Embedding civil legal aid services in care for high-utilizing patients using Medical-Legal Partnerships

Mr. Jackson (not his real name) is a 42-year old man who was hospitalized three times in a seven-month period at Lancaster General Hospital in Pennsylvania. These hospitalizations were due to complications from chronic obstructive pulmonary disease, morbid obesity, depression, chronic kidney disease, and lower extremity non-healing ulcers. He was depressed and concerned that he was not able to move beyond the revolving door of frequent inpatient admissions.

Mr. Jackson was also incurring a large debt due to copays and uncovered services and medications. But his problems were not just medical. He was having legal problems getting enrolled in Medicaid, and his Social Security benefits were being unlawfully garnished. After his last hospitalization, he was so distraught that he did not leave his house for six weeks.

Mr. Jackson represents one of the most fundamental problems we face in medicine today — controlling cost among the highest users of our health care system. We often call these individuals “super-utilizers,” but that term only defines one truth about their interaction with the health care delivery system. While high use leads to higher costs and poorer quality outcomes, it is often driven by psychosocial, financial, and societal barriers to care and points to a lack of coordination between health care, social service, and civil legal aid infrastructure.

A “patient-centered” approach is at the heart of many successful programs attempting to address the needs of super-utilizers. Between September 2011 and September 2012, Lancaster General Health conducted a pilot super-utilizer project that embedded lawyers within an inter-professional care team. The goal was to see what effect integrating civil legal aid services into the care of high-using patients like Mr. Jackson would have on health care use, cost, and fulfilling the promise of patient-centered care.