A case study on going beyond ROI to measure the benefits community partnerships bring to health care
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Imagine this: a mom rushes her young daughter to the emergency room in the middle of a severe asthma attack. It’s their second visit to the hospital this month, and the medication the doctor prescribed isn’t helping at home. Why? Their apartment is full of mold and their landlord refuses to clean it up. So, this time, instead of sending the patient home with pills, the doctor pages a different type of specialist at the clinic: a lawyer.
Scenarios like this happen every day at medical-legal partnerships (MLPs) around the country, where community-based legal aid organizations partner with healthcare entities to provide legal advice and services to patients. When healthcare staff spot patients with health-harming legal needs, such as denial of public benefits or risk of eviction, there is someone on the team trained and ready to help. Hundreds of healthcare entities have formed these partnerships with legal aid organizations in their communities. Two years ago, Kaiser Permanente became the first large, private, integrated health system to make a systemwide investment to scale MLP across six regions, collaborating with HealthBegins and the National Center for Medical-Legal Partnership (NCMLP), and it is expanding that investment in 2024.
These partnerships are part of a larger trend in health care to address social and structural factors that drive health inequities. But too often, health systems and payers measure the value of these interventions solely through their bottom line, in dollars returned through revenue or savings. While return on investment (ROI) is an important first measure of the financial impact of a program (see HealthBegins’ ROI calculator), social interventions can provide a wealth of other financial and non-financial benefits—to patients, staff, communities, and systems—that help a health system meet its mission. Certainly, for the mother holding her sick child in the emergency room and for the staff who see problems like hers regularly but can’t fix them alone, removing mold from an apartment can have a big impact on health and job satisfaction, respectively.
Considered alongside ROI, these additional benefits paint a fuller picture of the value on investment (VOI) of social interventions. HealthBegins urges healthcare and community partners to measure and communicate VOI, in addition to ROI, when assessing the value of health-and-social-care integration efforts. To see this principle applied in practice, here are the potential benefits that accrue when we use this more expansive lens to consider the value of medical-legal partnerships.
Patient health and well-being
The mission of healthcare organizations is to provide quality care that improves the health and well-being of people in their communities. Social needs like safe, stable housing and healthy food have a significant impact on health, and helping patients meet these needs can help health systems directly meet their missions. Studies have shown that MLP services help people obtain safe, affordable, and stable housing and keep their utilities turned on. While it can be difficult to directly link social interventions to health outcomes, there are studies that show MLP services have a positive impact on the physical health of some people with chronic illnesses. Improved housing conditions led to improved health in asthma patients, while youth with diabetes who received legal services had significant improvement in their glycemic control. At Kaiser Permanente in Baltimore, MLP services prevented a man from being evicted from his home while recovering from a heart attack, allowing him a chance to complete his medical treatment and recover in a safe environment. And in certain cases, legal interventions have been critical in facilitating life-saving care, like when a woman with breast cancer in Nebraska almost canceled her mastectomy after she received an eviction notice, until the MLP legal team helped her stay housed. In addition to these physical benefits, studies in Connecticut, New Jersey, and Arizona have shown that people report less stress and experience improvements in mental health after receiving legal services for a variety of issues. Where ROI calculations fall short, a VOI approach helps partners to better represent the real value of these health benefits.
Patient satisfaction and engagement
Too often, patients get labeled “non-compliant” when social barriers prevent them from engaging in care and treatment plans. Perhaps they don’t have the means to refrigerate their medications, or there is no public transportation between their home and the clinic. Addressing patients’ health-harming legal issues can remove some of those barriers. Research in both pediatric and cancer care settings showed that patients more commonly took their medications as prescribed and adhered to medical treatments after receiving free legal services. And patients who received MLP services in the emergency department were better able to connect with a “medical home.” While these outcomes aren’t often counted in financial metrics, improved adherence to medical treatment can directly impact health outcomes and provider morale, while patient satisfaction can increase longevity and continuity of care and therefore have indirect financial impacts.
Workforce knowledge and satisfaction
Many health systems have made significant investments in training and systems for social-needs screening and referrals. Working with community partners can make this investment more effective. For example, as a result of MLP education, healthcare providers and medical students have a deeper understanding of social needs and are more comfortable and more likely to screen patients for them. In preliminary 2023 data from Kaiser Permanente, NCMLP, and HealthBegins, 94% of healthcare staff who received training on common housing problems from MLP legal partners felt more comfortable identifying housing issues that patients were experiencing, and 89% felt more confident connecting them to assistance. Healthcare providers who receive MLP training are also more likely to see social needs screening as part of their job.
