Legal Services for Veterans (LSV): Protocol for evaluating the grant-based LSV initiative supporting community organizations' delivery of legal services to veterans.

BACKGROUND: 1.8 million Veterans are estimated to need legal services, such as for housing eviction prevention, discharge upgrades, and state and federal Veterans benefits. While having one's legal needs met is known to improve one's health and its social determinants, many Veterans' legal needs remain unmet. Public Law 116-315 enacted in 2021 authorizes VA to fund legal services for Veterans (LSV) by awarding grants to legal service providers including nonprofit organizations and law schools' legal assistance programs. This congressionally mandated LSV initiative will award grants to about 75 competitively selected entities providing legal services. This paper describes the protocol for evaluating the initiative. The evaluation will fulfill congressional reporting requirements, and inform continued implementation and sustainment of LSV over time. METHODS: Our protocol calls for a prospective, mixed-methods observational study with a repeated measures design, aligning to the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) and Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) frameworks. In 2023, competitively selected legal services-providing organizations will be awarded grants to implement LSV. The primary outcome will be the number of Veterans served by LSV in the 12 months after the awarding of the grant. The evaluation has three Aims. Aim 1 will focus on measuring primary and secondary LSV implementation outcomes aligned to RE-AIM. Aim 2 will apply the mixed quantitative-qualitative Matrixed Multiple Case Study method to identify patterns in implementation barriers, enablers, and other i-PARIHS-aligned factors that relate to observed outcomes. Aim 3 involves a mixed-methods economic evaluation to understand the costs and benefits of LSV implementation. DISCUSSION: The LSV initiative is a new program that VA is implementing to help Veterans who need legal assistance. To optimize ongoing and future implementation of this program, it is important to rigorously evaluate LSV's outcomes, barriers and enablers, and costs and benefits. We have outlined the protocol for such an evaluation, which will lead to recommending strategies and resource allocation for VA's LSV implementation.

Swimming Together Upstream: How to Align MLP Services with U.S. Healthcare Delivery.

Medical-legal partnership (MLP) embeds attorneys and paralegals into care delivery to help clinicians address root causes of health inequities. Notwithstanding decades of favorable outcomes, MLP is not as well-known as might be expected. In this essay, the authors explore ways in which strategic alignment of legal services with healthcare services in terms of professionalism, information collection and sharing, and financing might help the MLP movement become a more widespread, sustainable model for holistic care delivery.

Applying a Social Ecological Model to Medical Legal Partnerships Practice and Research.

The social ecological model (SEM) is a conceptual framework that recognizes individuals function within multiple interactive systems and contextual environments that influence their health. Medical Legal Partnerships (MLPs) address the social determinants of health through partnerships between health providers and civil legal services. This paper explores how the conceptual framework of SEM can be applied to the MLP model, which also uses a multidimensional approach to address an individual's social determinants of health.

Increasing LGBTQ+ Access to Legal Services via Medical-Legal Partnerships.

This Note details and proposes a solution to the deficit in access to justice and to care faced by the LGBTQ+ community due to historical and ongoing homophobia and transphobia in both the legal and medical fields. The proposed solution is the integration of medical-legal partnerships ("MLPs") into LGBTQ+ resource organizations. These organizations already serve and have the trust of the queer community, which lowers one barrier to access medical and legal services for the LGBTQ+ community: mistrust and negative past experiences. MLPs are the ideal solution to this problem because they would not only allow LGBTQ+ individuals to access medical and legal services, but to receive holistic services that account for their personal circumstances as well as their physical health. Underlying this premise is the concept of social determinants of health, which are environmental and social factors that create systemic roadblocks to wellness. By creating an integrated MLP, professionals can address these social determinants head on and remedy the underlying causes of poor health. This is especially important for LGBTQ+ people whose minoritized identities often lead them to have multiple negative social determinants of health. The integration of MLPs into LGBTQ+ resource organizations would allow queer individuals to get the care they need-not just physically, but socially and environmentally.

A care coordinator screening strategy to address health harming legal needs.

