Reducing asthma exacerbations in vulnerable children through a medical-legal partnership.

BACKGROUND: Asthma health disparities are widely recognized, with worse outcomes in children from low income families. In a Medical-Legal Partnership (MLP), an attorney is embedded in a healthcare setting to address social determinants of health. We studied whether an MLP could impact asthma exacerbation rates in a vulnerable urban population at an academic children's hospital. METHODS: The study population comprised children with asthma who were referred to the MLP between 2013 and 2017. We compared healthcare utilization for asthma exacerbations managed in primary care, emergency department and inpatient settings in the year before and year after MLP intervention. RESULTS: 98 children with asthma were included in the study. The mean total encounters per person per year decreased from 1.16 to 0.66 (relative reduction 44.2%, p < 0.01). The largest effect was on hospitalizations, with a reduction from 0.33 to 0.10 hospitalizations per patient per year (relative reduction 69.7%, p < 0.01). Encounters for asthma exacerbations in the primary care office and emergency department also decreased but these changes did not meet statistical significance. CONCLUSION: In a pediatric population with asthma, an MLP intervention was associated with a significant reduction in asthma exacerbation encounters and hospitalizations comparing the year before and after MLP intervention. Further studies are needed to better understand which interventions are most effective, and for which patient groups MLP referral would be particularly useful. MLPs may be an important way to reduce health disparities in patients with asthma and other chronic illnesses.

Medical Certification for Utility Shut-Off Protection and Health-Related Social Needs.

BACKGROUND AND OBJECTIVES: Children in families facing energy insecurity have greater odds of poor health and developmental problems. In this study of families who requested and received medical certification for utility shut-off protection and were contacted by our Medical Legal Partnership (MLP), we aimed to assess concurrent health-related social needs related to utilities, housing, finances, and nutrition. METHODS: After medical certificates were completed at our academic pediatric center, our MLP office contacted families and assessed utility concerns as well as other health, social, and legal needs. In this observational study, we present descriptive analyses of patients who received certificates from September 2019 to May 2020 via data collected through the MLP survey during the coronavirus disease 2019 pandemic (June 2020-December 2021). RESULTS: Of 167 families who received utility shut-off protection from September 2019 to May 2020, 84 (50.3%) parents and guardians were successfully contacted. Most (93%) found the medical certificate helpful. Additionally, 68% had applied for Energy Assistance, and 69% reported they were on utility company payment plans. Most (78%) owed arrearages, ranging from under $500 to over $20 000, for gas, electric, and/or water bills. Food, housing, and financial insecurity screening positivity rates were 65%, 85%, and 74%, respectively. CONCLUSIONS: Patients who were contacted by an MLP after receiving medical certification for utility shutoff protection were found to have challenges paying for utilities and faced multiple food, housing, and financial stressors. Through consultation and completion of medical forms for utility shutoff protection, pediatricians and MLPs can provide resources and advocacy to support families' physical, emotional, and psychosocial needs.

A Medical Financial Partnership in a Pediatric Medical Home.

The Volunteer Income Tax Assistance (VITA) program is an underutilized free taxpreparation service that directly addresses poverty by maximizing tax refunds. A pediatric medical home (PMH) with an embedded VITA site provides an excellent opportunity for a medical-financial partnership. We sought to assess the knowledge, attitudes, and practices of caregivers of children who used a PMH after embedding a VITA site. We found that a PMH-VITA site was a convenient, trusted, useful, and potentially tax-filing behaviorchanging intervention. Importantly, most caregivers who did not use the PMH-VITA site had no knowledge of availability of free tax filing services but would consider using one the following year. Improved marketing is needed to increase utilization in our target population.

The Impact of a Pediatric Medical-Legal Partnership on Pediatric Providers: A Qualitative Study.

OBJECTIVE: Medical-Legal Partnerships (MLPs) integrate medical and legal care to address prevalent health-harming legal needs (HHLN) among socioeconomically marginalized populations. MLPs address a diverse array of social determinants of health (SDOH) and have been shown to positively impact children's health. Less is known, however, about how MLPs affect health care providers. MLPs may affect child health by changing clinical practice and provider behavior, and transforming providers' relationships with their patients and patients' families. Examining and understanding how MLPs affect providers is thus critical to elucidating how MLPs may ultimately impact child health. METHODS: We examined one pediatric MLP at an academic medical center in New Haven, Connecticut. We conducted semi-structured interviews with 20 pediatric providers who had engaged with the MLP and 20 parents/guardians who had interacted with the MLP. We analyzed the qualitative data using inductive coding, primarily drawing upon provider interviews. RESULTS: The MLP affected providers in five major ways. The MLP 1) improved provider awareness of SDOH and HHLN, 2) expanded provider perceptions of their role and responsibilities as clinicians, 3) improved provider efficacy in addressing SDOH and HHLN, 4) empowered providers to engage in systemic advocacy, and 5) improved providers' relationships with patients' families. CONCLUSION: Our study identifies multiple ways that a pediatric MLP affects providers. Our findings suggest that MLPs can improve patient and population health by equipping providers with the knowledge and tools needed to assist patients with HHLN and SDOH, improving provider-family relationships, and encouraging providers to engage in systemic and institutional advocacy.

