OPAHL Training Manual

OPAHL TRAINING MANUAL FOR MEDICAL, LEGAL, AND SOCIAL SERVICES PROVIDERS Version: Draft 07.24.2022 Scan with your phone camera Link to PDF flipbook

TABLE OF CONTENTS PAGES TOPIC 3 OVERVIEW 4 SOCIAL DRIVERS OF HEALTH AND HEALTH-HARMING LEGAL NEEDS 5 IMPACTING PEOPLE LIVING WITH HIV (PLWH) | Session One 6-7 8 PUBLIC INTEREST LAW | Session Two 9 HIV CONTINUUM OF CARE | Session Three HEALTH HARMING LEGAL NEEDS AND PEOPLE LIVING WITH HIV | Session Four 10-11 INTEGRATION OF LEGAL SERVICES AND MEDICAL/HEALTH CARE | Session Five 12-13 PREREQUISTIES FOR SUCCESSFUL MEDICAL-LEGAL PARTNERSHIPS | Session Six 14-15 SCREENING FOR HEALTH HARMING LEGAL NEEDS | Session Seven 16-17 18-27 MEDICAL-LEGAL PARTNERSHIPS IN PRACTICE | Session Eight 28 DATA COLLECTION AND ANALYSIS | Session Nine SUPPLEMENTAL MATERIALS | AUTHORS AND ACKNOWLEDGEMENTS | 2

OVERVIEW | Medical-legal partnerships have been used by social justice-oriented medical, health, social and legal service practices to identify and address legal issues that create barriers to treatment, care, and recovery for a number of health conditions. Until recently, however, there has been no demonstrated evidence-based medical-legal partnership intervention package for improving HIV continuity of care. THE GOAL OF ORGANIZATIONAL PARTNERSHIPS FOR HEALTHY LIVING (OPAHL) IS TO HELP HEALTH CARE ORGANIZATIONS ESTABLISH MEDICAL-LEGAL PARTNERSHIPS WITH A FOCUS ON ORGANIZATIONS THAT SERVE PEOPLE LIVING WITH HIV (HEREIN REFERRED TO AS PLWH). This training consists of nine sessions that will lead to the development of an MLP for improving HIV continuity of care in health care organizations that previously did not provided legal services. Learning objectives By the end of the training, medical, health, social, and legal services providers will be able to: (1) Implement and operate an MLP using OPHAL intervention (2) Understand civil public interest law as a necessary tool to improve health outcomes (3) Identify health-harming legal needs that impact PLWH with regard to overall health, continuity of HIV care, and treatments for co-occurring conditions; (4) Effectively refer PLWH to legal services; (5) Participate in the coordination and monitoring of health-harming legal needs and HIV continuity of care for PLWH. Learning mechanisms During this session we expect to increase awareness of SDH and HHLN through the following educational methods of learning: (1) Consciousness raising, (2) Chunking of information, (3) Information transfer, (4) Relating these issues to professional experiences with patients/clients. During this session we expect to educate participants about public interest law, the range of legal issues public interest law lawyers handle, and the connection between public interest law and health through the following educational methods of learning: (1) Consciousness raising, (2) Chunking of information, (3) Information transfer, (4) Relating these issues to professional experiences with patients/clients. Reading materials Trainees are expected to read the materials listed on pages 18-22 of this manual prior to attending training. Overview of sessions Trainings will be conducted in person by the OPAHL intervention team and interdisciplinary co- facilitators. Trainees will be expected to have read two publications by the National Center for Medical- Legal Partnerships on establishing MLP prior to the training. This joint training approach establishes the intervention as a cohesive, collaborative initiative in which all care providers (medical, health, social services, legal) work as a team with the shared goal to improve patients’ health outcomes. Developing these internal staff relationships and building trust are essential for both effective internal operations and impactful patient/client support. The training will use problem solving learning, case studies identified through the formative stage of OPAHL during the prior study, and needs assessment quantitative data from OPAHL prior study. Although in-person trainings are costly in comparison to 3

online or self-guided trainings; this approach will ensure the fidelity and quality of delivery of the joint training. Session title Time Session #1: SDH and HHLN 30 minutes Session #2: Public interest law 30 minutes Session #3: HIV continuum of care 30 minutes Session #4: HHLN and PLWH 45 minutes Session #5: Integration of legal services and 60 minutes medical/health care Session #6: Prerequisites for MLP 60 minutes Session #7: Screening for HHLN 45 minutes Session #8: MLP in practice 60 minutes Session #9: Data collection and analysis 30 minutes 4

