A Qualitative Study of the Collaboration between Health Care Providers and Lawyers within the Family Advocates of Central Massachusetts Program

Abstract

Background:Family Advocates of Central Massachusetts (FACM) is a medical-legal collaborative between pediatric health care providers and lawyers at Legal Assistance Corporation of Central Massachusetts. The program is designed to assist disadvantaged families, and more specifically, to improve the health of children which is often impacted by legal issues. A needs assessment conducted by medical students in four pediatrics practices in the summer of 2003 determined that 50% of the approximately 80 families interviewed required referrals for legal services (Dhruvakumar et al. 2003). Reasons for referral fall under the broad categories of housing, financial stability (including benefits, employment, nutrition), dignity and safety (including domestic violence and immigration issues), and access to health care and educational services. In the two and one-half years since the inception of FACM, which now involves five pediatrics practices in central Massachusetts, fewer referrals than projected have been generated by health care providers (Keller et al. 2005). A recent study used the Massachusetts Advocacy Screening Questionnaire (MASQ), a self-administered survey, to assess the need for a legal referral among families waiting to see a health care provider. Following the clinical encounter, the provider was then asked whether the patient’s family required a referral for legal services. While the MASQ identified more patients potentially in need (sensitivity 0.81 for the MASQ and 0.65 for providers), health care provider assessment was similar to the MASQ in identifying patients who ultimately agreed to a referral (specificity 0.75 for the MASQ and 0.95 for providers), indicating that under-identification is only part of the problem. Other factors must be contributing to the lower-than-predicted referral rate. Ascertaining these factors may lead to improvements in the FACM medical-legal collaborative. Objectives:The goal of this qualitative study is to find out how FACM can enhance the collaboration between health care providers and lawyers advocating for low-income families with legal issues. The study utilizes focus groups of health care providers to uncover what is working, what is not working, and what improvements can be made to FACM. The information obtained can then be directly applied to FACM, providing the changes needed to create a more successful collaboration. Methods:The project proposal, recruitment letter, consent form, focus group script, and post-focus group demographics questionnaire were drafted and submitted to the IRB for approval, which was granted. Each of the five pediatrics practices within FACM received a letter and follow-up e-mail inviting health care providers and interested staff to participate in a research study. Targeted subjects included attending physicians, residents, nurse practitioners, nurses, medical assistants, social workers, care coordinators, and any other interested staff. Each volunteer was asked to sign a consent form in order to participate in a 60-minute focus group. The groups were asked a series of questions from a script, which generated discussion among the participants. Subjects offered their opinions of FACM as well as suggestions for improvement in answer to questions and prompts provided by the moderator. Each participant was then asked to complete a questionnaire for demographics purposes. All focus groups were recorded on two separate audio tapes and were transcribed by the co-investigator. Each of the transcripts was then analyzed by the primary investigator, co-investigator, and one of FACM’s legal partners using content analysis, in which the data was organized into categories and themes related to the key questions of the study. Results:Three focus groups and one extended in-depth interview were conducted. Focus groups took place at South County Pediatrics in Webster, Community Health Center in Fitchburg, and Family Health Center in Worcester with 5, 9, and 6 participants respectively. And extended in-depth interview with 2 participants was conducted at Pediatric Primary Care in Worcester. Community Pediatrics in Milford did not respond to the invitation to participate in the study. There were 22 participants in total: 5 attending physicians, 2 residents, 2 nurse practitioners, 5 nurses, 3 social workers, 2 care coordinators, 2 advocates, and 1 medical assistant. 18 participants were female and 4 were male. 12 had previously attended a FACM training session, 8 recalled receiving a FACM code card, and 4 had actually used the code card. As of March 2006, Webster has submitted 53 referrals, Fitchburg 14 referrals, FHC Worcester 46 referrals, Worcester Pediatrics 60 referrals, and Milford 9 referrals. The focus group data was broken down into five major categories: identification of patients in need, referral process of patients in need, feedback from FACM, practice changes as a result of FACM, and changes in children’s health as a result of FACM. Each category was then further divided into subcategories. Under the category of identification of patients, there were facilitators, barriers, and recommendations. Facilitators primarily revolved around the patients volunteering information—either bringing up a potential legal issue at a medical encounter, inquiring about legal services based on FACM signs seen posted in the waiting room, or asking the provider a non-medical question about his or her well-being that the provider was unable to answer. Some providers found that asking screening questions facilitated identification. Barriers were related