Computer-Supported Management of Medical-Legal Issues Impacting Child Health

Social determinants of health are the circumstances in which people are born, live, work and
age; as well as the systems that are put in place to deal with illness and disability.
Dramatic differences in health are closely related to degrees of social and economic
disadvantage. For example, poverty-induced hardships such as food insecurity, utility
shut-offs and substandard housing all have the potential to negatively impact health. In the
United States, there exist many laws and policies designed to address such issues. For
example, the Supplemental Nutrition Assistance Program (SNAP) seeks to address food
insecurity by providing a means for financially eligible recipients to access nutritious
food. When an individual is wrongly denied SNAP benefits, legal remedies are available.
Access to legal aid, much like access to nutritious food, is often limited by social and
economic disadvantage. It has been demonstrated that most legal problems experienced by
low-income individuals remain unresolved, with fewer than one in five being addressed with
the help of a lawyer.

A child's health status may be negatively affected when he or she does not receive the
benefit of laws designed to address such social determinates of health. Unhealthy housing
may lead to an increased risk of preventable injury or, in the case of dangerous molds,
asthma. An excessively cold environment brought on by a utility shut-off may also trigger
childhood asthma, or result in a family's decision to trade-off food for heat. Poor
nutrition may contribute to any number of deficiencies impacting a child's health. Laws
addressing such issues include those that require landlords to mitigate dangerous rental
housing conditions, those that protect access to utilities in certain circumstances, and
those that protect against unlawful denials of food-benefit programs.

Medical-legal Partnerships bring health care providers together with lawyers to address
social and legal needs, such as those described above, which may result in poor health
outcomes. Such partnerships across the nation provide direct legal advice and assistance to
patients, create internal systems that improve health care delivery, and promote change at a
policy level beyond discrete systems. This study has been designed to expand upon the
current medical-legal partnership concept and mitigate health disparities by creating an
innovative system that dramatically increases the identification of medical-legal issues in
pediatric clinics, improves the delivery of appropriate physician counseling and streamlines
access to legal resources when legal remedies are needed.

The investigators propose to intelligently insert a medical-legal issue screening tool and
tailored decision support protocol into the regular health care delivery process of our
existing computerized clinical decision support system (CDSS), the Child Health Improvement
through Computer Automation (CHICA) system. In short, a series of screening questions
regarding common legal issues that have the potential to negatively impact child health will
be included on a pre-screener form for all patients ≤36 months of age. This form will be
printed on paper and completed by the presenting caregiver in the waiting room. Answers to
the questions will then be scanned into the CHICA system prior to the physician encounter
and analyzed along with previously existing medical record information to generate the
content for a tailored physician worksheet and handouts. Together, these documents will help
guide physicians through the process of confirming identified medical-legal issues and
providing the most appropriate interventions in terms of education and/or referrals to a
medical-legal expert. This process as a whole will help physicians to accurately identify
such issues and immediately address them in an appropriate and sensitive way.

The investigators hypothesize that our innovative use of the CHICA computerized decision
support system to identify and address medical-legal issues in a consistent, appropriate and
effective way will help diminish the barriers that physicians often cite when questioned
about identifying medical-legal issues and taking steps to help address them. For example,
the investigators anticipate that our utilization of waiting room time to administer the
initial pre-screener questions will help minimize concerns about time constraints, and
CHICA's generation of highly-tailored worksheets that direct physicians through the process
of dealing with positive screens will help address physician concerns about lack of
education or experience with medical-legal issues.

To summarize, the investigators intend first to expand and modify the CHICA system to assist
pediatricians with the identification and management of four common medical-legal problems
(homelessness, unsafe rental home conditions, inadequate access to necessary utilities and
food insecurity) that have the potential to adversely impact child health (AIM 1). The
investigators will then evaluate the effect of the CHICA medical-legal module on the
identification and mitigation of medical-legal problems in four pediatric practices by
evaluating rates of medical-legal issue identification via pre/post chart abstraction, and
evaluating actions taken by physicians and patient caregivers (as reported in caregiver
interviews) to mitigate identified medical-legal issues (AIM 2). Next, the investigators
will evaluate physician and patient caregiver satisfaction with the CHICA medical-legal
module by evaluating physician comfort with medical-legal issue identification and
acceptance of the CHICA medical-legal module via physician survey, and evaluating patient
caregiver perceptions (as reported in caregiver interviews) about physicians' handling of
medical-legal issues and the CHICA medical-legal module process (AIM 3). Lastly, the
investigators will evaluate the impact of the CHICA medical-legal module on healthcare
utilization by comparing the overall utilization of Medicaid patients in our intervention
population to Medicaid patients in our control population over the course of 18 months (AIM
4).

Inclusion Criteria:

- Age 0 to 3 years

- Attending one of the intervention or control clinics in Indianapolis

Exclusion Criteria:

- Inability to complete study materials (provided in English and Spanish