{"subscriber":false,"subscribedOffers":{}} Legal Advocacy To Improve Care For Older Adults With Complex Needs | Health Affairs
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Legal advocacy is a recognized strategy to address social factors that influence the health of populations with complex care needs. Such advocacy can improve housing stability, increase access to public benefits that support a host of social needs, assure that medical and financial proxy decision makers are in place, and reduce psychosocial distress

Older adults are disproportionately likely to have complex medical needs. Legal advocacy has been recognized as integral to the health and health care of older adults in the medical literature since 1988, and in current Medicare quality metrics. Additionally, since 1965, the Older Americans Act has provided legal assistance as an “essential service” among other aging supports such as nutrition, transportation, and in-home care. Under the act, state area agencies on aging must provide legal services free to adults older than age 60 with the “greatest social or economic need.” 

Yet, while emerging care models for older adults with complex needs are highly multidisciplinary, none incorporate legal advocacy in their design. This is in some ways not surprising as clinicians are not trained to recognize or address legal needs of older patients, and older patients are unable to self-diagnose their legal problems, thus making it unlikely that they will articulate legal needs as such to health care providers, social workers, or case managers. 

In addition, funding mechanisms for health care and social services—especially civil legal services—are highly siloed and deeply asymmetrical. Historical underinvestment in civil legal services for the poor has led to a shortfall in the legal workforce serving this population. This may provide another explanation for why legal advocacy has not been particularly visible to health systems: Legal advocates are focused on emergency legal needs such as loss of housing, neglect and exploitation, and loss of public benefits. Although these needs could be better served through preventive and primary legal advocacy delivered holistically in coordination with other social services and health care, funding levels have not enabled such an approach. 

Thus, health-impacting legal needs of older adults largely go unmet. In 2017, 56 percent of low-income older adults reported experiencing a civil legal problem in the previous year, including 10 percent of seniors who experienced more than six problems. These older adults received inadequate or no professional legal help for 87 percent of their needs. 

These problems are not intractable. We describe below the legal needs of older adults in the complex care population and ways in which health systems can partner with legal advocates to address them. Shared savings from accountable care programs could provide one source of support for such partnerships. 

The Role Of Legal Advocacy 

By definition, older adults in the complex care population are those who face a high burden of functional limitations, chronic conditions, and social needs such as low income, low literacy, and social isolation. Between 12 percent and 63 percent of hospitalized older adults have dementia. Older adults in the complex care population face greater barriers to care, report more difficulty with care coordination, and have worse health outcomes than other older adults. 

Legal needs affect the health status of this population (Exhibit 1). Legal advocates can play an important role in care coordination by educating patients and their caregivers about their rights within regulatory and administrative systems that are key to accessing housing, transportation, economic, and nutrition benefits; assisting with disability and incapacity planning; and responding to elder abuse and neglect. This is work the legal community has done for decades, although largely not in coordination with health systems. 

Exhibit 1: Examples Of Health-Related Legal Needs Of Older Adults In The Complex Care Population

Source: Authors’ analysis. 

Legal advocates can also address structural factors facing the older complex care population. This group relies more heavily on long-term care supports than other older adults, and lack of access to home- and community-based care supports contributes to a higher risk for nursing home admission and Medicaid entry. Medicaid—the primary payer of long-term care services in the United States—has a historical, structural bias toward nursing home care, only paying for in-home or community-based care through limited state waiver programs. 

Compounding the problem, state Medicaid agencies often struggle to interpret program rules correctly or administer them inconsistently, resulting in highly variable access to care supports even among patients with the same functional needs. Legal experts can address these barriers by assisting older adults, their caregivers, and their health care providers in understanding and enforcing their rights within their state’s Medicaid program. 

Opportunities For Partnership Between Health Systems And Legal Advocates 

There are multiple levels of potential partnership between health systems and community legal agencies (Exhibit 2). 

Exhibit 2: Types of Partnership Between Legal Advocates And Health Systems

Source: Authors’ analysis.  

