Interprofessional Education in Medical-Legal Partnerships (MLPs) to Address Social Determinants of Health

Abstract

Medical-legal partnerships (MLP) address legal needs that contribute to health inequities. Health providers express discomfort accessing legal services and a desire for greater training, however best practices remain unclear.

Methods.

We conducted a scoping literature review and interviews with key informants to identify essential components of MLP training and best practices in MLP training.

Results.

Twenty-one articles out of an initial 1,247 met criteria. Most learners were medical (11; 52%) or law (13; 62%) students or residents (12; 57%). Training was primarily led by lawyers (18; 86%). Educational approaches included didactics (15; 71%). Content was focused on skill-acquisition (18; 86%). Most training was presented as stand-alone (5; 24%) courses. Essential skills included issue-spotting, adaptability, and trauma-informed care.

Conclusion.

Medical-legal partnerships make use of varied perspectives to address unmet legal needs. This review helped identify best practices in training and a need for future study on evaluation. Future research should explore how best to evaluate the effectiveness of MLP training.

Social determinants of health (SDH) are conditions in which people are born, grow, live, work and age. These conditions are shaped by the distribution of societal money, power, and resources and are drivers of health inequities.¹ Medical schools increasingly challenge physicians-in-training to understand and address nonmedical factors that influence patient outcomes.² While SDH training has not been emphasized in medical education, schools are now integrating the topic into curricula given the impact of SDH on health.^3–7

One strategy to identify and address SDH is through medical-legal partnerships (MLPs). The first formalized MLP was introduced in 1992,⁸ and today approximately 450 health organizations have developed MLPs in 49 states.⁹ Medical-legal partnerships vary in structure, but typically have three fundamental objectives: 1) to provide legal assistance to patients, 2) to transform health and legal institutions, and 3) to achieve health-related policy changes.¹⁰ The first function addresses patient-level health-related social needs (HRSN),¹¹ while the latter two relate to SDH more broadly by addressing institutional and community-level factors that create conditions leading to poor health. Legal-aid attorneys are particularly well-suited to aid patients due to their in-depth knowledge of how federal, state, and local policies affect patients’ ability to access health and public benefits.¹² Medical-legal partnership programs across the country have demonstrated the ability to address HRSN and SDH overall and may improve patient health.^10,13

Medical-legal partnerships provide an interprofessional approach to patient care through collaborations between legal experts and the health care team. Models vary, with some operating within a medical team, and others following a consultancy model. Medical students and resident physicians who receive MLP training may be more confident in their knowledge of public health benefits and more likely to screen patients for SDH compared with trainees who do not.^14,15 Medical-legal partnerships also present opportunities for students to develop practical skills to address SDH and work within interprofessional teams. Medical-legal partnerships educate professionals about how to identify and mitigate potential legal issues.¹⁶ However, many health providers express discomfort in accessing legal services and a desire for more training. Efforts to identify ideal training models for MLPs remain understudied. The purpose of this review was to identify essential components of MLP training and best practices.

Methods

Literature review.

We conducted a scoping literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.¹⁷ Our study questions were (1) How do programs train learners about MLPs? (2) How are programs implementing MLP training and how often? (3) How do programs assess learners following training?

We conducted our initial literature search in January 2019. A research librarian and interprofessional team of providers (i.e., physicians, lawyers, and researchers) identified key databases: PubMed MEDLINE 1946, Index to Legal Periodicals and Books 1978, Scopus 1788, and Nexis Uni 1790. Search terms were refined through an iterative process by identifying Medical Subject Headings and key phrases from formative references. The final search strategy included terms such as “legal services,” “health partnerships,” and “collaboration.” We based our search strategies for all databases on the terms used for PubMed (Appendix 1, available from the authors upon request).

Eligibility criteria.

We excluded articles if they were published prior to January 2009, not in English, based outside of the United States, lacked detail, or were not relevant to our study questions. We chose a 10-year cutoff to capture the most relevant literature for current educational needs. We included articles that discussed MLPs in the context of undergraduate professional training (law, medical, or other professional school), medical residencies, or health care systems.

Article review.

