Impact of a medical-legal partnership program on readmissions to a family medicine inpatient service
Authors: James Emma , Samson Emily , Manek Megha , Robinson Robert 
Published: July 2020

Background

The Centers for Medicare and Medicaid Services (CMS) value-based reimbursement prioritizes health outcomes and population health in a way that emphasizes social determinants of health, access disparities, and prevention. Unmet legal assistance needs are an area of considerable interest because it can impact access to healthcare services and can be a social determinant of health. Medical-Legal Partnerships (MLP) are tools to link patients with unmet legal needs with lawyers and other legal services. The goal of these programs is to address legal issues that complicate the life and healthcare of patients. With the hypothesis that unmet legal needs were a risk factor for poor health outcomes, we studied the impact of unmet legal needs on the readmission rate to the SIU Family and Community Medicine inpatient service at Memorial Medical Center in Springfield, Illinois.

Methods

All adult patients discharged between January 2016 and March 2018 were retrospectively studied to determine if the need for legal services was a significant predictor of all-cause hospital readmission within 30 days of discharge. Patients in need of legal services were identified using an interview-based screening tool and were referred to an HRSA-grant funded MLP. The impact of unmet needs for legal services was compared to validated risk factors for hospital readmissions such as the LACE index and HOSPITAL score.

Results

Data from 2500 hospital discharges from the SIU FCM service were analyzed. The overall readmission rate was 27%. Univariate analysis showed patients who were readmitted were older (57 vs 53 years, p < 0.001), had longer hospital stays (4.69 vs 4.17 days, p < 0.014), had higher Charlson Comorbidity Index values (2.31 vs 1.57, p < 0.001), HOSPITAL scores (4.79 vs. 3.14, p < 0.001), LACE index values (10.13 vs. 8.33, p < 0.001) and were more likely to need legal services (12% vs. 3%, p < 0.001). Multivariate analysis showed the HOSPITAL score (OR 2.12, p<0.001), LACE index (OR 1.16, p<0.001), Charlson Comorbidity Index (OR 0.70, p<0.001), hospital length of stay (OR 0.85, p<0.001), congestive heart failure (OR 2.10, p<0.001), COPD (OR 1.85, p<0.001), diabetes with complications (OR 1.88, p<0.001), and a need for legal services (OR 2.21, p<0.001) to be independent predictors of an increased risk of hospital readmission.

Conclusion

Unmet legal needs identified in this study via an interview-based screening tool appear to be an independent risk factor for hospital readmission. The predicted risk of readmission (OR 2.21) compares favorably with validated HOSPITAL score (OR 2.12) and LACE index (OR 1.16) readmission risk assessment tools. These findings suggest that the presence of unaddressed legal issues may be a modifiable non-medical risk factor for hospital readmission. Further study of the impact of MLP programs on hospital readmission is necessary to clarify the implications of this social determinant of health on a critical value-based care measurement.