which integrate legal assistance into health care settings, to address needs related to immigration for people living with and at risk for HIV, as well as the necessary ingredients for developing and harnessing these partnerships.

Methods

Our university’s Institutional Review Board approved all procedures. We conducted semi-structured, in-depth interviews with health care and social service providers, attorneys, and legal/policy experts from May 2018 to January 2019. We recruited key informants by telephone or email, using snowball sampling and our team’s knowledge of California’s HIV care and services landscape. Informants verbally consented and received a $100 honorarium for participation. Interviews lasted between 60 and 90 min, and were audio recorded and transcribed. Three analysts developed the codebook and conducted initial coding to establish intercoder agreement. Authors SMF and EAA coded the remaining transcripts. We conducted a thematic analysis [6] of the narratives about formal and informal MLPs.

Results

We conducted 20 interviews in three counties in Northern and Central California from May 2018 to January 2019 with medical providers (n = 6), case managers and patient navigators (n = 7), attorneys and other legal/policy experts (n = 5), and clinic or program administrators (n = 2). To protect confidentiality, we attribute quotes to the participant’s role, but blind organizational and county affiliations. Representative quotes are available in Table 1 and noted in the text (e.g. “[Q1]”).

Table 1.

Themes, sub-themes, and representative quotes

Increased demand for legal services

Heightened sense of urgency among clients to address immigration needs

Q1: “There’s a sense of urgency—even for people who are residents or have permanent residency, but are not US citizens. There’s this urgency of like: oh my God, I should get my citizenship… People are scared…I think that there becomes this community level of anxiety, and a heightened sense of urgency.”—Program Administrator (Key Informant # 6)

Clinics mobilizing to provide legal resources and information to patients

Q2: “…because of that training, we were able to help four families that had called asking to disenroll from programs. We were able to convince three of them to stay on out of the four.”—Policy Expert (Key Informant # 17)

Facilitating partnerships between medical and legal agencies

Clinic staff able to recognize and relate to immigration needs

Q3: “…people will frequently ask about immigration-related things at [our clinic] because I think it’s like a point of entry for them to get services and we’re a place where they know they can go to help navigate that stuff or get referrals.”—Medical Provider (Key Informant # 16)

Clinic is a trusted source for referrals, with case managers often accompanying clients to legal appointments

Q4: “Some of our care managers will walk the person to the lawyer’s office, or walk the person over to wherever it is that they need to be…I think having someone, who perhaps has been through that process before, someone who looks like them, someone who speaks their language, is really, really helpful. It develops that trust.”—Program Administrator (Key Informant # 6)

Q5: “We haven’t had too many problems with clients feeling uncomfortable necessarily coming in [to the legal clinic]…Oftentimes I’ve already spoken with the service provider, and so there will be that kind of communication going on, and I think reassurance by the service provider that, yes, it’s okay to visit our office. Oftentimes the service provider may come with a client, so that kind of provides a sense of security for them.”—Attorney (Key Informant # 1)

Prior relationships between clinics and legal agencies

Q6: “We have an established relationship with some attorneys already, and we can say, ‘These are people that we trust. You should go and talk to them. These are people we can recommend.”—PrEP Navigator (Key Informant # 10)

Ongoing partnership between medical and legal agencies perceived as mutually beneficial

Q7: “There is a special synergy that you get when you know the providers… I could call the medical social worker or call the doctor because [the client] might not be showing up for their legal appointments…It made it so much easier with that kind of trusting relationship to be able to get the kinds of documents we needed to support our cases and vice versa…the relationship was mutually beneficial.”—Attorney (Key Informant # 14)

Q8: “We’ve actually been getting more Asian patients coming directly from places like China and Korea…I don’t know this for sure, but I’m thinking it’s because we have a really good system for linking people to sort of asylum and immigration processes.”—Medical Provider (Key Informant # 2)

Room for improvement

Guidance needed around writing client support letters

Q9: “When I first started as a physician I didn’t really know what to write [in the asylum letter] for the lawyer. There are no guidelines… And actually what helped me was one of the providers had shared a letter that she wrote for a patient.”—Medical Provider (Key Informant #3)

Guidance needed for clinic-based screening of immigration needs

Q10: “I don’t want to set up an appointment for my client just to know that there’s nothing that the legal person can do for them, too. I really want to know for sure from a legal perspective that these undocumented clients can be helped…I wish there was more information about that.”—Case Manager (Key Informant # 15)

Q11: “What we are proposing is that there be a more consistent manner [of screening] throughout the department, throughout all the clinics, because you wouldn’t want anyone to fall through the cracks if, in fact, there may be an opportunity for them to legalize their status.”—Attorney (Key Informant # 1)

Need for additional funding and capacity to make MLPs more effective

Q12: “The reality is that it’s a more effective partnership if there is funding tied to it… When your HIV-positive patient is one in 200 callers that this organization is receiving, they’re not necessarily going to get priority… Even though there has been an increase in funding—the state has been very generous in increasing funding for legal services in California—there’s still a huge, huge gap in services.”—Attorney (Key Informant # 14)

Increased Demand for Legal Services

Since the 2016 federal election, informants described a “heightened sense of urgency” for clients to seek legal advice and obtain citizenship, asylum, or other lawful permanent resident status [Q1]. Under current rules, individuals who have fled persecution because of their sexual orientation, gender identity, and/or HIV status can petition for asylum. Yet, clients were concerned that the rules would change.