Clinical-community partnerships can also affect how those healthcare workers feel about their jobs. Healthcare providers who are able to consult with MLP lawyers and refer patients for legal services have reported increased job satisfaction and an improved ability to perform “at the top of their license.” When healthcare workers are more satisfied, they are more likely to stay at their jobs, saving health systems the time and expense of recruiting and rehiring. Employee job satisfaction is also linked to higher ratings and profits for hospitals. Despite these benefits, few clinical-community partnerships estimate or communicate the real value of improved workforce knowledge and satisfaction when making the business case for their work.
Fulfillment of regulatory and accreditation requirements
Accreditation bodies are beginning to require steps to advance health equity. The Joint Commission’s new accreditation requirements necessitate that health systems assess patients’ health-related social needs and refer them to community resources. The National Committee for Quality Assurance’s Health Equity Accreditation Plus includes a requirement to establish mutually beneficial partnerships with community-based organizations (CBOs). Community-based organizations broadly—and MLPs specifically—have an opportunity to help health systems meet these requirements. CBOs can learn to use a VOI approach to quantify the economic and financial value that they generate for a health system when it achieves accreditation thanks, in part, to a clinical-community partnership to address social needs.
Broader impact on equity
Addressing individual social needs is the entry point where many health systems and payers begin their equity work. But to make a broad and lasting impact on equity, leaders must build these efforts to address systems and structures beyond the level of individual patients, as HealthBegins’ Compass for Health Equity Transformation illustrates. MLPs have demonstrated how such systemic interventions can deliver meaningful value.
While all MLPs provide direct legal services to patients and train healthcare staff, some also engage in “patients-to-policy” work to address policy failures that help to create many health inequities. These efforts are still evolving to address racial inequity more directly, but they have nonetheless begun to make an important impact. For example, after seeing many patients with lead poisoning blocked from applying their federal housing assistance to a new home, the MLP at Erie Family Health Centers built a multi-state coalition that got the U.S. Department of Housing and Urban Development to update its federal lead regulations. Cincinnati Children’s Hospital Medical Center used their MLP data to strengthen community members’ efforts to improve the city’s housing stock. And in Washington, D.C., Whitman-Walker Health’s MLP team helped prevent platinum insurance plans widely used by patients with chronic illnesses from being eliminated in the local marketplace, preserving thousands of patients’ access to care.
Gains accrued to partners and other systems
Another important VOI consideration is how community-based organizations and other sectors benefit from a health system’s investment in social interventions. Community-based legal organizations are historically under-funded, able to provide legal services to less than half the people who seek them and less than 10% of people who need them. But MLPs demonstrate that legal services also work as a health care and public health intervention. Healthcare partnerships can help close the legal-aid funding gap, in part by tapping revenue streams created by the Health Resources and Service Administration and recent Medicaid policy changes. These investments have the potential to grow and help sustain a proven and much needed community resource.
What isn’t known is what impact MLP services have on other sectors outside health care—such as criminal justice, child welfare, and education. Many of the issues that MLPs address—like many other types of clinical-community partnerships—brush up against these other sectors For example, many MLPs help ensure children have the educational supports they need at school. Some of the benefits of this work may not be visible for years—but could hold value for health systems and provide broader social returns on investment (SROI) for communities and should be the subject of future implementation science research.
Expanding the Case for Investment
Return on investment (ROI) remains an important measure for demonstrating the financial returns of social interventions for health care systems and payers that “invest” in clinical-community partnerships. And MLPs’ ability to demonstrate ROI—by connecting legal services to reduced hospitalizations in both children and adults and increased access to insurance benefits that help cover unreimbursed clinical services—have been critical for growing investment in MLPs. But while cost matters, it’s far from the only thing that does.
When health systems weigh the merits of a social intervention and community partnership, they should consider all its areas of impact and value —gauging whether it improves patients’ health and well-being, helps the healthcare workforce better do their jobs, and, critically, advances equity. There is mounting evidence that social interventions are critical to meeting a health system’s mission. Community-based organizations need to prepare themselves to make this case, and health systems must consider it, as they join forces to improve care and advance health equity.
Kate Marple is a Boston-based writer who specializes in helping nonprofit, health care, and legal services organizations develop practices to ensure that the stories they tell are shaped by and benefit people directly impacted by the issue(s) those stories are about. Her website is https://whotellsthestory.org.
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