Optimizing Medical-Legal Partnerships in Pediatric Psychology to Reduce Health Disparities.

OBJECTIVE: To provide a topical review of the literature on the use of medical-legal partnerships (MLPs) to address social determinants of health (SDH) needs as a means to reduce health disparities, and to make recommendations for the implementation of MLPs within pediatric psychologists' clinical work, research, and training. METHODS: We conducted a topical review of the research on the intersection of MLPs, SDH needs, and health disparities among pediatric populations. Given the scarcity of literature available, both empirical and theoretical articles were included in the review. RESULTS: Though limited, the extant literature suggests that use of MLPs may help address the SDH needs that perpetuate disparities among pediatric populations. To date, MLPs are not as frequently incorporated in the training and work of pediatric psychologists as they may be in other related fields (e.g., medicine). CONCLUSIONS: MLPs provide an opportunity for psychologists to broaden their interdisciplinary collaborations, to more aptly meet the social and legal needs of their patients to assist in reducing inequities among underserved pediatric populations. The systematic incorporation of MLPs into pediatric psychology training may help to increase the utilization of these services moving forward.

Anti-Poverty Medicine Through Medical-Financial Partnerships: A New Approach to Child Poverty.

Poverty threatens child health. In the United States, financial strain, which encompasses income and asset poverty, is common with many complex etiologies. Even relatively successful antipoverty programs and policies fall short of serving all families in need, endangering health. We describe a new approach to address this pervasive health problem: antipoverty medicine. Historically, medicine has viewed poverty as a social problem outside of its scope. Increasingly, health care has addressed poverty's downstream effects, such as food and housing insecurity. However, strong evidence now shows that poverty affects biology, and thus, merits treatment as a medical problem. A new approach uses Medical-Financial Partnerships (MFPs), in which healthcare systems and financial service organizations collaborate to improve health by reducing family financial strain. MFPs help families grow assets by increasing savings, decreasing debt, and improving credit and economic opportunity while building a solid foundation for lifelong financial, physical, and mental health. We review evidence-based approaches to poverty alleviation, including conditional and unconditional cash transfers, savings vehicles, debt relief, credit repair, financial coaching, and employment assistance. We describe current national MFPs and highlight different applications of these evidence-based clinical financial interventions. Current MFP models reveal implementation opportunities and challenges, including time and space constraints, time-sensitive processes, lack of familiarity among patients and communities served, and sustainability in traditional medical settings. We conclude that pediatric health care practices can intervene upon poverty and should consider embracing antipoverty medicine as an essential part of the future of pediatric care.

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.

Free Polyethylenimine Enhances Substrate-Mediated Gene Delivery on Titanium Substrates Modified With RGD-Functionalized Poly(acrylic acid) Brushes.

Substrate mediated gene delivery (SMD) is a method of immobilizing DNA complexes to a substrate via covalent attachment or nonspecific adsorption, which allows for increased transgene expression with less DNA compared to traditional bolus delivery. It may also increase cells receptivity to transfection via cell-material interactions. Substrate modifications with poly(acrylic) acid (PAA) brushes may improve SMD by enhancing substrate interactions with DNA complexes via tailored surface chemistry and increasing cellular adhesion via moieties covalently bound to the brushes. Previously, we described a simple method to graft PAA brushes to Ti and further demonstrated conjugation of cell adhesion peptides (i.e., RGD) to the PAA brushes to improve biocompatibility. The objective of this work was to investigate the ability of Ti substrates modified with PAA-RGD brushes (PAA-RGD) to immobilize complexes composed of branched polyethyleneimine and DNA plasmids (bPEI-DNA) and support SMD in NIH/3T3 fibroblasts. Transfection in NIH/3T3 cells cultured on bPEI-DNA complexes immobilized onto PAA-RGD substrates was measured and compared to transfection in cells cultured on control surfaces with immobilized complexes including Flat Ti, PAA brushes modified with a control peptide (RGE), and unmodified PAA. Transfection was two-fold higher in cells cultured on PAA-RGD compared to those cultured on all control substrates. While DNA immobilization measured with radiolabeled DNA indicated that all substrates (PAA-RGD, unmodified PAA, Flat Ti) contained nearly equivalent amounts of loaded DNA, ellipsometric measurements showed that more total mass (i.e., DNA and bPEI, both complexed and free) was immobilized to PAA and PAA-RGD compared to Flat Ti. The increase in adsorbed mass may be attributed to free bPEI, which has been shown to improve transfection. Further transfection investigations showed that removing free bPEI from the immobilized complexes decreased SMD transfection and negated any differences in transfection success between cells cultured on PAA-RGD and on control substrates, suggesting that free bPEI may be beneficial for SMD in cells cultured on bPEI-DNA complexes immobilized on PAA-RGD grafted to Ti. This work demonstrates that substrate modification with PAA-RGD is a feasible method to enhance SMD outcomes on Ti and may be used for future applications such as tissue engineering, gene therapy, and diagnostics.