Once duplicate articles were removed, search results were uploaded to Rayyan (Qatar Computing Research Institute, Doha, Qatar), a reference management software program used for systematic reviews.¹⁸ Screening was conducted in two phases. First, TB and LAG screened all articles by title and abstract only. The remaining articles were divided among three reviewer pairs (EP/LAG, KS/TB, and ABS/AS) for full-text review. Aided by an internally developed reviewer guide, pairs were instructed to code articles as either in or out and meet to reconcile discrepancies. A third reviewer (KS) determined eligibility when consensus was not reached. After confirming eligibility, we extracted relevant data using a standardized review form created in Research Electronic Data Capture (REDCap).¹⁹ The form was piloted with five articles and then revised in this light for the remaining. All authors extracted data regarding the following: learner type, training components, instructor type, education approaches, and evaluation (if reported).

Data synthesis.

We examined general features of each article including targeted learners, interprofessionalism, training topics, educational approaches, instructors, and duration. Training development, implementation, and evaluation were also assessed.

Semi-structured interviews.

As we only identified a limited number of articles in the scoping review, we conducted semi-structured interviews with individuals who were determined to have comprehensive knowledge and experience with MLPs to supplement the literature review and gain a richer understanding of development, implementation and training, and best practices.

Semi-structured interview development.

The study team contacted three nationally recognized experts in MLPs to conduct open-ended discussions related to development, implementation, and training for MLPs. The authors then developed a semi-structured interview guide using an iterative process for subsequent interviews (Appendix 2, available from the authors upon request). This study was approved by the Northwestern University Institutional Review Board.

Participants.

Interview participants were (1) experts in MLPs, (2) experienced interprofessional educators who conducted MLP training, and (3) professionals who had implemented MLPs at medical institutions. Participants were recruited through snowball sampling and a roster received from a local MLP conference. A total of 30 participants were contacted by the study coordinator with an electronic consent form that described the purpose of the study. Seven participants were interviewed.

Interviews.

We used a qualitative semi-structured interview guide to conduct approximately one-hour interviews. The interviews were carried out by study team members (EP, KS, AS, ABS, TB). All interviews were audio-recorded and transcribed.

Analysis.

Transcripts were analyzed by two independent coders and manually coded (EP and LAG). Using an iterative process, we identified emerging themes and resolved any discrepancies through consensus. Once the codes were finalized, we applied the codebook to the remaining interviews. Representative comments were selected and are presented in Box 1.

Box 1.

KEY THEMES AND REPRESENTATIVE STATEMENTS

Theme	Representative Statement
Issue-spotting	And I do some work with them in terms of training them to understand legal issues, help them to understand different systems and different things that go on in the community that impact their patients (Participant SL) “. . . and the purpose of the exercise was to have the students number one identify these issues and then start a dialogue among themselves on how they would consult each other or how they would try to get these problems solved. You know, problems of drug abuse, mental health issues, child custody, loss of parental rights, mental health, suicidal ideations, IV drug use, you know, we have a whole litany of problems. And access to mental health, access to things like Medicaid, documented immigrant status, all of that.” BM
Adaptability	It’s understanding the patient population, understanding how to communicate effectively, understanding how to—being able to understand where they’re coming from and what their goals are (Participant SL)
Trauma-informed care	Trauma-informed lawyering or motivational interviewing, how you actually work with clients is not usually a big part of the law school curriculum. . . And, that’s a deeply traumatizing moment for the listener and not as much at all as the talker. We are in a helping role. And, having tools on how to help would be really good. (Participant HS) “I’ve gone to one-off seminars on trauma-informed care, for example, where I attended that alongside a lot of the staff, where that was something that just happened to be available to us at that time. . . . and for [the partner health center], it’s important that I, as a person who is interacting with patients alongside them, am able to be comfortable in those situations and kind of aware of the situations and aware of how to react and respond.” JP
Capacity of legal remedies	I found that if it’s a training geared towards providers, I spend a lot more time talking about what’s not a legal issue. I’ve learned over the years that that’s as important as anything else in a training . . . every issue is not a legal issue (Participant SH)
Advocacy	And I think, in terms of advocacy, like I mentioned at the beginning, that’s one area where I think we [want to] be better advocates because it’s a system that really requires reform (Participant SL)
Case-based learning	So, these are [kind of] desktop exercises. And I think that they’re very valuable. It goes beyond giving lectures, you known. That’s boring. That’s why we try to have this sort of hands on participation (Participant MR) “. . . and I’ve also learned to use case studies. I’ve learned to change the way I do training so that it’s more closely similar to what health care providers see most frequently.” KM
Case-based learning	“I’ve found that (case-based learning is) really necessary. And, also because people don’t care as much unless they know [for example] that a child has Down syndrome and is deaf and hasn’t gotten a proper education for all her 13 years of life. That’s a totally different conversation. . .” SH
Lack of evaluation	But training in terms of ways to think about capturing outcomes and capturing benefits from MLPs, I think is really important (Participant SL) “We track outcomes in our case management system, but they are more framed around legal outcomes, [than] capturing health outcomes. KM “We have been tracking outcomes internally. And this is something that I think in the next year we’re [going to] take steps to sort of formalize it and expand on it. But we have been tracking outcomes in terms of what was the objective with the case and what have we accomplished.” JS
Social determinants of health	I typically talk about social determinants of health and root all of this in the public health sort of realm (Participant HS)
Interprofessional collaboration	Seeing the value of a partner and realizing what you don’t know and can learn from partners in other fields.. . . critical that students actually practice collaborating together with other professional students (Participant BR) “. . . [physicians and lawyers are] like cats and dogs. So, there aren’t a lot of good ways to interact. So, it was kind of my thought that if we can get the doctors and lawyers talking together—and as students thinking together—[we can] use the mechanism of these [professionals] identifying social determinants of health.” (Participant BM) “seeing the value of a partner and realizing what you don’t know and can learn from partners in other fields [is important]. An example of collaborative learning is through joint ‘case rounds’ and hav[ing] students share their perspectives.” (EB) “I also think it’s most helpful when the trainings are done by a lawyer and a doctor or another health care provider in collaboration as opposed to just having a lawyer come in and talk to health care providers because I found that [learners in those types of sessions] are less receptive when it’s just me coming in and talking at them.” KM
Length of training	“We had a training curriculum when I was in Toledo where we would rotate over 18 months kind of the same topic. And that was in part because of the residents and how their time with the clinics rotated, but then, obviously, the other doctors and attendings would keep coming and then have refreshers.” KM “I would say it’s an ongoing training. There were certain things that I needed to learn upfront, but I think one of the nice things about the [MLP] as an organization is that they’re constantly training and retraining their staff.” JS