BACKGROUND: Medical legal partnerships provide an opportunity to help address various social determinants of health; however, the traditional practice of screening patients during clinical encounters is limited by the capacity of busy clinicians. Our medical legal partnership utilized care coordinators trained by the legal service attorneys to screen patients outside of clinical encounters for health harming legal needs. The goal of our study was to demonstrate that our novel model could successfully identify and refer patients of a safety-net healthcare system to appropriate legal services. METHODS: We conducted a mixed methods evaluation of the program. Data was collected during the implementation period of the program from March 2017 to August 2018. Operational data collected included number of patients screened, number of referrals to the legal partner, source and reason for referrals. Return on investment was calculated by subtracting program costs from the total reimbursement to the health system from clients' insurance benefits secured through legal services. RESULTS: During the 18-month study, 29,268 patients were screened by care coordinators for health harming legal needs, with 492 patients (1.7%) referred for legal assistance. Of the 133 cases closed in 2017, all clients were invited to participate in a telephone interview; 63 pre-consented to contact, 33 were successfully contacted and 23 completed the interview. The majority (57%) reported a satisfactory resolution of their legal barrier to health. This was accompanied by an improvement in self-reported health with a decrease of patients reporting less than optimal health from 16 (89%) prior to intervention to 8 (44%) after intervention [risk ratio (95% confidence interval): 0.20 (0.04, 0.91)]. Patients also reported improvements in general well-being for themselves and their family. The healthcare system recorded a 263% return on investment. CONCLUSIONS: In our medical legal partnership, screening for health harming legal needs by care coordinators outside of a clinical encounter allowed for efficient screening in a high risk population. The legal services intervention was associated with improvements in self-reported health and family well-being when compared to previous models. The return on investment was substantial.

Evaluating the Efficacy of Medical-Legal Partnerships that Address Social Determinants of Health.

BACKGROUND: Medical-legal partnerships (MLPs) are health system-community partnerships composed of multi-disciplinary teams designed to improve patient and community health. MLPs provide legal services to address health-harming legal needs that contribute to health inequities. METHODS: A grant provided by the Association of American Medical Colleges (AAMC) and the Centers for Disease Control and Prevention established the Accelerating Health Equity, Advancing through Discovery (AHEAD) Initiative to identify, evaluate, and disseminate community-based interventions that improve health equity. Three geographically and demographically diverse institutions were chosen to strengthen the evidence-base surrounding MLP by developing standardized evaluation tools in the areas of community health, health system savings, and learner outcomes. RESULTS: The generalizable process leading to evaluation tool development is described herein, and includes the formation of multi-institutional teams, logic model development, and stakeholder interviews. CONCLUSIONS: Although MLP is presented, this process can be used by various types of community health partnerships to develop evaluation tools surrounding social determinants of health (SDOH).

A Systematic Review of Medical-Legal Partnerships Serving Immigrant Communities in the United States.

The medical-legal partnership addresses social and political determinants of health. Yet, relatively little is known about best practices for these two service providers collaborating to deliver integrated services, particularly to im/migrant communities. To investigate evaluations of existing medical-legal partnerships in order to understand how they function together, what they provide, and how they define and deliver equitable, integrated care. We searched five databases (PubMed, Medline, Web of Science, HeinOnline, and Nexus Uni) using search terms related to "medical-legal partnerships", "migrants", and "United States". We systematically evaluated ten themes related to how medical and legal teams interacted, were situated, organized, and who they served. Articles were published in English between 2010 and 2019; required discussion about a direct partnership between medical and legal professionals; and focused on providing clinical care and legal services to im/migrant populations. Eighteen articles met our inclusion criteria. The most common form of partnership was a model in which legal clinics make regular referrals to medical clinics, although the reverse was also common. Most services were not co-located. Partnerships often engaged in advocacy work, provided translation services, and referred clients to non-medical providers and legal services. This review demonstrates the benefits of a legal-medical partnership, such as enhancing documentation and care for im/migrants and facilitating a greater attention to political determinants of health. Yet, this review demonstrates that, despite the increasing salience of such partnership, few have written up their lessons learned and best practices.

Reducing the Justice Gap and Improving Health through Medical-Legal Partnerships.

A recent study by the Legal Services Corporation reported that 71% of low-income U.S. households experienced at least one civil legal problem in 2017 and that 86% of these needs went unresolved. In this article, we examine the potential for medical-legal partnerships (MLPs) to address this "justice gap." We draw on qualitative interviews, conducted with 20 parents and guardians in one pediatric MLP, to identify barriers to legal access and examine how the MLP model may uniquely address these barriers. Our data suggest that MLPs can (1) identify legal needs and create awareness of legal rights among individuals who would not have sought legal services; (2) create an access point for legal services; (3) improve access to legal advice and brief intervention; (4) support ongoing relationships between patients and lawyers that allow for the timely identification of subsequent legal needs; (5) foster trust and confidence in the legal system; and (6) address affordability concerns. These findings suggest that by improving access to justice, MLPs can address critical social and legal determinants of health and, ultimately, advance health equity.

