Improving Maternal Health
Outcomes with a Medical-Legal
Partnership
State of Delaware
Medical-Legal Partnership
Pilot Project
DHMIC Annual Summit 2014 Wilmington, DE
Presented by Daniel Atkins
Marissa Band
Robert Locke
Vikrum Vishnubhakta
April 9, 2014
© 2009 APS Healthcare, Inc.
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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
and
improve health and wellbeing for America’s most
vulnerable
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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 Inc.
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 Scales
Physical Functioning: Xbar = 8.64, p = 0.12
Role-Physical: Xbar = 27.27, p = 0.01
Bodily Pain: Xbar = 14.09, p = 0.15
General Health: Xbar = -1.36, p = 0.81
 Mental Health Scales
Vitality: Xbar = 16.36, p = 0.04
Social Functioning: Xbar = 17.05, p = 0.06
Role-Emotional: Xbar = 6.06, p = 0.56
Mental 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
© 2009 APS Healthcare, Inc.
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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
3
2
5
Perceived Stress
© 2009 APS Healthcare, Inc.
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Case Examples

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.
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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
© 2009 APS Healthcare, Inc.
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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.ht
m.
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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.
© 2009 APS Healthcare, Inc.
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Acknowledgements
 HWHB Sites
– Brandywine Women’s Health Associates
– Westside Family Healthcare
 Delaware Healthy Mother and Infant Consortium
(DHMIC) Executive Committee
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Thank You