Results

Of the original 1,247 references identified, 21 (<2%) met inclusion criteria (Figure 1).^{12,14,15,16, 20–36} We summarized study characteristics and examined results by (1) educational approaches, (2) implementation, and (3) educational content (see Box 2).

Figure 1.

Summary of literature search and review process

Box 2.

SUMMARY OF INCLUDED ARTICLES

	Participant Level							Discipline of Trainer					Educational Approach					Main Purpose
Ref	MS	MR	LS	SWS	NS	Other	Duration	L	PL	HP	SW	Other	Clinical	Didactic	RL	CB	Other	CK	CA	SKA	Training was:
18	x	x	x	x		x	Varied	x		x			x	x	x	x	x	x	x	x	Other
19	x	x	x	x		x	Varied	x					x	x	x	x				x	Other
20			x					x					x	x	x			x	x	x	Stand-alone course
21	x		x			x	<6 mo	x									x	x	x	x	Other
22						x	1 year	x					x							x	Other
23	x		x				1 year	x		x		x				x		x	x	x	Other
24	x		x				<6 mo	x		x				x	x	x		x	x	x	Other
25	x	x	x			x	Varied	x		x		x	x	x	x	x	x	x	x	x	Other
26	x	x					Varied	x		x	x	x	x	x	x	x	x	x		x	Other
27		x						x					x	x		x		x		x	Integrated into another course
28			x					x					x	x	x	x		x		x	Other
29		x														x				x	Clinical rotation
30			x				<6 mo	x				x		x	x	x		x	x	x	Stand-alone course
31			x				<6 mo	x	x	x	x		x	x		x		x	x		Stand-alone course
32		x					<6 mo	x	x					x			x	x	x		Stand-alone course
33	x		x				<6 mo	x		x		x	x	x	x	x	x	x	x	x	Other
34	x	x	x	x		x	Varied	x		x	x		x					x	x	x	Clinical rotation
35	x	x	x	x		x	Varied	x		x			x	x		x		x	x	x	Stand-alone course
36		x											x	x	x			x	x	x	Integrated into another course
37		x					1 year	x	x	x	x		x	x		x		x	x	x	Clinical rotation
38	x	x																			Clinical rotation

Ref = Reference

MS = Medical Student MR = Medical Resident

LS = Law Student

SWS = Social Work Student NS = Nursing Student

L = Lawyer

PL = Paralegal

HP = Health Professional (MD, PA, Nursing) SW = Social Worker

RL = Reflective Learning CB = Case-Based

CK = Change in Knowledge CA = Change in Attitudes SKA = Skill Acquisition

Types of learners.