to providers’ inability to probe for legal issues due to time constraints and true medical concerns being the priority. Recommendations surrounded outreach—targeting the patient population more to promote self-referral to providers and involving more non-physician personnel in training and education since it is often those staff members to whom patients will reveal their need for assistance. Regarding the referral process, there were also facilitators, barriers, and recommendations. Participants liked the fact that making a referral involves completing a simple one-page form and faxing it. They also liked knowing to whom they were referring. However, at times patients are reluctant to be referred due to fear (e.g. undocumented patients) or pride. Providers admitted not knowing the extent of the services that FACM provides and therefore not knowing which issues are appropriate for referral. Recommendations centered on making FACM a more prominent presence in the practices—publishing brochures, posting signs, and having face-to-face meetings with providers and staff. When asked about feedback from FACM, some responses fell under the category of sufficient with providers commenting that phone calls and e-mails are promptly returned and patients report positive interactions and outcomes. However, most responses reflected insufficient feedback with providers not knowing the outcome of their patients’ legal conflicts and often not knowing whether contact was even made between the lawyers and the patient. Recommendations were all ways in which FACM can provide feedback to the practices. Providers would like to be notified by e-mail or phone when a lawyer has made contact with a referred patient. Feedback concerning the final outcome of a legal conflict would also be appreciated. Participants were also interested in receiving feedback about what kind of issues their respective practices are referring the most and least often and also updates on changes in the law that may affect their patient populations, especially immigration law. The final two categories, practice changes and changes in the health of children, were subdivided into changes that have occurred and proposed future changes. In terms of practice changes, providers feel much more confident and supported now that they have FACM backing them up—they are happy to be able to have their questions answered, provide comprehensive care to their patients, address the increasing social and financial issues they are seeing, and safely refer their undocumented patient population. Proposed practice changes echoed the sentiments above—add a question about legal issues to already existing routine patient questionnaires, invite the lawyers to be more of a presence in the practice both through office hours and training/educational sessions, and involve more non-physician personnel in FACM-related matters. Changes in children’s health are difficult to report, primarily related to the aforementioned lack of feedback. However, many participants revealed anecdotes about patients who reported very positive outcomes after being referred to FACM. Overall, providers seem to agree that FACM allows families to be educated and empowered, and that the program undoubtedly has the potential to positively impact the future health of children in Worcester County. Conclusions:Several conclusions can be drawn from general observation of the groups. Milford has conveyed a concerning lack of interest in FACM both in failing to respond to the invitation to participate in this study, and in their paucity of referrals. This raises the question of whether Community Pediatrics in Milford is an appropriate site for identifying and referring patients in need. Fitchburg had the highest number of participants but the least amount of knowledge about FACM, asking a number of questions about the program. The interest is there, but more training and education has to be provided to this site. As of right now, it is an untapped source of patients in need, as the issues are there, but FACM is underutilized. Both Webster and FHC Worcester have a great deal of knowledge about FACM and generate a large number of referrals. Of interest, both sites have care coordinators, social workers, and advocates actively involved in referral of patients, which is a consideration in terms of what groups FACM should be targeting in current and future practices involved in the collaborative. Worcester Pediatrics was a difficult focus group to arrange due to scheduling difficulties, and certainly not a lack of interest. In this busy practice, utilizing a survey instrument or non-physician personnel may increase the already impressive number of referrals. Looking at the data generated by the focus groups, there are a number of things that FACM is doing well. The aspect of the identification and referral process that can be improved seems to be outreach, both to patients and families as well as to all types of providers and staff in the practices. Feedback is a major concern and should be addressed by FACM. Notifying providers that a patient has been contacted will certainly put providers’ minds at ease, enhance their collaboration with the lawyers, and encourage them to make future referrals. Individual providers have certainly altered the way they practice somewhat, knowing that FACM is a resource that is available to them. Broader changes are subject to the standards of each individual practice. Finally, anecdotal evidence reveals small improvements in the health and well-being of children whose families have been involved with FACM. Future directions should include a more formal assessment of practice changes and improvements in children’s health as a result of FACM.