SOCIAL DRIVERS OF HEALTH AND HEALTH-HARMING LEGAL NEEDS IMPACTING PEOPLE LIVING WITH HIV (PLWH) | Session One | 30 minutes Overview Social drivers of health (SDH) and health-harming legal needs (HHLN) have a profound impact on health outcomes. The goal of this interactive training session is to educate medical, health, and social providers about SDH and HHLN that impact health of underserved communities in general and PLWH in particular. This session should be completed within 30 minutes. Competencies By the end of this session, providers will be able to: 1. Explain SDH 2. Explain the impact of SDH on health in general and on PLWH in particular 3. Describe HHLN that result from SDH By the end of this session, providers will: 1. Understand the interconnectedness of SDH, HHLN, and health outcomes 2. Appreciate the importance of addressing HHLN to reduce barriers to health and improve health outcomes. Learning mechanisms During this session we expect to increase awareness of SDH and HHLN through the following educational methods of learning: (1) Consciousness raising, (2) Chunking of information, (3) Information transfer, (4) Relating these issues to professional experiences with patients/clients. Instructions for facilitator 1. Ask participants “Are you familiar with the term “social drivers of health?” Explain that SDH are conditions in the places where people live, work, learn, and play that affect a wide range of health risks and outcomes. Invite participants ideas about what SDH means and what they are. Discuss what this means in practical terms and discuss real-world examples. 2. Ask participants “Are you familiar with the term “health-harming legal needs?” Explain that a health-harming legal need is a social problem that adversely affects a person's health or access to health care and which is better remedied through the combination of legal care and health care rather than health care alone. 3. Ask participants “In your experience, what SDH creates barriers to healthcare access and/or adherence to treatments?” Ask participants to share examples from their patient experiences. 4. Ask participants “In your experience, what HHLN interferes with your patients’ access or adherence to care?” Ask participants to share a patient example. 5. Propose to participants “Let’s create a list of potential health-harming legal needs for each stage of the HIV continuum of care.” Divide the group into five subgroups, each corresponding to a stage in the HIV continuum of care (Testing, Linkage, Prescription/Pharmaceutical, Retention, Suppression). Ask each group to identify, from their experiences, common health harming legal needs for that stage of the continuum. Discuss each of the brainstormed lists as a group. 6. Ask participants “How would addressing HHLN improve health?” When the participants can explain SDH and HHLN and provide appropriate examples of how these factors impact PLWH, take a 10-minute break before moving on to Session #2. 5

PUBLIC INTEREST LAW | Session Two | 30 minutes Overview Public interest law refers to free legal representation for people who cannot afford a lawyer. HHLN can be appropriately and effectively addressed with public interest law services. Legal aid attorneys have the expertise and experience to address many health harming legal needs that impede patients’ potential to achieve health and wellness, therefore identifying these patients in the context of the health care setting is particularly important. The goal of this session is to demonstrate that health harming factors can be effectively and efficiently addressed through legal support within the health care system in ways that the traditional health care system cannot. Competencies By the end of this session, participants will be able to: 1. Describe the scope of services public interest law attorneys provide 2. Explain the ways in which civil public interest law can address HHLN 3. Appreciate the health center as a critical access point for legal intervention to address HHLN 4. Provide examples from their experience in which public interest law may have benefited one of their patients By the end of the session, participants will: 1. Understand the scope of services that many public interest law attorneys can provide 2. Appreciate the impact of public interest law on HHLN and patient health Learning mechanisms During this session we expect to educate participants about public interest law, the range of legal issues public interest law lawyers handle, and the connection between public interest law and health through the following educational methods of learning: (1) Consciousness raising, (2) Chunking of information, (3) Information transfer, (4) Relating these issues to professional experiences with patients/clients. Instructions for facilitator 1. Explain that public interest law consists of non-profit organizations and pro bono lawyers that provide legal services free of charge to those who cannot afford to hire a lawyer on their own. There are often income thresholds that determine eligibility for public interest law services. Convey that there is limited funding for public interest law services. 2. Ask participants “Can you describe some legal issues that public interest law attorneys might handle?” 3. List issues mentioned on a large pad or whiteboard. Include: housing issues (wrongful eviction, housing discrimination, failure to make necessary repairs); benefits issues (improper denial or reduction of benefits, etc.), denial of Medicaid benefits, domestic violence (orders of protection), criminal arrest, employment issues (failure to make necessary accommodations, wrongful termination, denial of FMLA leave, workplace discrimination) 4. Ask participants “How do you think these legal issues impact health, HIV care, treatment, and medication adherence?” 5. Ask participants “Are there any legal issues you think may have interfered with your patients’ access or adherence to care?” Ask participants to share examples. 6

When the participants can discuss public interest law services, the impact legal support can have on health and medication adherence and provide appropriate examples of how these factors impact PLWH, take a 10-minute break before moving on to Session #3. 7

HIV CONTINUUM OF CARE | Session Three | 30 minutes Overview HIV is a disease embedded in social and economic inequity. To achieve the UNAIDS 95-95-95 goals, SDH that create barriers to care and treatment must be addressed. SDH make it difficult for many PLWH to manage their illness and maintain health. Low-income communities are at great risk for SDH that decrease the likelihood PLWH will adhere to medication and achieve viral load suppression. Adherence to HIV treatments is often complicated by co-occurring conditions. Competencies By the end of this session, participants will be able to: 1. Explain the 95-95-95 UNAIDS goals 2. Discuss HIV care & treatment overview 3. Explain CDC guidelines for comprehensive HIV primary care 4. Appraise best practices and adaptations to the CDC guidelines for comprehensive HIV primary care/co-occurring conditions 5. Discuss the various factors--SDH, HHLN, co-occurring conditions--that impact PLWH 6. Explain the impact of HIV on the individual, community, and society By the end of the session, participants will: 1. Understand the CDC guidelines and the HIV care continuum 2. Appreciate the SDH, HHLN that impact many PLWH 3. Discuss the co-occurring conditions that impact many PLWH 4. Understand the broad impact of HIV Learning mechanisms During this session we will review with participants CDC guidelines, HIV Care Continuum, and co- occurring conditions that often impact PLWH through the following methods: (1) Consciousness raising, (2) Chunking of information, (3) Information transfer Instructions for facilitator 1. Explain the 95-95-95 UNAIDS goals a. Goal 1: 95% PLWH know their status b. Goal 2: 95% PLWH are in treatment c. Goal 3: 95% PLWH who are in treatment reach viral load suppression 2.HIV care & treatment overview a. Medication i. Mechanisms of ART ii. Treatment considerations iii. Goals of ART b. Case management considerations i. ART counseling ii. Adherence is a common challenge in HIV care 3. Co-occurring conditions that often impact PLWH 4. Discuss impact of HIV individual, community, society 5. Present the following info about the financial impact of HIV: a. PLWH with undetectable viral loads, cannot transmit HIV. Therefore, increasing the number of PLWH who are virally suppressed is a national priority. 8