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

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.

Striving for Health Equity through Medical, Public Health, and Legal Collaboration.

This article discusses (1) the ways in which law functions as a determinant of health, (2) historical collaborations between the health and legal professions, (3) the benefits of creating medical-public health-legal collaborations, and (4) how viewing law through a collaborative, population health lens can lead to health equity.

Dissolving the stiff upper lip: Opportunities and challenges for the mainstreaming of therapeutic jurisprudence in the United Kingdom.

Although therapeutic jurisprudence ("TJ") is increasingly well-established internationally, particularly within the United States of America ("US"), to date it remains relatively unacknowledged within the United Kingdom ("UK"). This article will explore the opportunities presented within contemporary UK society for the greater promotion, and eventual mainstreaming, of TJ. It will also consider the challenges faced during this process and how best to overcome these. Its first key area of focus will be upon the potential role of legal education in the UK in educating law students (and academics) about TJ, considering which approaches are likely to be most effective in incorporating TJ perspectives, at what stage this should occur and to what extent TJ is likely to impact on the existing curricula at a time when proposed changes relating to entry into the legal profession are heavily influencing the work of Law Schools. The article will then move on to consider the receptiveness of the UK legal profession to the TJ paradigm in light of recent attempts to move to a competency-based approach to practice and to reconceptualise professionalism to meet the challenges of increasing fragmentation and corporatisation. The third key area it will explore is the UK's recent plans to reintroduce problem-solving courts ("PSCs") into its criminal justice system. The authors will discuss the downfall of the six UK Drug Court ("DC") pilots originally established in 2005 theorising upon their failures and reflecting upon whether the current UK criminal justice system is truly able to support a fresh round of PSC initiatives. The article will end with recommendations for ways in which the international TJ community should begin the process of mainstreaming TJ within the UK. It will conclude that there are currently significant opportunities to be utilised, but that this requires significant commitment and mobilisation amongst existing TJ scholars and practitioners.

Medical-Legal Partnership in Western North Carolina: Addressing Social Determinants of Health Through Team-Based Care.

Having an attorney on a health care team helps address patients' social determinants of health. Through a medical-legal partnership, Pisgah Legal Services provides an attorney embedded within the Mountain Area Health Education Center clinical practices. The attorney impacts the Triple Aim of reducing costs by improving health and the patient experience.

Economic Evaluation of the Juvenile Drug Court/Reclaiming Futures (JDC/RF) Model.

Juvenile drug court (JDC) programs are an increasingly popular option for rehabilitating juvenile offenders with substance problems, but research has found inconsistent evidence regarding their effectiveness and economic impact. While assessing client outcomes such as reduced substance use and delinquency is necessary to gauge program effectiveness, a more comprehensive understanding of program success and sustainability can be attained by examining program costs and economic benefits. As part of the National Cross-Site Evaluation of JDC and Reclaiming Futures (RF), an economic analysis of five JDC/RF programs was conducted from a multisystem and multiagency perspective. The study highlights the direct and indirect costs of JDC/RF and the savings generated from reduced health problems, illegal activity, and missed school days. Results include the average (per participant) cost of JDC/RF, the total economic benefits per JDC/RF participant, and the net savings of JDC/RF relative to standard JDC.

Qualitative examination of enacted stigma towards gay and bisexual men and related health outcomes in Tajikistan, Central Asia.

Gay and bisexual men (GBM) in Tajikistan are an extremely stigmatised group at high risk for sexually transmitted infections and HIV. However, there is a paucity of research on how and in what way stigma affects their lives. We conducted a qualitative study to examine the impact of stigma on GBM's lives in Tajikistan, focusing on stigma enactors, settings, factors affecting vulnerability of GBM and health consequences. Eight individual in-depth interviews and 3 focus-group discussions with 13 participants (N = 21) from GBM community were conducted in two cities of Tajikistan. Results reveal that police frequently engage in blackmail and perpetrate sexual and physical violence against GBM. Service providers often discriminate against GBM limiting their access to health and legal services. Exposure to stigma results in chronic stress affecting mental health of GBM. Fear of disclosure, low social cohesion, absence of prominent opinion leaders and activists reduce resilience of GBM community to stigma. State-sanctioned violations of human rights of marginalised populations and lack of effective legal protection mechanisms have enabled widespread harassment of GBM. These findings warrant further research on stigma leading to the development of culturally adapted and tailored multilevel structural interventions, including broad legal and policy reforms.