Of the 21 programs, 12 (52%) were taught to interprofessional learners. Types of learners included: medical students (11; 52%), medical residents (12; 57%), law students (13; 62%), social work students (4; 19%) and other learners (7; 33%). Other types of learners included public health students, pediatric staff, and attending physicians. Of the 11 programs that had exclusively one type of learner, six (55%) were taught to medical students and four (36%) were taught to law students. For an overview of program types in tabular form, see Table 1.

Table 1.

CHARACTERISTICS OF TRAINING PROGRAMS. N=21

	N	%
Learner
Medical student	11	52
Resident	12	57
Law student	13	62
Social work student	4	19
Nursing	0	0
Other	7	33
Trainer
Lawyer	18	86
Paralegal	3	14
Health professional (MD, PA, RN)	10	56
Social worker	4	22
Other	5	27
Duration
1 year	3	14
< 6 months	6	29
Varied	6	29
Not reported	6	29
Educational approach
Clinical	14	67
Didactic	15	71
Reflective learning	10	48
Small group	14	67
Other	6	29
Type of curriculum
Stand-alone	5	24
Clinical rotation	4	19
Integrated into another course	1	5
Other	10	48
Not documented	1	5
Main objective of training
Knowledge	17	81
Attitudes	14	67
Skills acquisition	18	86

Several interviewees emphasized the importance of teaching learners in an interprofessional fashion, ideally early in their education. According to interviewees, this was important for learners to understand the roles and thought processes of other professions and how they could work together.

Types of trainers.

Of the 21 articles, 18 reported the profession of the trainers. Of those 18, all programs included a lawyer as a primary trainer. Twelve programs (63%) were taught by an interprofessional team. Types of professionals on interprofessional teams included lawyers (18; 100%), paralegals (3; 17%), health professionals (MD, PA, RN; n=10; 56%), social workers (4; 22%) and others (5; 27%). Other types of trainers included community advocates and guest speakers.

Interviewees also emphasized that MLP trainings were best led by an interprofessional team. While most training was primarily conducted by lawyers, interviewees emphasized that having a health professional co-lead was well received by trainees.

Training duration.

Many programs did not specify the duration of their training (6; 29%). Of the remaining, three (14%) were integrated over a year-long period, six (29%) were implemented over a period of six months or less, and six (29%) had variable duration. Variations depended on the setting (i.e., whether training was implemented in a curriculum or in an established MLP) and on perceived training needs (i.e., whether refresher training was needed).

Interviewees described a variety of training durations based on the needs of the trainees. Some found that longer periods of training were not feasible for residents/physicians, so a shorter period was adapted. A common theme related to duration was that refresher training should be available and adapted to the learners.

Educational approach.

A variety of educational approaches was reported in the 21 articles reviewed. The majority reported using a didactic approach (15; 71%). Other methods were clinical (14; 67%), reflective learning (10; 48%), and small group participation (14; 67%).

A common theme emphasized in the interviews, but not found in the literature review, was the use of case-based training. Many interviewees commented that they had changed their training methods to include more cases, as they found case-based methods to be more effective than traditional didactic training in imparting to learners an appreciation for the impact of MLPs.

Objective of training.

Of the 21 articles reviewed, the stated main objectives of the training were related to skill acquisition (18; 86%), knowledge (17; 81%), and change in attitudes (14; 67%). Box 3 outlines content topics related to these objectives. A topic that was not found in the literature, but was discussed by many interviewees, was the concept of trauma-informed care. Trauma-informed care emphasizes patient-centeredness, understanding the health effects of trauma, and the importance of interprofessional collaboration to create a trauma-informed approach.³⁷

Box 3.

CONTENT OF TRAINING

Knowledge	Skills	Attitudes
• Human rights • Education law • Disability law • Housing • Public benefits • Employee rights • Medical insurance • Immigration • Population health • Health disparities • Health law • Personal stability (advanced directives, domestic violence)	• Negotiation • Counseling • Planning • Stress management • Policy making • Advocacy • Problem solving • Cross-disciplinary Collaboration • Relationship building • Communication • Media advocacy • Client interviewing • Fact finding • Legal research • Issue-spotting	• Professional ethics • Professional roles/Responsibilities • Patient/provider Relationship • Implicit bias • Stakeholder buy-in

Interviewees also emphasized that MLP training should be focused on skill acquisition, particularly related to issue-spotting, a skill often taught in law school but not in medical school. Issue-spotting refers to an individual’s ability to identify legal issues based on a review of a fact, pattern, or story. In the context of MLPs, issue-spotting entails identifying SDH that negatively affect the patient’s health.