b. The lifetime cost of HIV treatment is $367,134 per person, therefore every HIV infection avoided is a $367,134 savings c. The costs associated with PLWH who are not in treatment, who have delays in accessing treatment, who reside in medically underserved communities, and/or are affected by systemic barriers to HIV treatment adherence are triple the costs of those who access and are retained in HIV treatment and care. d. PLWH who are out-of-care have life expectancies of 12.5 years less than those PLWH, which creates a tremendous social and economic costs to society and their communities. When the participants can discuss CDC guidelines, HIV care continuum, and co-occurring conditions, take a 15-minute break before moving on to Session #4. 9

HEALTH HARMING LEGAL NEEDS AND PEOPLE LIVING WITH HIV | Session Four | 45 minutes Overview HHLN pose significant barriers to progress along the HIV continuum of care. The goal of this interactive training session is for participants to understand the HHLN that often affect PLWH (based on socioeconomic, psychosocial, and behavioral issues common among PLWH), the potential of MLP to facilitate positive movement along the HIV care continuum. Competencies By the end of this session, participants will be able to: 1. Discuss the HHLN that often impact PLWH 2. Discuss how legal services can improve the ability of PLWH to engage in HIV care, adhere to treatment, and achieve and maintain viral load suppression By the end of this session, participants will: 3. Present descriptive quantitative data from the formative research for OPAHL (r21 study) on common health harming legal needs for PLWH. 4. Convey the importance of access to legal support for PLWH to address these HHLN Learning mechanisms During this session we expect to increase knowledge through the following educational methods of learning: (1) Consciousness raising, (2) Chunking of information, (3) Role modeling, and, (4) Problem identification Instructions for facilitator 1. Ask participants to name some SDH and HHLN among PLWH (homelessness/housing insecurity and unsafe housing, substance use, mental illness, lack of benefits, stigma, discrimination, etc.) 2. Discuss how these SDH and HHLN may impact the health and wellness of PLWH 3. Distribute two qualitative case studies from MLP providers working with PLWH: (1) PLWH who participated in MLP; and, (2) PLWH who did not participate in an MLP. Ask the group to compare both cases and identify the points where the MLP changed the trajectory of the health, treatment, and adherence of the PLWH patient. Divide participants into five subgroups, each corresponding to a stage in the HIV continuum of care (Testing, Linkage, Prescription/Pharmaceutical, Retention, Suppression). Ask each group to identify the HHLN for the assigned stage of the HIV continuum of care. 4. Ask participants for some examples of HHLN that have impacted PLWH patients from their experience. Discuss as a group and consider how MLP might have helped. When the participants can discuss have achieved these competencies, take a 10-minute break before moving on to Session #5. 10

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INTEGRATION OF LEGAL SERVICES AND MEDICAL/HEALTH CARE SESSION | Session Five | 60 minutes Overview INTEGRATING CIVIL PUBLIC INTEREST LAW INTO THE HEALTH CARE SETTING PROVIDES THE OPPORTUNITY TO IDENTIFY HEALTH HARMING LEGAL NEEDS AND ALLEVIATE THE BARRIERS TO HEALTH WITHIN THE HEALTH CARE SYSTEM. The goal of this session is to provide a foundational understanding of the benefits to co-locating legal and medical services for populations in general and PLWH in particular Competencies By the end of this sessions, participants will be able to: 1. Discuss the benefits of having legal services on site at the health center 2. Discuss the importance of relationship-building to a successful MLP 3. Describe the potential health benefits for patients, staff, and health center By the end of the session, participants will: 1. Understand the impact of on-site public interest law to address HHLN, thereby improving patient health 2. Understand the critical importance of relationship-building and communication among patients/clients, health care practitioners, social services, and lawyers 3. Understand the potential benefits to patients, staff, and health center Learning mechanisms During this session, we expect to introduce participants to the MLP approach in action through the following educational methods of learning: (1) Consciousness raising, (2) Chunking of information, (3) Information transfer, (4) Relating to professional experiences with patients/clients. Instructions for facilitator 1. MLP success depends on relationship-building among health practitioners, legal and social services staff, and patients. 2. Discuss the barriers to legal services that are removed when lawyers are on site at the health center 3. Discuss the barriers to health that are removed and/or reduced the result of accessible legal assistance 4. Discuss advantages to patients (legal support can remove/minimize barriers to health and wellness caused by HHLN, improvement in SDH) 5. Discuss advantages to MLP staff (improved workflow, better overall care, improved job satisfaction, etc.) 6. Discuss possible benefits to health care organization (higher reimbursement rates from health insurance enrollment, more adherent patients, improvements to overall community health) 7. Ask participants to describe a situation they’ve had with a patient that might have had a better outcome with public interest law integrated into the health care setting 12

When the participants can discuss the implication of MLP and the benefits to all parties, take a 30- minute break before moving on to Session #6. 13

