AW & ETHICS Civil Legal Services and Medical-Legal Partnerships Needed by the Homeless Population:A National SurveyJack Tsai, PhD, Darlene Jenkins, DrPH, and Ellen Lawton, JDObjectives. To examine civil legal needs among people experiencing homelessness and the extent to which medical-legal partnerships exist in homeless service sites, which promote the integration of civil legal aid professionals into health care settings.Methods. We surveyed a national sample of 48 homeless service sites across 26 states in November 2015. The survey asked about needs, attitudes, and practices related to civil legal issues, including medical-legal partnerships.Results. More than 90% of the homeless service sites reported that their patients experienced at least 1 civil legal issue, particularly around housing, employment, health insurance, and disability benefits. However, only half of all sites reported screening patients for civil legal issues, and only 10% had a medical-legal partnership. The large majority of sites reported interest in re- ceiving training on screening for civil legal issues and developing medical-legal partnerships.Conclusions. There is great need and potential to deploy civil legal services in health settings to serve unstably housed populations. Training homeless service providers how to screen for civil legal issues and how to develop medical-legal partnerships would better equip them to provide comprehensive care. (Am J Public Health. 2017;107:398- 401. doi:10.2105/AJPH.2016.303596)METHODSIn November 2015, we distributed Web-based surveys to homeless services organizations that were members of the Practice-Based Research Network within the National Health Care for the Homeless (HCH) Council. The National HCH Council is a network composed of more than 250 federally funded health center grantees and includes a Practice-Based Research Network that consists of 61 grantees. Representatives, who were mostly program directors and clini-cal managers, were geographically dispersed across the major regions of the United States spanning 26 states. Of the 61 homeless service organizations,48 (78.7% response) completed the survey.The survey was developed by a research group within the Practice-Based Research Network in consultation with HCH sites and the National Center for Medical-Legal Partnerships. The survey asked HCH sites for information about their operations, knowl- edge, and attitudes about legal services and legal-related practices including medical-legal partnerships (defined as having a lawyer in- tegrated on-site in the health care setting who works with patients). The survey also asked sites to rate the extent to which their patients experienced any of a list of civil legal issues and then asked open-ended questions about which civil legal issues were most commonly encountered and which most affected patient health. Civil legal issues, which are noncriminal problems, can affect housing, access to health care, disability payments for income support, family issues, and relief from fi- nancial exploitation.1 People with low income are often at a disadvantage when they have civil legal issues because many cannot afford a lawyer. Individuals who are homeless represent the most vulnerable, indigent group in the United States and thus may have great civil legal needsthat must be addressed to prevent andend homelessness.One novel approach to addressing civil legal problems within health care settings is medical-legal partnerships. Medical-legal partnerships represent an innovative health care delivery approach that integrates lawyers into health care teams to address various complex problems that affect vulnerablepopulations.2 They strive to addresslegal problems before they require litigation by using preventive administrative legal solutions.3A few studies have shown that medical- legal partnerships can improve the health and lives of various patient populations,4-7 but more research is needed to examine the need and potential for medical-legal partnerships for homeless populations.8 Thus, we sur- veyed a national sample of homeless health clinics about their needs, attitudes, and practices related to civil legal issues and medical-legal partnerships.ABOUT THE AUTHORS 398 Public Health Law Peer Reviewed Tsai et al.AJPH March 2017, Vol 107, No. 3Jack Tsai is with the Veterans Affairs New England Mental Illness Research, Education, and Clinical Center and the Division of Mental Health Services Research, Yale School of Medicine, New Haven, CT. Darlene Jenkins is with National Health Care for the Homeless Council, Nashville, TN. Ellen Lawton is with the National Center for Medical-Legal Partnership, George Washington University, Washington, DC.Correspondence should be sent to Jack Tsai, PhD, 950 Campbell Ave, 151D, West Haven, CT 06516 (e-mail: j..i@yale. edu). Reprints can be ordered at http://www.ajph.org by clicking the "Reprints" link.This article was accepted November 23, 2016. doi: 10.2105/AJPH.2016.303596RESULTSTable 1 describes the characteristics of participating sites. Only 60.4% of the sites re- ported that they screened patients for civil legal problems, and only 19% of the sites had received training on legal screening, although most were interested in receiving training. The large majority of sites also reported that there is a need for