Delaware Hones in on Medical-Legal Partnerships to Reduce Infant Mortality

A pregnant woman living in poverty faces stress that often has negative consequences for her and her baby’s health, including infant mortality. Unmet housing needs, lack of access to quality healthcare, financial insecurity, immigration status and family stability are just some of the social determinants of health affecting pregnant women. Many of these stressful situations require legal aid, but healthcare and the law have historically worked separately.

The Delaware team participating in the Collaborative Improvement and Innovation Network to Reduce Infant Mortality (Infant Mortality CoIIN), led by NICHQ, is working to develop medical-legal partnerships (MLPs) to address these stressors in an integrated way and improve health outcomes for women and babies.

The Delaware medical-legal partnership began as a pilot project in 2013 between the state division of public health (DPH) and the state’s Community Legal Aid Society (CLASI).

“Although it was a small sample, it was a clear success, and a great fit with Delaware’s infant mortality prevention efforts,” says Leah Jones Woodall, MPA, chief of the Family Health Systems Section of DPH and IM CoIIN team member.

The MLP works as a referral system from healthcare providers to legal services. Providers are trained in how MLPs improve health outcomes for their patients and how to refer to the legal partner. Clinicians and social workers give their patients a questionnaire called the "Perceived Stress Scale" to assess anxiety and stress levels. They also obtain information about stressors during the patient visit. If it is appropriate, the patient is referred to CLASI.

In one of many success stories, the Nurse Family Partnership (NFP) referred a patient who had tried unsuccessfully for 10 months to get the landlord to resolve unsanitary conditions with her apartment. The CLASI attorney sent a letter to the landlord demanding repairs. The patient reported that the landlord started repairs the next day.

Starting an MLP 

"To build an MLP, it is important to have a champion on both the provider and legal sides,” says Marissa Band, Esq. at CLASI. “You have to get buy-in from participating providers.”

It is also critical to have the following:

  • Literature showing how stress negatively affects health outcomes for pregnant women
  • DPH to promote the MLP as an effective health intervention
  • Healthcare providers to screen and refer patients
  • Legal staff to assess legal needs and provide appropriate legal services

“Healthcare staff are busy, and they may see the questionnaire and screening as just one more thing they have to do,” says Vikrum Vishnubhakta, MBA, MPH, epidemiologist, state consultant and IM CoIIN team member. “Showing providers that referring to legal aid is easy and can improve health outcomes for their patients by reducing their stress levels offers them another tool they can use to help their patients.”

For example, a patient may return again and again to their healthcare provider with exacerbated asthma, despite the correct medication and dose compliance. The underlying problem is substandard housing. Providers cannot change this; lawyers can.

In addition to provider resistance, another barrier can be patient follow-up. “We often have patients whose phones are shut off or for other reasons, such as housing insecurity, are hard to follow up with,” says Band. “But because we have a partnership with their provider, we can ask for their help with contact information or even meet the patient at one of her prenatal visits.”

As the MLP gets up and running, Delaware IM CoIIN team members advise having an evaluator. The team also recommends utilizing resources from the National Center for Medical Legal Partnerships.

“Monitoring your progress is the only way to know how you’re doing and to have insight into how to overcome barriers,” says Mawuna Gardesey, chief of the Center for Family Health Research and Epidemiology at State of Delaware. “We have data on how many patients are filling out questionnaires and number of referrals. Although it was a small sample, it was a clear success, and a great fit with Delaware’s infant mortality prevention efforts. Our next step is to link this with outcomes.”

So far in the pilot study, MLP participants reported an improvement in mental and physical well-being as well as a lower level of perceived stress after receiving MLP services. Gardesey said these results were statistically significant and has led to the expansion of the partnership program statewide. Approximately 180 women have been referred to the statewide project since its inception in May 2015.

“The IM CoIIN collaborative is great because it is so important to share information so that the program can be improved, replicated and scaled across the country,” says Woodall.

Other states participating in IM CoIIN, most notably Massachusetts, have very successful MLP programs.