PREREQUISTIES FOR SUCCESSFUL MEDICAL-LEGAL PARTNERSHIPS | Session Six | 90 minutes Overview AS IN ANY HEALTHY PARTNERSHIP OR COLLABORATION, THERE MUST BE CLEARLY DEFINED ROLES AND RESPONSIBILITIES THAT DRAW ON EACH PARTNER’S EXPERTISE, CAPACITY, AND PROFESSIONAL RESPONSIBILITY REQUIREMENTS. In addition, since partnerships are living, breathing efforts, there should a continuous process in place for partners to regularly check-in and assess what is working, wht needs to be revised, and ensure effective lines of communication are in place. The goals of this session are to identify the requirements, staff, and organization, and begin the discussion about how the various components of the intervention will be implemented. (CONFLICTS OF INTEREST) Competencies By the end of this session, participants will be able to: 1. Discuss the role and responsibilities of the health facility/organization 2. Discuss the role and responsibilities of the health facility/organization staff 3. Discuss the role and responsibilities of the attorney 4. Discuss the role and responsibilities of internal social services staff (employed by health center) 5. Identify strategies to maintain continuous quality improvement on the team that can help ensure ongoing clarity re: roles and responsibilities. 6. Discuss how appropriate communication among cross-sector/cross-organizational partners will be maintained and how questions or concerns will be addressed/resolved. By the end of this session, participants will: 1. Be able to clearly explain the distinct roles and responsibilities of all partners and the importance of working collaboratively with a patient-centered focus 2. Understand available options for implementing continuous quality improvement that can assure refinement of roles and responsibilities as needed 3. Understand how to set boundaries for communication across the interdisciplinary team, which are impacted by many external variables including HIPAA, mandated reporting obligations, conflicts of interest, and legal professional responsibility obligations 4. Be able to identify key elements of an MOU Learning mechanisms During this session, we expect to allocate roles and responsibilities for MLP implementation and ongoing operations of the MLP through the following educational methods of learning: (1) Consciousness raising, (2) Chunking of information, (3) Information transfer, (4) Relating to professional experiences. Instructions for facilitator 1. The Memorandum of Understanding (MOU) memorializes the roles, responsibilities and appropriate lines of communication of health facility, health care staff, social services staff and attorneys, to create an effective and efficient MLP. The MOU addresses: a. The purpose of the partnership 14

b. Workspace and equipment resources necessary for success, when operating at the healthcare site and/or at the legal organization site (consider proximity to PLWH patients, accessibility to staff, privacy) c. Budget and funding responsibility d. Scope of work, e.g., activities undertaken by each partner (ranging from screening to scheduling of legal intake appointments to intake interviews to direct representation parameters to MLP team meetings and training and team based CQI/feedback loops and data/outcome reporting and analysis). e. Roles and responsibilities of each partner in connection with each specified activity. f. Noting of any restrictions on communication between partners based on HIPAA, mandated reporting obligations, conflicts of interest, and legal professional responsibility obligations – and any related impacts on the scope of legal services that can be provided to patients. g. Researcher authorization and access to HER/EMR for the purposes of collecting the necessary data for the project. 2. Invite participants to share any questions or concerns they have . If they raise any questions or concerns, make a note of them and at the end of the training, see if they have been resolved there. If not, set up a follow-up call with leadership to address these concerns. When the participants can discuss the roles, responsibilities, and communication boundaries of the MLP staff and organizations, take a 15-minute break before moving on to Session #7. 15

SCREENING FOR HEALTH HARMING LEGAL NEEDS | Session Seven | 45 minutes Overview THIS SESSION FOCUSES ON THE IMPORTANCE OF THE LEGAL NEEDS SCREENING INSTRUMENT AND PROCESS, WHICH – DEPENDING ON POSITIVE/NEGATIVE RESPONSES – MAY TRIGGER ACCESS TO LEGAL SERVICES. It is critical to have a protocol in place that insures all PLWH patients receive a screening for health harming legal needs and, as appropriate, are offered legal services. Competencies By the end of this session, participants will be able to: 1. Explain the procedure for legal needs screening 2. Explain the importance of the legal needs screening process and the need to consistently conduct screenings for all patients 3. Identify the staff person/people who will conduct the legal needs screening 4. Discuss the issues/activities that will be handled by staff and the issues that will be elevated to the attorney 5. Demonstrate an effective legal needs screening encounter By the end of this session, participants will be: 1. Familiar with the legal needs screening tool and how to conduct an effective legal needs screening 2. Identify who will be conducting the legal needs screening 3. Explain the procedure for legal needs screening and the actions to take upon completion [triage flow chart] What can each level do—first self-screening by participant and second in-depth intake by attorney Social services referral for immediate services (food bank, etc) Legal services are next step There is something in between sending them out to community for support and sending them to the MLP lawyer... Learning mechanisms During this session, we expect to introduce participants to learn about the importance of and mechanism for legal needs screenings through the following educational methods of learning: (1) Consciousness raising, (2) Chunking of information, (3) Information transfer. Instructions for facilitator “The screening for health harming legal needs is the key to identifying patients whose health outcomes may be directly impacted by HHLN. The screening process is the mechanism by which these HHLN are identified. There are several components to the screening phase that must become part of the health center’s standard protocol. It’s important to consider the following: 1. The screening tool is the most critical component of this intervention because it triggers the potential accessibility of legal services. There are many legal needs patients may be dealing with. Let’s look at the legal needs screening together (hand-out or PowerPoint). 16