Clinics also sought to better understand issues related to immigration policy by organizing trainings, developing procedures for interactions with immigration authorities, and providing guidance to patients. Clinics often relied on expertise from legal partners to conduct these informational sessions with their staff and patients, and found that patients benefited from and appreciated the guidance [Q2].

Facilitating Partnerships Between Medical and Legal Agencies

Clinics played a crucial role in facilitating referrals to legal services. Staff often recognized clients who had needs related to immigration in the course of helping them navigate the health care system and access HIV care and prevention services [Q3]. In addition, several clinicians had personal experiences with immigration, which was helpful in supporting patients through the asylum process [Q4]. For patients expressing interest in legal counsel, clinics were well positioned to provide a trusted, warm handoff [Q5]. Case managers often accompanied clients or facilitated telephone appointments with legal services, alleviating any fears or language barriers.

Referral processes could be formalized or ad hoc, but were often mediated by prior relationships between medical and legal entities. MLPs for people living with HIV have existed since the early days of the epidemic, so medical providers referred patients to trusted legal partners [Q6]. In fact, a number of lawyers were well known within the HIV community, with some specializing in legal assistance for people living with HIV.

Clinic staff and providers reported remaining involved throughout the client’s work with legal services. For example, case managers often had current contact information or other knowledge about the client that could help a client’s legal case, provided that the client had given consent to share the information. Ongoing partnership was seen as mutually beneficial for legal and medical teams [Q7]. One provider attributed an influx of new patients to their clinic’s success in connecting patients with effective legal services [Q8].

Room for Improvement: Additional Training, Guidance and Funding to Support MLPs

Clinic-based informants expressed interest in further training and guidance related to immigration. Several providers had been asked to write letters of support for asylum cases, a challenging task because there were no guidelines on what to include [Q9]. Elsewhere, a case manager sought recommendations for screening patients for immigration needs to avoid unnecessary referrals [Q10].

Legal informants also perceived wide variation in screening practices at clinics. Some providers would ask directly about immigration needs, while others would wait for the patient to raise the issue. One lawyer suggested having standard procedures in place to screen for immigration needs so that clinic staff could offer referrals and other assistance [Q11].

Both legal and medical informants also called for increased funding and resources to support effective MLPs [Q12].

Discussion

This report adds to the growing body of literature on the value of MLPs in addressing structural barriers to care [7, 8]. MLPs address social determinants relevant to immigrant communities highly impacted by HIV, including immigration status, delays in HIV prevention and treatment, insurance coverage, and access to transportation and housing. However, MLPs are rarely acknowledged in discussion of HIV structural interventions.

We identified a number of barriers and facilitators to utilizing MLPs. Strong referral networks and personal connections between medical providers and lawyers were valuable, and could promote formal and informal partnerships that expanded the range of services available to support clients. Referrals were also facilitated by case managers, echoing other literature on the important role of case managers and social workers in the MLP model [9]. Legal consults via telephone reduced barriers, especially for clients who were concerned about leaving home. Having template letters available for providers and helping case managers screen for immigration needs could also enhance the effectiveness of MLPs. For instance, a screening tool called I-HELP can allow clinicians to identify issues that may have legal remedies including: income/insurance (I), housing (H), education/employment (E), legal status (L), and personal/family stability (P) [8]. However, additional funding and resources may be needed to support screenings, referrals, and provision of legal services. Furthermore, facilitating communication and information sharing between medical and legal institutions may be helpful, though this recommendation comes with important ethical and professional considerations [10]. Even the screenings themselves would need to be conducted carefully so as not to create fear or distrust among patients. For instance, before asking any questions, providers should clarify why questions are being asked, how the information will be kept private, and that patients can answer to the extent that they feel comfortable. We recommend that MLPs consult with local community stakeholders and advocates to assess and further refine screening questions related to immigrant legal needs. Clinics should also consult with attorneys to ensure that information cannot be used against patients should it be subpoenaed (e.g. by avoiding any explicit documentation of immigration status).

Our study has several limitations. Interviews were conducted in three counties and focused on access to HIV care and prevention services, so findings may not be representative of all MLPs across the state or country. Although our key informants could provide stories about clients who had disengaged from care, most of their experiences were with people who were actively seeking medical and legal services. Additional research is needed to understand how MLPs can be fully utilized and promoted for difficult-toreach populations. Furthermore, California has progressive state-level immigration policy compared to other states in the US. Practices presented here may be more difficult to implement in states or countries with more restrictive policies.

Despite these limitations, our findings underscore the benefits of using MLPs to identify immigration-related needs and connect patients to legal support to address structural barriers that may contribute to poor health. We also highlight factors that can promote engagement in MLPs, such as providing culturally competent services and using case managers to support clients as they navigate between medical and legal entities. In this current political environment, providing access to legal aid is critical in protecting the health and safety of immigrants. Although our paper focused on the provision of care and services for people living in the community, immigration attorneys can also help to advocate for access to care and treatment for the growing numbers of people in detention facilities. Thus, the potential areas for intervention through the MLP model are broad and comprehensive. By alleviating barriers to care, MLPs not only have potential to improve the wellbeing of those impacted by HIV, but also to address other health disparities affecting immigrant communities, including support for their basic human rights.