civil legal services, that access to civil legal services would benefit their patients, and that their organization is interested in developinga medical-legal partnership. Among the only 5 sites (10%) with medical-legal partnerships, 4 reported that they partnered with a legal aid office, and 1 site partnered with a pro bono legal organization; 2 sites had been operating for longer than 2 years, and the remaining 3 sites had been operating for a shorter amount of time. Among the 43 sites that did not havea medical-legal partnership, qualitative rea- sons they gave for not having a medical-legal partnership were categorized as follows:d 13 sites stated that it was not a priority; d 13 sites were not sure or had not heard ofmedical-legal partnerships;d 10 sites described a lack of staff and fi-nancial resources;d 6 sites reported relying on legal pro-fessionals but not in a partnership model (e.g.,referral to community legal aid); d and 1 site gave no reason.Spearman correlation analyses found that sites that had a medical-legal partnership were more likely to serve unaccompanied youths (r = 0.30; P = .038) and to have received training on screening for legal issues(r = 0.36; P = .012) and in developing medical-legal partnerships (r = 0.64;P 5000Screening for civil legal needs VerbalPaper-basedElectronic medical record-based NoneApproach to legal needsRely on social workersReferral to outside legal providersHas medical-legal partnershipReceived training on assessing legal needsReceived training on developing medical-legal partnershipKnowledge and attitudes about legal services Comfortable assessing legal needsaKnowledgeable about legal aid programsbBelieve legal services needed at organizationcAgree access to legal services would benefit patientsd Request training material about legal screening Organizational interest in developing a medical-legalpartnershipeCivil legal-related needs of patients reported by HCH sites EmploymentHealth insuranceMedicaid enrollmentMean 6SD or No. (%) 22.2 610.3114.3 6133.613 (27.1) 9 (18.8) 10 (20.8) 16 (33.3)9 (18.8) 21 (43.8) 7 (14.6) 11 (22.9) 9 (18.8)45 (93.8) 26 (54.2) 26 (54.2) 22 (45.8) 11 (22.9)5 (10.4)6 (12.5) 27 (56.3) 10 (20.8)16 (33.3) 10 (20.8) 7 (14.6) 19 (39.6)23 (47.9) 22 (45.8) 5 (10.4) 9 (18.8) 4 (8.3)39 (81.3) 26 (54.2) 45 (93.8) 39 (81.3) 47 (97.9) 34 (70.8)46 (95.8) 45 (93.8) 43 (89.6)ContinuedAJPH LAW & ETHICS March 2017, Vol 107, No. 3 AJPHTsai et al.Peer ReviewedPublic Health Law 399TABLE 1?Characteristics, Practices, Attitudes, and Civil Legal-Related Needs Among National Health Care for the Homeless Council (HCH) Sites: United States, 2015AJPH LAW & ETHICS TABLE 1?ContinuedSite Characteristics and Civil Legal-Related NeedsMedicare enrollmentSocial Security/benefits enrollmentTemporary Assistance for Needy Families enrollment Bankruptcy/debtor reliefHousingUtilitiesLandlord issuesEducationVeteran benefitsLegal statusCriminal recordIdentificationRevoked driver's licenseGuardianship issuesDivorce or child custody issuesGarnishment of wagesMean 6SD or No. (%)44 (91.7) 47 (97.9) 34 (70.8) 38 (79.2) 47 (97.9) 43 (89.6) 46 (95.8) 39 (81.3) 42 (87.5) 41 (85.4) 45 (93.8) 44 (91.7) 42 (87.5) 34 (70.8) 33 (68.8) 36 (75.0)Very few HCH sites surveyed hada medical-legal partnership. Sites that served homeless youths and had received previous training on legal screeningwere more likely to have a medical-legal partnership. Although more than 70% of the sites reported organizational interest in forming a medical-legal partnership,many cited challenges with lack of financial and staff resources to develop medical-legal partnerships. Medical-legal partnershipsin other clinical settings often involve partnerships with public or nonprofit agencies that have a small but dedicated funding stream.10,11 Homeless service- focused medical-legal partnerships, like other medical-legal partnerships,should seek to optimize those small funding streams via structured partnerships that can draw in additional investment from service funding streams. As home- lessness persists, we need to explorenew opportunities to address social determinants of health, including civil legal issues, in homeless and at-risk populations.PUBLIC HEALTH IMPLICATIONSPreventing and ending homelessness require addressing the civil legal needs of homeless populations. Our survey showed that many people experiencing homelessness have civil legal needsthat could benefit from legal aid. Training homeless service providershow to screen for civil legal issues and how to develop medical-legal partnerships would better equip them to provide comprehensive care.CONTRIBUTORSJ. Tsai and D. Jenkins conceptualized the study, analyzed the data, and wrote the article. D. Jenkins collected the data. E. Lawton helped advise on the data collection and the writing of the article.ACKNOWLEDGMENTSSpecial thanks to Katelyn Kang and Catherine Brickel for their assistance with the data and the Practice-Based Re- search Network of the National Health Care for the Homeless Council for their participation.HUMAN PARTICIPANT PROTECTIONInstitutional review board approval was not needed for this work because there were no human subjects involved and the surveys collected did not contain any identifying information. Note. The sample size was n = 48.aCoded as "somewhat comfortable" or "very