2. PLWH will ideally be screened by case managers; however other designated staff members should be prepared to screen patients in the event case managers aren’t available. 3. Where will the screening be conducted? (Exam room? Separate room?) 4. Have the participants pair up and take turns role playing the screener and patient. Identify the case managers—case managers are in the best position to conduct the screenings and will most often screen patients. However, everyone should be familiar with the screening tool and be able to conduct screenings in case they are needed. 5. Discuss triage flow chart that directs patient to either social services or attorney (flow chart is included in Supplemental Materials at the end of the training document) When the participants understand legal needs screening procedures and protocols, take a 10-minute break before moving on to Session #8. 17

MEDICAL-LEGAL PARTNERSHIPS IN PRACTICE | Session Eight | 90 minutes Overview This session focuses on the point at which a patient’s legal needs have been identified, triggering the offer of and connection to legal services. This section teaches MLP providers how to refer patients to legal services, support legal engagement, and use the public interest law attorney as a resource. Competencies By the end of this session, providers will be able to: 1. Explain the process of patient referral and legal engagement 2. Explain the types of matters that are referred to an attorney and those that are handled by other staff members 3. Explain informed consent for information sharing between health care providers and attorney and the process of obtaining informed consent By the end of this session, providers will: 1. Understand informed consent, how to discuss it with potential participants, how to document it 2. Understand the importance of documenting in EMR screening results 3. Understand the issues that trigger referral to social services, patient navigator, and attorney services 4. Understand the importance of facilitating the referral to legal services when legal issues are identified 5. Demonstrate an effective patient-attorney introduction 6. Use the attorney as a resource for the staff Learning mechanisms During this session, we expect to introduce participants to the procedure triggered by a positive legal needs screening using: (1) Consciousness raising, (2) Chunking of information, (3) Information transfer; (4) Relate to professional experience. Instructions to facilitators -Informed Consent 1. Informed consent is the process of providing potential study participants with information about the study, their rights, and information about the sharing of their personal information throughout the study, to which they can agree (and provide informed consent) or disagree and refuse participation in the study 2. Participants must give permission for communication between health center staff and attorney as necessary to provide appropriate clinical care and legal services—discuss process of obtaining informed consent 3. Patient has the option to sign an informed consent that includes information sharing between lawyers and health/medical practitioners to the extent that it is necessary for the attorney to handle the client’s legal needs. 4. Patients will still have access to legal services if they choose not to permit the sharing of information between lawyer and healthcare practitioners. 18

-Introduction of participant to attorney 1. Document in EMR/EHR the possible legal issues identified through the screening 2. Sample script: From the information you provided, it looks like you might have some legal issues. I’d like you to meet “Rachel,” the lawyer here. She works with our patients and might be able to help you. Can I introduce you/put you in touch? Document patient answer to the offer of legal services. 4. If patient wants to meet with lawyer, either make the introduction at that time or make an appointment (depending on what is feasible at the moment). To set up a positive introduction and transfer the trust and confidence patient has in case worker, referral should include language such as “This is Doug our lawyer. Doug works here with us and can talk to you about your legal issues.” 5. If patient declines or is resistant to meet with attorney, advise patient that the attorney is a part of the staff and is there specifically to support the patients. Offer patient information/brochure about health harming legal needs and provide a phone number and email for future contact. -Role of attorney 1. Handle informed consent for information sharing between clinical service providers and attorney (documentation required in EHR); Explain to participant that refusal to permit communication between attorney and health center staff a. is not required for legal services b. will not impact the attorney-client relationship c. The purpose of this communication is to ensure that the attorney has any pertinent medical info that may be relevant to participant’s legal issues and that may help attorney advocate for client 2. Identify the legal needs that the attorney will handle internally and serve as participant’s attorney 3. Identify the legal needs for which the patient will be offered referral to other organizations (provide access to a list of organizations that handle legal needs beyond the scope of the MLP attorney) 4. Provide monthly workshops for participants on common legal issues (landlord/tenant, denials of benefits, etc.), patient rights, self-advocacy, etc. -Communication is critical 1. Communication between healthcare practitioners and patients 2. Communication between attorney and patient/client 3. Communication between healthcare practitioners and attorney—if informed consent siged When the participants have a solid understanding of MLP in practice, take a 15-minute break before moving on to Session #9. 19

DATA COLLECTION AND ANALYSIS | Session Nine | 30 minutes Overview Data collection is a critical component of our research. The goal of this study is to assess the impact MLP has on PLWH with regard to engagement in care, viral load suppression, and patient outcomes. To ensure that complete data for every participant is collected for analysis, we have research assistants who are responsible for reviewing HER/EMR. It is important that research assistants have access to all health center data and public interest law data for the research subjects for collection and analysis. Two tasks are critical for this step: (1) the internal collection of data on exposure to the intervention (see section 6.5 below) and, (2) the monitoring of patients’/clients’ progress in the HIV and legal continua of care. Data collection from participants will be handled by XXX. For the first task, OPAHL will require OPAHL research assistant to collect data and collaborate with health care staff to collect health and social services exposure data following a designated protocol by OPAHL. For the second task, attorney will take notes on encounters with participants that occur throughout the 6-month engagement and complete a post participant encounter report at the conclusion of the six months that provides an account of what transpired during the course of the relationship, including: The number of encounters attorney had with participant during the 6-month period The legal issues referred to other attorney/public interest law group Legal issues addressed by in-house attorney Status of legal issues addressed internally [other info from Theresa and Linda’s report?] Competencies By the end of this session, participants will be able to: 1. Explain the importance of data collection to this study 2. Explain who has access to the data Be the end of this session, participants will: 1. Know what data will be collected 2. Know where the data is to be recorded 3. Know who has access to the data Learning mechanisms During this session, we expect to introduce participants to learn about the procedure triggered by a positive legal needs screening: (1) Consciousness raising, (2) Chunking of information, (3) Information transfer; (4) Relate to professional experience. Instructions to facilitators “To fully understand the impact of MLP on PLWH, it is important that we collect patient information from both the health center EMR/HER and the lawyer. We can only collect this info if it is ascertained 20