Establishing a legal service for major trauma patients at a major trauma centre in the UK.

BACKGROUND: Major trauma causes unanticipated critical illness and patients have often made few arrangements for what are sudden and life-changing circumstances. This can lead to financial, housing, insurance, legal and employment issues for patients and their families.A UK law firm worked with the major trauma services to develop a free and comprehensive legal service for major trauma patients and their families at a major trauma centre (MTC) in the UK. METHODS: In 2013, a legal service was established at North Bristol NHS Trust. Referrals are made by trauma nurse practitioners and it operates within a strict ethical framework. A retrospective analysis of the activity of this legal service between September 2013 and October 2015 was undertaken. RESULTS: 66 major trauma patients were seen by the legal teams at the MTC. 535 hours of free legal advice were provided on non-compensation issues-an average of 8 hours per patient. DISCUSSION: This initiative confirms a demand for the early availability of legal advice for major trauma patients to address a range of non-compensation issues as well as for identification of potential compensation claims. The availability of advice at the MTC is convenient for relatives who may be spending the majority of their time with injured relatives in hospital. More data are needed to establish the rehabilitation and health effects of receiving non-compensation advice after major injury; however, the utilisation of this service suggests that it should be considered at the UK MTCs.

Predictors of seeking financial compensation following motor vehicle trauma: inception cohort with moderate to severe musculoskeletal injuries.

BACKGROUND: Compensation related factors have been repeatedly associated with poor recovery following orthopaedic trauma. There is limited research into the factors associated with seeking financial compensation. Further understanding of these factors could facilitate injury recovery by purposeful compensation scheme design. The aim of this study was to investigate the predictors of seeking financial compensation, namely making a claim and seeking legal representation, following motor vehicle related orthopaedic trauma. The study was conducted in New South Wales (NSW), Australia, in motor vehicle crash and workers' compensation schemes. METHODS: Participants were patients admitted with upper or lower extremity factures following a motor vehicle crash to two trauma hospitals. Data were collected at baseline within two weeks of injury. Participants were followed up at six months. Analysis involved: descriptive statistics for baseline characteristics; comparison of compensable and non-compensable participants with Analysis of Variance (ANOVA) and chi-squared tests; and logistic regression for predictor models. RESULTS: The cohort consisted of 452 participants with a mean age 40 years; 75% male; 74% working pre-injury; 30% in excellent pre-injury health; 56% sustained serious injuries with an Injury Severity Score (ISS) 9-15; 61% had a low-middle range household income; and 35% self-reported at fault in the crash. There was no significant difference in pre-injury/baseline health between compensable and non-compensable participants. Follow up data was available for 301 (67%) participants. The significant predictor of claiming compensation in the adjusted analysis was higher body mass index (BMI) (overweight Odds Ratio [OR] 3.05, 95% Confidence Interval [CI] 1.63-5.68; obese OR 1.63, 95% CI 0.83-3.20). Participants less likely to claim were: involved in a motorcycle crash (OR 0.47, 95% CI 0.28-0.82); socioeconomically less disadvantaged (OR 0.37, 95% CI 0.17-0.82) or least disadvantaged (OR 0.39, 95% CI 0.17-0.90); at risk for short term harm (injury) due to alcohol consumption (OR 0.56, 95% CI 0.32-0.97); and with fair-poor pre-injury health (OR 0.30, 95% CI 0.09-0.94). The predictors for seeking legal representation were speaking a language other than English at home (OR 2.80, 95% CI 1.2-6.52) and lower household income (OR 3.63, 95% CI 1.22-10.72). Participants less likely to seek legal representation were least socioeconomically disadvantaged (OR 0.15, 95% CI 0.04-0.50). CONCLUSIONS: Seeking financial compensation was associated with a higher pre-injury BMI rather than injury-related factors. Seeking legal representation was solely related to socio-economic factors.

