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© 2009 APS Healthcare, Inc. 1 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. 2 Road Map About Us Background on Medical-Legal Partnerships Pilot Project Results Implications of Medical-Legal Partnerships Limitations Next Steps
© 2009 APS Healthcare, Inc. 3 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
© 2009 APS Healthcare, Inc. 4 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 well- being for America’s most vulnerable
© 2009 APS Healthcare, Inc. 5 What Is A Medical-Legal Partnership? Where we work, live, and play… …determines our health status.
© 2009 APS Healthcare, Inc. 7 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).
© 2009 APS Healthcare, Inc. 8 MLP Connection to Health Improved physical environment. Increased access to health care. Increased access to basic necessities. Decreased stress. Increased access to educational services.
© 2009 APS Healthcare, Inc. 9 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
© 2009 APS Healthcare, Inc. 10 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): –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, –Hedegaard, M., Henriksen, T., Secher, N., et al. (1996). Do stressful life events affect duration of gestation and risk of preterm delivery? Epidemiol, 7, –Lobel, M., Dunkel-Schetter, C., Scrimshaw, S. (1992). Prenatal maternal stress and prematurity: a prospective study of socioeconomically disadvantaged women. Health Psychol, 11, 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.).
© 2009 APS Healthcare, Inc. 11 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, September 6, 2013.
© 2009 APS Healthcare, Inc. 12 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)
© 2009 APS Healthcare, Inc. 13 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
© 2009 APS Healthcare, Inc. 14 Results Physical Health Scales Physical Functioning: X bar = 8.64, p = 0.12 Role-Physical: X bar = 27.27, p = 0.01 Bodily Pain: X bar = 14.09, p = 0.15 General Health: X bar = -1.36, p = 0.81 Mental Health Scales Vitality: X bar = 16.36, p = 0.04 Social Functioning: X bar = 17.05, p = 0.06 Role-Emotional: X bar = 6.06, p = 0.56 Mental Health: X bar = 10.91, p = 0.08
© 2009 APS Healthcare, Inc. 15 Results Physical Health Component: X bar = 10.17, p = 0.02 Mental Health Component: X bar = 12.07, p = 0.02 SF-36 Overall: X bar = 10.93, p = 0.00 Perceived Stress Scale: X bar = 0.08, p = 0.34
© 2009 APS Healthcare, Inc. 16 Results - ΔNo Δ+ Δ Physical Functioning 326 Role-Physical047 Bodily Pain236 General Health704 Vitality209 Social Functioning137 Role-Emotional245 Mental Health236 Perceived Stress325
© 2009 APS Healthcare, Inc. 17 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
© 2009 APS Healthcare, Inc. 18 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. 19 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
© 2009 APS Healthcare, Inc. 20 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.http://www.caction.org/health/PrescriptionForWellness/CommunityHealth/HealthInd.ht m
© 2009 APS Healthcare, Inc. 21 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
© 2009 APS Healthcare, Inc. 22 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. 23 Acknowledgements HWHB Sites –Brandywine Women’s Health Associates –Westside Family Healthcare Delaware Healthy Mother and Infant Consortium (DHMIC) Executive Committee
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