and recorded by the appropriate staff member. See the Supplemental materials section for the data collection tools that will be used in this study. When the participants can explain the importance of the data and understand their roles in data collection, ask if they have any questions about this or anything else we have discussed throughout the training. Thank you for taking the time for this training and we look forward to working with you. If you have any questions or if you’d like to reach out to us, please feel free to contact us. [provide contact info]. 21

SUPPLEMENTAL MATERIALS | Supplemental materials 1. Readings Trainees are expected to read the following prior to attending the in-person training. 1. Marple, K. (2015). Framing Legal Care as Health Care: A guide to help civil public interest law practitioners message their work to health care audiences. National Center for Medical-Legal Partnership. Available at: https://medical-legalpartnership.org/wp- content/uploads/2015/01/Framing-Legal-Care-as-Health-Care-Messaging-Guide.pdf 2. Trott, J., Theiss, J., Peterson, A. (2019). VA Medical-Legal Partnership Readiness Guide: Building and Strengthening Medical-Legal Partnerships for Veterans. National Center for Medical-Legal Partnership Available at: https://medical-legalpartnership.org/wp-content/uploads/2019/05/VA- MLP-Readiness-Guide.pdf 3. Regenstein, M., Teitelbaum, J., et al. (2015). Medical-Legal Partnership and Health Centers: Addressing Patients’ Health-Harming Civil Legal Needs as Part of Primary Care. National Center for Medical-Legal Partnership. Available at: https://medical-legalpartnership.org/wp- content/uploads/2015/02/Medical-Legal-Partnership-and-Health-Centers.pdf 22

Supplemental materials 2. Foundational Step from Leadership Perspective Potential participating health care organizations have signed letters of support. During this initial step we will secure the commitment of health care organization leadership. The OPAHL scientific and collaborative boards have designed a “pitch” one-to-one intervention activity with administrators consisting of three in-person meetings with the OPAHL team and the leadership of the local Legal Aid society. The intervention team will work with the selected health care organization and a local Legal Aid organization to create a Memorandum of Understanding (MOU). This MOU will outline the mission and goals of the partnership, designate roles and responsibilities between health care organization and public interest law services, and identify the organizational contribution of each partner organization. The health care organization will provide office space, computer, phone, and the necessary access to patient files and records. The public interest law organization, in coordination with the intervention team, will hire an attorney licensed to practice in the state and the public interest law organization will provide office space, phone, access to computer systems at the public interest law office. The grant will support the attorneys’ salaries, benefits, and malpractice insurance. This step will be supported by the consulting team of National Coalition of Medical-Legal Partnerships (NCMLP) which provide informational sessions to agencies in the process of building partnership for legal services within health settings. Deliverables (Outputs) 1. Identify/hire attorney to serve at the health care organization 2. Designate health care organization point person to take lead on implementation and liaise with attorney 3. Devise internal communication system and strategy that works within existing health care organization mechanism (including informed consent that grants permission for information sharing between health center and attorney, whether added to current IC or creation of an IC that specifically addresses this) 4. Develop communication strategy/system between health and legal care providers and client/patient (e.g., given the specific context of the health care organization, how is communication currently handled; how can attorney be integrated into this process; how will communication be handled for legal appointment reminders/case updates) 5. Identify screening protocol, specifically: What screening tool will be used; Who conducts the legal screening in the health care organization; Where is legal screening conducted; What legal issues will/won’t be addressed (referral process for legal issues that fall outside of the scope of practice); How will the introduction to attorney be made; 6. Define the legal services operations within the health care organization: Who has access to add clients to attorney schedule; What are the available appointment times; How are urgent legal matters handled. 23