Civil Legal Services and Medical-Legal Partnerships Needed by the Homeless Population: A National Survey.

OBJECTIVES: To examine civil legal needs among people experiencing homelessness and the extent to which medical-legal partnerships exist in homeless service sites, which promote the integration of civil legal aid professionals into health care settings. METHODS: We surveyed a national sample of 48 homeless service sites across 26 states in November 2015. The survey asked about needs, attitudes, and practices related to civil legal issues, including medical-legal partnerships. RESULTS: More than 90% of the homeless service sites reported that their patients experienced at least 1 civil legal issue, particularly around housing, employment, health insurance, and disability benefits. However, only half of all sites reported screening patients for civil legal issues, and only 10% had a medical-legal partnership. The large majority of sites reported interest in receiving training on screening for civil legal issues and developing medical-legal partnerships. CONCLUSIONS: There is great need and potential to deploy civil legal services in health settings to serve unstably housed populations. Training homeless service providers how to screen for civil legal issues and how to develop medical-legal partnerships would better equip them to provide comprehensive care.

In(ter)dependência entre decisões judiciais e pareceres psicossociais nos juízos criminais: análise qualitativa / In(ter)dependence between judicial decisions and psychosocial reports in criminal courts: a qualitative analysis / La in(ter)dependencia entre las decisiones judiciales y los informes psicosociales en la corte penal: análisis cualitativo

O parecer psicossocial consiste no principal meio de assessoramento aos operadores do Direito em processos judiciais que necessitam de uma análise psicossocial, sendo documento fundamental essa interdisciplinaridade. A partir da análise de aspectos qualitativos de 178 decisões judiciais proferidas entre 2010 e 2012, esta pesquisa objetivou verificar se juízes têm acolhido ou desconsiderado sugestões ou alusões de risco em pareceres psicossociais que avaliaram situações de violência doméstica contra crianças, adolescentes e mulheres. A interpretação qualitativa dos dados resultou na construção de três zonas de sentido: 1. O interesse da vítima no prosseguimento do feito é central para a decisão judicial; 2. A atuação psicossocial tem como objetivo realizar o acompanhamento ou tratamento das partes; e 3. A atuação psicossocial tem como objetivo assessorar a tomada de decisão judicial. Sugere-se investimento na interdisciplinaridade entre as ciências psicossociais e jurídica, com base nos paradigmas dos Direitos Humanos, redes sociais e reparação das vítimas.

The psychosocial report, an essential document to the establishment of an interdisciplinary approach among psychological, social and legal areas, is the main way to advisor judges on legal procedures that require a social and psychological analysis. Throughout a qualitative analysis of 178 courts' decisions from the year 2010 to 2012, this research aimed to verify the acceptance or not of suggestions or reference of risk in psychosocial reports that evaluated domestic violent situations against children, adolescents and women. The qualitative analysis of the court's decisions resulted in three different meaning areas: 1. Victim's intention to carry on the legal procedure is central to the court's decision, 2. The psychosocial work aims to make psychological monitoring or treatment of the victims and their families, 3. The psychosocial work aims to advise the process of making a legal decision. Continued investment in the interdisciplinary between psychosocial and legal areas, based on the paradigms of the Human Rights, social networks and redress of the victims, is strongly suggested.

El informe psicosocial es la principal forma de asesoramiento a los profesionales del derecho en procedimientos judiciales que requieren un análisis psicológico y social, y es un documento fundamental para el establecimiento de esta interdisciplinariedad. Con base en el análisis de los aspectos cualitativos de 178 decisiones judiciales entre 2010 y 2012, esta investigación tuvo como objetivo determinar si los jueces han considerado las sugerencias o las alusiones de riesgo en informes psicosociales que evaluaran la violencia doméstica contra niños, adolescentes y mujeres. La interpretación cualitativa de los datos resultó en la construcción de tres áreas de significado: 1. El interés de la víctima en la continuidad del proceso penal es fundamental para la decisión judicial; 2. El trabajo psicosocial tiene como objetivo hacer acompañamiento o tratamiento de las partes, y 3. El trabajo psicosocial tiene como objetivo asesorar la toma de decisión judicial. Se sugiere la continuidad de inversión en la interdisciplinariedad entre las ciencias psicosociales y jurídicas, basado en los paradigmas de los derechos humanos, las redes sociales y la reparación de las víctimas.