Design of binary polymer brushes with tuneable functionality.

Using coarse grained molecular dynamics simulations, we study how functionalized binary brushes may be used to create surfaces whose functionality can be tuned. Our model brushes consist of a mixture of nonresponsive polymers with functionalized responsive polymers. The functional groups switch from an exposed to a hidden state when the conformations of the responsive polymers change from extended to collapsed. We investigate quantitatively which sets of brush parameters result in optimal switching in functionality, by analyzing to which extent the brush conformation allows an external object to interact with the functional groups. It is demonstrated that brushes with species of comparable polymer lengths, or with longer responsive polymers than nonresponsive polymers, can show significant differences in their functionality. In the latter case, either the fraction of responsive polymers or the total grafting density has to be reduced. Among these possibilities, a reduction of the fraction of responsive polymers is shown to be most effective.

Enzyme immobilization on protein-resistant PNIPAAm brushes: impact of biotin linker length on enzyme amount and catalytic activity.

Thermoresponsive poly(N-isopropylacrylamide) (PNIPAAm) brushes with terminal click functionality can be used to selectively immobilize enzymes. Exploiting their inherent protein-repellent and thus non-fouling properties, surfaces with specific bioactivity can be created in this way. This report describes the functionalization of alkyne-PNIPAAm brushes with two biotin linkers of different poly(ethylene glycol) (PEG) spacer length via click chemistry and the subsequent immobilization of streptavidin-conjugated horseradish peroxidase (SA-HRP) by the strong interaction between biotin and streptavidin. Spectroscopic ellipsometry is used to quantify the biotin and the SA-HRP amount on the PNIPAAm brushes. Enzyme activities are determined by UV­vis spectroscopy. A better accessibility to the alkyne-functionalized chain ends for the short biotin-PEG3 linker leads to a higher biotin amount on these PNIPAAm brushes, which in turn results in higher SA­HRP amounts on biotin-PEG3-modified brushes in the swollen (20 °C) and collapsed state (37 °C) compared to biotin-PEG23-modified ones. For both linkers, an increased immobilization temperature leads to higher SA-HRP amounts due to an enhanced reaction kinetics and mobility. All immobilized SA-HRP amounts are in range of 81-98% monolayer coverage, except for SA-HRP immobilized on biotin-PEG23-modified PNIPAAm brushes at 20 °C, exhibiting only 43% monolayer coverage. A high mobility of the biotin linker combined with a low surface loading of SA-HRP is found to be beneficial for the activity of SA-HRP. Hence, the highest specific activity as measured by HRP-catalyzed 3,3´,5,5´­tetramethylbenzidine (TMB) oxidation is found for a low SA-HRP amount on biotin-PEG23-modified brushes.

Biofunctionalization of Titanium Substrates Using Nanoscale Polymer Brushes with Cell Adhesion Peptides.

The grafting of polymer brushes to substrates is a promising method to modify surface properties such as wettability and the affinity toward proteins and cells for applications in microelectronics, biomedical devices, and sensors. Poly(acrylic) acid (PAA) brushes are of high interest because of their stimuli-responsive behavior and the presence of carboxy (COOH) groups, which allow for immobilization of bioactive molecules. The "grafting-to" approach results in homogeneous and well-defined polymer brushes, but, although grafting-to has been demonstrated with PAA brushes on silicon (Si) substrates, it has not been performed on biocompatible materials such as titanium (Ti). Here, we have described a facile method to modify biocompatible Ti substrates with PAA brushes to amplify their substrate functionality. The grafting-to PAA "pseudo" brushes were successfully grafted to Ti substrates and retained their pH-dependent swelling behavior. An RGD peptide was covalently bound to COOH groups of the PAA brushes (PAA-RGD) as a model bioactive group. While NIH/3T3 cell adhesion was significantly decreased on PAA-functionalized Ti substrates, PAA-RGD on Ti had cell adhesion comparable to that of flat Ti at 24 and 48 h, with significantly more cells adhered to PAA-RGD compared to PAA on Ti at 48 h.