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PPO 16-337 – HSR Study

PPO 16-337
VA-Legal Clinic Partnerships to Increase Veterans' Mental Health and Substance Use Treatment Access, Initiation, and Engagement
Christine Timko, PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: September 2017 - August 2018
Veterans involved in the legal system have more extensive mental health (MH) and substance use (SU) disorders than other Veterans. Veterans frequently report legal difficulties related to obtaining and using VA health care benefits. In community samples, 54%-60% with civil legal problems have SU and MH disorders, and an estimated 56% of community samples with MH and SU disorders have civil legal problems, most often in the health care domain. The prevalence of legal, MH, and SU problems is likely higher in Veteran than in community populations. Resolution of patients' civil legal problems is associated with lower health care costs.
A new model, VA-housed legal clinics, has developed, with an emphasis on helping Veterans to gain access to VA health care (e.g., obtain needed military discharge upgrades and VA benefits), and to address civil legal issues that are barriers to utilizing treatment even when Veterans have access to care (e.g., driver's license reinstatement to enable transportation to health appointments). By addressing legal needs, VA-housed legal clinics help Veterans receive health care services and improve their health and quality of life. However, even with access, Veterans with SU and MH disorders are likely to need intensive (or facilitated) referral to initiate and engage with treatment.

Despite their rapidly increasing number, there has been no systemwide study of VA-housed legal clinics in terms of population served, function, or organization, or empirically-based suggestions on how to further improve their usefulness to VA and Veterans, such as their potential as a setting in which Veterans with MH and SU problems may receive assistance with linking to VA health services to improve their well-being. This project conducted a survey (developed and pretested prior to funding, in a Locally Initiated Project) of all VA-housed legal clinics nationwide. It also collaborated with the VA Palo Alto and VA San Francisco legal clinics to assess and follow their Veteran clients.

The survey (n=96 VA-housed legal clinics; 71% of all active clinics) applied a framework describing the core elements of medical-legal partnerships shown to improve health (Regenstein et al., Health Affairs, 2018). These elements concerned clinics' formal agreements, defined populations, screening and referral of clients, staffing, staff training, information sharing, and funding. The survey was completed online from January to June 2018 by the lead attorney for each clinic.
In collaborating with the VA Palo Alto and VA San Francisco legal clinics to assess and follow their Veteran clients, the purpose was to collect data on clients' acceptance of participating in a longitudinal research project that tracks their SU and MH problems and VA treatment and outcomes (via self-reports and health records). We collected baseline data from 61 Veterans using the legal clinics and followed 77% two months later.

Clinics had been operating a mean of 3.8 years (SD=2.7), served a mean of 20.0 clients per month (SD=26.0), and were located largely in urban areas (65%). Clients' legal problems were mainly family problems (e.g., child support), estate planning, obtaining VA benefits, and housing problems; 3% of clinics provided criminal legal services. Fully 86% of clinics had a formal agreement with the VA; however, 63% of clinics rarely interacted with VA health care providers, and 35% did not have dedicated and adequate space. And, 58% of clinics had a defined population, mostly low-income or homeless veterans. For screening and referral, we focused on MH and SU disorders frequently occurring among Veterans. Only about one-quarter of clinics had any policies regarding screening for mental illness or SU among clients seeking or receiving legal services; only about one-fifth had arrangements with MH or SU treatment programs for client referral. Regarding staffing, most attorneys worked pro bono (M=4.4 [SD=4.4] out of M=5.2 [SD=6.1) attorneys). Under training, although 65% of clinics were unable to serve most Veterans seeking legal services, only 27% cited lack of staff training as a reason, whereas 58% and 73%, respectively, cited lack of staff time and of funding. About one-third of respondents agreed that legal clinic staff should be trained to explain to clients how to use VA health care, and to screen and refer for MH and SU problems; similarly, one-third agreed that VA health care providers should meet with clients at the clinic to assess and explain health care needs. Regarding information sharing, 70% of clinics did not have access to Veteran clients' VA health care records, and 75% did not track clients' VA healthcare access. The percentage of total legal clinic funding was highest from private foundations, legal aid agencies, and government.

This project met priorities of the VA Blueprint for Excellence, HSR&D, the Center for Innovation to Implementation (the research team's HSR&D Center of Innovation), our VA operations partner, the Veterans Justice Programs (VJP), and the White House Legal Aid Interagency Roundtable (WH-LAIR). We have shared preliminary results with the leaders of VJP and WH-LAIR, and will present results at the national Correction Health Conference (Taylor E, Timko C, Brett E, Nash A, & Finlay AK (March 2019). Veterans' Civil Legal Needs and Health Care: Perspectives from the Department of Veterans Affairs. 12th Academic and Health Policy Conference on Correctional Health Conference, Las Vegas, NV). This research program has the potential to improve access to care by a sizable but underserved and vulnerable Veteran population. The pilot project fills a critical gap by gathering information about functions of the rapidly expanding number of VA-housed legal clinics, and about health services needs of Veterans they serve. We will use the pilot's findings in an IIR project to develop and test an intervention to facilitate transition to treatment and thus enable better outcomes among Veterans using VA-based legal clinics. Our ultimate goal is to improve practices across VA facilities by which Veterans using legal clinics are referred to, initiate, and engage in treatment, in order to improve their health outcomes and reduce their use of expensive health services. This research program will contribute to better coordination between VA and community systems working to improve Veterans' well-being.

External Links for this Project

NIH Reporter

Grant Number: I21HX002318-01

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DRE: TRL - Applied/Translational
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