It Was Just Nice to Have Someone That I Felt Was on My Side : Implementation and Evaluation of a Medical-Legal Partnership in a Neonatal Intensive Care Unit and Fetal Care Program

Background: Social determinants of health (SDOH), or nonmedical factors that shape health, often negatively impact families with infants hospitalized in neonatal intensive care units (NICUs). Many of these SDOH also disproportionately affect people who identify as Black, American Indian or Alaska Native (AIAN), and certain Latino/a groups, as well as those with low socioeconomic position and/or living in rural areas. Some SDOH have legal implications, or health-harming legal needs(HHLN), which require interdisciplinary and collaborative approaches to mitigate impacts on health. Medical-Legal Partnerships(MLPs) integrate attorneys within healthcare teams to recognize, treat, and prevent HHLNs by providing free civil legal care to low-income families. Social workers have an integral role in MLPs through bridging disciplines and conducting HHLN screening and referrals. We implemented the first MLP in a NICU in 2020. Since that time, over 90 families who received public insurance or whose household income was less than 200% of the federal poverty level (FPL) have received MLP services. This paper shares results from a program evaluation of this novel MLP, including ways the research will inform further program development.

Methods: Our interdisciplinary research team of social workers and physicians used qualitative descriptive methods to conduct a program evaluation of this MLP located in an academic medical center in the Pacific Northwest. We purposively sampled participants who met inclusion criteria: parents of surviving infants who received NICU care, who completed MLP participation, and who spoke English or Spanish. We conducted interviews via telephone using a structured interview guide to explore how participants experienced the MLP, how the MLP influenced their NICU experience and transition home after discharge, and their suggestions for improvement. We conducted a reflective thematic analysis using an inductive approach at a semantic level. Three study team members independently open-coded two transcripts then developed a shared coding scheme, which was applied to the remaining transcripts. Once all transcripts were coded, we collapsed codes into themes, prioritizing those with resonance to research questions.

Results: Of the study participants (n=16), eleven identified as white, two as AIAN, one as multiracial, and two unknown/declined to answer. Half identified as non-Hispanic, five as Hispanic, and three unknown/declined to answer. All participants preferred English and received public health insurance and/or had a household income at or below 200% FPL. We found that 1) MLP facilitates holistic, interdisciplinary healthcare; 2) therapeutic, trauma-informed legal care mitigates parental distress; 3) MLP addresses structural barriers to family stability; 4) MLP would be improved by increased transparency, visibility, and capacity.

Conclusions: While NICU hospitalization is distressing for families and may intensify HHLNs, MLPs offer opportunities to reduce distress, improve family stability, strengthen relationships between clinicians and families, and ultimately address the complex and persistent fractures in systems that negatively impact families. Through this innovative approach, social workers have a critical role in facilitating interdisciplinary collaboration and individualized care that addresses HHLN. Our findings suggest ways to improve MLPs by being careful to present clear expectations about available services, evaluating equitable participation, and balancing the need for services with resource limitations.