Data And Systems Design 

Health systems are uniquely situated to help identify older adults with legal needs because of the increasing sophistication of their data collection and risk stratification processes. However, health systems are unlikely to identify legal solutions to patient problems without a legal partner involved in data and systems analysis. Partnership between legal agencies and health systems can identify patient legal needs and effectively target limited legal resources. For example, identifying older patients who are at risk of extended hospital stays due to lack of in-home care support, long-term care placement availability, or the absence of a financial decision maker, and providing them with upstream, person-centered planning, could promote patient satisfaction and prevent unnecessary use of health care resources. 

Once these needs are identified, legal experts could then assist in mapping legal solutions to existing clinical workflows to ensure that the needs of complex older adults are recognized at key points, such as at the time of a new diagnosis of dementia, at discharge planning, or other care transitions. Legal experts could then develop tools such as social needs screening and referral protocols to assist the clinical teams. 

Two screening tools, the PRAPARE and Accountable Health Communities screening tools, are increasingly popular for identifying social needs in vulnerable populations. However, both fail to screen for trustworthy, legally recognized financial caregivers (for example, an agent in a durable power of attorney for finances), a key need of older adults in the complex care population. Health systems should consider adapting their screening processes to ensure that this need is identified either in the tool itself or in subsequent workflows. Additionally, legal advocates can help triage patient social needs to prevent the need for “acute” legal intervention such as guardianship downstream. 

Clinical Team Support And Education 

Legal partners can provide training to clinicians, navigators, social workers, and other health care team members who are responsible for implementing workflows but who may not otherwise have opportunities to develop their own legal literacy. Lawyers can also collaborate with social workers to distribute advocacy work efficiently, keeping in mind a state’s scope of practice laws as well as practical limitations such as bandwidth. 

Patient Education 

Legal partners can assist in the development of patient education materials required to be provided under several Medicare quality metrics. Five of the high-priority quality measures in the Medicare Merit-based Incentive Payment System are of particular import to complex older adults: care plan, dementia caregiver education and support, dementia safety, elder maltreatment, and falls. As previously referenced, these metrics direct clinicians to provide patients and caregivers with information about social supports, many of which implicate patient legal needs. In the experience of the authors, the quality and availability of such materials can be highly variable across states; legal help for patients in this area is particularly important because social supports for older adults are often specific to state law and local resource availability. Additionally, legal partners can ensure that materials and referral practices are attuned to the risk of exploitation and undue influence, a heightened concern in this population. 

Patient Access To Legal Assistance 

Systems-level integration of legal expertise and health workforce training are important but are unlikely to fully address civil justice barriers for the most medically and socially complex older patients. These individuals would also benefit from direct access to on-site or in-home legal assistance, such as the type provided in the medical-legal partnership model. In this model, a lawyer is integrated as a member of the health care team to provide direct legal assistance to patients, as well as training and consultation to providers on the legal needs of their patients. 

Medical-legal partnerships have demonstrated successes, including improved housing, access to benefits, and reduced psychosocial symptoms. This model has been adopted by 330 health institutions nationwide. While older adults represent 30 percent of patients served by this model, only four partnerships nationally are specifically designed with the needs of older adults in mind. 

One of the few medical-legal partnerships that does focus on older adults resides in San Francisco, where the University of California, San Francisco Medical Center and the San Francisco Veterans Administration Health Care System (SFVAHCS) have partnered with the University of California Hastings College of the Law in the Medical-Legal Partnership for Seniors (MLPS). The legal team trains geriatricians, palliative care teams, primary care teams, social workers, and discharge planners in understanding and identifying legal needs of older adults. The team is embedded at multiple clinic sites and provides curbside and formal consults to clinicians on specific patient cases. Legal services are provided at no charge to patients through home visits, on site in clinic and at hospitals, and in long–term-care facilities. 

The SFVAHCS recently determined that MLPS generated an estimated $800,000 in cost savings by reducing hospital length-of-stays for just five high-need older patients. More importantly, the patients were able to obtain care that aligned with their preferences. 

Legal advocates are important but overlooked allies in efforts to improve care of older adults with complex medical needs. If thoughtfully targeted, integrated, and supported, legal resources have the potential to impact a health system’s capacity to deliver equitable, person-centered, high-value care. 

Authors’ Note

Sarah Hooper has received grant funding in the past year from the Health Resources and Services Administration, the Gordon and Betty Moore Foundation, the John A. Hartford Foundation, and the Merck Foundation. Joel Teitelbaum receives royalties from Jones and Bartlett Publishing.

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