Supplemental material 3. Implementation of Legal Services into Health Care Organization serving PLWH Once the organizational components of the health care organization- legal services partnership is in place, four months from the point start of Step 1 above, we will launch the OPAHL model within the health care organization. In this step, PLWH patients will be screened for health harming legal needs and, if identified as having health harming legal needs, they will be offered legal support. Those who decide to accept the offer will sign a letter of engagement with the attorneys and become clients. ● For the next 12 months, the attorneys will have the following tasks: (1) Identify the level of severity of health-harming legal needs (broad and specific to HIV); (2) Provide advice, counsel, and/or representation to clients to mitigate their health harming legal needs; (3) Serve as a resource for health care organizations staff (answer questions, provide advice, conduct trainings); (4) Coordinate with medical and health-social services addressing health-harming legal needs; (5) conduct client/patient workshops; and (6) Collect data according to study requirements. ● During the same period, medical, health-social services providers will have the following tasks: (1) Provide comprehensive HIV primary care, treatments, or referrals to services for co-occurring conditions, case management and related health and social services as recommended by the CDC; (2) Identify health-harming legal needs of patients who are living with HIV; (3) Refer patients with identified health-harming legal needs to legal services providers in the MLP; (4) Communicate in a timely manner to legal services of any health issue that may impede addressing health-harming legal needs; (5) Coordinate communications between medical and legal services as part of case management of PLWH (patient-specific issues, weekly staff meetings, trainings); (6) Collect data according to study requirements. Legal scope training for attorneys To increase the potential sustainability of OPAHL, it is imperative that the legal services of OPAHL resemble the scope of legal services work that can be legally provided by traditional public interest law services. In other words, the Legal Services Corporation (LSC): America's Partner for Equal Justice is the major provider of funding for public interest law organizations in the country. LSC funding prohibits lawyers representing people in criminal cases or individuals who are not U.S. citizens with limited exceptions such as lawful permanent residents, H2A agricultural workers, H2B forestry workers, and victims of abuse, extreme cruelty, sexual assault or trafficking. Thus, for the purpose of this intervention, OPAHL attorneys will: (1) provide comprehensive civil public interest law services, as defined by state laws and regulations; (2) refer unauthorized migrants to local migration public interest law organizations; (3) refer criminal cases to local criminal defense public interest law organizations; and, (4) refer specialized cases that require legal expertise and resources beyond those available through OPAHL to the local pro-bono legal services. Educational training for PLWH by attorney on health harming legal needs OPAHL attorneys will be expected to provide trainings to health organization staff to educate them on various legal issues that impact their patient population. Attorneys will also be expected to provide monthly workshops for patients/clients to educate them about their legal rights. Educational videos (by the National Coalition of Medical Legal Partnerships, ACLU and ALIA) will be shown once a week in the waiting room. The objective of this educational training is PLWH to: prioritize addressing health-harming legal needs that might serve as barriers to their progress in HIV care. 24







Supplemental material 7. Our philosophy OPAHL IS BASED ON FIVE INTERVENTION PRINCIPLES. 1. Sustainable continuity of HIV care requires moving beyond medical interventions alone. Barriers to treatment and care for people living with HIV (PLWH) cannot be managed with medical- public health approaches alone. In the early 2000s, researchers, practitioners, and policy makers began designing and implementing HIV structural interventions to prevent HIV transmission, increase access to HIV treatment, and reduce community level viral load. By 2015, it became evident that HIV medication adherence requires tremendous, multilevel support.14 2. Achieving 95/95/95 HIV care goals require addressing social drivers of health. HIV is a disease embedded in social and economic inequity.5 Achieving the UNAIDS 95-95-95 goals, i.e., increasing the current levels of HIV diagnosis, treatment and HIV viral suppression to 95 each, requires addressing the social drivers of health (SDH) that may serve as barriers to HIV treatment and care.6,7 SDH impact the ability of people living with HIV (PLWH) to manage their illness and maintain a healthy lifestyle. x9 In low income communities in the United States, PLWH are at risk of losing their housing, high medical costs, limited income, and limited ability to continue working due to related illnesses; these barriers in turn decrease their likelihood of medical adherence and achieving HIV viral load suppression.10 Adherence to HIV treatments is often complicated by other co-

occurring conditions, including substance use disorders, mental illness, and other structural barriers, such as incarceration.11-13 3. Synergistic care continua approaches are imperative to address the HIV/AIDS epidemic. Integration of services is increasingly recognized as a means to develop more effective models of care and improve patient outcomes. ● The philosophy behind the HIV continuum of care is that in order to achieve HIV viral suppression and improve the quality of life of PLWH, the person first need to know their HIV status, has access and be linked to HIV treatment and care services, if the person is HIV positive. Then assist the patient retain in HIV care in spite of external and internal barriers to care including social drivers of health. ● The legal continuum of care follows a similar philosophy, in order for people to have equitable access to health care, we first must identify the health-harming legal needs that are precluding access to care in the first place. Based on the foundational research for OPAHL, there are five stages of the legal continuum of care are: identification of health harming legal need(s), linkage to legal support, engagement in legal services, resolution of legal issue(s), access to continued legal support. ● Moving PLWH through the social services continuum of care, is critical for both advanced ion the HIV and legal continua of care. Identifying social and behavioral needs, and addressing through social interventions such as behavioral health and social services case management, HIV evidenced-based case management, multi-level interventions in co-occurring issues, increase the

likelihood of retention in HIV care. Addressing health-harming legal needs also increase retention in social-behavioral interventions and positive movement towards addressing the burdens of unequitable burden of social drivers of health for PLWH. ● The synergies amongst these continua of care and the time linkage are critical. The closer in time this linkage occurs, the more likely it is that these issues will be successfully managed. When patients are engaged with case managers, peer navigators, patient educators, support groups, transportation, food, and emergency assistance, they are more likely to adhere to ART and achieve and maintain viral suppression. Ongoing access to social services support is critical to long-term management of medical, behavioral, substance use, mental health, and other issues, and to address new issues as they arise. 4. Integration of legal services may reduce time to achieve sustainable HIV viral suppression The identification of at least one health harming legal need triggers the legal continuum of care, though key informants reported most PLWH have two or more legal issues. When a legal need has been identified and the patient expresses an interest in legal support, the patient arrives at the first step of the legal continuum--linkage to counsel. The time-sensitivity of legal services is most pronounced when urgent issues arise, such as eviction, utility shut-off, and orders of protection, making immediate access (same day) to legal support is critical. Though other legal issues, such as denials of benefits or employment accommodations, might not require same- day legal intervention, it is important for connection to legal support to occur quickly. ● A critical predictor for success of legal intervention is the time between identification of a health harming legal need and 26