Another important concept seen as crucial to MLP education, as elucidated in the interviews, was defining the limits of legal remedies. Specifically, interviewees stressed that training should include identification of what issues can be addressed through legal means. Training concepts were tailored to what that particular MLP could address. If, for example, an MLP could not address immigration issues, then that topic would not be taught to learners.

Evaluation.

While some articles did report that evaluations of training were conducted, no particular pattern or robust data were reported. Similarly, interviewees shared that some level of evaluation occurred at their MLPs, but there were no clear standard or evidence-based tools. Many interviewees commented that a lack of evaluation is a major challenge for MLPs, both in terms of the outcomes of the legal services they provide and the education they conduct. This is an area that is ripe for future research.

Discussion

Health care and legal aid communities come together in MLPs to address HRSN of individual patients and SDH more broadly through addressing unmet legal needs and systemic advocacy related to social and economic conditions that affect individuals and populations. Professionals engaged in MLPs bring highly relevant skill sets required to address complex social and economic conditions. There is increasing focus on preparing health care providers to deliver team-based, patient-centered care that is responsive to the multiple non-medical factors that affect health.^36,37 Yet, many providers express discomfort in accessing legal services on patients’ behalf and a desire for greater training in legal advocacy.

Our literature review found that there was little standardization in how providers are trained to use MLPs; however, key features of training were identified. Training ideally began early in learner education. Most learners were either medical students or residents. Medical-legal partnership training typically used an interprofessional model where students from various professions learned together. Training was usually facilitated by lawyers, but experts agreed that training was ideally presented by an interprofessional (health provider and lawyer) team. There were several educational approaches identified including clinical vignettes, didactics, small group discussion, and reflective learning. The interviews supplemented the literature review by elucidating more details about the real-world application of training. For example, most experts identified case studies as being an optimal way to engage learners and change attitudes. One of the unique features of MLP training is that it is primarily focused on skill-acquisition to address unmet legal needs. Essential skill sets identified included adaptability, issue-spotting, and the practice of trauma-informed care. Adaptability of training content and delivery was an important feature identified in the interviews. Informants expressed that MLPs should be tailored to the needs of the patient population and are often adapted to availability of learners, especially related to time-constraints for physicians. Interviewees also expressed the importance of issue-spotting, or the ability to identify legal issues even when not directly presented. Interviewees stressed the need to teach about the capacity of legal remedies (i.e., what can and cannot be remedied through legal means). If an MLP could not address a particular need (e.g., an MLP might prevent eviction, but have limited capacity to eliminate homelessness), then they would not train about that topic. Finally, using trauma-informed care approaches acknowledges theory-based concerns about the trauma of screening for adverse childhood experiences.³⁸

A common theme found in both the scoping review and the interviews was that there is very little evaluation of MLP outcomes or training to work in them. Evaluations should focus on effectiveness of MLP educational practices on professional behavior change, as changes in knowledge or attitudes are poor predictors of behavior.³⁹ Additionally, many interviewees commented on the need for standardization in evaluating outcomes of MLP interventions, particularly as they relate to the primary functions of MLPs. Learning in an interprofessional setting and how to interact with other professions were also important features to promote collaboration. Interprofessional theory proposes that different professions learning together enhances understanding of team roles, collaboration, and ability to manage complex scenarios. Studies have demonstrated that interprofessional education improves attitudes towards other professions, effective collaboration, and team functioning.^40,41 However, future work is needed to understand the impact that MLP training has on learner behavior and on SDH at the patient level. Additionally, future work should address whether MLP education leads to provider behaviors that address community and social factors beyond the individual patient.

By identifying what is currently offered to train professionals about MLPs, this scoping review and interview study helps to set the stage for the development and evaluation of future curricula. While there was variety in how learners were trained, several characteristics were identified as important features of working in an MLP. This study had limitations. First, there was a small sample size of interviewees. Analysis of conducted interviews appeared to demonstrate thematic saturation; however, it is possible this was a homogeneous group that would have benefited from more national representation. Second, because searching legal databases required adaptation of our search strategies for medical databases relevant publications may have been missed. Finally, the use of expert informants to develop the scoping review strategy and snowball sampling methods used for the interview study could have introduced bias. There is a need for future research to explore how best to evaluate the effectiveness of MLP training.