comfortable" about assessing legal needs.bCoded as "somewhat familiar" or "extensive knowledge."cCoded as feel "some need" or greater for legal services at respondent's organization.dCoded as "agree" or "strongly agree" that access to a lawyer would benefit patients at respondent's organization.eCoded as "somewhat interested" or greater.Table 1 also summarizes the civil legal- related needs of patients reported by HCH sites; 93.0% reported that their patients experienced at least 1 of the 20 civil legal-related needs listed. The civil legal-related needs most highly en- dorsed (93%-98%) were related to housing, Social Security/benefits enrollment, em- ployment, and health insurance. Analysis of open-ended responses from HCHsites found that the 3 most commoncivil legal problems were related to housing (40 sites), public benefits (29 sites), and health insurance (7 sites), and sites reported that the same top 3 civil legal problems most affected patient health(36 sites reporting housing, 29 sites reporting public benefits, and 11 sites reporting health insurance).DISCUSSIONThis was one of the first national studies to survey civil legal needs and services among homeless service organizations. AlthoughHCH sites may not represent all homeless service organizations, we found that there was a clear need for civil legal assistance because more than 90% of the HCH sites reported that their patients experienced at least 1 civil legal issue. Although not directly comparable, only 66% of a random sample of the general population reported that they have experi- enced a civil legal issue.9In our sample, the most common civil legal issues were around housing, employment, health insurance, and disability benefits. Our survey also found that an overwhelming majority of homeless service sites reported that access to legal services would benefit patients, but only half of all sites reported systematically screening for civil legalissues, and only 19% of the sites had received training on screening for legal services. Nearly all HCH sites requested training materials, and many sites were interested in developing a medical-legal partnership, suggesting that this is an area for development that administratorsand program directors in these settings should attend to. 400 Public Health Law Peer Reviewed Tsai et al.AJPH March 2017, Vol 107, No. 3REFERENCES1. Legal Services Corporation. Documenting the Justice Gap in America. Washington, DC: Legal Services Corporation; 2007.2. Cohen E, Fullerton DF, Retkin R, et al. Medical-legal partnership: collaborating with lawyers to identify and address health disparities. J Gen Intern Med. 2010;25(suppl 2):S136-S139.3. Zuckerman B, Sandel M, Lawton E, Morton S. Medical-legal partnerships: transforming health care. Lancet. 2008;372(9650):1615-1617.4. O'Sullivan MM, Brandfield J, Hoskote SS, et al. En- vironmental improvements brought by the legal in- terventions in the homes of poorly controlled inner-city adult asthmatic patients: a proof-of-concept study.J Asthma. 2012;49(9):911-917.5. Retkin R, Brandfield J, Bacich C. Impact of Legal Interventions on Cancer Survivors. New York, NY: LegalHealth; 2007.6. Weintraub D, Rodgers MA, Botcheva L, et al. Pilot study of medical-legal partnership to address social and legal needs of patients. J Health Care Poor Underserved. 2010;21(2):157-168.7. Teufel JA, Werner D, Goffinet D, Thorne W, Brown SL, Gettinger L. Rural medical-legal partnership and advocacy: a three-year follow-up study. J Health Care Poor Underserved. 2012;23(2):705-714.8. Tsai J, Middleton M, Retkin R, et al. Partnerships be- tween health care and legal providers in the Veterans Health Administration. Psychiatr Serv. 2016;Epub ahead of print.9. Sandefur RL. Accessing Justice in the Contemporary USA: Findings From the Community Needs and Services Study. Chicago, IL: American Bar Foundation; 2014.10. Wong CF, Tsai J, Klee A, Udell HR, Harkness L, Middleton M. Helping veterans with mental illness overcome civil legal issues: collaboration betweena Veterans Affairs psychosocial rehabilitation center and a nonprofit legal center. Psychol Serv. 2013;10(1):73-78.11. Sandel M, Hansen M, Kahn R, et al. Medical-legal partnerships: transforming primary care by addressing the1. summarize what you read, be specific and thorough note this is not an opinion component, but a summary of the reading.2. ? Include what you learned from what you read or how it caused you to think differently about the topic.3. Discuss your understanding of the statistics as compared to what you understood at the beginning of the term be specific and give examples to support your comments.4. What do you still have questions about with regard to the topic? ?

hi ha Reading Reflection on Services for Homeless, Due 11/20 Hide Assignment Information Instructions In this reflection, you're to write about key components of the reading in this module and what you learned from the reading. 1. Summarize what you read. Be specific and thorough. Note: this is not an opinion component but a summary of the reading. 2. Include what you learned from what you read or how it caused you to think differently about the topic. 3. Discuss your understanding of the statistics, as compared to what you understood at the beginning of the term. Be specific and give examples to support your comments