connection to legal support. The likelihood that patients will avail themselves of accessible legal services decreases with the passage of time. ● There are two distinct approaches to identifying legal issues: the “screen-in” approach and the “screen-out” approach. For MLPs that screen-in, the goal is to identify and address as many legal issues as possible. For MLPs that screen-out, the organization seeks to handle a specific cadre legal issues, often based on the more common needs of the particular patient populations they serve and the availability of legal resources/specialists to address those issues. In both situations, once the attorney- client relationship has been established, the attorney can initiate or respond to legal action on behalf of the client. Legal representation continues through resolution of the matter. ● Legal work may require brief engagement, such as writing a letter demanding a landlord remediate mold, helping the client file paperwork for a legal name and gender change, or appealing a decision denying benefits. There may other instances where the legal work requires more protracted work, or even litigation. ● An important component of the legal continuum is the continued availability of legal support to address additional issues as they arise. As part of this continuity of legal support, some MLPs incorporate an educational component to their services. For example, lawyers from an MLP legal service provider in Florida conduct legal workshops on multiple topics to educate clients about their legal rights, empower them to become self-advocates, and maintain an ongoing relationship with the client, making it easier for individuals to access legal support in the future. ● The need for legal intervention might be an indicator of a breakdown in social services support, explaining that most barriers to health can be addressed early on through social services, when the issues are less complicated and less urgent. 6

When these issues aren’t effectively addressed through social services, they can quickly become crises requiring legal intervention. All of the key informants agreed on the importance of screening to identify for social service needs early in the clinical engagement. 5. Co-location of medical-health-social-legal services potentially reduces health care costs Since the 1980s, health care costs in the United States have been a major national concern. Several economic models have tried to address the continuing expanding costs associated with chronic health conditions. OPAHL is based on a basic economic health care model of co-location of services in order to achieve better health outcomes without increasing costs. ● By increasing the levels of HIV viral suppression, we decrease dramatically the likelihood of HIV transmission. In fact, several longitudinal trials have demonstrated that PLWH who have undetectable viral loads, cannot transmit HIV. Therefore, increasing the number of PLWH who are virally suppressed is a national priority because for every person not-getting infected with HIV, there is a lifetime cost save of $367,134 per person in potential life HIV treatment costs. 27

● The costs associated with PLWH who are not in treatment, who have delays in accessing treatment, who reside in medically underserved communities, and/or are affected by systemic barriers to HIV treatment adherence are triple than those who access and are retained in HIV treatment and care. Furthermore, those PLWH who are out-of-care have life expectancies of 12.5 years less than those PLWH with tremendous social and economic costs to society and their communities. ● Through the testing of the OPAHL intervention package, we will examine how the co-location of legal, medical and social services approach may reduce HIV care opportunity costs, and, decrease organizational health care costs such as: visits to the emergency departments, resistance to HIV medications. Conceptually, MLPs have the capacity to create sustainable, efficient, comprehensive structural changes that minimize barriers to HIV care and treatment and improve health and quality of life outcomes. The effects of these structural-level changes have the potential to reverberate throughout other levels of the ecological model and create population level structural changes that impact communities, organizations and institutions, interpersonal relationships, and individuals.10 7







AUTHORS AND ACKNOWLEDGEMENTS | This article is based on data collected from the research study entitled, “Examining the impacts of medical-legal partnerships on the HIV continuum of care),” a project sponsored by the U.S. National Institute of Mental Health (grant number: 1R21MH115820-01; 2018–2020; Principal investigators, Omar Martinez and Miguel Muñoz-Laboy). We would like to thank our research participants and the members of OPAHL community and scientific collaborative boards. The content of this manual is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. National Institute of Mental Health or the National Institutes of Health. About the Authors Robin Davison, JD, MPH, is the project director of OPAHL. She completed her law degree from the Benjamin N. Cardozo School of Law, Yeshiva University, and her public health degree from Columbia University's Mailman School of Public Health. Davison is currently Associate Research Scientist at Temple University’s College of Public Health, School of Social Work. Her areas of intervention research are: health law, civil law, environmental health, health and human rights, medical-legal partnerships and HIV continuity of care. Omar Martinez, JD, MPH, MS, is the principal investigator of OPAHL. He completed his law and public health degrees from Maurer School of Law and School of Public Health at Indiana University, and his post-doctoral fellowship and his masters in statistics from Columbia University's Mailman School of Public Health. Martinez is currently Assistant Professor at Temple University’s College of Public Health, School of Social Work His areas of intervention research are: health law, migrant health, substance use, LGBTQ health, minority health, medical-legal partnerships and HIV continuity of care. Miguel Muñoz-Laboy, DrPH, MPH, is the co-principal investigator of OPAHL. He completed his public health degrees at University of Connecticut Department of Community Medicine and Columbia University's Mailman School of Public Health; and his post-doctoral fellowship at Columbia University’s Department of Psychiatry. Muñoz-Laboy is Associate Professor in the Department of Community Health and Social Medicine, School of Medicine at the City University of New York. His areas of intervention research are: substance use, men’s health, global health, LGBTQ health, minority health, sexual- reproductive health, medical-legal partnerships and HIV continuity of care. Suggested citation Davison, R., Martinez, O., Muñoz-Laboy, M. (2020). OPAHL Training manual for medical, health and social services providers.